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Torous, J., Lipschitz, J., Ng, M., & Firth, J. (2020). Dropout rates in clinical trials of smartphone apps for depressive symptoms: A systematic review and meta-analysis. Journal of Affective Disorders, 263, 413-419.

Depression is a leading cause of disability worldwide, and yet more than 50% of people do not have access to adequate therapy. One solution might be to provide individuals with smartphone apps to help screen, monitor, or provide treatment. Smart phones are ubiquitous, and depression apps are one of the most downloaded categories of apps by the public. Research seems to suggest that smartphone apps provide some positive results for members of the public, but these findings are compromised by the high drop-out rates reported in the primary studies. Further, one study found that although many people download the apps, only about 4% actually use them. Whereas smartphone apps appear attractive to the consumer, very few actually make use of and therefore benefit from them. In this systematic review, Torous and colleagues conduct a meta-analysis of drop-out rates from studies that test the use of smart phone apps. They found 18 independent studies representing data from 3,336 participants who received a psychological intervention for depression via a cell phone app, or who were in a placebo control condition. A total of 22 different apps were tested in the studies. Initially, the pooled drop-out rate from the depression app treatment arms appeared to be about 26.2% (95% C.I.=11.34% to 46.75%), which would be in line with average drop-out rates from randomized controlled trials of face to face psychotherapy. But, the authors noted two things. First, the drop-out rate from the placebo control conditions (14.2%; 95% C.I. = 8.236 to 23.406) was almost half as high as that found for the apps. Second, through some sophisticated statistical analyses, they found evidence of “publication bias” in this research area. This means that a number of studies testing these apps likely were completed but never published (i.e., these might be studies funded by an app manufacturer that demonstrated negative findings or high drop-out rates). When the authors statistically adjusted for publication bias, they found that the actual drop-out rate from the apps was about 47.8%. That is, almost half of users did not complete or dropped out of the studies. There were no differences in drop-out between types of interventions (CBT, mindfulness, or others), and studies with larger sample sizes (i.e., better quality studies) had higher drop-out rates.

Practice Implications

Although smartphone apps appear really attractive and may be potentially useful as an adjunct to face to face psychotherapy for depression, their utility is plagued by extremely low usage rates (4%) and high drop-out rates from studies (almost 50%). Leading writers and researchers define psychotherapy as primarily a healing relationship that also includes specific interventions. The key ingredient is the human relationship. Depressed or otherwise troubled individuals cannot (because of feeling demoralized) or will not interact with a machine for healing. One way or another, when it comes to smartphone apps, depressed individuals are voting with their feet. Given these findings, health care providers should consider the ethics of giving a depressed individual only e-therapy as the primary mode of treatment.

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.

Negative Effects of Psychotherapy

Cuijpers, P., Reijnders, M., Karyotaki, E., de Wit, L., & Ebert, D.D. (2018). Negative effects of psychotherapy for adult depression: A meta-analysis of deterioration rates. Journal of Affective Disorders, 239, 138-145.

Several types of psychotherapy are effective to treat depression, and there appears to be very little difference among the treatments in term of their effectiveness. Despite the documented effectiveness of psychotherapies to treat depression, there is also a growing interest in the clinical and research community about negative effects. Negative effects refer to the deterioration or worsening of depressive symptoms during treatment. Some may also refer to drop-out or non-response as a negative effect because these events are demoralizing and may prevent a patient from seeking more adequate care. Some researchers estimated that 5% to 10% of patients deteriorate during therapy. Deteriorations may not be due solely to the therapy itself, but instead may reflect the natural course of depression. In this meta-analysis, Cuijpers and colleagues examined studies in which a psychotherapy for depression was compared to a control condition in which patients did not receive an active treatment. In such studies, one might expect the control condition to represent what would happen in terms of symptoms if the patient received no treatment. Despite over 100 randomized controlled trials of a psychotherapy versus a non-active treatment control condition for depression, only 18 studies reported enough information to estimate negative effects. There was a median deterioration rate in the psychotherapy groups of about 4%, whereas the risk of deterioration in the control groups was about 11%. There were no differences in deterioration rates among types of psychotherapy (CBT vs others), treatment format (group vs individual), or type of control group (wait-list vs care as usual).

Practice Implications

Only 6.2% of research studies reported enough information to estimate negative effects, making it difficult to get a good estimate that represents all studies and patients. Nevertheless, receiving psychotherapy reduced deterioration rates by more than 61% compared to untreated control conditions, suggesting that psychotherapy can help some patients who might get worse with no treatment. Therapists should work to recognize and evaluate deterioration rates in therapy because they do occur for an important minority of patients. Some have suggested ongoing progress monitoring as a means of reducing the number of patients who might get worse during 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.

Owen, J., Tao, K. W., Imel, Z. E., Wampold, B. E., & Rodolfa, E. (2014). Addressing racial and ethnic microaggressions in therapy. Professional Psychology: Research and Practice, 45(4), 283–290.

Overt forms of racism and prejudice still occur in society, and less overt forms are likely more prevalent. Microaggression are those less overt forms of racism and prejudice that may include direct and indirect insults, slights, and discriminatory messages. Specific types of microaggression are: microinvalidations (e.g., denying that racism exists), microassaults (e.g., direct racism but done in private), and microinsults (e.g., believing a group’s cultural norms are pathological). Microaggression are by definition ambiguous and subtle, and they may target culture, race, gender, sexual orientation, and other group identities. Microaggressions are associated with psychological distress in the recipient. Microaggressions can also occur in therapy if a patient perceives a therapist’s dismissing or negating messages about the patient’s culture, or if a therapist engages in culturally inappropriate interventions. Microaggressions represent a special type of therapeutic alliance rupture that could lead to negative patient outcomes. It is also possible that therapists and clients who address microaggressions after they occur are capable of repairing the alliance rupture and moving forward with a stronger relationship. However, there is very little research of the impact of client perceived microaggressions on the therapeutic alliance. In this unique study, Owen and colleagues asked 120 racial and ethnic minority university counselling centre patients treated by 33 different therapists (23 of whom were White) to rate their experience microaggressions, to indicate if the microaggression was discussed, and to rate the therapeutic alliance. In total, 53.3% of patients experienced a microaggression in therapy, and of those patients, 68.4% were treated by a racial or ethnic minority therapist. Clients who reported fewer microaggressions also reported stronger therapeutic alliances (r = .28, p = .01). Of the patients who reported a microaggression, only 24% (13 patients) reported that the microaggression was discussed by the therapist. Of these 13 patients, almost all (12 patients) reported that the discussion was successful. Therapist and patient dyads who successfully discussed the microaggression: (1) had alliance scores comparable to patients who did not experience a microaggression, and (2) had alliance scores that were significantly higher than dyads who experienced but did not discuss the microaggression.

Practice Implications

Microaggressions appear to be ubiquitous in daily life and in psychotherapy – no therapist is immune. More than 53% of patients in this study reported a microaggression, despite what was likely their therapists’ good intentions. Microaggression are a special case of therapeutic alliance ruptures, which are known to be associated with poor patient outcomes. Therapists must develop a strong multicultural orientation and take a culturally humble stance with clients from a different culture or group. This involves therapists being attuned to the possibility of committing a microaggression, inviting patients to alert the therapist should a microaggression occur, and being open to clarifying misunderstandings and owning missteps.

Mental Health Disorders Increase Health Care Utilization in Adults with Chronic Disease

Sporinova B, Manns B, Tonelli M, et al. (2019). Association of mental health disorders with health care utilization and costs among adults with chronic cisease. JAMA Network Open. Published online: 2(8):e199910. doi:10.1001/jamanetworkopen.2019.9910

Chronic diseases like diabetes, heart disease, chronic obstructive pulmonary disease (COPD), chronic kidney disease are common and represent a major burden on the individual and on society. So much so that chronic diseases represent about 60% of global disease burden. There is also a documented association between mental and physical health, such that mortality in cancer, diabetes, and following a heart attack is significantly higher in those with depression. The cost of chronic disease to the Canadian economy represents about 60% of the annual health care budget, and depression alone has a $32.3 billion impact on the Canadian economy. In this economic study, Sporinova and colleagues sought to quantify the impact of having a mental disorder on health care utilization and cost for those with chronic diseases. The study used a large data base of adults from Alberta, Canada who had at least one chronic disease including asthma, COPD, heart failure, myocardial infarction, diabetes, epilepsy, and chronic kidney disease. Mental disorders were defined as a concurrent diagnosis of depression, schizophrenia, or substance use disorder. Factors like sex, income, and rural residency were controlled in the analyses. Of the cohort with a chronic illness, 15.8% had a mental disorder, with depression as the most common mental disorder at 11.2%. People with chronic illness and a mental disorder tended to be younger, women, with a lower socio-economic status, and they tended to die at a higher rate during the study period. The mean total 3-year health costs of those with a chronic illness was $20,210 (95% CI: $19,674, $20,750) Canadian dollars, whereas for those with a concurrent mental disorder the cost was significantly higher at $38,250 (95% CI: $36,476, $39,935). Higher costs were driven by greater hospitalizations, prescription drug use, and physician visits. Costs were higher for older people, and for those with more than one mental disorder.

Practice Implications

The results clearly indicated that an important proportion of those with chronic illnesses were also diagnosed with a mental disorder. Further, a diagnosis of a mental disorder drove up the burden of the chronic illness significantly, both for the individual and for the health care system. Past research indicated improved medical outcomes when treating depression in medical patients. And so, although the physical symptoms of chronic illness may appear prominent, clinicians must treat mental health problems when they exist concurrently, if they want to improve patient medical and mental health outcomes.