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
Is Psychotherapy Effective? Revisited.
Munder, T., Fluckiger, C., Leichsenring, F, Abbass, A.A., Hilsenroth, M.J., … Wampold, B.E. (2018). Is psychotherapy effective? A re-analysis of treatments for depression. Epidemiology and Psychiatric Sciences, 1-7.
Based on a deeply flawed review in 1952, Hans Eysenck declared that psychotherapy was no more effective than custodial care for treating mental disorders. Later, he qualified this by stating that behaviour therapy was effective and other forms of psychotherapy were not. These statements touched off decades of angst and debate in the psychotherapy community, and also resulted in a great deal of research about psychotherapy’s effectiveness. By the 1970s the new research technique of meta-analysis was developed and was applied to psychotherapy research. In their seminal meta analysis of controlled studies, Smith and Glass found that psychotherapy was useful and with large effects compared to no treatment. And yet the debate continues. In 2018, Cuijpers argued that waitlist control groups (i.e., a common control condition in psychotherapy studies in which patients receive no treatment) are an inappropriate comparison leading to exaggerated estimates of the effects of psychotherapy. Recently, Munder and colleagues argued that waitlist controls are a way of estimating the natural course of the disorder (what would happen with no treatment) plus the effect of expecting to receive treatment (client expectations of receiving treatment tend to have a positive impact on symptoms). In fact, research shows that pre- to post-study effect sizes for the waiting period is approximately g = .40, or a medium effect. In other words, waiting for therapy in a study results in a moderate proportion of individuals getting better on their own without treatment. Therefore, Munder and colleagues argued that comparing psychotherapy to a waitlist control is appropriate and may be a conservative estimate of psychotherapy’s effects (i.e., psychotherapy has to outperform the effects of clients expecting treatment to help them). In their meta analysis, Munder and colleagues re-analysed 71 studies of psychotherapy for depression compared to a waitlist control condition. They found that the effect size in favour of psychotherapy was g = 0.75 (SE = 0.09) indicating a moderate to large effect. Psychotherapy was also more effective than care as usual (i.e., compared to another intervention that was not psychotherapy), g = 0.31 (SE = 0.11). There were no differences between types of psychotherapy (CBT, IPT, PDT, etc.) for depression outcomes.
Despite various attempts during the history of psychotherapy to downplay or disparage its efficacy, research continues to show that psychotherapy is in fact effective. The average effect size compared to the natural history of depression is moderate to large (and that is likely an under-estimate). Again, there is no evidence that one type of psychotherapy is superior to another for treating depression. It is time for the field to move beyond questions of efficacy of psychotherapy and of the relative efficacy of different treatments, and look to understanding therapist interpersonal stances, client characteristics, and relationship factors that may improve outcomes from psychotherapy.
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.
Does Continuation of Anti-Depressant Medication Reduce Relapse?
Gueorguieva, R., Chekroud, A.M., & Krystal, J.H. (2017). Trajectories of relapse in randomised, placebo-controlled trials of treatment discontinuation in major depressive disorder: An individual patient-level data meta-analysis. Lancet Psychiatry.
Individuals with a history of depression who get better have a 30% to 50% chance of relapse in the first year. That is, major depression tends to take a recurrent course, so that about a third to half of patients who initially improve will then experience a re-emergence of symptoms. In this meta-analysis, Gueorguieva and colleagues looked at whether they could identify classes of patients who respond differently to antidepressant medications depending on whether they discontinued or continued with the medications after symptoms improved. The meta-analysis included over 1,400 patients from four studies of duloxetine or fluoxetine (i.e., Cymbalta or Prozac) who participated in a discontinuation trial. A discontinuation trial design involves randomly assigning patients who respond positively to the medication either (1) to stay on the effective medication or (2) to discontinue the treatment and receive a placebo. Such a design gives us an estimate of the advantage of maintenance versus discontinuation of medications to reduce relapse of depression in the longer term. Gueorguieva and colleagues found that 33% of those in the medication continuation condition relapsed (i.e., 33% those who responded well to the initial trial of medications and who then continued with medications had a recurrence of depressive symptoms). By contrast, 46% of those in the placebo/medication discontinuation condition relapsed (i.e., 46% of those who responded well to the initial trial of medications and who then received a placebo had a recurrence of depressive symptoms). In other words, continuation of antidepressant medications resulted in a small 13% reduction in relapse rates compared to continuation with a placebo.
This meta analysis indicates that continuing with antidepressant medications after depressive symptoms remit provides only a modest level of protection against a relapse of depression. Thus continuation with antidepressants after symptoms improve may not be worth it for patients who struggle with medication side effects and complications, or who cannot afford continuation of the medications. There is growing evidence that psychotherapy is effective for preventing relapse, likely because psychotherapy teaches patients ways of coping and interacting with others that allows them to manage life stresses more effectively after the treatment is over.
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.
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.
The Logic of Placebos in Medicine and Psychotherapy
The Great Psychotherapy Debate: Since April, 2015 I review parts of The Great Psychotherapy Debate (Wampold & Imel, 2015) in the PPRNet Blog. This is the second edition of a landmark and sometimes controversial book that surveys the evidence for what makes psychotherapy work. You can view parts of the book in Google Books.
A couple of decades ago Martin Seligman famously said: “Whenever you hear someone demanding a double-blind study of psychotherapy, hold on to your wallet.” In this chapter, Wampold and Imel continue their examination of the Medical Model versus the Contextual Model for psychotherapy by discussing the viability of double-blind placebo control designs in psychotherapy. This topic sounds a little esoteric, but it’s not – this issue reaches into the very core of the definition of psychotherapy. A placebo-controlled trial in medicine often involves comparing a medication that contains an active biochemical ingredient versus a “sugar pill” that is exactly like the medication but without the active biochemical ingredient. Key to the placebo controlled design is that the health care provider, the patient, nor the researcher/evaluator knows which patient received which pill (i.e., the classic “double-blind” design). However, double-blinding is impossible in psychotherapy – the therapist must know what they are providing, which means that they know which treatment is expected to be effective, and which treatment is favoured by the researchers. Further, the researchers know which patients are getting which intervention of study condition. This affects a critical aspect of psychotherapy, that is, the therapist’s ability to provide a good rationale for the disorder and for the efficacious actions of the therapy. Additionally, patients are often aware that they are getting a pseudo-treatment in the placebo, and so their expectation of outcomes is also lowered (actually, this is often true in medical trials as well as most medications have side effects, and the absence of a side effect signals to the patient and the researcher that the patient is receiving the placebo). Wampold and Imel argue that common factors like emotional arousal, an acceptable explanation of the disorder, an understanding and empathic therapist, a structure to the treatment, and therapist and client expectations and hope are integral to the effectiveness of psychological therapies. They further argue that these are the very factors that medical trials try to control with a double-blind placebo controlled trial. Nonetheless placebo-like controls have been tried in psychotherapy to test the active or specific ingredients of a therapy – that is, to isolate the effects of active ingredients from the relationship context of the therapy. Placebo-like controls in psychotherapy have been called: minimal treatment, supportive counselling, non-directive counselling, etc. However, as mentioned, these placebo control conditions often contain elements that are integral to the effectiveness of psychotherapy, like: emotional arousal, an empathic therapist, and client expectations. And so not surprisingly, after reviewing meta-analyses of placebo-like conditions in psychotherapy research, Wampold and Imel conclude that when the studies are well constructed, these placebo-like conditions perform nearly as well as evidence-based treatments.
What is the take home message for the clinician of this seemingly esoteric topic about research design? Although the placebo-controlled double-blind randomized design is the gold standard in medical research, this design is not possible or even logical for psychotherapy. The relationship, therapist factors, expectations, and contextual factors that one tries to control in a placebo-controlled trial are some of the very ingredients that are active in psychotherapy. The technical and specific ingredients of psychotherapies (e.g., transference interpretations, cognitive restructuring, two-chair techniques, etc.) are also part of the mix; but in the end, one cannot separate contextual relationship factors from techniques when it comes to providing psychotherapy.