Cuijpers, P., Karyotaki, E., Ciharova, M., Miguel, C., Hisashi, N., &Furukawa, T.A. (2021). The effects of psychotherapies for depression on response, remission, reliable change, and deterioration: A meta-analysis. Acta Psychiatrica Scandinavica, 10.1111/acps.13335. Advance online publication.
Many meta-analyses report that psychological therapies are effective to treat depression, that there are no differences between types or orientations of therapy in their outcomes, and that psychotherapy is as effective as medications in the short term and perhaps more effective in the longer term. But what do these findings mean for everyday practice? Many meta-analyses report a standardized mean effect size between treatment and control conditions. However, the effect size is an abstraction that may be difficult to interpret unless you understand the statistic. Clinicians may ask a more practical question: what is the proportion of patients that improve (have meaningful reductions in depression scores) and recover (improved and no longer are depressed)? This meta-analysis by Cuijpers and colleagues of 228 studies representing over 23,000 adult patients looked at the proportion of patients who improved and recovered after psychotherapy relative to those in control conditions (no treatment, care as usual, pill placebo). The psychotherapies were short term manualized treatments like CBT, behavioral activation, interpersonal psychotherapy delivered in individual, group, and self-help formats. About 41% of patients improved with psychotherapy for depression compared to 17% that improved with usual care and 31% for pill placebo. However, after statistically controlling for publication bias (i.e., the likelihood that some unflattering studies were never published), the improvement rate for psychotherapy was 38%. Recovery rates for psychotherapy ranged from 26% to 34%, and recovery in the control conditions ranged from 9% to 17%. There were no differences between therapy orientations. Highest rates of recovery or improvement were achieved by individual therapy and the lowest rates were seen in guided self-help. Deterioration rates were just below 5% in psychotherapy and about 7% to 13% in control conditions.
The effects of time-limited manualized psychotherapies tested in randomized controlled trials were modest. About 40% of patients improved and about 30% recovered. On the positive side, psychotherapies resulted in only about 5% of patients getting worse. The authors argued that clinicians must consider more effective strategies beyond these approaches to improve outcomes for depression. Some have focused on improving psychotherapist effectiveness, rather than on specific interventions. Methods like progress monitoring, managing countertransference, and repairing therapeutic alliance ruptures are means of improving psychotherapists’ effectiveness.