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Cuijpers, P., Sijbrandij, E.M., Koole, S.L., Andersson, G., Beekman, A.T. & Reynolds, C.F. (2014). Adding psychotherapy to antidepressant medication in depression and anxiety disorders: A meta-analysis. World Psychiatry, 13(1), 56-67.

Anxiety and depressive disorders occur at a high rate and are very burdensome to those who suffer. These disorders are also related to high levels of health care costs, loss of productivity, and lower quality of life. Both pharmacological and psychotherapeutic interventions are effective, yet in recent years there has been a trend for patients to receive psychotropic interventions alone rather than psychotherapy. Cuijpers and colleagues (2014) conducted a meta analysis comparing pharmacotherapy alone versus pharmacotherapy combined with psychotherapy. Studies in the meta analysis included a variety of disorders such as depressive disorders and anxiety disorders. (Meta analysis is an important tool to review and combine the effects of interventions across a large number of studies. Rather than simply counting studies with positive, neutral, or negative findings, meta analysis allows one to calculate an effect size, average the effect sizes across different studies, and look at predictors or moderators of the effects. Aggregated effect sizes in a meta analysis are much more reliable [i.e., dependable] than any single study result). Cuijpers and colleagues’ meta analysis included 52 studies with 3,623 patients. Most studies tested cognitive behavioral therapy, though a large minority also included interpersonal psychotherapy and psychodynamic therapy. Most studies used selective serotonin reuptake inhibitors (SSRI), though some included tricyclic antidepressants and others. There was a moderately large overall difference between pharmacotherapy versus combined pharmacotherapy plus psychotherapy for major depression, panic disorder, and obsessive compulsive disorder (OCD). That is, adding psychotherapy resulted in a clinically meaningful improvement above and beyond pharmacotherapy alone. There were no significant differences found for type of antidepressant medication or for type of psychotherapy. Eleven studies included a placebo control condition to which medication alone vs medication plus psychotherapy was compared. The effect of combining medication and psychotherapy was twice as large as the effect of medication alone when compared to a placebo control condition. Nineteen studies followed patients after treatment (from 3 to 24 months post treatment), and the superiority of combined treatment versus medication alone remained strong and significant well into follow up.

Practice Implications

There has been a trend over the past decade to provide medication as a first line of treatment for depression and anxiety disorders. However, the results of this meta analysis indicate that monotherapy with medication alone is not optimal treatment for most patients, and that psychotherapy results in additive clinically meaningful improvement for most patients. The additive effects of psychotherapy are especially pronounced for major depression, panic disorder, and OCD.

Handbook of Psychotherapy and Behavior Change: Starting in March 2013 I will review one chapter a month from the Handbook of Psychotherapy and Behavior Change in addition to reviewing psychotherapy research articles. Book chapters have more restrictive copy right rules than journal articles, so I will not provide author email addresses for these chapters. If you are interested, the Handbook table of content and sections of the book can be read on Google Books.

Crits-Christoph, P., Connolly Gibbons, M.B., & Mukherjee, D. (2013). Psychotherapy process-outcome research. In M.E. Lambert (Ed.), Bergin and Garfield’s Handbook of Psychotherapy and Behavior Change, 6^th Edition (pp. 298-340). New York: Wiley.

In this section of their chapter in the Handbook, Crits-Christoph and colleagues (2013) review research on: (1) specific techniques of cognitive behavioural therapy (CBT), and (2) change mechanisms of CBT for depression. Research on techniques and mechanisms of change tests the specific or unique effects of a treatment and the rationale for its use. The first issue addresses whether therapist adherence and competence in using CBT techniques produce desired outcomes in patients. CBT techniques include: following an agenda, reviewing homework, asking about specific beliefs, practicing rational responses with patients, and asking patients to keep thought records. Crits-Christoph and colleagues (2013) report that the research findings on the association between using specific CBT techniques and depression outcomes are mixed. The strongest evidence is for concrete techniques such as setting agendas, reviewing homework, and practicing rational responses. However the number of studies that control for prior symptom change and other factors like therapeutic alliance is small, and so the evidence for the specific effects of CBT techniques remains meagre. The second issue addresses whether targeting depressogenic cognitions with CBT results in positive outcomes. Generally, CBT theory argues that the mechanisms by which CBT works is to focus on core depressogenic schemas (i.e., less consciously long held negative beliefs about the self), conscious negative automatic thoughts, and dysfunctional attitudes (i.e., patterns of automatic thoughts) that lead to or maintain depression. Theoretically, addressing these cognitions in CBT should reduce depressive symptoms. Overall, the research shows that both CBT and medication treatment for depression reduce self-reported negative thinking; that is, the effects on negative thinking were not specific to CBT. Few studies show that changes in cognitions precede changes in depressive symptoms, which is a key CBT tenet. The most promising findings suggest that learning compensatory skills (i.e., finding alternative explanations for negative events and thoughts, and problems solving) may be part of the mechanism by which CBT works, but again this mechanism may not be specific to CBT.

Practice Implications

CBT is an effective treatment for depression. CBT theory suggests that the reason for its effectiveness is the use of specific techniques (i.e., reviewing homework, asking for specific beliefs, practicing rational responses with patients, and asking patients to keep thought records) that target the purported causes of depression (i.e., depressogenic shemas, negative thoughts, and dysfunctional attitudes). Currently there is little research evidence that supports the specificity of CBT techniques or that supports the notion that specific changes in cognitions as a result of CBT reduce depression. Nevertheless, in general, concrete techniques (i.e., setting agendas, reviewing homework, and practicing rational responses) are clinically useful for depressed patients, as is learning compensatory skills like problem solving.

Handbook of Psychotherapy and Behavior Change: Starting in March 2013 I will review one chapter a month from the Handbook of Psychotherapy and Behavior Change in addition to reviewing psychotherapy research articles. Book chapters have more restrictive copy right rules than journal articles, so I will not provide author email addresses for these chapters. If you are interested, the Handbook table of content and sections of the book can be read on Google Books.

Crits-Christoph, P., Connolly Gibbons, M.B., & Mukherjee, D. (2013). Psychotherapy process-outcome research. In M.E. Lambert (Ed.), Bergin and Garfield’s Handbook of Psychotherapy and Behavior Change, 6^th Edition (pp. 298-340). New York: Wiley.

In their chapter in the Handbook, Crits-Christoph and colleagues (2013) review research in which psychotherapy processes are related to patient outcomes. I reported in the July 2013 PPRNet Blog that therapeutic alliance is reliably correlated with treatment outcomes in a variety of disorders and treatment types. Alliance refers to an agreement on tasks and goals of therapy, and the bond between therapist and client. The common assumption is that alliance is a necessary condition that in part causes change in client symptoms. However therapeutic alliance studies tend to be correlational, that is, the studies show a relationship but the study designs do not allow one to say that alliance causes good outcomes. What if the opposite were true; what if early experiences of symptom reduction caused the therapeutic alliance to improve? If that were the case, then alliance would be an artificial and not particularly important aspect of psychotherapy. Crits-Christoph and colleagues (2013) review the literature on this topic. Some studies of cognitive behavioural therapy (CBT), for example, found that prior change in symptoms predicted later therapeutic alliance, but prior alliance did not predict later symptom change. In a more sophisticated study, Crits-Christoph and colleagues (2011) found that previous change in the alliance was related to later change in outcomes, but not vice versa. In the same study, the authors noted that measuring patient alliance at a single early session accounted for only 4.7% of the outcome variance at post treatment, whereas averaging assessments of alliance across 6 early sessions accounted for almost 15% of the outcome variance. In other words, averaging assessments across many sessions produced a more dependable measurement of alliance. Several studies now report a reciprocal relationship between alliance and outcome, indicating that change in alliance and change in outcomes across therapy sessions progress in a mutually reinforcing spiral. That is, early change in alliance causes subsequent change in outcome, which in turn results in further change in alliance, which precipitates more change in symptoms, etc. The review by Crits-Christoph and colleagues (2013) also noted that the importance of alliance seems to be greater for patients with a disorder like depression, compared to anxiety disorders.

Practice Implications

Developing an early alliance with a client is related to treatment outcomes. Measuring alliance repeatedly (not just once) will give the best indicator of the state of the therapeutic relationship. Patients and therapists who have a genuine liking for each other, who agree on how therapy will be conducted and on the goals of therapy will improve the chances that psychotherapy will be successful. Alliance and symptom change may work together throughout therapy so that improvement in one will cause change in the other on an ongoing basis across therapy sessions. Alliance may be particularly important for patients with depressive disorders that are characterized by isolation from others, loneliness, and low self esteem.

Cuijpers, P., Huibers, M., Ebert, D.D., Koole, S.L., & Andersson, G. (2013). How much psychotherapy is needed to treat depression? A metaregression analysis. Journal of Affective Disorders, 147, 1-13.

The question of the number of psychotherapy sessions and of frequency sessions (i.e., number of sessions per week) that are optimal for good outcomes could have implications for how psychotherapy is practiced and how it is reimbursed. In my August 2013 PPRNet Blog, I reported on research that indicated half of patients recover after 21 sessions of psychotherapy. However, that also means that half do not recover in that number of sessions. Many of those who do not recover require another 29 sessions to recover. Research and practice in psychotherapy is largely based on a “one-session-per-week” model. Some researchers, however, have found that an increase in the frequency sessions per week could improve or speed up outcomes. Cuijpers and colleagues (2013) did a meta-regression to assess these questions for short-term psychotherapies for depression. (Meta-regression is a type of meta-analysis in which predictors from many studies are aggregated and their averaged effects on the aggregated outcome are assessed. This produces much more reliable findings than are possible from a single study.) The authors assessed predictors such as the number and frequency of sessions, and they looked at symptom outcomes for depression. The authors found 70 controlled studies that included 5403 patients. More than two-thirds of the studies included CBT as the psychotherapy. Average length of treatment was 11 sessions, and the maximum number of sessions was 24. The number of sessions across studies ranged from .44 to 2 per week, and the average per week was 1. The overall effect size for the treatment was medium sized (g = .59), though the effect became smaller (g = .40) when publication bias was corrected. (Publication bias refers to the likelihood that some less favorable studies or results were not published thus creating an overestimation of the effect of the treatment. See my May 2013 PPRNet Blog). Cuijper and colleagues’ meta-regression showed a small but significant association between greater number of sessions and outcomes for depression; but more importantly, a greater number of sessions per week had a considerably larger positive influence on the effects of psychotherapy for depression.

Practice Implications

The findings from Cuijpers and colleagues (2013) meta-regression are particularly relevant to time limited treatment of depression with CBT. The total number of sessions was less important than the frequency of sessions per week. The results suggest that increasing the intensity or frequency of CBT sessions per week might result in a more efficient therapy and faster relief for patients with depression.

Author email: p.cuijpers@vu.nl

Driessen, E., Van, H.L., Don, F.J., Peen, J., Kool, S. ....Dekker, J.J. (2013). The efficacy of cognitive-behavioral therapy and psychodynamic therapy in the outpatient treatment of major depression: A randomized clinical trial. American Journal of Psychiatry, 170, 1041-1050.

Psychotherapy is one of the most widely used treatments for major depression. Unfortunately there is no commercial entity like the pharmaceutical industry to support research and development of psychotherapy. As a result, researchers have limited ability to conduct larger-scale studies of comparative treatment effectiveness, of which there are only a handful. Although psychodynamic therapy (PDT) has been used to treat depressed patients for decades, randomized controlled trials of its efficacy are relatively infrequent. A concurrent problem with outcome research in psychotherapy is that sample sizes tend to be too small to actually test if two treatments are equivalent in what is called an “equivalency trial”. Without large samples, all one can conclude is that two treatments are “not significantly different” (a statistical note: an equivalency trial is planned from the outset to have a large enough sample to test the hypothesis that, with 95% certainty, the effect of one treatment falls within a narrow, predetermined margin of the effect of another treatment). The study by Driessen and colleagues was conducted in several sites in Amsterdam, in which 341 patients seeking outpatient psychotherapy for depression in psychiatric clinics were randomized to PDT or cognitive behavioural therapy (CBT). This is largest trial ever of PDT. Participants received 16 weeks of therapy and then were followed up for 1 year. About 40% of patients started with severe depression. Therapists were 93 experienced and well trained therapists who provided one of the two treatments. The main outcome was remission from depression, defined by achieving a low score on a validated observer rating scale. Post treatment remission rates were 21% for CBT and 24% for PDT, indicating that the treatments were equivalent.

Practice Implications

Cognitive-behavioral therapy (CBT) and short-term PDT provided similar outcomes for patients with a major depressive episode, but remission rates at the end of treatment were low for both treatments. Lower remission rates were likely due to the greater level of severity for these patients compared to those seen in primary care settings. The results highlight that even the best available psychological (and pharmacological) treatments yield modest outcomes for more severely depressed patients. Nevertheless, this rare equivalency trial found that both CBT and PDT were equivalent in terms of outcomes for these patients.

Author email: e.driessen@vu.nl

Handbook of Psychotherapy and Behavior Change: Starting in March 2013 I will review one chapter a month the Handbook of Psychotherapy and Behavior Change in addition to reviewing psychotherapy research articles. Book chapters have more restrictive copy right rules than journal articles, so I will not provide author email addresses for these chapters. If you are interested, the Handbook table of content can be viewed on Amazon.

Forand, N.R., DeRubeis, R.J., & Amsterdam, J.D. (2013). Combining medication and psychotherapy in the treatment of major mental disorders. In M.J. Lambert (Ed.) Bergin and Garfield’s handbook of psychotherapy and behaviour change (6^th ed.), pp. 735-774. Hoboken, N.J.: Wiley.

This comprehensive chapter covers evidence for combining medication and psychotherapy for several disorders. This month I report on the section of the chapter on depression. Psychotherapy and antidepressant medications appear to have similar efficacy in short-term treatment trials, though psychotherapy has better outcomes than medication in the longer term. Psychotherapeutic treatments including Brief Dynamic Therapy (BDT), Interpersonal Psychotherapy (IPT), and Cognitive Behavioral Therapy (CBT) confer enduring benefit by preventing relapse and recurrence when compared to discontinuing medication. Antidepressant medication is modestly effective during initial short-term treatments with remission rates less than 50% and long term recurrence range from 40% to 85%. Combining medication with psychotherapy provides a small to moderate short term advantage over monotherapy of medication or psychotherapy. Combining medication and psychotherapy is more useful for when considering chronicity rather than severity of depression. The results are consistent for BDT, IPT, and for CBT.  In the longer term, efficacy of combined treatments is not better than either monotherapy. Taken together, the evidence for combined therapy for depression is modestly positive with little evidence that treatments interfere with each other (by contrast, see the March 2013 blog for findings of interference in combined therapy for anxiety disorders). Nevertheless, prolonged continuation of medication monotherapy is an added expense that is often ineffective. In fact, prolonged antidepressant medication maintenance can worsen the course of depressive illness for some, and efficacy tends to fade after 3 to 6 months of maintenance. Finally, there is emerging evidence of progressive tolerance (tachyphylaxis) or even worsening of symptoms during medication maintenance. Studies suggest that psychotherapy added to maintenance medication was associated with decreased relapse rates when compared to medication alone in the longer term.

Practice implications

Combined treatments (antidepressant medication plus psychotherapy) for major depression provide modest incremental improvements in response over monotherapy. Results of combination treatments are better, though still modest, for those with chronic depression. The evidence does not support the use of combined treatments for mild to moderate depression, unless the individual does not responds to initial monotherapy. Practitioners could consider monotherapy (i.e., psychotherapy or medication) first, followed by switching therapy or augmenting therapy for non-responders. If a patient is started on short term monotherapy of medication, practitioners may consider switching to psychotherapy for better long term relapse prevention.