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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.

Jennissen, S., Huber, J., Ehrenthal, J.C., Schauenburg, H., & Dinger, U. (2018). Association between insight and outcome of psychotherapy: Systematic review and meta-analysis. The American Journal of Psychiatry. Published Online: https://doi.org/10.1176/appi.ajp.2018.17080847

For many authors, one of the purported mechanisms of change in psychotherapy is insight. In fact, the utility of insight for clients with mental health problems was first proposed over 120 years ago by Freud and Breuer. Briefly, insight refers to higher levels of self-understanding that might result in fewer negative automatic reactions to stress and other challenges, more positive emotions, and greater flexibility in cognitive and interpersonal functioning. Although insight is a key factor in some psychodynamic models, it also plays a role in other forms of psychotherapy. Experiential psychotherapy emphasises gaining a new perspective through experiencing, and for CBT insight relates to becoming more aware of automatic thoughts. Jennissen and colleagues defined insight as patients understanding: the relationship between past and present experiences, their typical relationship patterns, and the associations between interpersonal challenges, emotional experiences, and psychological symptoms. In this study, Jennissen and colleagues conducted a systematic review and meta analysis of the insight-outcome relationship, that is the relationship between client self-understanding and symptom reduction. They reviewed studies of adults seeking psychological treatment including individual or group therapy. The predictor variable was an empirical measure of insight assessed during treatment but prior to when final outcomes were evaluated. The outcome was some reliable and empirical measure related to symptom improvement, pre- to post- treatment. The review turned up 22 studies that included over 1100 patients mostly with anxiety or depressive disorders who attended a median of 20 sessions of therapy. The overall effect size of the association between insight and outcome was r = 0.31 (95% CI=0.22–0.40, p < 0.05), which represents a medium effect. Moderator analyses found no effect of type of therapy or diagnosis on this mean effect size, though the power of these analyses was low.

Practice Implications

The magnitude of the association between insight and outcome is similar to the effects of other therapeutic factors such as the therapeutic alliance. When gaining insight, patients may achieve a greater self-understanding, which allows them to reduce distorted perceptions of themselves, and better integrate unpleasant experiences into their conscious life. Symptoms may be improved by self-understanding because of the greater sense of control and master that it provides, and by the new solutions and adaptive ways of living that become available to clients.

Author email: Simone.Jennissen@med.uni-heidelberg.de

Munder, T., Fluckiger, C., Leichsenring, F, Abbass, A.A., Hilsenroth, M.J., … Wampold, B.E. (2018). Is psychotherapy effective? A re-analysis of treatments for depression. Epidemiology and Psychiatric Sciences, 1-7.

Based on a deeply flawed review in 1952, Hans Eysenck declared that psychotherapy was no more effective than custodial care for treating mental disorders. Later, he qualified this by stating that behaviour therapy was effective and other forms of psychotherapy were not. These statements touched off decades of angst and debate in the psychotherapy community, and also resulted in a great deal of research about psychotherapy’s effectiveness. By the 1970s the new research technique of meta-analysis was developed and was applied to psychotherapy research. In their seminal meta analysis of controlled studies, Smith and Glass found that psychotherapy was useful and with large effects compared to no treatment. And yet the debate continues. In 2018, Cuijpers argued that waitlist control groups (i.e., a common control condition in psychotherapy studies in which patients receive no treatment) are an inappropriate comparison leading to exaggerated estimates of the effects of psychotherapy. Recently, Munder and colleagues argued that waitlist controls are a way of estimating the natural course of the disorder (what would happen with no treatment) plus the effect of expecting to receive treatment (client expectations of receiving treatment tend to have a positive impact on symptoms). In fact, research shows that pre- to post-study effect sizes for the waiting period is approximately g = .40, or a medium effect. In other words, waiting for therapy in a study results in a moderate proportion of individuals getting better on their own without treatment. Therefore, Munder and colleagues argued that comparing psychotherapy to a waitlist control is appropriate and may be a conservative estimate of psychotherapy’s effects (i.e., psychotherapy has to outperform the effects of clients expecting treatment to help them). In their meta analysis, Munder and colleagues re-analysed 71 studies of psychotherapy for depression compared to a waitlist control condition. They found that the effect size in favour of psychotherapy was g = 0.75 (SE = 0.09) indicating a moderate to large effect. Psychotherapy was also more effective than care as usual (i.e., compared to another intervention that was not psychotherapy), g = 0.31 (SE = 0.11). There were no differences between types of psychotherapy (CBT, IPT, PDT, etc.) for depression outcomes.

Practice Implications

Despite various attempts during the history of psychotherapy to downplay or disparage its efficacy, research continues to show that psychotherapy is in fact effective. The average effect size compared to the natural history of depression is moderate to large (and that is likely an under-estimate). Again, there is no evidence that one type of psychotherapy is superior to another for treating depression. It is time for the field to move beyond questions of efficacy of psychotherapy and of the relative efficacy of different treatments, and look to understanding therapist interpersonal stances, client characteristics, and relationship factors that may improve outcomes from psychotherapy.

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).

Practice Implications

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.

Cameron, S. K., Rodgers, J., & Dagnan, D. (2018). The relationship between the therapeutic alliance and clinical outcomes in cognitive behaviour therapy for adults with depression: A meta‐analytic review. Clinical Psychology and Psychotherapy, DOI: 10.1002/cpp.2180.

The therapeutic alliance refers to the collaborative agreement between therapist and client on the tasks of therapy (homework, treatment approach, intervention style) and goals of therapy (to reduce depressive symptoms, to improve interpersonal relationships, to cope better with stress), plus the emotional bond between therapist and client. The alliance is part of a larger concept of therapeutic relationship that also includes the real relationship between client and therapist and the transference relationship (maladaptive relational patterns in the client based on a history of relationships with parental figures). The alliance is thought to be a common factor across different therapeutic orientations, including cognitive behavioral therapy (CBT), time-limited psychodynamic psychotherapy (TLPP), and interpersonal psychotherapy (IPT). In fact, the alliance is known to have a moderate and robust relationship to client outcomes regardless of who rates the alliance (therapist, client, observer), which measure is used, and when in therapy the alliance is rated (early, middle, late). Although Beck emphasized the alliance as a key therapeutic principle in CBT, some CBT writers argue that the alliance is not so important. In this study, Cameron and colleagues conducted a meta analysis of 13 randomized controlled trials that assessed the relationship between therapeutic alliance and CBT outcomes for depression in adult clients. The overall mean correlation between therapeutic alliance and outcome was r = 0.26 (95% CI [.19–.32]), which indicates a moderate and significant relationship. This is very close to the value found in a larger meta analysis of over 200 alliance – outcome studies.

Practice Implications

The study demonstrates the importance of the therapeutic alliance to client outcomes in CBT. The association was at similar levels to those found in other types of therapy. Therapists conducting CBT should attend to building and maintaining an alliance, which provides a context to facilitate CBT interventions. If a client is not completing homework for example, it is likely that there is a lack of agreement on tasks of therapy, and this part of the alliance may need to be renegotiated. Therapists may also benefit from routinely assessing the alliance in therapy with their clients on a session by session basis using short and easy to use measures. Reviewing these scales regularly can alert a therapist to potential problems in the alliance and the need to repair any tensions or ruptures.

So, M., Yamaguchi, S., Hashimoto, S., Sado, M., Furukawa, T.A., & McCrone, P. (2013). Is computerised CBT really helpful for adult depression?-A meta-analytic re-evaluation of CCBT for adult depression in terms of clinical implementation and methodological validity. BMC Psychiatry, 13, 113. 

Depression is a major cause of disability in the world, and so efforts to improve access to its treatment have been ongoing for several decades. In particular, many researchers and clinicians propose cognitive behavioural therapy (CBT) as an effective treatment with a good evidence-base. There have been many clinical trials showing the efficacy of CBT. In recent years, there have also been attempts to computerize CBT (CCBT) as a self help intervention in order to increase its accessibility for those with depression, and perhaps also to improve its cost effectiveness. In fact, the Increasing Accessibility to Psychotherapy (IAPT) program in the UK provides CCBT as the most common first treatment for depression. However there remain questions about the longer term effectiveness of CCBT to reduce symptoms of depression, its potentially high patient dropout rate (a negative outcome), and its effects on quality of life of those burdened by depression. In this meta analysis, the largest of its kind, So and colleagues assess these issues with regard to CCBT. They reviewed 14 direct comparison randomized controlled trials that provided 16 comparisons of CCBT versus a control condition (wait list or treatment as usual) for adults with depression. At post-treatment, CCBT was more effective than controls in reducing depression −0.48 [95% CI −0.63 to −0.33]. However, at follow up (up to 6 months), the effects of CCBT disappeared −0.05 [95% CI −0.19 to 0.09]. Also improvement in functioning and quality of life were not significantly different between CCBT and control conditions, −0.05 [95% CI −0.31 to 0.22]. The rate of drop out from CCBT (32%) was almost double that of control conditions (17%), RR = 1.68 [95% CI 1.31 to 2.16]. There was also evidence of publication bias (i.e., a tendency for some researchers not to publish non-significant findings), so that the positive post-treatment results in favour of CCBT might be inflated.

Practice Implications

Although CCBT may be touted as a way to increase access to treatment for depression, this meta analysis indicates some concerns about the widespread implementation of CCBT. The effects of CCBT appear to be limited to a short-term reduction of depressive symptoms that may not be sustained in the longer run. There was no appreciable impact of CCBT on quality of life relative to controls, and so CCBT may have a limited impact on the burden of depression. Most troubling was a high drop out rate of 32%. Drop out from CCBT in the IAPT program in the UK is about 50%, and this may be indicative of the actual drop out rate in real world practice.