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Cuijpers, P. (2020) Measuring success in the treatment of depression: What is most important to patients? Expert Review of Neurotherapeutics, 20, 123-125.

There is lots of evidence now that psychotherapies of various types are efficacious for the treatment of depression. Psychotherapy trials focus largely on depressive symptoms, and define major depression according to psychiatric diagnostic manuals. However, the diagnosis of major depression, for example, is not a unitary construct. That is, it is simply a collection of symptoms and signs that are purported to make up a category of disorder. In fact, people with major depression are quite varied on a whole range of things, like severity, coping style, motivation, attachment style, personality, and extent of comorbidity with other diagnoses. This means that many psychotherapy studies may be focusing on patient outcomes (i.e., reduction of depressive symptoms) that may or may not be important to patients. In this paper, Cuijpers reviews the literature on what patients want from psychotherapy. He found that while symptom reduction was important to patients with depressive disorders, it was not the only outcome they wanted from psychotherapy. Patients also want to have a more fulfilling lives, to return to productive work, to solve conflicts with close loved ones, to learn to live with a chronic disability or disease, to learn to handle the effects of trauma, and other quality of life issues. Fortunately, some studies do report the effects of psychotherapy on quality of life, social functioning, anxiety, hopelessness, and interpersonal problems. However, even these studies treat such outcomes as if they were uniformly important to all patients in the study. Very few studies take a personalized approach to patient outcomes, in which the outcomes of interest are those determined by each patient specific to their own circumstances and wishes.

Practice Implications

Psychotherapists who practice from an evidence-informed perspective often try to measure outcomes in their own practices using reliable measurements. However, many of these measurements may be too general for any specific patient, or they may represent outcomes that do not align with what the individual patient wants. Practicing clinicians who assess outcomes in their own practices, may want to consider supplementing standard symptom outcome measures with more personalized assessments for patients.

Cuijpers, P., Noma, H., Karyotaki, E.,  Vinkers, C.H., Cipriani, A., & Furukawa, T.A. (2020). A network meta‐analysis of the effects of psychotherapies, pharmacotherapies and their combination in the treatment of adult depression. World Psychiatry, 19, 92-107.

Mental disorders represent a significant health burden worldwide, with over 350 million people affected. Depression is the second leading cause of disease burden. There is ample evidence that psychotherapies and pharmacotherapies are effective in the treatment of depression. There is also evidence for the efficacy of different types of psychotherapy (CBT, IPT, PDT), and for different types of antidepressant medications. Some research suggests that combining psychotherapy and medications is better than either intervention alone, but the evidence is inconclusive. Existing meta analyses only compare two existing treatments directly to each other at a time: psychotherapy vs medications, psychotherapy vs combined treatments, medications vs combined treatments. In this meta-analysis, Cuijpers and colleagues use a method called “network meta-analysis” to study the relative impact of medications, psychotherapy, or their combination. Network meta-analysis is controversial because it relies on indirect comparisons to estimate effects. For example, let’s say one study compared medications (A) to psychotherapy (B), and another study compared medication (A) to combination treatment (C), then a network meta-analysis would estimate the effects of psychotherapy vs combination treatment by using the transitive principle (if A = B, and B = C, then A = C). This logic relies on everything being equivalent across studies. However, in treatment trials one cannot assume that the different studies comparing A, B, and C are equivalent in terms of quality and bias (in fact, we know they are not). In any case, Cuijpers and colleagues found that combined treatment was superior to ei­ther psychotherapy alone or pharmacotherapy alone in terms of standardized effect sizes (0.30, 95% CI: 0.14-0.45 and 0.33, 95% CI: 0.20-0.47). No significant difference was found between psychotherapy alone and pharmacotherapy alone (0.04, 95% CI: –0.09 to 0.16). Interestingly, acceptability (defined as lower patient drop-out rate and better patient adherence to the treatment) was significantly better for combined treatment compared with pharmacotherapy (RR=1.23, 95% CI:

1.05-1.45), as well as for psychotherapy compared with pharmacotherapy (RR=1.17, 95% CI: 1.02-1.32). In other words, pharmacotherapy alone was less acceptable to patients than another treatment approach that included psychotherapy.

Practice Implications

This network meta-analysis by a renowned researcher and in a prestigious journal adds to the controversy around the relative efficacy of psychotherapy vs medications vs their combination. What is clear is that patients find medication alone to be less acceptable as a treatment option, and previous research shows that patients are 4 times more likely to prefer psychotherapy over medications. Unfortunately, most people with depression receive medications without psychotherapy.

Imel, Z. E., Pace, B. T., Soma, C. S., Tanana, M., Hirsch, T., Gibson, J., Georgiou, P., Narayanan, S., & Atkins, D. C. (2019). Design feasibility of an automated, machine-learning based feedback system for motivational interviewing. Psychotherapy, 56(2), 318–328.

I do not mean to conjure up the image of a dystopian future, but I could not resist the pithy title for this blog. Ideally, psychotherapists in training or those who seek professional development would receive high quality accurate feedback about their behavior (e.g., about interpersonal skills, empathy, vocal tone, body language) and competence (e.g., regarding specific interventions) in real time. This would allow psychotherapists and trainees can make fine-tuned adjustments to their behaviors and interventions that match or complement the specific patient with which they are working. But, given the current technology, this is impossible. Instead psychotherapy training and feedback to practicing clinicians is slow, cumbersome, and imprecise. Current supervision and consultation practices rely on giving feedback based on the clinician’s verbal case report or, at best, based on viewing video recordings. There are systems that provide feedback on patient outcomes that may alert psychotherapists to something going amiss in for the patient. But such feedback occurs post-session, is based on patient self-report, and does not inform immediate in-session therapist behaviors. In this study, Imel and colleagues evaluated an initial proof of concept of an automated feedback system that generated quality metrics about specific therapist interventions and about therapist skills like empathy. They used computer technology based on natural language processing to take conversational data from video of psychotherapy sessions in order to answer questions like: “what did the therapist and patient talk about during the session?”, “how empathic was the therapist?”, and “how often did the therapist use reflections versus closed questions in the session?” The authors developed a machine learning tool to transcribe, code, and rapidly generate feedback to 21 experienced and novice therapists who recorded a 10-minute session with a standardized patient (a standardized patient is an actor who loosely follows a script). The machine learning technology was accurate at defining or coding a “closed question” by a therapist (e.g., a question with a yes/no answer; inter rater agreement with a human coder ICC = .80), but not as accurate at defining or coding a therapist empathic statement (inter rater agreement with a human coder ICC = .23). The system provided immediate feedback the therapists about their behaviors during the session using graphics and text (fidelity to specific interventions, counseling style, empathy, percent open/closed questions, percent reflections). All therapists rated the tool as “easy to use”, 86% strongly agreed that the feedback was representative of their performance, 90% agreed that if the tool was available, they would use it in their clinical practice.

Practice Implications

Typically, professional consultation or supervision involves a consultant giving the therapist feedback based on imprecise descriptions of events in a therapy session that occurred at some point in the recent past. This method of training and consultation in psychotherapy has not changed much in the past 60 years. One key drawback of current methods of training and consultation is that they do not make use of real-time feedback to help therapist adjust behaviors to the specific patient or context. It is possible that in the near future with rapid advances in artificial intelligence and machine learning a therapist will be able to finish a session with a patient and receive an immediate feedback report about the previous hour. The feedback might include metrics on empathy, the percent of questions vs reflections, competence in specific interventions, among other personalize ratings. This future might also have novice trainees receive immediate real-time in-session feedback about behaviors of interest that need to be adjusted, or for which more training is necessary. For some, this might be a vision of a dystopian future, for others it may represent a way forward in which therapists achieve more refined skills and better patient outcomes.

Negative Effects of Psychotherapy

Cuijpers, P., Reijnders, M., Karyotaki, E., de Wit, L., & Ebert, D.D. (2018). Negative effects of psychotherapy for adult depression: A meta-analysis of deterioration rates. Journal of Affective Disorders, 239, 138-145.

Several types of psychotherapy are effective to treat depression, and there appears to be very little difference among the treatments in term of their effectiveness. Despite the documented effectiveness of psychotherapies to treat depression, there is also a growing interest in the clinical and research community about negative effects. Negative effects refer to the deterioration or worsening of depressive symptoms during treatment. Some may also refer to drop-out or non-response as a negative effect because these events are demoralizing and may prevent a patient from seeking more adequate care. Some researchers estimated that 5% to 10% of patients deteriorate during therapy. Deteriorations may not be due solely to the therapy itself, but instead may reflect the natural course of depression. In this meta-analysis, Cuijpers and colleagues examined studies in which a psychotherapy for depression was compared to a control condition in which patients did not receive an active treatment. In such studies, one might expect the control condition to represent what would happen in terms of symptoms if the patient received no treatment. Despite over 100 randomized controlled trials of a psychotherapy versus a non-active treatment control condition for depression, only 18 studies reported enough information to estimate negative effects. There was a median deterioration rate in the psychotherapy groups of about 4%, whereas the risk of deterioration in the control groups was about 11%. There were no differences in deterioration rates among types of psychotherapy (CBT vs others), treatment format (group vs individual), or type of control group (wait-list vs care as usual).

Practice Implications

Only 6.2% of research studies reported enough information to estimate negative effects, making it difficult to get a good estimate that represents all studies and patients. Nevertheless, receiving psychotherapy reduced deterioration rates by more than 61% compared to untreated control conditions, suggesting that psychotherapy can help some patients who might get worse with no treatment. Therapists should work to recognize and evaluate deterioration rates in therapy because they do occur for an important minority of patients. Some have suggested ongoing progress monitoring as a means of reducing the number of patients who might get worse during psychotherapy.

Cognitive Behavioral Analysis System of Psychotherapy (CBASP) for Chronic Depression

Schramm, E., Kriston, L., Zobel, I., Bailer, J., Wambach, K., …Harter, M. (2017). Effect of disorder-specific vs nonspecific psychotherapy for chronic depression: A randomized clinical trial. JAMA Psychiatry, 74, 233-242.

The lifetime prevalence of chronic depression is somewhere between 3% and 6% of the population. Chronic depression refers to depression that develops into a chronic course of more that 2 years. Compared to those with acute depression (< 2 years depressed), patients with chronic depression experience greater social, physical, and mental impairments. This large randomized controlled trial by Schramm and colleagues assessed the efficacy of the Cognitive Behavioral Analysis System (CBASP) compared to so-called non-specific psychotherapy (NSP), both delivered in 24 sessions. CBASP is a structured therapy that combines cognitive and interpersonal treatments focused on problems solving and learning the effects of one’s own behaviors on others. On the other hand, therapists delivering NSP were limited to reflective listening, empathy, and helping the client feel hopeful. Specific interventions associated with cognitive or interpersonal therapies were prohibited. A total of 262 patients with chronic depression were randomly assigned to receive 24 sessions of either CBASP or NSP. Main outcomes included indicators of “response” to treatment (a 50% reduction in a depression scale score) or “recovery” (a very low score on the scale at the end of treatment). Both CBASP and NSP resulted in a significant decline in depressive symptoms after 48 weeks. The CBASP condition was slightly more effective than simply providing NSP (d = 0.39, NNT = 5). About 38.7% responded to CBASP compared to 24.3% who responded to NSP (OR = 2.02; 95% CI, 1.09-3.73; p = .03; NNT = 5). In terms of remission, 21.8% recovered after CBASP compared to 12.6% in NSP (OR = 3.55; 95% CI, 1.61-7.85; p = .002; NNT = 4). Average drop-out rates were similar between the two treatments at about 22%.

Practice Implications

CBASP represents a highly structured integrative treatment for chronic depression. It did modestly better than NSP in which therapists were prohibited from engaging in any technical intervention. In the end, the longer-term rates of recovery for CBASP were also modest at about 21.8%. On the one hand, chronic depression is notoriously difficult to treat with psychotherapy or medications, so perhaps CBASP will provide relief for some. On the other hand, an average 21.8% recovery rate for CBASP was modest. CBASP was slightly better than providing active listening and empathy alone.

Adverse Events During Psychotherapy

Meister, R., Lanio, J., Fangmeier, T., Harter, M., Schramm, E., … Kriston, L. (2020). Adverse events during a disorder‐specific psychotherapy compared to a nonspecific psychotherapy in patients with chronic depression. Journal of Clinical Psychology, 76, 7-19.

Adverse events refer to negative or unwanted outcomes of psychotherapy that may be due to the therapy itself when delivered correctly, or to the application of the therapy when delivered incorrectly. For example, patients may report worsening of symptoms, relationship problems with partners or family, problems at work, stigma, and other disadvantages. Adverse events during pharmacologic treatment are well studied and are often considered when making treatment decisions. However, adverse events in psychotherapy are largely ignored in the research and clinical literature. A recent meta analysis reported that the median deterioration rates in psychotherapy studies is about 4%, which is likely less than half the rate of deterioration seen in regular clinical practice. In this study, Meister and colleagues look at deterioration rates in a randomized controlled trial comparing the Cognitive Behavioral Assessment System of Psychotherapy (CBASP) versus non-supportive psychotherapy (NSP). In that study that was previously summarized in this blog, 262 depressed patients were randomly assigned to receive 24 weeks of either CBASP or NSP. Participants who received CBASP were slightly better off than those who got NSP, and the drop-out rates were equivalent between conditions. Therapists asked patients at each session if the patient experienced an adverse event in the previous week. Patients reported an average of about 12 adverse events during the 24 weeks of psychotherapy, and there was no difference in the number of adverse events between CBASP and NSP. However, patients receiving CBASP reported more severe adverse events related to their personal life and work life compared to patients receiving NSP. Suicidal thoughts were infrequently reported by patients, and their frequency did not differ between CBASP and NSP.

Practice Implications

The study highlights that symptoms and interpersonal conflicts may temporarily increase as a result of being in psychotherapy. The authors argued that the increases in problems with work and personal relationships may be due to the specific interpersonal treatment elements of CBASP that require changes in the patient’s interpersonal behaviors that temporarily may be disruptive to their lives. Therapists may consider informing patients about the possible temporary negative effects of psychotherapy on their relationships or functioning. This preparation might help patients to make informed decisions about psychotherapy and to prepare them to cope with changes in their relationships.