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Once-Weekly or Twice-Weekly Sessions of Psychotherapy?

Bruijniks, S., Lemmens, L., Hollon, S.D., Peeters, F.P., ….Huibers, M.J. (2020). The effects of once- versus twice-weekly sessions on psychotherapy outcomes in depressed patients. The British Journal of Psychiatry, doi: 10.1192/bjp.2019.265. [Epub ahead of print].

Some research has suggested that the number of sessions per week, not the total number of sessions received, is correlated with patient outcomes. It is possible that higher session frequency per week might lead clients to better recall the content of sessions, which in turn may lead to better treatment outcomes. Or perhaps, higher frequency of sessions might lead to a better therapeutic alliance and higher client motivation thus leading to better outcomes. Although previous research has suggested that more sessions per week is better, no study has ever directly assessed this issue until now. Bruijniks and colleagues conducted a large randomized controlled trial of 200 adults with depression seen across nine specialized clinics in the Netherlands. Researchers randomly assigned clients to receive either cognitive-behavioral therapy (CBT) or interpersonal psychotherapy (IPT) for a maximum of 20 sessions. Half of the clients in either type of therapy received the 20 sessions on a twice a week basis, and half of clients in each type of therapy received the 20 sessions on a once a week basis. The therapies were manualized, therapists were trained and supervised, and clients were carefully selected to meet criteria for depression. More patients dropped out of weekly (31%) compared to twice weekly (17%) therapy. There were no differences between CBT and IPT in depression outcomes. However, there was a significant effect of session frequency on patient outcomes in favor of twice weekly sessions (d = 0.55). Using a strict criteria of “recovery” from depression at 6 months post treatment, 19.6% of patients receiving once weekly therapy “recovered” compared to 29.5% of patients receiving twice weekly therapy.

Practice Implications

This large multi-site study has intriguing implications for practice. More frequent sessions per week may result in significantly better patient outcomes regardless of the type of therapy offered. Not surprisingly, IPT and CBT were equally effective. However, their effectiveness was limited in that only between 20% to 30% of patients recovered from depression. This finding is similar to the results previous trials, and speaks to the limitations of time-limited manual-based therapies for depression. Nevertheless, it appears that more frequent therapy per week may be a better option for some clients.

De Smet, M. M., Meganck, R., De Geest, R., Norman, U. A., Truijens, F., & Desmet, M. (2020). What “good outcome” means to patients: Understanding recovery and improvement in psychotherapy for major depression from a mixed-methods perspective. Journal of Counseling Psychology, 67(1), 25–39.

Many researchers consider the randomized controlled trial (RCT) as the best research design for testing medical and psychological treatments. However, critics of the design point to its limitations. For example, in order to collect homogenous samples of patients, researchers may exclude those with complex comorbidities. As a result, patient samples in RCTs may not represent patients one might see in real clinical practice. Also, researchers, and not patients, tend to define the meaning of what is a “good outcome” in these studies. It is possible that researchers and patients may not share the same definition of what it means to have a good outcome from psychotherapy. One key statistical and measurement method that researchers use to define outcomes is the reliable change index, which calculates the degree of change on a symptom scale from pre-treatment to post-treatment relative to the unreliability of the measurement. Using this method, researchers classify patients as “recovered” (reliably changed and passing a clinical cut-off score), “improved” (reliably changed but remaining in the clinical range), “not improved”, or “deteriorated”. However, this commonly used approach does not indicate whether the changes are actually meaningful to the patients. In this study, De Smet and colleagues interviewed patients from a randomized controlled trial of time-limited psychotherapy (16 sessions of CBT vs psychodynamic therapy) for depression who were classified as “recovered” or “improved” at post-treatment based on the reliable change index of a commonly used depression self-report scale. The authors asked how the patients experienced their depression symptom outcome, and what changes the patients valued since the start of therapy. In the original treatment trial of 100 patients, 28 were categorized as “recovered” and 19 patients were categorized as “improved”. During the post-therapy interview, the “recovered” and “improved” patients typically reported a certain degree of improvement in their symptoms. However, the patients categorized as “improved” reported that their gains were unstable from day to day, some reported having relapsed, and half did not feel that they improved at all. None of the “recovered” patients indicated that they felt “cured” of depression. Patients identified three domains of change that they experienced and valued. First, they felt empowered – that is, they had increased self-confidence, greater independence, and new coping skills. Second, they found a personal balance – that is, they had better relationships with loved ones, felt calmer, and had greater insight into their problems. Third, patients tended to identify ongoing struggles despite positive changes in the other domains – that is, certain key problems remained unresolved. “Improved” patients, and even some in the “recovered” group, indicated that their core difficulties had not been altered by the therapy.

Practice Implications

Although measurement of symptom change can give a clinician a general sense of how the patient is doing with regard to their symptoms and whether the patient is on track, such measurement may not capture the complexity of patients’ experiences of the therapy and any broader changes they may value. Patients in this trial, especially those classified as “improved”, had varied experiences. Aside from symptom reduction, clinicians should assess what their patients may value, such as: better relationships, greater self-understanding, more self-confidence, and feeling calmer. Most patients, including some who “recovered”, felt that they were engaged in an ongoing struggle, even after therapy. These findings suggest that addressing some of the core difficulties patients face may require longer term psychotherapy.

Adverse Events During Psychotherapy

Meister, R., Lanio, J., Fangmeier, T., Harter, M., Schramm, E., … Kriston, L. (2020). Adverse events during a disorder‐specific psychotherapy compared to a nonspecific psychotherapy in patients with chronic depression. Journal of Clinical Psychology, 76, 7-19.

Adverse events refer to negative or unwanted outcomes of psychotherapy that may be due to the therapy itself when delivered correctly, or to the application of the therapy when delivered incorrectly. For example, patients may report worsening of symptoms, relationship problems with partners or family, problems at work, stigma, and other disadvantages. Adverse events during pharmacologic treatment are well studied and are often considered when making treatment decisions. However, adverse events in psychotherapy are largely ignored in the research and clinical literature. A recent meta analysis reported that the median deterioration rates in psychotherapy studies is about 4%, which is likely less than half the rate of deterioration seen in regular clinical practice. In this study, Meister and colleagues look at deterioration rates in a randomized controlled trial comparing the Cognitive Behavioral Assessment System of Psychotherapy (CBASP) versus non-supportive psychotherapy (NSP). In that study that was previously summarized in this blog, 262 depressed patients were randomly assigned to receive 24 weeks of either CBASP or NSP. Participants who received CBASP were slightly better off than those who got NSP, and the drop-out rates were equivalent between conditions. Therapists asked patients at each session if the patient experienced an adverse event in the previous week. Patients reported an average of about 12 adverse events during the 24 weeks of psychotherapy, and there was no difference in the number of adverse events between CBASP and NSP. However, patients receiving CBASP reported more severe adverse events related to their personal life and work life compared to patients receiving NSP. Suicidal thoughts were infrequently reported by patients, and their frequency did not differ between CBASP and NSP.

Practice Implications

The study highlights that symptoms and interpersonal conflicts may temporarily increase as a result of being in psychotherapy. The authors argued that the increases in problems with work and personal relationships may be due to the specific interpersonal treatment elements of CBASP that require changes in the patient’s interpersonal behaviors that temporarily may be disruptive to their lives. Therapists may consider informing patients about the possible temporary negative effects of psychotherapy on their relationships or functioning. This preparation might help patients to make informed decisions about psychotherapy and to prepare them to cope with changes in their relationships.

Gilbody, S., Littlewood, E., Hewitt, C., Brierley, Tharmanathan, P....White, D. (2015). Computerised cognitive behaviour therapy (cCBT) as treatment for depression in primary care (REEACT trial): Large scale pragmatic randomised controlled trial. BMJ, 351, h5627. Doi: 10.1136/bmj.h5627.

Depression is one of the most common reasons why people see family physicians for consultation. The personal and economic burden of depression is high, such that depression is the leading cause of disability worldwide. Effective treatments for depression include antidepressant medications and psychotherapy. Cognitive behavioral therapy (CBT) is an effective treatment for depression, but is not always accessible for those who live in remote areas, and for those who cannot easily find or afford a trained psychotherapist. One solution, touted by some is to provide computerized CBT (cCBT) via internet or CD. In fact, the National Institute for Health and Care Excellence (NICE) in the UK recommend cCBT programs as a first step of care for depression. Commercially available cCBT programs include “Beating the Blues”, and freely available programs include “MoodGYM”. Previous research shows a large effect of cCBT for reducing depressive symptoms, but non-adherence (i.e., not completing the modules) and patient dropout rates tend to be high. Another issue is that most of the studies of cCBT were conducted by the developers of the programs, and so there may be researcher allegiance effects that could bias the findings. In this large trial, Gilbody and colleagues asked: “How effective is supported computerized cognitive behavior therapy (cCBT) when it is offered in addition to usual primary care in adults with depression?” The authors recruited 691 depressed patients seen in primary care with a general practitioner (GP) in the UK. All participants had access to a computer and high speed internet. The participants were randomly assigned to receive: (1) usual GP care plus 8 50-minute sessions of Beating the Blues, or (2) usual GP care plus 6 weekly modules of MoodGYM, or (3) only usual GP care. Usual GP care included providing antidepressants, counselling, or brief psychotherapy which are all offered as part of the UK National Health Service. Computerized CBT was supported by weekly telephone calls followed by reminder emails to encourage participants to access, use, and complete the programs. At 4 months after the start of treatment, about half of all participants were no longer depressed, and there were no differences between the three study conditions on any of the outcomes (e.g., depression, quality of life). The results were consistent up to 2 years post treatment. However, only about 17% of those receiving one of the cCBT treatments completed all of the sessions. The average number of sessions completed of cCBT was very low (Beating the Blues = 2 out of 8 sessions; MoodGYM = 1 out of 6 sessions). The authors concluded that there was no significant benefit of adding supported cCBT to usual GP care.

Practice Implications

Adding cCBT to usual GP care did not provide added benefit to depressed patients. Low adherence and low engagement with cCBT likely reduced the utility of computerized delivery of therapy. It is possible that more intensively supported cCBT (i.e., with weekly face to face contacts) might have improved the added value of cCBT, but would also have reduced the practically utility and accessibility of cCBT. Those who are depressed might have difficulty with summoning the energy and concentration necessary to repeatedly log on to computers and engage in computerized or internet based treatment.

Fonagy, P., Rost, F., Carlyle, J., McPherson, S.,… Taylor, D. (2015). Pragmatic randomized controlled trial of long-term psychoanalytic psychotherapy for treatment-resistant depression: The Tavistock adult depression study (TADS). World Psychiatry, 14, 312-321.

Usually I do not write about individual studies, mainly because meta-analyses and systematic reviews are much more reliable. But occasionally a unique study is published that is important enough to report. This is a rare trial that focuses on “treatment-resistant” depression defined as long-standing depression that has not responded to at least two previous evidence-based interventions. Depression is known to have a relapsing chronic course for about 12% to 20% of patients. And not responding to treatment is highly predictive of non-response to future treatment for depression. Fonagy and colleagues argued that in order to be effective, treatments for chronic and resistant depression need to be longer and more complex than current time-limited evidence-based approaches. Further, they argued that follow ups should be of longer duration. The authors tested a manualized long term psychoanalytic psychotherapy (LTPP). The treatment involved 60 sessions over 18 months provided by 22 trained therapists. In this trial, the “control” condition was treatment as usual (TAU) as defined by the National Institute for Clinical Excellence in the United Kingdom. TAU was made up of short term evidence-based interventions like antidepressant medications or CBT provided by licensed trained professionals. LTPP plus TAU was compared to TAU alone for 129 patients randomly assigned to one of the conditions. At pre-treatment, the majority of patients scored in the severe range on the Beck Depression Inventory (BDI) or the Hamilton Depression Rating Scale (HDRS). The average patient had 4 previous unsuccessful treatments for depression. No differences were found between LTPP and TAU at post treatment, but differences began to emerge after 24 months. Complete remission was infrequent in both conditions after 42 months (14.9% LTPP vs 4.4% TAU). However, partial remission at 42 months was significantly more likely in LTPP (30.0%) than TAU (4.4%). Patients were significantly more likely not to meet DSM-IV criteria for depression at 42 months in LTPP (44%) than in TAU (10%). The differences between conditions in mean BDI and HDRS scores were significant and medium sized indicating greater improvement with LTPP.

Practice Implications

This is the first study of its kind to test a manualized LTPP for treatment resistant depression. Patients in LTPP were more likely to maintain gains whereas those receiving evidence-based TAU were more likely to relapse. Although this is only one study and should be interpreted cautiously, it does suggest that chronic treatment-resistant depression is more likely to respond to longer and more complex treatment, and that outcomes of such treatment tend to be maintained in the longer term.