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.
This month...
…I blog about therapist empathy, psychotherapeutic treatment for borderline personality disorder, and research on psychological treatment of depression.
Type of Research
Topics
- ALL Topics (clear)
- Adherance
- Alliance and Therapeutic Relationship
- Anxiety Disorders
- Attachment
- Attendance, Attrition, and Drop-Out
- Client Factors
- Client Preferences
- Cognitive Therapy (CT) and Cognitive-Behavioural Therapy (CBT)
- Combination Therapy
- Common Factors
- Cost-effectiveness
- Depression and Depressive Symptoms
- Efficacy of Treatments
- Empathy
- Feedback and Progress Monitoring
- Group Psychotherapy
- Illness and Medical Comorbidities
- Interpersonal Psychotherapy (IPT)
- Long-term Outcomes
- Medications/Pharmacotherapy
- Miscellaneous
- 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
- Termination
- Therapist Factors
- Training
- Transference and Countertransference
- Trauma and/or PTSD
- Treatment Length and Frequency
April 2015
The Efficacy of Psychotherapy for Depression in Parkinson’s Disease
Xie, C.L., Wang, X.D., Chen, J., Lin, H.Z., Chen, Y.H., Pan, J.L., & Wang, W.W. (2015). A systematic review and meta-analysis of cognitive behavioral and psychodynamic therapy for depression in Parkinson’s disease patients. Neurological Sciences, 1-11.
Parkinson’s disease (PD) is a neurodegenerative brain disorder that progresses slowly in most people. When dopamine producing cells in the brain are damaged or do not produce enough dopamine, motor symptoms of PD appear. Non-motor symptoms, including depression, apathy, and sleep disorders are also common so that in clinical settings about a 40% of patients with PD may have a depressive disorder. Depression is a top predictor of poor quality of life in patients with PD. Depression in PD is not well understood but may be due to neurobiological vulnerability and to psychological factors. Antidepressant medications are often prescribed for depression in PD but their efficacy is questionable. Xie and colleagues argue that long term use of some antidepressants may lead to worsening of some PD motor symptoms. In this meta analysis, Xie and colleagues examine the efficacy of brief psychological interventions, including cognitive behavioral therapy (CBT) and psychodynamic psychotherapy for depressive symptoms in PD. Twelve eligible studies were included in the meta analysis representing 766 patients with a mean age of 62 years (48% men). As an interesting note, 9 of the 12 studies were conducted in China and 3 were from the US or UK. Six of the studies used CBT for depression, and the remaining used psychodynamic therapy for depression in PD patients. Control conditions were often “treatment as usual”, and varied from antidepressant medication (e.g., Citalopram), nursing care, telephone calls, or no treatment for the depression. The effects of psychological interventions compared to control conditions on depressive symptoms were large, and remained large even after removing outlier studies. Outcomes for psychodynamic psychotherapy were better than for CBT, although both interventions resulted in large effects. There were also significant positive effects of brief psychotherapies on cognitive functioning, but not on quality of life. The authors were concerned that the quality of studies was variable and that many studies demonstrated a risk of bias. Further, most studies did not report outcomes at follow up periods.
Practice Implications
Significant depressive symptoms commonly occur in patients with Parkinson’s disease (PD). As a result, overall quality of life may be reduced in patients with PD. Medications for depression may be complicated by the neurodegenerative nature of PD – that is, effects of medications on depressive symptoms may be small and their neuro-motor side effects may be intolerable for some patients. This meta analysis by Xie and colleagues of 12 studies suggests that better research on psychotherapy for depression in PD needs to be conducted with adequate follow ups. Nevertheless, the findings suggest that brief psychological interventions may represent viable and effective alternatives for patients with PD who have a depressive disorder.
March 2015
The Efficacy of Existential Therapies for Physically Ill Patients
Vos, J., Craig, M., & Cooper, M. (2015). Existential therapies: A meta-analysis of their effects on psychological outcomes. Journal of Consulting and Clinical Psychology, 83, 115-128.
Existential therapies are a group of psychological interventions that address questions about existence, and they assume that by overcoming existential distress, psychological problems may be decreased. Underlying existential therapy is the assumption that: people need a meaning or purpose, individuals have a capacity to choose and actualize this potential, people will do better when they face challenges rather than avoid them, and human experiencing is related to others’ experiences. Vos and colleagues list four main schools of existential therapies: Daseinanalysis which focuses on free expression and greater openness to the world; logo-therapies which are aimed at helping clients establish meaning in their lives through didactics, British existential therapy which encourages clients to explore their experiences, and the existential-humanistic approach which help clients face mortality, freedom, isolation, and meaninglessness. Vos and colleagues review the research literature showing that meaning in life and positive well-being are associated with coping with stressful life events including life threatening illnesses. In this meta-analysis, the authors review the randomized controlled trials of different types of existential therapies to assess the efficacy of the treatments compared to a control condition like social support groups, being on a waiting list, or receiving care as usual. They grouped outcomes into four areas: meaning in life, psychopathology, self-efficacy, and physical well-being. Their meta-analysis included 15 studies of 1,792 participants, 13 of the studies were with medically ill patients, and 10 of those studies were aimed at patients with cancer. Effects of existential therapy versus a control condition on meaning in life tended to be positive and moderate. Effects on psychopathology and self-efficacy were positive and small. The effects of existential therapies versus a control condition on physical well-being were not significant. There were no differences between the types of existential therapy, though the number of studies was small to adequately assess these differences.
Practice Implications
Clients seem to benefit from group therapy interventions focused on meaning compared to social support groups, being on a waiting list, or receiving care as usual. Medically ill patients who received existential therapy found greater meaning in their lives, and the effects were moderate to large. Their psychopathology and self-efficacy also improved significantly but effects were small. The quality and number of studies was not optimal which limits the confidence one can have in these findings. The authors conclude that despite the small number of studies, existential therapies that use structured interventions that incorporate psychoeducation and discussions on meaning in life are a promising treatment for physically ill patients.
February 2015
Evidence for Psychotherapy of PTSD in Adults Who Experienced Childhood Abuse
Ehring, T., Welboren, R., Morina, N., Wicherts, J.M., Freitag, J., & Emmelkamp, P.M.G (2014). Meta-analysis of psychological treatments for posttraumatic stress disorder in adult survivors of childhood abuse. Clinical Psychology Review, 34, 645-657.
Post-traumatic stress disorder (PTSD) occurs at a very high frequency among those who experienced childhood physical and/or sexual abuse. As adults these individuals often request mental health services. Previous meta analyses of psychotherapies for PTSD have combined samples of those with PTSD due to childhood maltreatment and those due to trauma in adulthood. This meta analysis by Ehring and colleagues is the first specifically to look at treatment of PTSD in those with childhood abuse. Some argue that PTSD due to childhood abuse is different because of the high level of complex symptoms like emotion regulation problems, impulsivity, depression, dissociation, substance abuse, and others. And so treatments for PTSD related to childhood abuse may require different characteristics and may have different outcomes. Further, there is a long standing debate about whether trauma-focused treatments are appropriate for those with PTSD who have high levels of complex symptoms. There is concern for example that the focus on trauma memories may exacerbate symptoms like dissociation. Previous reviews showed that treatments targeting the trauma memory (i.e., focus on processing the memory and its meaning) had the largest effect on PTSD outcomes. This is likely because of the impact that memory processes (i.e., re-accessing memories, maladaptive attributions of memories) have on the maintenance of the disorder. Would these large treatment effects also be found in PTSD that resulted specifically from childhood abuse? (A note about meta analyses: meta analyses are the best way to synthesize a research area because this method combines the effect sizes from multiple studies into a single effect size. The findings of meta analyses are much more reliable than findings from any single study. See my November 2013 blog). Ehrling and colleagues conducted a meta analysis of 16 studies that included over 1200 participants with PTSD due to childhood abuse. Treatments included: trauma-focused cognitive behavioral therapy (CBT), non-trauma-focused CBT, eye movement desensitization and reprocessing (EMDR), and others. Psychological interventions were effective for PTSD related to childhood abuse, and the effects were large for both PTSD symptom severity and for other symptoms (i.e., depression, anxiety, dissociation). Psychological interventions were more effective that control conditions (i.e., wait lists or treatments as usual), and these effects were moderate. Effects remained large or moderate well into post-treatment follow-ups. Trauma focused treatments were more effective than non-trauma-focused treatments, and individual interventions were more effective than group-based interventions.
Practice Implications
Psychological interventions for PTSD in adults who experienced childhood abuse are effective in reducing symptom severity with moderate to large effects. Other symptoms like anxiety, depression, and dissociation also showed large positive changes in these individuals. Research shows that trauma-focused treatments are under-used in routine practice. This may be due to the concern that trauma-focused treatments may not be safe in some individuals with complex symptoms. Trauma-focused treatments may lead to higher effects than non-trauma focused treatments, indicating the potential importance of processing the trauma memory.
Placebo Response is Increasing in Trials of Antipsychotic Medications
Rutherford, B.R., Pott, E., Tandler, J.M., Wall, M.M., Roose, S.P., & Lieberman, J.A. (2014). Placebo response in antipsychotic clinical trials: A meta-analysis. JAMA Psychiatry, doi:10.1001/jamapsychiatry.2014.1319.
The placebo response refers to improvements in symptoms among participants in medication trials that cannot be specifically attributed to the active ingredient of the intervention. For this reason, it is common to have a placebo control condition in trials of medications. In these trials, some participants are randomly assigned to the medication condition, and some are randomly assigned to a placebo control condition. Typically, the placebo is a pill that looks exactly like the medication but that has no active ingredient. Both patients and providers are blind or unaware of whether the patient is receiving the active medication or the placebo. The placebo response is usually attributed to a number of sources: (1) the patient’s expectation of receiving benefit, (2) the patient’s contact with a caring provider and the healing effect of factors like therapeutic alliance and provider empathy, (3) statistical and measurement error, and (4) random changes in patient symptoms that are unrelated to the medication or the placebo. The first two sources are psychological factors that are often specifically active and purposefully enhanced in psychotherapies. That is, some psychotherapists actively work to develop an alliance with the patient and to align therapeutic interventions with patient expectations and preferences. (For a broader discussion, see my review of Common Factors in this month’s PPRNet blog.) The placebo response can sometimes be quite powerful such that antidepressant medications, and antipsychotic medications for example, only tend to be modestly superior to placebo. People with schizophrenia have cognitive difficulties that may reduce their expectations of receiving benefits from treatment. These patients also have significant interpersonal difficulties so that their alliance with health care providers may be significantly hampered. For these reasons, it may be possible that the placebo response may play a smaller role in the medical treatment of patients with schizophrenia. Rutherford and colleagues conducted a meta analysis of 105 studies of over 24,000 participants from 1960 to the present. Their goal was to examine if the average drug-placebo difference decreased significantly over time (i.e. across years of publication). They found that the placebo response significantly increased from 1960 to the present. That is, the average placebo patient tended to get worse in the 1960s, but by the 2000s the average placebo participant tended to get better. The effect of this trend was large (r = .52). By contrast, treatment change associated with antipsychotic medications decreased over time, and the effect of this trend was moderate (r = -.26). The authors suggested possible explanations for this trend. The average participant in drug trials in the 1960s was more severely ill than the average patient enrolled in drug trials in the 2000s. It is possible that the placebo response is more powerful in less severely ill individuals. Also, the authors suggested that a number of study design factors (e.g., multi site vs single site trials, financial incentives to recruit more patients may result in less severely ill and younger samples) may also contribute to this trend.
Practice Implications
One of the practical implications of these findings is that drug companies may be less inclined to fund research and development of new medications for mental illnesses if the research is increasingly showing only modest benefits over control conditions. On the other hand, health care workers who provide: support and empathy, a positive therapeutic alliance, positive expectations about benefits of treatment, attention to patient preferences, and a coherent narrative to understand their patient’s illness may help to enhance the effects of interventions including antipsychotic medications. This may be especially true for younger and less severely ill individuals with schizophrenia.
January 2015
Rate of Drop-Out From Psychotherapy Differs by Treatment Type, but Only for Some Disorders
Swift, J. K., & Greenberg, R. P. (2014). A treatment by disorder meta-analysis of dropout from psychotherapy. Journal of Psychotherapy Integration, 24(3), 193-207.
In one of my first PPRNet Blogs I reported on a meta analysis by Swift and Greenberg (2012) in which they found that almost 1 in 5 patients in clinical trials dropped out of therapy. There were no differences between therapeutic orientations in the drop out rates. However, the authors did report that those with eating disorders (23.9%) and personality disorders (25.6%) dropped out at a higher rate than other disorders. Premature termination from therapy is an important problem in that those who drop out are less satisfied and have poorer outcomes than treatment completers. In this follow up to their meta analysis, Swift and Greenberg ask the interesting question of whether premature termination differs across therapy orientations for any of the specific disorders. They compared the drop out rates of different treatment approaches for each of 12 separate disorders. The studies defined drop out in various ways, including: unilateral termination, not attending a set number of sessions, not achieving clinically significant change, etc. Treatment orientations, included: behavior therapy, cognitive–behavioral therapies, dialectical behavior therapy (DBT), psychodynamic psychotherapies, solution-focused therapy, interpersonal psychotherapy, humanistic/existential/supportive psychotherapies, and integrative approaches. Primary diagnoses included: depression, eating disorders, borderline personality disorder, other personality disorder, somatoform disorder, bereavement, obsessive compulsive disorder, generalized anxiety disorder, panic disorder, post-traumatic stress disorder (PTSD), psychotic disorders, and social phobia. The authors conducted 12 meta analyses, one for each disorder to compare the therapy approaches. Overall, they included 587 studies. There were no differences in drop out rates among therapy approaches for 9 of the 12 disorders. For depression, integrative therapy had significantly lower drop out rates than other approaches (10.9% vs 19.2%), and for PTSD integrative therapy also had the lowest drop out rate compared to other treatments (8.8% vs 21.0%). Also, for PTSD, exposure based interventions had the highest drop out rates (up to 28.5%). For eating disorders, DBT had the lowest drop out rates compared to other approaches (5.9% vs 24.2%), but this was largely explained by older patient samples and shorter duration of treatment in DBT.
Practice Implications
There were no differences between treatments in drop out rates for 9 of 12 disorders. Swift and Greenberg argued that for these disorders, other factors (e.g., therapeutic alliance, client expectations) rather than specific techniques were enough to keep clients in therapy. For depression and PTSD, integrative treatments resulted in the lowest drop out rates. This suggests that therapists might consider incorporating techniques from other orientations that increase the acceptability of therapy for their clients with depression and PTSD. Use of exposure based interventions for PTSD may require a significant amount of work to prepare clients in order to reduce higher drop out rates.
December 2014
Does Cognitive Therapy Have an Enduring Effect Superior to Keeping Patients on Medication?
Cuijpers, P., Hollon, S. D., van Straten, A., Bockting, C., Berking, M., & Andersson, G. (2013). Does cognitive behaviour therapy have an enduring effect that is superior to keeping patients on continuation pharmacotherapy? A meta-analysis. BMJ open, 3(4).
In another in a series of meta analyses by this primarily Dutch group, Cuijpers and colleagues tackle the question of whether the longer term effects of cognitive behavioral therapy (CBT; a short time-limited treatment for depression) outweighs the long term effects of continuation on anti depression medications. CBT is considered an efficacious treatment for depression (see my June 2014 Blog). CBT also has comparable effects as antidepressant medications, but CBT tends to have lower rates of treatment drop outs. What is not clear is whether short term CBT leads to lasting change that is comparable to long term use of medications for depression. One could argue for example, that short term CBT or other comparable psychological interventions teaches patients skills or changes psychological functioning such that future recurrences of depression are less likely. That is, psychological interventions may cause changes that eventually will prevent relapse. Pharmacotherapy on the other hand, may not result in psychological change or acquisition of new skills to forestall a relapse. In fact, patients with chronic depression tend to be kept on medications indefinitely, and patients who recently remit (i.e., no longer have symptoms of depression) are typically kept on pharmacotherapy for another 6 to 12 months to reduce the risk of recurrence. Information about the relative longer term effects of short term treatment with a psychological intervention like CBT versus longer term maintenance on pharmacotherapy can help practitioners and patients decide on the best course of action depending on patient preferences. Cuijpers and colleagues asked: is short term CBT without continuation of treatment as effective as short term treatment of pharmacotherapy with and without long term continuation? They conducted a meta analysis in which the effects of short term CBT were compared to pharmacotherapy in adults diagnosed with depression across follow up periods of 6 to 18 months. Nine studies representing 506 patients were included in the meta analysis. There was a non-significant trend showing that short term CBT outperformed continuation pharmacotherapy at one-year post treatment. On the other hand, CBT resulted in better long term outcomes compared to pharmacotherapy that was discontinued at post treatment. The odds of dropping out of treatment were significantly higher for those receiving pharmacotherapy compared to CBT. There were no differences in any of the findings for type of antidepressant medications.
Practice Implications
The findings reaffirm CBT as a first-line treatment of depressive disorders. It also suggests that equally effective other psychological treatments may also have similar enduring effects compared to pharmacotherapy. Patients and providers need to consider all of the evidence when weighing the pros and cons of psychotherapy or medications for the treatment of depression. Although pharmacotherapy might be more widely available to patients through primary care physicians, the research is suggesting that enduring effects and treatment compliance are higher among those who have access to psychological interventions.