The Psychotherapy Practice Research Network (PPRNet) blog began in 2013 in response to psychotherapy clinicians, researchers, and educators who expressed interest in receiving regular information about current practice-oriented psychotherapy research. It offers a monthly summary of two or three published psychotherapy research articles. Each summary is authored by Dr. Tasca and highlights practice implications of selected articles. Past blogs are available in the archives. This content is only available in English.
…I blog about CBT, negative effects of psychological interventions, and what people want from therapy.
Type of Research
- ALL Topics (clear)
- Alliance and Therapeutic Relationship
- Anxiety Disorders
- Attendance, Attrition, and Drop-Out
- Client Factors
- Client Preferences
- Cognitive Therapy (CT) and Cognitive-Behavioural Therapy (CBT)
- Combination Therapy
- Common Factors
- Depression and Depressive Symptoms
- Efficacy of Treatments
- Feedback and Progress Monitoring
- Group Psychotherapy
- Illness and Medical Comorbidities
- Interpersonal Psychotherapy (IPT)
- Long-term Outcomes
- Neuroscience and Brain
- Outcomes and Deterioration
- Personality Disorders
- Placebo Effect
- Practice-Based Research and Practice Research Networks
- Psychodynamic Therapy (PDT)
- Resistance and Reactance
- Self-Reflection and Awareness
- Suicide and Crisis Intervention
- Therapist Factors
- Transference and Countertransference
- Trauma and/or PTSD
- Treatment Length and Frequency
Adding Short-Term Psychodynamic Psychotherapy to Antidepressants
Driessen, E., Fokkema, M., Dekker, J.J.M., Peen, J., Van, H.L…. Cuijpers, P. (2022). Which patients benefit from adding short-term psychodynamic psychotherapy to antidepressants in the treatment of depression? A systematic review and meta-analysis of individual participant data. Psychological Medicine.
Short-term psychodynamic psychotherapy (STPP) and anti-depressant medications are both considered empirically supported treatments for depression. And there have been several trials demonstrating the efficacy of long-term psychoanalytic psychotherapy for treatment-resistant depression. Despite this research, it remains unclear which patient might benefit from anti-depressant medication alone and which patient might benefit from adding STPP to the antidepressants. The best use of scarce resources makes this an important question. There are challenges to doing a meta-analysis of patient characteristics that predict different outcomes in antidepressants alone versus antidepressants plus STPP. A key challenge is that common meta-analyses use study-level data (an overall summary of the effect size found in a study), and so statistical power often is limited by the small number of studies. The unique aspect of this study by Driessen and colleagues is that they conducted a meta-analysis of patient-level data. That is, they got individual patient data from the authors of the seven studies that specifically tested the effects of antidepressants alone vs antidepressants plus STPP. So instead of being limited by seven summary effect size statistics, the authors had a sample of 482 patient effect sizes to work with. The effect of adding STPP to antidepressants was larger for participants with high rather than low baseline depression scores [B = −0.49, 95% CI: −0.61 to −0.37, p < 0.0001], for participants with ⩽8 rather than more years of education (B = −0.66, 95% CI −1.05 to −0.27, p < 0.0009), and for participants with a depressive episode duration of >2 years rather than <1 year (B = −0.68, 95% CI −1.31 to −0.05, p = 0.03) or less than 1–2 years (B = −0.86, 95% CI −1.66 to −0.06, p = 0.04). At follow-up, higher baseline depression scores and longer depressive episode duration were still associated with better outcomes for those receiving a combination of antidepressants plus STPP.
The results of this patient-level meta-analysis suggests that adding short-term psychodynamic psychotherapy to antidepressant medication might be particularly efficacious for patients with higher initial levels of depression and/or with longer duration of depressive symptoms. It is possible that the addition of a psychological treatment like STPP may tackle some of the underlying psychological vulnerabilities whose treatment is necessary for those who have more persistent and severe depressive symptoms.
Placebo Response in Transcranial Magnetic Stimulation for Depression
Razza, L. B., Moffa, A. H., Moreno, M. L., Carvalho, A. F., Padberg, F., Fregni, F., & Brunoni, A. R. (2018). A systematic review and meta-analysis on placebo response to repetitive transcranial magnetic stimulation for depression trials. Progress in Neuro-Psychopharmacology & Biological Psychiatry, 81, 105-113.
Transcranial magnetic stimulation (TMS) is a new treatment for depression thought to modulate brain activity through electromagnetic pulses delivered by a coil placed over the patient’s scalp. A meta analysis shows that TMS may be effective in treating depressive disorders when compared to a placebo control, although only 18.6% of those receiving TMS were no longer depressed at the end of treatment. The placebo control condition usually involves a sham version of TMS in which the coil is placed over the scalp but no magnetic stimulation is applied. In antidepressant trials, the placebo response is quite high such that approximately 40% of patients respond to the placebo condition (in antidepressant trials, the placebo condition includes an identical pill that is inert). In this meta analysis, Razza and colleagues assess the placebo response in TMS. They included only double blind randomized controlled trials (i.e., trials in which both the patient and physician were not aware if the treatment was real or a sham). The authors estimated the placebo response based on pre- to post-sham TMS scores of common measures of depression. The meta analysis included 61 studies of over 1300 patients. The main result showed that sham response was large (g = 0.80; 95%CI = 0.65–0.95). Trials including patients with only one episode of depression or who were not treatment resistant (g =0.67, 95%CI = 0.06–1.28, p= 0.03) had higher placebo responses than those trials in which patients previously had two or more failed antidepressant treatments (g = 0.5, 95%CI = 0.03–0.99, p = 0.048).
The results of this meta analysis demonstrates a high placebo response in trials testing TMS. This is similar to the high level of placebo response commonly seen in patients in antidepressant medication trials. It appears that psychological factors like attention, instillation of hope, patient expectations of receiving benefit, and perhaps working alliance may account for an important portion of why pharmacological and other medical interventions appear to work for those with depressive disorders. This is particularly true for patients who are receiving treatment for the first time or for whom previous medical treatment was successful.
Therapeutic Relationship Predicts Pharmacological Treatment Outcomes
Totura, C.M.W., Fields, S.A., & Kraver, M.S. (2018). The role of the therapeutic relationship in psychopharmacological treatment outcomes: A meta-analytic review. Psychiatric Services, 69, 41-47.
There is evidence to suggest that pharmacological treatments are effective for a wide range of disorders. However, a high level of adherence to taking psychotropic medications is necessary in order for them to have a chance of working. Medical interventions in general do not work well when patients are non-adherent to the regimen, and non-adherence is a significant problem in medicine. Treatment adherence is particularly problematic in those with a mental health condition. Low adherence may have to do with problems with the medications themselves, like unpleasant side effects. And low adherence also may be due to issues related to mental health impairment, like low motivation and problems with reasoning. A particular issue in mental health treatment is the manner in which patients receive the medication. Unlike some medical interventions, psychotropic medications are often taken by patients on their own and away from the clinic or hospital. In psychotherapy, we know that a good therapeutic alliance improves outcomes partly because a good alliance provides a context within which psychological interventions can work (i.e., clients may be more adherent to the treatment recommendations) and partly because the alliance itself may be therapeutic. In this meta analysis, Totura and colleagues examine if there is an association between the therapeutic alliance and mental health outcomes for patients who receive pharmacological interventions for their mental illness symptoms. Eight studies of 59 samples representing over 1,000 patients were included. Four studies were of pharmacological treatment for affective disorders, two for schizophrenia, and two for mixed diagnoses. The results indicated a statistically significant and moderate effect: z = .30 (CI=.20, .39, SE=.048, z=6.192, p=.05), such that greater therapeutic alliance predicted better mental health outcomes among patients receiving pharmacotherapy.
Higher quality of the physician-patient relationship was related to better mental health treatment outcomes for patients taking pharmacotherapy. The therapeutic alliance appears to be just as import in pharmacological treatment as it is in psychotherapy. It is possible that a good alliance with the provider may increase patient adherence, which may lead to better outcomes. It is also possible, however, that the alliance itself is therapeutic. That is, negotiating an alliance and repairing alliance tensions may lead to positive changes in patients’ ability to cope with emotions and to make the most of their social supports. The results also suggest the importance of training physicians in communication skills to improve therapeutic relationships.
The Importance of Psychosocial Factors in Mental Health Treatment
Greenberg, R.P. (2016). The rebirth of psychosocial importance in a drug-filled world. American Psychologist, 71, 781-791.
In this thoughtful piece, Greenberg reviews the research on psychosocial factors that affect mental health treatment outcomes – including for medications and in psychotherapy. There has been an important shift in the last few decades to view mental disorders, including depression, as biologically based. For example, surveys indicate that the public’s belief in biological causes of mental illness rose from 77% to 88% during a 10 year period. During the same period the belief in the primacy of biological treatment for mental disorders rose from 48% to 60%. Further, 20% of women and 15% of men in the US are currently taking antidepressant medications. Some of these trends are due to direct to consumer marketing of medications by the pharmaceutical industry, which saw a 300% increase in sales in antidepressants. Some of these trends are also due to Federal agencies like the National Institute of Mental Health that vigorously pursued an agenda of biological research. But what is the evidence for a purely biological view of mental health? Greenberg notes that the evidence is poor. For example, no one has been able to demonstrate that a chemical imbalance actually exists to explain depressive symptoms – which undermines the reason for using medications to treat depression. Further, research on the efficacy of antidepressant medications shows that they perform only slightly better than a placebo pill, prompting a former editor of The New England Journal of Medicine to declare that this difference is unlikely to be clinically meaningful. The placebo effect is essentially a psychosocial effect. It refers to: the patient’s experience of a caring relationship with a credible professional, and the patient’s expectations and hopes of getting better. Placebo is a very real phenomenon that also has an impact on purely medical interventions like surgeries. In psychotherapy trials, relational/contextual factors like therapeutic alliance, expectations, therapist empathy, and countertransference likely account for more of the client’s outcomes than the particular therapeutic technique that is used. In both psychotherapy and medication treatments for depression, it appears that the more patients perceived their doctors as caring, empathic, open, and sincere, the greater their symptom improvement. There is also good evidence that psychotherapy is as effective and antidepressants for mild to moderate depression, and that antidepressants are slightly superior for chronic depression. However, even the latter should be interpreted carefully and within the context that patients prefer psychotherapy, their adherence to medications is poorer, side effects are worse for medications, and drop out rates are lower for psychotherapy.
Patients benefit from antidepressant medications, but perhaps not exactly for the reasons that they are told. Psychosocial factors likely account for a large proportion of the effects of many medically-based interventions for mental disorders. Psychosocial factors are actively used in many psychotherapies, and therapists’ qualities like their ability to establish an alliance, empathy, and professionalism account for a moderate to large proportion of why patients get better.
Has Increased Availability of Treatment Reduced the Prevalence of Mental Disorders?
Jorm, A.F., Patten, S.B., Brugha, T.S., & Mojtabai, R. (2017). Has increased provision of treatment reduced the prevalence of common mental disorders? Review of the evidence from four countries. World Psychiatry, 16, 90-99.
Mental disorders are a major source of disability. However, many individuals remain untreated, such that 36% to 50% of serious cases in industrialized countries went untreated in the previous year. In 2001 the World Health Organization argued for making treatment more accessible and to train more mental health professionals. In this wide-ranging review, Jorm and colleagues look at data from the U.K, the U.S., Canada, and Australia to assess if in fact treatment provision has increased over time, and whether this increase was associated with declines in the prevalence of common mental disorders. In all of the countries surveyed, antidepressant use among those with mental disorders (mainly anxiety and depressive disorders) increased dramatically from 1990 to 2011, such that their use rose by 300% or more during that period. The use of psychotherapy increased in Australia by about 46% among those with a diagnosable disorder. While the rates of psychotherapy-use remained the same in the U.K., they declined dramatically in the U.S. from 71.1% in the late 1980s to 43.1% in 2007 (no data was available from Canada). At the same time however, the prevalence of mental disorders has been increasing or remaining the same in all of the four countries. For example, in England the prevalence of common mental disorders among women went from 18.1% in 1993 to 18.9% in 2007. The authors then speculated as to why the dramatic increase in the use of antidepressants was not followed by a decrease in diagnosed mental disorders. They were able to rule out a number of possibilities like increased reporting of mental illnesses, or an increase in risk factors in the communities involved. The authors did suggest however that antidepressant medications may not be prescribed as intended by primary health care providers. For example, in Australia, only 50% of people prescribed antidepressants receive them as recommended in clinical guidelines. In an Alberta, Canada study, 67.2% of those who reported taking an antidepressant had no active mood or anxiety disorder at the time of the survey. Among those with major depression, only 14.3% reported receiving psychotherapy.
This large review highlights some findings that are already well known: that antidepressant use is dramatically on the rise, and that psychotherapy use is declining slightly over time. This may be due to the quick and easy availability of antidepressant medications, the direct to consumer advertising done by the pharmaceutical industry in some countries, and to a possible cultural need for easy fixes to complex problems. What is new in this review, is that the rise in available antidepressant medications appears not to have made a dent in the rate of mental illness in four industrialized countries.
Placebo Response Rates in Antidepressant Trials
Furukawa, T.A., Cipriani, A., Atkinson, L.A., Leucht, S., Ogawa, Y., … Salanti, G. (2016). Placebo response rates in antidepressant trials: A systematic review of published and unpublished double-blind randomised controlled studies. Lancet Psychiatry, 3, 1059-1066.
The placebo response in medication trials is an interesting and important phenomenon. Placebo response refers to improvement in clients that is due to therapeutically powerful factors like client’s expectations that an intervention will be effective and to the therapeutic relationship with the health care provider. In medication trials, placebo is seen as problematic because researchers typically want to demonstrate the effectiveness of the active medication (e.g., selective serotonin re-uptake inhibitors) independent of any other factors. For this reason, randomized clinical trials of medications are often double-blind and placebo controlled (i.e., clients and clinicians are unaware of who received the active medication and who received the inert placebo pill). It has widely been suspected that over the years the placebo response has been increasing in antidepressant trials possibly due to the types of patients included in trials (i.e., more recently, patients with more severe symptoms are included) and to other methodological issues (e.g., use of multi-centre trials, dosing schedule). An increasing placebo response is suspected of contributing to the growing number of failed anti-depressant trials (i.e., trials that show little or no effectiveness of the medication). Using advanced statistical methods, Furukawa and colleagues evaluated in a meta analysis if placebo response in medication trials was increasing over time. They defined a response as a 50% or greater reduction in observer-rated depression scale scores from baseline to 8 weeks. Their review included 252 placebo controlled trials of antidepressants from 1978 to 2015. Placebo response rates ranged widely from 0% to 70% (I2 = 74.1%) with a mean placebo response of 35% to 40%. Year of publication was not significantly related to placebo response rate after controlling for methodological variables like length of the trial, multi-centre trials, and dose regimen. That is, once change in the methodology of conducting trials over time was accounted for, the placebo response appeared to remain largely the same from year to year.
The placebo response is very real and complicates our understanding of how and why antidepressants might work for some patients. About 35% to 40% of patients who benefit from antidepressants may be benefitting largely because of the expectation of getting better. Greater treatment response to antidepressants for a large proportion of patients appears to be dependent on the therapeutic features of supportive contact with a caring health professional.