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The Great Psychotherapy Debate: Starting in 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.

Change in dysfunctional attitudes or cognitions is one of the specific mechanisms by which cognitive therapy (CT) is thought to be effective in the treatment of depression. In this part of their book, Wampold and Imel discuss the evidence that addresses the specific change mechanisms for CT. The reason they focus on CT is that CT is by far the most researched psychotherapy approach, and there is a substantial number of CT studies that have addressed this issue of change mechanisms. In an early meta analysis, Oei and Free (1995) found a significant relationship between change in cognitions and CT. However, in the same meta analysis, the authors found that CT and non-cognitive therapies did not differ in terms of their effects on cognitions. That is, most treatments, whether CT or not, appeared to change cognitions. In another study, three different interventions (behavioral activation, CT, and CT plus behavioral activation) all resulted in change in cognitions and improved depression. In other words, cognitive interventions do not seem to be needed to alter cognitions and reduce depression. Wampold and Imel argue that nonspecific processes in CT (and other psychotherapies for that matter) are largely responsible for the effectiveness of psychotherapy. For example, there is evidence to suggest that a number of patients show substantial symptom improvement early in treatment before specific cognitive techniques are introduced. Some have argued that this early favourable response is largely due to the effects of client expectations, reassurance, and remoralization rather than the specific procedures of the therapy. Moreover, patients who experience this remoralization early-on may be better at successfully applying techniques taught in CT. A large review of this literature concluded that there was insufficient evidence to support the notion that challenging thoughts was responsible for the positive effects of CT.

Practice Implications

This line of research appears to indicate that the specific practice of challenging thoughts or dysfunctional attitudes is not primarily responsible for patient change in CT. It may be that for any psychological treatment that has a cogent rationale for the disorder and is administered by an acknowledged expert, client progress may be determined largely by contextual factors. These factors may include a therapeutic alliance, client expectations of benefit, and client remoralization, which may in turn allow clients to benefit from the specific interventions of psychological treatments.

Weitz, E.S., Hollon, S.D., Twisk, J., van Straten, A., Huibers, M.J.H., David, D., …. Cuijpers, P. (2015). Baseline depression severity as moderator of depression outcomes between cognitive behavioral therapy vs pharmacotherapy: An individual patient data meta-analysis. JAMA Psychiatry. doi:10.1001/jamapsychiatry.2015.1516.

The American Psychiatric Association guidelines for the treatment of depression indicates that although psychotherapy is adequate for mild to moderate depression, anti-depressant medications are indicated for the treatment of severe depression in major depressive disorder. These recommendations are mainly based on the findings of the National Institute of Mental Health Treatment of Depression Collaborative Research Program that was published in the mid 1990s. Several authors since then have disputed this claim, but no meta-analyses have been done on the studies of head-to-head patient-level comparisons of psychotherapy vs antidepressant medications for the purpose of evaluating their relative efficacy for severity of depression. In this meta analysis, Weitz and colleagues look at medications vs psychotherapy for depression and then evaluate if initial severity of depressive symptoms helped to explain any differences. The authors looked at all studies that compared cognitive behavioral therapy (CBT) against antidepressant medications for depression. They focused on CBT because it was the most often studied of the psychotherapies in this context. A systematic review turned up 24 studies, and they were able to get original patient-level data from the authors of 16 of the 24 studies. This represented over 1,700 participants with major depression. These 16 studies were no different from the 8 studies that did not provide original data. Between 17% and 54% of the 1,700 depressed participants met criteria for severe depression at pre-treatment. There were no significant differences between antidepressant medications and CBT on clinically relevant outcomes in terms of “response” (i.e., improvement) or “remission” (i.e., symptom-free). In total, 63% of patients in the antidepressant medication condition and 58% of patients in the CBT condition responded to treatment, and 51% of patients in the antidepressant medication condition and 47% of patients in the CBT condition met criteria for remission. Most importantly, the effects of CBT and antidepressant medications on response to treatment or remission did not differ based on initial severity of depressive symptoms.

Practice Implications

Patients with severe depression were no more likely to require medication to get better than patients with less severe depression. This meta analysis that included the majority of studies that exist on the topic found no evidence to support the guidelines that severe depression should be treated with antidepressant medications over psychotherapy. The authors conclude that CBT may also be a first-line treatment for severe depression.

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.

Clarke, K., Mayo-Wilson, E., Kenny, J., & Phillig, S. (2015). Can non-pharmacological interventions prevent relapse in adults who have recovered from depression? A systematic review and meta-analysis of randomised controlled trials. Clinical Psychology Review, 39, 58-70.

According to the American Psychiatric Association, the risk for relapse from depression can be as high as 60% for those who had one episode, 70% for those who had two episodes, and 90% for those who had three previous episodes. Intervening after recovery from an episode of depression might prevent relapse. A relapse is defined as any significant deterioration in depression following a period of clear improvement. We know that relapse after discontinuing antidepressant treatment is greater than relapse after discontinuing psychotherapy, likely because psychotherapy and not medications result in the patient acquiring new coping skills and strengths. Clarke and colleagues conducted a meta analysis of psychological interventions that were designed or adapted in order to reduce relapse after the acute phase depression. These include mindfulness based therapy (MBT) which helps individuals process experience without judgment by using mindfulness techniques; cognitive behavioral therapy (CBT) which helps to modify thoughts and behaviors key to depression; and interpersonal psychotherapy (IPT) which focuses on helping to deal with interpersonal and social role problems related to depression. Clarke and colleagues reviewed 29 studies that included 4216 participants who had at least one episode of depression, had recovered after treatment, and who received either MBT, CBT, or IPT to prevent relapse. These were compared to control conditions that included wait-lists, treatment as usual, or some other active intervention. Compared to all of the controls, MBT, CBT, and IPT reduced relapse rates from 21% to 25% among patients one year post acute treatment. The effects for CBT were maintained up to two years post treatment. There were no differences between psychotherapies and control conditions in drop out rates.

Practice Implications

Psychotherapies (e.g., MBT, CBT, and IPT) reduce relapse from depression by about 22%. up to one year post recovery. Practitioners should consider offering MBT, CBT, or IPT as a form of booster sessions to reduce the likelihood of relapse from a previous episode of depression. Such interventions are important given the increasing relapse rates for each subsequent episode of depression.

The Great Psychotherapy Debate: Since in 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.

Wampold, B.E. & Imel, Z.E. (2015). The great psychotherapy debate: The evidence for what makes psychotherapy work (2^nd edition). New York: Routledge.

The narrative about the relative efficacy of psychotherapies for depression has shifted over the past several decades. In the early days (1970s – 1980s) there appeared to be accumulating evidence that cognitive behavioural therapy (CBT) was more efficacious than “other psychotherapies”. However, today one look at the Society for Clinical Psychology list of empirically supported treatments for depression indicates that a variety of interventions are efficacious. In this part of their book, Wampold & Imel examine this change. Early in their book, they defined psychotherapy as: (1) based psychological principles, (2) involving a trained therapist and a client who is seeking help for a mental disorder, (3) intended to be helpful for the client’s complaints, and (4) adapted to the client’s problem. Wampold and Imel argue that many of the treatments compared to CBT in the early days did not meet this definition of psychotherapy. That is, many of the early comparison treatments were not bona-fide therapies; so the comparisons were not expected to be therapeutic. Common comparisons to CBT were “usual care”, “supportive therapy”, and “self directed care” that for the most part did not meet the definition of psychotherapy. Further, the providers of usual care or supportive therapy had no allegiance to the treatment or expectation that the intervention was useful, which eroded the credibility of these interventions for the client. When bona-fide psychotherapies are compared to each other, the effect sizes tend to be small or negligible. For example, Braun and colleagues (2013) conducted a large meta analysis of 53 studies with nearly 4,000 patients.  When they looked specifically at studies of bona fide therapies, and pairs of treatments that were compared in at least 5 studies, there were no differences between the treatments. Similar findings are reported in large a network meta analysis by Barth and colleagues (2013) (198 studies with 15,118 patients) that was summarized in the July 2014 PPRNet Blog.

Practice Implications

Psychotherapies that are based on sound psychological principles, delivered by trained therapists for clients who seek help and that are intended to be helpful for the client’s complaint are likely to be equally effective for depressive disorders. A variety of psychotherapies including, CBT, emotionally-focused therapy, interpersonal psychotherapy, and short-term psychodynamic therapy have demonstrated empirical support for their efficacy in treating depression. Client expectations of receiving benefit and therapist allegiance to treatment enhance the effectiveness of treatments.

Johnsen, T. J., & Friborg, O. (2015, May 11). The effects of cognitive behavioral therapy as an anti-depressive treatment is falling: A meta-analysis. Psychological Bulletin. Advance online publication. http://dx.doi.org/10.1037/bul0000015

Depression is a highly debilitating disorder and ranked third in terms of disease burden in the world. Cognitive behavioral therapy (CBT) is an effective treatment for depression that was introduced over 40 years ago. In part, CBT sees depression as caused by maladaptive thoughts that maintain emotional distress and dysfunctional behavior. Reducing depression is achieved by eliminating the impact of or chancing maladaptive thoughts. CBT is the most researched psychological treatment for depression, and the research goes back several decades. A number of technical variations and new additions have been made over the years to CBT to improve patient outcomes. The volume of research and its history provides a unique opportunity to assess time trends in the effects of CBT. In this meta analysis, Johnsen and Friborg asked: “have the effects of CBT changed over time”? They also looked at whether client factors (e.g., demographics, symptom severity), therapist factors (e.g., age, experience, training), common factors (e.g., therapeutic alliance, client expectancies), and technique factors (e.g., fidelity to a treatment manual) can explain these trends. Johnsen and Friborg reported on 70 studies of 2,426 patients conducted from 1977 to 2014. Males accounted for 30.9% of patients, 43% had comorbid psychiatric conditions, and the average patient was at least moderately depressed. The average effect of CBT in reducing depression was large (g = 1.46 after accounting for publication bias). Women had better outcomes, studies with poorer methodological quality showed larger effects, and patients of more experienced therapists had better outcomes. There were too few studies measuring therapeutic alliance to assess the effect of common factors on outcomes. Most interesting was a significant relationship between effect sizes and year of publication. That is, the effects of CBT declined significantly over the years, though the average effect remained large. Surprisingly, there was a steeper decline for studies that used a treatment manual compared to those that did not. No other variables were reliably associated with this decline.

Practice Implications

Women and patients of more experienced therapists appear to benefit most from CBT. Although the effects of CBT declined over time, the treatment remained highly effective. Johnsen and Friborg’s study could not easily explain this decline. The authors suggested that the placebo effect (expectation on the part of patients, researchers, and therapists) is typically stronger for new treatments. However, as time passes the strong initial expectations tend to wane thus reducing the overall effect of the intervention. They also suggested that CBT treatment outcomes may be improved not by technical variations and new additions, but by better ways of integrating common, therapist, and client factors.

Author email: tjj@psykologtromso.no