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.
…I blog about psychotherapy for borderline personality disorder, capacity to metnalize and therapy resistant depression, and negative effects of psychotherapy
Type of Research
- ALL Topics (clear)
- Alliance and Therapeutic Relationship
- Anxiety Disorders
- Attendance, Attrition, and Drop-Out
- Client Factors
- Client Preferences
- Cognitive Therapy (CT) and Cognitive-Behavioural Therapy (CBT)
- Combination Therapy
- Common Factors
- Depression and Depressive Symptoms
- Efficacy of Treatments
- Feedback and Progress Monitoring
- Group Psychotherapy
- Illness and Medical Comorbidities
- Interpersonal Psychotherapy (IPT)
- Long-term Outcomes
- Neuroscience and Brain
- Outcomes and Deterioration
- Personality Disorders
- Placebo Effect
- Practice-Based Research and Practice Research Networks
- Psychodynamic Therapy (PDT)
- Resistance and Reactance
- Self-Reflection and Awareness
- Suicide and Crisis Intervention
- Therapist Factors
- Transference and Countertransference
- Trauma and/or PTSD
- Treatment Length and Frequency
Psychological and Pharmacological Treatments for Generalized Anxiety Disorder
Carl, E., Witcraft, S.M., Kauffman, B.Y., Gillespie, E.M., Becker, E.S…. Powers, M.B. (2019). Psychological and pharmacological treatments for generalized anxiety disorder (GAD): a meta-analysis of randomized controlled trials. Cognitive Behaviour Therapy, DOI:10.1080/16506073.2018.1560358
Generalized anxiety disorder (GAD) is characterized by excessive and difficult to control worry about events or activities. GAD is associated with a high level of impairment in social functioning, work productivity, and health-related quality of life. GAD is also associated with a high level of medical costs and health care utilization. About 4.3% of the general population have experienced GAD at one time in their life. In this updated meta-analysis, Carl and colleagues reviewed the empirical literature to compare the effects of psychotherapies and pharmacotherapy to control conditions. Seventy-nine studies with over 11,000 participants were included in the review. In 39 comparisons, evidence-based psychotherapies outperformed control conditions on measures of anxiety at posttreatment (g = 0.76, 95% CI: 0.61–0.91, p < 0.001), suggesting a medium to large effect. Only 12 studies evaluated follow-up data, and they found that psychotherapy resulted in a small but statistically significant average effect on anxiety symptoms (g = 0.27, 95% CI: 0.00–0.53, p = 0.05). Compared to older patients, younger patients tended to do better in psychotherapy. Forty-three studies found that pharmacotherapy consistently outperformed control conditions at post-treatment (g = 0.38, 95% CI: 0.30–0.47, p < 0.001) suggesting a small effect. There were no studies that assessed pharmacotherapy at a follow-up date. Patient age or treatment dose did not affect outcomes of pharmacotherapy. The authors were careful to point out that that the effect sizes of psychotherapy and pharmacotherapy were not comparable in this meta-analysis because psychotherapy trials tended to use no-treatment controls whereas pharmacotherapy trials tended to use placebo controls, and the latter tends to produce more conservative (smaller) estimates of effects.
Both psychotherapy and pharmacotherapy appear to be effective by post-treatment for patients with GAD. The effects of psychotherapy at follow-up is diminished, and no studies evaluated whether patients receiving pharmacotherapy maintained any gains at follow-up. Research has suggested that compared to psychotherapy, pharmacotherapy outcomes for depression at follow up is poorer. Although this study does not allow one to compare psychotherapy to pharmacotherapy, evidence from another meta-analysis suggests that patients would strongly prefer psychotherapy if given the choice. And patients receiving their preferred treatment tend to experience significantly better outcomes.
Author email: email@example.com
Placebo Response in Transcranial Magnetic Stimulation for Depression
Razza, L. B., Moffa, A. H., Moreno, M. L., Carvalho, A. F., Padberg, F., Fregni, F., & Brunoni, A. R. (2018). A systematic review and meta-analysis on placebo response to repetitive transcranial magnetic stimulation for depression trials. Progress in Neuro-Psychopharmacology & Biological Psychiatry, 81, 105-113.
Transcranial magnetic stimulation (TMS) is a new treatment for depression thought to modulate brain activity through electromagnetic pulses delivered by a coil placed over the patient’s scalp. A meta analysis shows that TMS may be effective in treating depressive disorders when compared to a placebo control, although only 18.6% of those receiving TMS were no longer depressed at the end of treatment. The placebo control condition usually involves a sham version of TMS in which the coil is placed over the scalp but no magnetic stimulation is applied. In antidepressant trials, the placebo response is quite high such that approximately 40% of patients respond to the placebo condition (in antidepressant trials, the placebo condition includes an identical pill that is inert). In this meta analysis, Razza and colleagues assess the placebo response in TMS. They included only double blind randomized controlled trials (i.e., trials in which both the patient and physician were not aware if the treatment was real or a sham). The authors estimated the placebo response based on pre- to post-sham TMS scores of common measures of depression. The meta analysis included 61 studies of over 1300 patients. The main result showed that sham response was large (g = 0.80; 95%CI = 0.65–0.95). Trials including patients with only one episode of depression or who were not treatment resistant (g =0.67, 95%CI = 0.06–1.28, p= 0.03) had higher placebo responses than those trials in which patients previously had two or more failed antidepressant treatments (g = 0.5, 95%CI = 0.03–0.99, p = 0.048).
The results of this meta analysis demonstrates a high placebo response in trials testing TMS. This is similar to the high level of placebo response commonly seen in patients in antidepressant medication trials. It appears that psychological factors like attention, instillation of hope, patient expectations of receiving benefit, and perhaps working alliance may account for an important portion of why pharmacological and other medical interventions appear to work for those with depressive disorders. This is particularly true for patients who are receiving treatment for the first time or for whom previous medical treatment was successful.
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.
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.
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.
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.
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.
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.
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).
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.