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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 Placebo response rates in antidepressant trials: A systematic review of published and unpublished double-blind randomised controlled studies.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.

Practice Implications

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.

Fried, E.I. (2016). The 52 symptoms of major depression: Lack of content overlap among seven common depression scales. Journal of Affective Disorders.

Depression is a leading cause of disability in the world and an important reason why people seek psychotherapy. Depression is also the most commonly studied disorder in psychological treatment studies. Measuring depression with self-report or clinician rating scales seems straight forward, but it turns out that it is not. This is important for clinicians because we assume that scales assess depressive symptoms in a reliable way, and that this measurement gives a valid indicator of a patient’s level of depression and improvements in the depressive symptoms. In this review Fried examined the content of the seven of the most common measures of depression including: the Beck Depression Inventory (BDI), the Centre for Epidemiological Studies Depression Scale (CESD), and the Hamilton Rating Scale for Depression (HRDS). Many might assume depression to represent a single construct – meaning depression is sometimes thought to represent one unitary thing that is consistent across individuals. Because of that assumption, some might consider depression scales to be interchangeable. But according to Fried, these seven scales listed a total of 52 different symptoms. Using a statistical approach called a Jaccard Index, Fried found that the overlap in symptoms among the different depression scales was low (i.e., different scales seemed to be tapping into different symptoms). When he reviewed the content of each scale, this low overlap seemed clear. For example, the BDI (developed by the founder of CBT) emphasizes cognitive symptoms of depression, the CESD has a number of items that are only indirectly related to depressive symptoms (like interpersonal sensitivity), and the HRDS (often used in medication trials to evaluate side effects) emphasizes somatic symptoms like insomnia, fatigue, and sexual dysfunction. Perhaps this lack of overlap is not so surprising given that the concept of depression is likely multidimensional and not representative of a single uniform construct.

Practice Implications

So what does this mean for clinical practice? Many clinicians use a depression scale to assess their patients and monitor their outcomes. Which scale one uses seems to make a difference in terms of what is being measured and what outcomes are monitored. Using the BDI will emphasize the cognitive aspects of depression, whereas ratings with the HRDS may emphasize the somatic aspects of depression. Fried recommends that researchers use more than one scale, and if the findings differ across scales, then that provides more nuanced information about the effects and outcomes of depression and its treatment. Perhaps the same can be said for clinical practice – if clinicians use only one depression scale, then they should be aware of what aspects of depression or what kind of information about their patent’s depression that the scale is providing.

Falkenström, F., Grant, J., & Holmqvist, R. (2016): Review of organizational effects on the outcome of mental health treatments. Psychotherapy Research, DOI: 10.1080/10503307.2016.1158883

Many psychotherapists treat patients within organizational contexts. These contexts might include university clinics, hospitals, primary care centers, community health centers, or even shared or group private practices. Psychotherapy researchers are often concerned with patient outcomes and predictors of outcomes like patient, therapist, or relationship variables. However, rarely do psychotherapy researchers consider the effects of the larger organizational context within which the psychotherapy is provided. On the other hand, many organizational psychology researchers are interested in organizational culture and management practices but seldom link these directly to patient outcomes. Is there an effect of the organizational context (i.e., culture and climate) on patient outcomes, and can we understand its effects in order to improve outcomes? Falkenstrom and colleagues review this literature. Organizational culture refers to shared norms, beliefs, and expectations in an organization or unit. These can be affected by hierarchical structure (i.e., perceived power differences between professions), managerial principles and styles (e.g., rigid vs lax styles, supportive and active vs undermining, micro-managing, or disengaged), and by technology. Various organizations appear to engender different cultures such that the staff can be more or less committed to the organization strategies and to the work itself. This is the basis of the well known expression: “culture eats strategy for breakfast”. Organizational climate refers to the overall sense of psychological security in a work environment. This may have an impact on workers’ attitudes and performance, and may also affect their willingness to report errors and to problem solve. In their review, Falkenstrom and colleagues found only 19 studies that directly assessed the effects of organizational context on patient mental health outcomes. Differences between organizations appeared to account for between 6% and 60% of patient outcomes. This is a very wide range that may be the result of many differences between studies (i.e., different patient populations, different definitions of outcomes, different definitions and measurements of organizational variables, etc.). However, even at 6%, this represents what most researchers would call a medium and meaningful effect. For example, Falkenstrom and colleagues reviewed specific studies and found that organizational climate (i.e., low conflict, low emotional exhaustion, and high cooperation and job satisfaction) were related to better psychosocial functioning in children placed in state custody. Several other studies showed that high staff turnover, low levels of support from leadership, and low mutual respect among professionals was associated with poorer mental health outcomes for a variety of patient populations. One study found that an intervention to improve organizational culture and climate resulted in improving mental health outcomes among children and adolescents.

Practice Implications

There are surprisingly few studies that look at the relationship between organizational culture and patient outcomes. Although limited, most of the studies point to the effects of organizational culture and climate on staff and on patient outcomes. With increased emphasis on quality control in mental health care, it makes sense for managers, practitioners, researchers and patient groups to carefully consider an organization’s managerial practices, leadership, culture, and climate when looking to improve patient outcomes.

Sledge, W., Plukin, E.M., Bauer, S., Brodsky, B.,... Yoemans, F. (2014). Psychotherapy for suicidal patients with borderline personality disorder: An expert consensus review of common factors across five therapies. Borderline Personality Disorder and Emotion Dysregulation, 1:16. doi:10.1186/2051-6673-1-16.

Treating patients with suicidal ideation and borderline personality disorder (BPD) can cause significant anxiety, concern, anger, and guilt in clinicians. Strong emotional reactions can lead to risky therapeutic interventions, poor clinical decisions, and professional burn out. The outcome of therapy can have serious consequences for such patients. Recently, a panel of 13 experts reviewed the efficacy of the most common treatments for suicidal ideation in BPD. As part of the review, they identified the common factors that may be useful for all clinicians who work with these clients. The five therapies they reviewed included the following. Dialectical behavior therapy, which emphasizes the role of emotional dysregulation and impulsivity in suicide. Treatment includes distress tolerance, emotional regulation, interpersonal effectiveness, and mindfulness. Schema therapy decreases suicide risk by challenging negative thoughts with cognitive and behavioral techniques while using the therapeutic relationship to improve the patient’s capacity to attach to others. Mentalization based therapy works toward improving the patient’s capacity to keep in mind the patient’s own mind and the mind of the other. This encourages new perspectives on relationships and emotion regulation. Transference focused psychotherapy views suicidal behavior in BPD as related to distorted images of the self and others. The treatment emphasizes gaining greater awareness of self in relation to others, and integrating a more realistic experience of the self. Good psychiatric management is an integrative approach that uses both psychodynamic and behavioral concepts. The approach sees BPD as a problem with interpersonal hypersensitivity, but the management tends to be more pragmatic than theoretically based. The expert panel defined six common factors among these treatments. (1) Negotiation of a frame for treatment – in which roles and responsibilities of therapist and patient are defined before the start of treatment, including an explicit crisis plan. (2) Recognition of the patient’s responsibilities within therapy. (3) The therapist having a clear conceptual framework for understanding the disorder that then guides the interventions. (4) Use of the therapeutic relationship to engage the patient and to address suicide actively and explicitly. (5) Prioritizing suicide as a topic whenever it comes up in the therapy. (6) Providing support for the therapist through supervision, consultation, and peer support.

Practice Implications

Suicidal ideation in patients with BPD can have serious consequences for the patient and can be highly stressful for the clinician. This expert panel identified six common features of most major treatment approaches to suicidal ideation in BPD. Even if clinicians are not explicitly trained in any one of the approaches, ensuring that these six factors are present in their work will improve the likelihood that their patients will experience a good outcome.

Wampold, B. E. (2015). How important are the common factors in psychotherapy? An update. World Psychiatry, 14, 270-277.

What is the evidence for the common factors in psychotherapy and how important are they to patient outcomes? In their landmark book, The Great Psychotherapy Debate, Wampold and Imel cover this ground is some detail, and I reviewed a number of the issues raised in their book in the PPRNet blog over the past year. This article by Wampold provides a condensed summary of the research evidence for the common factors in psychotherapy, including: therapeutic alliance, therapist empathy, client expectations, cultural adaptation of treatments, and therapist effects. Therapeutic alliance refers to therapist and client agreement on tasks and goals of therapy, and the bond between therapist and client. A meta-analysis of the therapeutic alliance included over 200 studies of 14,000 patients and found a medium effect of alliance on patient outcomes (d = .57) across a variety of disorders and therapeutic orientations. A number of studies are also concluding that the alliance consistently predicts good outcomes, but that early good outcomes do not consistently predict a subsequent higher alliance. Further, therapists and not patients were primarily responsible for the alliance-outcome relationship. Another common factor, empathy, is thought to be necessary for cooperation, goal sharing, and social interactions. A meta-analysis of therapist empathy that included 59 studies and over 3,500 patients found that the relationship between empathy and patient outcome was moderately large (d = .63). Patient expectations that they will receive benefit from a structured therapy that explains their symptoms can be quite powerful in increasing hope for relief. A meta-analysis of 46 studies found a small but statistically significant relationship (d = .24) between client expectations and outcome. Cultural adaptation of treatments refers to providing an explanation of the symptoms and treatment that are acceptable to the client in the context of their culture. A meta analysis of 21 studies found that cultural adaptation of evidence-based treatments by using an explanation congruent with the client’s culture was more effective than unadapted evidence-based treatments, and the effect was modest (d = .32). Finally, therapist effects, refers to some therapists consistently achieving better outcomes than other therapists regardless of the patients’ characteristics or treatments delivered. A meta analysis of 17 studies of therapist effects in naturalistic settings found a moderately large effect of therapist differences (d = .55).

Practice Implications

These common factors of psychotherapy appear to be more important to patient outcomes than therapist adherence to a specific protocol and therapist competence in delivering the protocol. As Wampold argues, therapist competence should be redefined as the therapist’s ability to form stronger alliances across a variety of patients. Effective therapists tend to have certain qualities, including: a higher level of facilitative interpersonal skills, a tendency to express more professional self doubt, and they engage in more time outside of therapy practicing various psychotherapy skills.

Wampold, B.E. & Imel, Z.E. (2015). The great psychotherapy debate (2^nd ed.). New York: Routledge.

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

In the concluding chapter of their book, Wampold and Imel discuss the evidence and strategies that therapists can use to improve patient outcomes. As indicated in previous PPRNet Blogs, Wampold and Imel concluded that the differences between specific treatment approaches is small. In other words, Wampold and Imel argue that there is no good evidence that one bona fide psychotherapy is more effective than another for most disorders. By “bona fide” treatments, they mean psychotherapy that: provides the client with a plausible theory/explanation of the disorder, delivers a structured intervention based on the plausible theory, and is offered by an effective therapist. The authors also found that contextual factors (e.g., therapeutic alliance, therapist empathy, client expectations) accounted for a sizeable proportion of patient outcomes. A key element in this understanding of effective therapy is the role of the therapist. The authors reviewed various studies and meta analyses that showed that therapists differ widely in their outcomes and in their ability to establish a therapeutic alliance. Unfortunately, therapists tend to be overly-optimistic about their clients’ outcomes. Therapists often do not have quality data on their clients’ progress, and the complexities of the therapeutic work makes it difficult for therapists to keep in mind all aspects of the therapy that is helpful or not helpful to clients. For example, some therapists may be good at establishing an alliance, but they may not be so good at providing a viable treatment structure. Other therapists may be highly empathic with clients who have moderately severe symptoms, but the same therapists may not respond as empathically with more difficult clients. Outcome or process monitoring (i.e., providing therapists with reliable information about the ongoing status of patient symptoms or about the quality of the therapeutic relationship) provides an evidence-based aid in helping therapists to improve their clients’ outcomes.

Practice Implications

Regardless of the type of psychotherapy they use, therapists are responsible for achieving good outcomes for their clients. This includes continually developing therapeutic skills over time. There is some evidence that a reflective attitude towards one’s psychotherapy practice is helpful. Unfortunately, therapists may not be continually improving or reflecting on their practice. This is indicated by research showing that trainees and interns appear to be as competent as experienced clinicians. Therapists need quality information about their clients in order to improve their own practice and clients’ outcomes. But psychotherapy practice is complex, the therapeutic relationship is multifaceted, and clients are variable in their presenting issues and life experiences. All of these make it difficult for any therapist to make accurate decisions in therapy. Progress or process monitoring (i.e., continually measuring outcomes and relationship processes with a psychometrically valid instrument), may be one way for therapists to receive high quality feedback about patient progress in order to improve their psychotherapy practice.