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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.

Handbook of Psychotherapy and Behavior Change: The Handbook of Psychotherapy and Behavior Change is perhaps the most important compendium of psychotherapy research covering a large number of research areas related to psychotherapy. Starting in March 2013, I will review one chapter a month 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 anxiety disorders. Monotherapy of medication or psychotherapy are each effective in treating anxiety disorders, though relapse rates can be high. Simultaneously combining medications and psychotherapy is a common practice that is endorsed by several treatment guidelines. Some may also believe that medication and psychotherapy have additive effects or that those who do not respond to one treatment might respond simultaneously to the other. For panic disorder, short term outcomes slightly favour combined therapy of medications (e.g., antidepressants like SSRIs) and psychotherapy (i.e., that often include exposure). However, long term outcome data indicate that combined treatment was no different than cognitive behavioural therapy (CBT) alone. There is also evidence that medications may interfere with exposure-based treatment of panic disorder so that relapse is greater with combination therapy. It is possible for example that medications may suppress fear-related cognitions thus preventing encoding of corrective information, and/or medication may inhibit extinction learning by suppressing cortisol secretion (in the short term) that facilitates consolidation of memories. The evidence for combining medication and psychotherapy for social anxiety disorder, post traumatic stress disorder, generalized anxiety disorder (GAD), and obsessive compulsive disorder are more mixed but still not clearly supportive of long term superiority of simultaneously combining medications and psychotherapy. Other combination approaches appear to show more promise. For example, there is better evidence for starting with a monotherapy initially and adding an alternative therapy for non-responders. Starting with medications first may allow allows cortisol to normalize over time perhaps reducing medication-induced inhibition of extinction learning. Then treatments such as exposure based CBT or brief dynamic therapy for GAD may be additionally helpful to those who do not respond to medication alone. The existing trials tend not to show evidence of incremental benefit of adding medication after initiating psychotherapy. CBT may be effective in helping individuals taper medications while maintaining treatment gains.

Practice implications

Simultaneously combining medication and psychotherapy for anxiety disorders may be common practice. There is an overall lack of evidence that combining treatments improves outcomes, especially in the longer term. Evidence points to medications interfering with the effectiveness of psychotherapy when they are initiated simultaneously. Compared to monotherapy, combined treatments are more complex, time-consuming, expensive, and expose the patient to increased side effect risk. Combination treatments may be best reserved for those who are refractory to initial monotherapy.

Swift, J.K., Greenberg, R.P., Whipple, J.L., & Kominiak, N. (2012). Practice recommendations for reducing premature termination in therapy. Professional Psychology, 43, 379-387.

As discussed in a previous blog entry, Swift and Greenberg (2012) found that almost 20% of adult individual therapy patients drop out of therapy. Dropping out is generally defined as clients unilaterally terminating psychotherapy prior to benefitting fully and against their therapist recommendation. In this paper, Swift and colleagues review five methods with the best research evidence to reduce premature termination. (1) Providing education about duration and course of therapy. Research indicates that 25% of clients expect to recover after only two sessions of therapy, 44% after four sessions, and 62% expect to recover after 8 sessions. However the research literature indicates that it takes 13 to 18 sessions for 50% of clients to recover. Further, although some clients improve quickly and maintain that, some clients may feel worse before they get better, especially if the symptoms are related to painful feelings or events. So aligning client expectations about the length of treatment and the course of treatment may reduce dropping out. This education should be research based to increase the credibility of the information. (2) Providing role induction. Clients who are naıve to therapy may start not knowing what behaviors or roles are most appropriate on their part and could feel lost or like they are doing things wrong. Role induction refers to providing clients with some pre-treatment education or orientation about appropriate therapy behaviors. This could be done by video, verbally, or in writing. A meta analysis found that pre-therapy role induction increases attendance and reduces drop outs. (3) Incorporating client preferences. Client preferences include wants or desires concerning the type of treatment that is to be used, the type of therapist one would like to work with, and the roles and behaviors that are to take place in therapy. A recent meta analysis found that clients who had their preferences accommodated were almost half as likely to drop out of treatment prematurely compared with clients whose preferences were not taken into account. (4) Strengthening early hope. Although it is important that clients do not hold unrealistic expectations (i.e., recovery after only two sessions), it is also important that they have a general hope that therapy can help them get better. Research evidence shows that expectations for change explain as much as 15% of the variance in therapy outcomes. (5) Fostering the therapeutic alliance. The therapeutic alliance involves agreeing on goals and tasks of therapy, and a positive bond between client and therapist. A rupture in the alliance has been associated with dropping out of therapy, and a previous meta analysis found that a stronger alliance was associated with fewer drop outs.

Practice Implications

Therapists can do 5 things that are research supported to reduce patient drop outs. (1) Provide education about duration and course of therapy.  Practicing clinicians can help their clients to develop realistic expectations about duration and recovery prior to the start of therapy. Clinicians working with a more severely disturbed population or working from an orientation that espouses longer treatment durations may want to alter the education they provide to better fit their clients. (2) Provide role induction. Clinicians can provide education about the “jobs” of both the client and the therapist, such as who is expected to do most of the talking and who will be responsible for structuring or directing sessions. This type of induction should also include a discussion of the rationale for the approach that will be used. (3) Incorporate client preferences. Accommodating client preferences does not mean the therapist should automatically use the client’s preferred methods. Often clients are unaware of what treatment options are available or best suited for their particular problems. Instead, therapists should consider sharing their knowledge about the particular disorder and the nature of different approaches to the treatment of those problems with clients. Clients can then share their preferences regarding those treatment options with the therapist and work collaboratively toward a decision about which approach might be best. (4) Strengthen early hope. Therapists should express confidence that the therapy will work for their patient. Knowing the research evidence on the efficacy of psychotherapy will increase the therapist’s credibility in making such statements. (5) Foster a therapeutic alliance. Efforts to foster the therapeutic alliance should occur early on in therapy when the risk of premature termination is high, and as also therapy progresses. Early efforts should focus on making sure there is an agreement on the goals and tasks before jumping to treatment interventions.

Author email: Joshua.Keith.Swift@gmail.com

Handbook of Psychotherapy and Behavior Change: The Handbook of Psychotherapy and Behavior Change is perhaps the most important compendium of psychotherapy research covering a large number of research areas. The Handbook is updated approximately every 10 years, and the most recent 6^th edition was published in January 2013. In the coming months I will review one chapter a month in addition to commenting on psychotherapy research articles. Book chapters have more restrictive copy right rules about distributing content, so I will not provide author email addresses for these chapters. If you are interested, you can view the table of contents on Amazon.

Lambert, M.J. (2013). The efficacy and effectiveness of psychotherapy. In M.J. Lambert (Ed.) Bergin and Garfield’s handbook of psychotherapy and behaviour change (6^th ed.), pp169-218. Hoboken, N.J.: Wiley.

This comprehensive chapter in the Handbook reviews research on the efficacy and effectiveness of psychotherapy. Lambert’s reviews focus on meta-analyses, which is a way of summarizing effect sizes in a research area. The bottom line is that psychotherapy is effective so that 40% to 60% of clients show substantial benefit in controlled research trials, though the effect is likely smaller in routine practice.  Concurrently, a consistent proportion of adults (5% to 10%) deteriorate during psychotherapy. Patients who receive formal treatment are better off than those who receive no treatment, and bona fide treatments are superior to control conditions that provide only some aspects of effective treatment. When psychotherapy is offered by skilful therapists, on average clients experience appreciable gains and return to normal functioning. Fifty percent of patients achieve clinically significant gains after 8 sessions, and 50% achieve recovery after about 20 sessions of psychotherapy. The effects of psychotherapy tend to be long lasting. For example, only 25% treated depressed patients relapse, whereas 50% of those who receive antidepressants relapse. Research continues to support those therapies that have been rigorously tested, and differences in effectiveness between therapy types (e.g., cognitive behavioural therapy (CBT), psychodynamic, interpersonal, etc.) tend to be small or negligible for many disorders. Cognitive behavioural therapy is still the most tested therapy modality, though other treatments are also accumulating evidence of efficacy. Treatment is likely facilitated by a therapeutic relationship that is characterized by trust, understanding, acceptance, kindness, and warmth. The effect of the therapist providing the therapy is at least as large as the effect of different therapy techniques. That is, some therapists are unusually effective, whereas others may not help the majority of patients who seek their services. Continuous monitoring of outcomes and providing regular feedback to the therapist improves the therapy’s effectiveness.

Practice Implications

Providers and patients can be assured that a broad range of formally defined and tested psychotherapies when provided by skilful therapists are likely to result in appreciable gains in clients including a return to normal functioning. Therapy relationships characterized by trust, understanding, acceptance, and warmth can greatly facilitate change in depression, anxiety, inadequacy, and inner conflicts. When making a decision about which therapy to choose, clients would be wise to consider the therapist as a person at least as much as the type of therapy being offered. Treatment efforts should be based on the best evidence available for treatment types, therapist behaviors, and relationship factors. Routinely monitoring the effects of therapy with each patient will give the therapist ongoing information about their effectiveness and may improve their patients’ outcomes.

Fowler, J.C. (2012). Suicide risk assessment in clinical practice: Pragmatic guidelines for imperfect assessments. Psychotherapy, 49, 81-89.

The journal Psychotherapy regularly publishes Practice Reviews, which are clinician-friendly practical articles that are based on the best current evidence. Recently, James Fowler published a Practice Review on suicide risk assessment. The assessment, management, and treatment of suicidal patients are some of the most stressful events in clinical practice. However, there is very little that is clear in the evidence base to help clinicians to make accurate assessments about suicide risk. Assessing suicide risk factors tends to result in making an inordinate number of false-positive predictions (i.e., deciding that a patient will attempt suicide when in fact the patient will not attempt suicide). Making false positive suicide predictions might be seen by some as desirable because doing so represents a conservative course of action. However, a clinician acting as if a patient will suicide when he or she will not can lead to unintended negative consequences for the therapeutic alliance and for the patient’s future trust in health professionals. Fowler suggests an assessment approach in which efforts are made to enhance therapeutic alliance by negotiating a collaborative approach to assessing risk and understanding why thoughts of suicide are so compelling. The list of protective factors (e.g., supportive social contacts, religious beliefs, therapeutic contacts) and risk factors (e.g., past suicide attempts) based on the most current evidence are presented in the article in easy to read tables. Fowler also presents a list of clinician resources for suicide assessment and facts with handy web site addresses. For example, Fowler suggests the Suicide Assessment Five-step Evaluation and Triage (SAFE-T) that incorporates the risk and protective factors with the best evidence base.

Practice Implications

Most methods of predicting suicide risk result in false positives (i.e., predicting suicide when suicide will not occur). Though conservative, a false positive prediction of suicide risk can have a negative impact on therapeutic alliance and patients’ future trust in health care providers. Evidence-based assessments of risk and protective factors may help. A free SAFE-T pocket guide is available to download at the Substance Abuse and Mental Health Services Administration (SAMHSA) web site: http://store.samhsa.gov/product/SMA09-4432.

Author email: cfowler@menninger.edu