Blog

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.

April 2017

Patients are More Likely to Refuse and Drop Out of Pharmacotherapy Than Psychotherapy

Swift, J.K., Greenberg, R.P., Tompkins, K.A., & Parkin, S.R. (2017). Treatment refusal and premature termination in psychotherapy, pharmacotherapy, and their combination: A meta-analysis of head-to-head comparisons. Psychotherapy, 54, 47-57.

Treatment refusal occurs when a patient is offered an intervention but then fails to begin it. In treatment studies, this may occur when a patient initially agrees to participate in a trial but then discontinues immediately after finding out what intervention they will receive. In a clinic setting, a patient might call a mental health professional to schedule an initial appointment but not show up. This causes problems for the patient who is not receiving treatment, and for the professional who has an unfilled therapy hour. Premature termination, on the other hand occurs when a patient begins treatment but ends unilaterally against the provider’s recommendations and prior to recovery. Again, these patients typically do not improve and they do not receive an adequate dose of the treatment. Barriers to accepting or completing psychotherapy might include the cost, and the time and effort involved to engage in the therapeutic process. Barriers to accepting or completing pharmacotherapy might also include cost, unpleasant side effects, and fewer contacts with a non-judgemental listening professional. The aim of Swift and colleagues’ meta-analysis was to compare rates of treatment refusal and premature termination between psychotherapy and pharmacotherapy. The meta-analysis included 186 studies, 57 of which (with 6,693 participants) reported data on treatment refusal. A significant number of patients (8.2%; 95% CI: 7.0, 9.6%) failed to start treatment after they were told what treatment they would receive. Participants were 1.76 times more likely (95% CI: 1.27, 2.45) to refuse treatment if they were offered pharmacotherapy compared to psychotherapy. The average premature termination rate from treatment was 21.9% (95% CI: 20.6%, 23.3%). Patients assigned to pharmacotherapy were 1.2 times more likely (95% CI: 1.03, 1.41) than those who were assigned to psychotherapy to discontinue treatment prematurely.

Practice Implications

Participants were almost 2 times more likely to refuse treatment if they were offered pharmacotherapy compared to psychotherapy, especially for social anxiety disorder, depression, and panic disorder. Similarly, premature termination was higher for pharmacotherapy compared to psychotherapy, especially for eating disorders and depressive disorders. Previous research indicated that patients are 3 times more likely to prefer psychotherapy over medications for mental disorders. Research indicates that mental health professionals should work to incorporate patient preferences, values, and beliefs when making treatment decisions in order to reduce premature termination and treatment refusal.
Efficacy of Psychotherapies for Borderline Personality Disorder

Cristea, I.A., Gentili, C., Cotet, C.D., Palomba, D., Barbui, C., & Cuijpers, P. (2017). Efficacy of psychotherapies for borderline personality disorder: A systematic review and meta-analysis. JAMA Psychiatry. doi:10.1001/jamapsychiatry.2016.4287.

Borderline personality disorder (BPD) is a debilitating disorder characterized by: severe instability of emotions, relationships, and behaviors. More than 75% of those with BPD have engaged in deliberate self-harm, and suicide rates are between 8% and 10%. BPD is the most common of the personality disorders with a high level of functional impairment. Several psychotherapies have been developed to treat BPD. Most notably, dialectical behavior therapy (DBT), cognitive behavioral therapy (CBT), and psychodynamic treatments like mentalization-based and transference-focused psychotherapy. This meta-analysis by Cristea and colleagues examined the efficacy of psychotherapy for BPD. Studies included in the meta-analysis (33 trials of 2256 clients) were randomized controlled trials in which a psychotherapy was compared to a control condition for adults with BPD. For all borderline-relevant outcomes (combined borderline symptoms, self-harm, parasuicidal and suicidal behaviors) yielded a significant but small effect of the psychotherapies over control conditions at post treatment (g = 0.35; 95%CI: 0.20, 0.50). At follow up, there was again a significant effect of the psychotherapies over control conditions with a moderate effect (g = 0.45; 95% CI: 0.15, 0.75). When the different treatment types were looked at separately, DBT (g = 0.34; 95% CI: 0.15, 0.53) and psychodynamic approaches (g = 0.41; 95% CI: 0.12, 0.69) were more effective than control interventions, while CBT (g = 0.24; 95% CI: −0.01, 0.49) was not. The authors also reported a significant amount of publication bias, suggesting that published results may be positively biased in favor of the psychotherapies.

Practice Implications

The results indicate a small effect of psychotherapies at post-treatment and a moderate effect at follow-up for the treatment of BPD. DBT and psychodynamic treatment were significantly more effective than control conditions, whereas CBT was not. However, all effects were likely inflated by publication bias, indicating a tendency to publish only positive findings. Nevertheless, various independent psychotherapies demonstrated efficacy for symptoms of self harm, suicide, and general psychopathology in BPD.

March 2017

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.

Practice Implications

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.

February 2017

Mindfulness-Based Cognitive Therapy to Prevent Relapse of Depression

Kuyken, W., Warren, F.C., Taylor, R.S., Whalley, B., Crane, C….Dalgliesh, T. (2016). Efficacy of mindfulness-based cognitive therapy in prevention of depressive relapse An individual patient data meta-analysis from randomized trials. JAMA Psychiatry, 73, 565-574.

Depression results in a high level of disability and its social and economic costs appear to be rising. Although many effective treatments for depression do exist, relapse of depressive symptoms is a significant problem for many who successfully complete treatment. One of the interventions used to prevent relapse is mindfulness-based cognitive therapy (MBCT). MBCT teaches psychological skills that target cognitive factors that may cause relapse among those who have a history of depression by combining mindfulness training with cognitive interventions. Previous reviews have indicated the efficacy of MBCT for relapse prevention. In this meta-analysis, Kuyken and colleagues update the previous reviews and look at specific sub groups of patients who may respond differently to MBCT. From a comprehensive search of the literature, they identified 9 published randomized controlled trials comparing MBCT to another condition such as usual care, antidepressant medications, or another active treatment. These 9 studies included 1258 patients. MBCT resulted in a reduced risk of relapse in depressive symptoms compared to those who did not received MBCT within a 60 week follow up period (hazard ratio (HR), 0.79; 95%CI, 0.64-0.97). Four studies specifically compared MBCT to antidepressant medication and showed that those who received MBCT had a reduced risk of relapse compared to antidepressants (HR, 0.77; 95%CI, 0.60 – 0.98; I², 0%). The authors also found that the preventive effect of MBCT on depression relapse declined over time. No demographic variables were associated with the effects of MBCT, but higher levels of depression at baseline were associated with a larger effect of MBCT.

Practice Implications

The findings of this meta analysis show that MBCT helps to prevent depression relapse in those who have recovered from depressive symptoms. Its effects appear to be superior to usual care and to antidepressant medications. Unlike anti depressants, those who were treated with MBCT learned skills that helped them to cope with stressors that may precipitate another depressive episode. The effects of MBCT appear to be particularly useful for those with greater depressive symptoms at the outset, but those with lower depressive symptoms may not benefit as much from MBCT.

January 2017

Individual versus Group Psychotherapy

Burlingame, G.M., Seebeck, J.D., Janis, R.A., Whitcomb, K.E., Barkowski, S., Rosendahl, J., & Strauss, B. (2016). Outcome differences between individual and group formats when identical and nonidentical treatments, patients, and doses are compared: A 25-year meta-analytic perspective. Psychotherapy, 53, 446-461.

With increasing service demands being put on mental health systems, clinicians and administrators are looking to more efficient ways of providing care to more patients. One option is group therapy in which more patients can be treated with fewer resources. However, are groups as effective as individual therapy for mental disorders? This meta-analysis by Burlingame and colleagues addresses this question by examining 67 studies in which group and individual therapy were directly compared within the same study. The majority of studies included adults with anxiety, mood, or substance use disorders, with some studies focusing on medical conditions, eating or personality disorders. Two-thirds of studies were of cognitive-behavioral therapy, but other treatment types like interpersonal, psychodynamic, and supportive therapy were also tested. Groups were defined as having at least 3 patients per group. The average number of sessions for group and individual therapy were equivalent (group M = 14.67, SD = 8.75; individual 15.94, SD = 14.37)), and as expected group therapy sessions were longer in minutes (M = 100.39, SD = 30.87) than individual therapy sessions (M = 56.55, SD = 14.37) given the multi-person demands of groups. Groups were primarily closed to new members after starting, they tended to have homogenous membership based on diagnosis, and groups tended to be co-led by 2 therapists. Individual and group therapy were not significantly different for all disorders and outcomes at post-treatment (g = -0.03; 95%CI = -0.10, 0.04), short-term follow-up (g = 0.01; 95% CI = -0.13, 0.11), and long-term follow-up (g = 0.00; 95% CI= -0.12, 0.13). Drop out rates for group therapy (17.28%) and individual therapy (14.96%) were not significantly different (OR = 1.10; 95% CI = 0.90, 1.33), and patients were likely to accept group therapy (88.76%) as often as they accepted individual therapy (84.83%) when one or the other was offered. Pre- to post-treatment effect sizes were moderately large for both interventions (group: g = 0.60, 95% CI = 0.48, 0.72; individual: g = 0.53, 95% CI = 0.42, 0.65). Patients presenting with depression, substance us, anxiety, or eating disorders had the highest level of improvement.

Practice Implications

When identical treatments, patients, and doses are compared, individual and group therapy resulted in equivalent outcomes across of a variety of disorders. This is good news for clinicians and agencies looking to maximize resources to treat more patients. However, running a group is more complex than providing individual therapy. Finding a sufficient number of patients to start a group, assessing and preparing each patient prior to starting a group, writing a note per patient per session, and managing attrition is logistically more challenging. Further, most therapists are not formally trained to provide group interventions and so they may find the task of managing a substantially larger amount of within-session group process information to be complex. Finally, as Burlingame and colleagues indicate, there are institutional considerations so that group programs require a milieu that supports group referrals and flexibility in scheduling. Nevertheless the findings of this meta analysis indicate the potential for group therapy to provide efficacious treatments for mental disorders.

December 2016

Effects of Combining Psychotherapy and Pharmacotherapy on Quality of Life in Depression

Kamenov, K., Twomey, C., Cabello, M., Prina, A.M., & Ayuso-Mateos, J.L. (2016). The efficacy of psychotherapy, pharmacotherapy, and their combination on functioning and quality of life in depression: A meta-analysis. Psychological Medicine, doi: 10.1017/S0033291716002774.

Both psychotherapy and pharmacotherapy are efficacious for reducing symptoms of depression. Some studies suggest that functioning (i.e., the ability to engage in work, school, and social activities) and quality of life (i.e., satisfaction with these activities and perception of one’s health) are just as important to depressed patients as is reducing their symptoms. In fact, many patients place greater priority on improving functioning compared to reducing symptoms. In this meta analysis, Kamenov and colleagues assess the relative efficacy of psychotherapy vs pharmacotherapy in improving functioning and quality of life. They also evaluate if combining psychotherapy and pharmacotherapy is efficacious relative to either treatment alone. The meta analysis included k = 153 studies of over 29,000 participants. Psychotherapies often included CBT and interpersonal psychotherapy. Compared to control groups (k = 37 to 52) both psychotherapy (g = 0.35, 95% CI = 0.24, 0.46) and medications (g = 0.27, 95% CI = 0.21, 0.32) significantly improved functioning. Also, compared to controls both psychotherapy (g = 0.35, 95% CI = 0.26, 0.44) and medications (g = 0.31, 95% CI = 0.24, 0.38) significantly improved quality of life in depressed participants. In studies that directly compared psychotherapy and medications, there were no significant differences when it came to improving functioning, but there was a small significant advantage to psychotherapy over medication for improving quality of life (g = 0.21, 95% CI = 0.01, 0.43). Combined psychotherapy and medications (k = 19) was more effective to improve functioning compared to pharmacotherapy alone (g = 0.34, 95% CI = 0.18, 0.50) and compared to psychotherapy alone (g = 0.32, 95% CI = 0.14, 0.49). Combined treatment was also more efficacious for improved quality of life compared to medications alone (g = 0.36, 95% CI = 0.11, 0.62) and to psychotherapy alone (g = 0.39, 95% CI = 0.19, 0.58).

Practice Implications

Combined treatment of medications and psychotherapy is more effective than either treatment alone for improving functioning and quality of life. However, most patients prefer psychotherapy to medications, and some studies indicate that many patients choose not to get treated at all rather than receive medications. Further, quality of life can be substantially compromised by medication side effects. Clinicians should take these factors into account when considering monotherapy with antidepressant medications or combined treatment of pharmacotherapy and psychotherapy for depression.

This month...

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April 2017

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March 2017

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February 2017

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January 2017

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December 2016

Practice Implications

Psychotherapy Practice Research Network (PPRNet)