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.

July 2017

Cost-effectiveness of Short-term Versus Long-term Psychotherapy

Maljanen, T., Knekt, P., Lindfors, O., Virtala, E., Tillman, P., et al. (2016). The cost-effectiveness of short-term and long-term psychotherapy in the treatment of depressive and anxiety disorders during a 5-year follow-up. Journal of Affective Disorders, 190, 254-263.

There is substantial evidence that short-term psychotherapy is effective for depressive and anxiety disorders, including at follow-up. There are also a few meta-analyses showing the effectiveness of longer term therapy. Although there is research indicating the cost-effectiveness of short-term treatments, less research has evaluated the cost-effectiveness of longer term therapy, and even less research at long term follow-ups. In this study from the Helsinki Psychotherapy Study Group, the authors evaluated the cost-effectiveness of short-term therapy (solution-focused therapy [12 sessions] or short-term dynamic therapy [20 sessions]) versus long term dynamic psychotherapy (2-3 sessions weekly for up to 3 years). Participants (N = 326) with anxiety or mood disorders were randomized to one of the three therapies. Symptoms and work ability were assessed at pre-treatment, post-treatment, and several times during a 5 year follow-up period. A previous publication with this sample showed that long-term treatment resulted in greater recovery with regard to symptoms and work ability (recovery for both outcomes exceeding 60%) compared to short-term treatment (50% recovered). For this study the authors asked: is long-term treatment cost-effective – in other words, is the better outcome from long-term treatment justified by greater cost? Both direct costs (health care utilization) and indirect costs (lost productivity) were calculated in this study using standard econometrics. Long-term therapy cost 3 times as much as short-term treatments. This amount was smaller than expected because those who received short-term treatments had higher auxiliary costs (i.e., the need for other treatments after the short term therapy ended). Shorter therapies were equally cost-effective, but both were more cost-effective than the longer treatment. That is, despite being more effective and requiring less auxiliary treatment, the longer-term therapy was more costly per unit of improvement with regard to symptoms and productivity compared to the shorter treatments.

Practice Implications

From an economic point of view, short-term treatments make the most sense. However, given that many patients needed other treatments after the end of short-term therapy, and given that on average the longer-term therapy was more effective in the long run, a clinician may want to weigh the economics with the specific needs and preferences of each patient.
Is Psychodynamic Therapy as Efficacious as Other Empirically Supported Treatments?

Steinert, C., Munder, T., Rabung, S., Hoyer, J., & Leichsenring, F. (2017). Psychodynamic therapy: As efficacious as other empirically supported treatments? A meta-analysis testing equivalence of outcomes. American Journal of Psychiatry (AJP In Advance)

Mental disorders are an important health concern that confer high levels of personal and economic burden. Up to 45% of primary care patients have at least one mental disorder. Many practice guidelines indicate that cognitive behavioral therapy (CBT), interpersonal therapy (IPT) , and specific pharmacotherapy interventions as empirically supported for common mental disorders. However, many psychotherapists practice psychodynamic therapy (PDT), and a number of reviews have provided evidence for the efficacy of short-term PDT compared to wait-lists, treatment as usual, and other forms of psychotherapy for depression and anxiety disorders. However, there also have been inconsistent findings with regard to the efficacy of PDT. A particularly strict test of efficacy of a therapy involves a comparison of the treatment to a rival intervention that has established efficacy. Such comparisons in which no differences are expected are referred to as equivalence trials. The problem is that no single study in psychotherapy so far is large enough to test for equivalence (technically, this refers to studies being statistically underpowered to detect a small effect), but a meta-analysis that combines samples from many studies can represent a large enough sample and be adequately powered. In this study, Steinert and colleagues conducted a meta-analysis of randomized controlled trials in which PDT was compared to a treatment established in efficacy. Outcomes included target symptoms (anxiety, depression, etc.) measured with reliable instruments. The authors found 21 randomized controlled trials with 2,751 patients, and all of the comparisons included CBT. Based on predetermined accepted standards, the authors decided that an effect size of g = -0.25 to +0.25 would indicate equivalence (i.e., a small and clinically not meaningful difference). Post-treatment differences between PDT and comparison treatments was g = -0.153 (90%CI: -0.227 to -0.079), and similar results were found at follow-up. In other words there were small, non-significant, and clinically not meaningful differences between PDT and other established treatments with accepted efficacy. The studies were rated as high in quality, there was no effect of diagnosis on the results, and there was no evidence of publication bias.

Practice Implications

This meta-analysis found PDT to be as efficacious as other treatments with established efficacy (i.e., CBT). The finding suggest that established practice guidelines may need to be revisited to include PDT. Response rates for anxiety disorders and depressive disorders (around 50%) for those receiving CBT, and even lower remission rates, indicate that there is room for improvement. Having other treatment options may be particularly important for patients who do not respond to one form of therapy and who may need to be switched to another type of intervention.
Are the Effects of Psychotherapy Inflated?

Driessen, E., Hollon, S.D., Bockting, C.L.H., Cuijpers, P., Turner, E.H. (2015). Does publication bias inflate the apparent efficacy of psychological treatment for major depressive disorder? A systematic review and meta-analysis of US National Institutes of Health-funded trials. PLoS ONE 10(9): e0137864. doi:10.1371/journal.pone.0137864.

In 2008 Turner published a well-known study in which he found that almost 50% of antidepressant trials registered with the Food and Drug Administration in the US were never published or were positively “spun” (i.e., essentially negative findings were interpreted to be positive). Almost all of the unpublished trials showed unfavorable results for the antidepressants’ effects. By contrast, the published studies were almost always were positive. This is evidence of publication bias caused by selective publication of some data and suppression of other data. As you can imagine, this has important implications for treatment of depression as the published record appeared to over-inflate effects of antidepressants by 25% (the mean effect size decreased from g = .41 [CI_95% 0.36~0.45] to 0.31 [0.27~0.35] when unpublished studies were included). Has the same type of publication bias occurred in the published record of psychotherapy’s efficacy? In this study by Driessen and colleagues, the authors reviewed all psychotherapy studies for depression funded by the National Institutes of Mental Health in the US between 1972 and 2008. They wanted to determine which ones were published, which were never published, and what the impact of nonpublication was on the mean effect size. Of the 55 grants that were funded, 13 (26.3%) were never published, and the authors were able to obtain data from 11 of those unpublished studies. The overall mean effect size (psychological treatment versus a control condition) of unpublished studies was g = 0.20 (CI_95% -0.11~0.51) indicating a small non-significant effect. The overall mean effect size for published studies was g = 0.52 (CI_95%0.37~0.68) indicating a medium significant effect. Adding the unpublished studies to published studies resulted in a 25% decrease in effect size estimate to g = 0.39 (0.08~0.70), indicating a small but significant effect of psychotherapy.

Practice Implications

This study indicated that psychotherapy is effective but that the effects are likely smaller than indicated in the published record. As in the case of antidepressant medication research, a minority of researchers may not publish findings that are not in line with their preconceived expectations or wished-for results. Regardless, there is certainly room for psychotherapy to improve. After decades of focusing largely on the efficacy of specific psychotherapies like CBT, psychodynamic therapies, and interpersonal therapy, perhaps it is time to shift to studying how and why therapies work, and which patients benefit from specific interventions. There are promising avenues such as research on: repairing therapeutic alliance tensions, enhancing therapist expertise, progress monitoring and feedback, client factors, and managing countertransference.

June 2017

Costs and Benefits of Funding Psychological Services as Part of Medicare in Canada

Vasiliadis, H-M., Dezetter, A., Latimer, A., Drapeau, M., & Lesage, A. (2017). Assessing costs and benefits of insuring psychological services as part of Medicare for depression in Canada. Psychiatric Services in Advance.

About 20% of the population have a mental disorder like depression during their lifetime, and depression is associated with a number of negative health outcomes like mortality, health system costs, and low quality of life. Most patients prefer psychotherapy over medications, but there are significant barriers to accessing psychotherapy, with cost as the biggest barrier. Recently in the United Kingdom, a cost-benefit analysis was used to argue that the development of the Improving Access to Psychological Therapies (IAPT) program would pay for itself in five years. The IAPT is a system of reimbursing psychological therapies through the publicly funded National Health Service in the UK. Similar models are in place in France and Australia. Vasiliadis and colleagues also conducted an economic study in Canada to evaluate the cost-effectiveness of providing psychological services as part of Canada`s Medicare system. They did so by using economic modeling of incidences of depression among patients over a 40-year period, and assessing the relative costs and outcomes of increasing publicly funded access to psychotherapy compared with the status quo. They used known incidence rates for depression in the adult population (2.9%), and estimated health service use from the Canadian Community Health Survey (CHS), and estimated costs (hospitalizations, GP visits, specialist visits, seeing a psychologist or counsellor, antidepressant prescriptions) from provincial health billing manuals. They also used the existing research literature to estimate the average effects of psychotherapy for depression on various outcomes (quality of life, suicide and attempts, health service use, etc.). Adequate mental health services for depression was defined as either 8 sessions of psychotherapy or use of antidepressants. They found that 36.7% of Canadians with depression did not use mental health services, and only 67.4% of those who did access treatment received adequate care. In the economic models that were tested, increasing access to care resulted in a projected decrease in depression, suicidality, health system and societal costs. Increasing access would cost an additional $123 million per year, but savings to society in terms of reduced health system costs and increased productivity was $246 million per year. In other words, for every $1 spent by Medicare on psychotherapy, Canada would recoup $2 in reduced costs and increased productivity.

Practice Implications

The findings of this Canadian study echo those of similar economic studies done in the UK, France, and Australia. Increasing access to psychotherapy for depression through Medicare is more effective and less costly than the status quo. In fact this Canadian study may underestimate potential gains because it did not account for the increased use of the health system by depressed people with chronic medical conditions. Currently, public expenditures for mental health and addictions in Canada account for only 7.2% of the total health budget. An increase of 0.07% of the total health budget to cover psychological services would result in health care cost savings, improved mental health, reductions in disability, and increased productivity among Canadians.
Is the Alliance Really Therapeutic?

Zilcha-Mano, S. (2017). Is the alliance really therapeutic? Revisiting this question in light of recent methodological advances. American Psychologist, 72, 311-325.

The therapeutic alliance is often defined as the agreement between the client and therapist on the goals and tasks of treatment within the context of an affective bond. The alliance is associated with good treatment outcomes regardless of how it is measured, who measures it, when it is measured, and what type of therapy is offered. But researchers and theorists debate the causal role of the alliance in therapy. Is the therapeutic alliance simply a byproduct of an effective treatment (i.e. people begin feel better in therapy and therefore experience a better alliance)? Or is the alliance a client trait which is a necessary factor that enables effective treatments to work (i.e., some clients are better at developing an alliance which is required for therapeutic interventions to take hold). Or is the alliance a state-like factor that fluctuates over time and is therapeutic in and of itself (i.e., the growth in the alliance by itself is sufficient to induce symptom change). In this review of recent advanced methods to research the alliance, Zilcha-Mano provides an overview of statistics that model the session to session dynamic fluctuations and impacts of growth in the therapeutic alliance. She argues convincingly that for the most part, the alliance is not a byproduct of symptom improvement. Using this advanced methodology research indicates that session by session change in symptoms do not precede change in the alliance. The research supporting trait-like aspects of the alliance indicates that some clients are more adept than others at developing an alliance with their therapists. Therefore an early alliance in therapy indicates a client trait that provides a necessary context for effective therapies to do their work. However, research also shows that the alliance changes dynamically over the course of treatment, and that change in the alliance from a preceding session predicts change in symptoms in subsequent sessions. This indicates that alliance also has state-like elements that dynamically fluctuate and influence outcomes, which provides evidence that this aspect of the alliance is therapeutic in and of itself.

Practice Implications

The accumulating research evidence indicate that the therapeutic alliance is a key aspect of successful therapies. New research is showing how to best manage the alliance, like how to repair alliance ruptures. The research also indicates that the role of the alliance may differ according to client characteristics. Those clients who arrive for treatment with better trait-like characteristics (more adaptive representations of self, more adaptive relationships with others) may be better able to create a strong alliance early. For these clients, the alliance may not be highly therapeutic in itself, but rather set the context for therapy interventions to work. However, some clients find it difficult to maintain satisfying relationships with others including the therapist. For these clients, state-like changes in the alliance may be essential for treatment – that is, developing a strong alliance over the course of treatment may be therapeutic in itself to improve their interpersonal relationships outside of therapy.
Specific and Non-Specific Effects in Psychotherapy

Palpacuer, C., Gallet, L., Drapier, D., Reymann, J-M., Falissard, B., & Naudet, Florian (2016). Specific and non-specific effects of psychotherapeutic interventions for depression: Results from a meta-analysis of 84 studies. Journal of Psychiatric Research.

Specific effect in psychotherapy refer to those technical interventions that are based on a treatment model that are specific to a particular modality. For example, the effects on symptoms caused by transference interpretations, cognitive restructuring, or exposure might all be considered specific effects. Non-specific effects is a very broad term that sometimes refers to effects on symptoms caused by common factors across all psychotherapies like therapist empathy, therapeutic alliance, or positive regard. Non-specific effects has also been used to refer to any extra-therapeutic effects that are more peripherally related to treatments, like type of control groups used in a study, researcher allegiance, number of treatment sessions, or length of follow-up. In this meta-analysis of 84 studies of over 6000 participants, Palpacuer and colleagues examined the association between non-specific factors (defined as intervention format [group or individual], client demographics, number of treatment sessions, length of follow up, and researcher allegiance to one of the treatment modalities) and treatment outcomes for depression. First, they looked at whether the specific type of intervention (cognitive behavioral, psychodynamic, interpersonal, problem solving, and others) was associated with reductions in depressive symptoms. Second, they assessed if the non-specific factors added to the prediction of improved depressive symptoms and accounted for some of the effects of specific types of interventions. Similar to previous findings, all psychotherapies were significantly more effective than waiting-list controls. However, the effects of the specific intervention approaches became non-significant when the non-specific factors were included in the analysis. That is, non-specific factors seemed to account for some of the effects of the specific treatments. In particular, if the study was conducted in North America vs Europe (β = 0.55, 95% CI: 0.22; 0.90), if the researcher had an allegiance to a particular therapeutic approach (β = 0.29, 95% CI: 0.07; 0.52), or if the number of sessions was higher (β = 0.03, 95% CI: 0.01; 0.04) then depressive outcomes were better.

Practice Implications

This meta analysis of over 87 studies suggests that although various psychotherapies are effective, there remain questions about how and why they work. For example, the findings suggest that North American patients may have different expectations and higher responses to treatment, that a researcher's belief in the effectiveness of their favored intervention actually improves patients' outcomes, and that a higher number of sessions may also result in better outcomes. These factors appear to account for an important proportion of the specific effects of each type of psychotherapy.

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July 2017

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Psychotherapy Practice Research Network (PPRNet)