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.
…I blog about transtheoretical principles of change, microaggressions and outcomes, interpretations and outcomes.
Type of Research
- ALL Topics (clear)
- Alliance and Therapeutic Relationship
- Anxiety Disorders
- Attendance, Attrition, and Drop-Out
- Client Factors
- Client Preferences
- Cognitive Therapy (CT) and Cognitive-Behavioural Therapy (CBT)
- Combination Therapy
- Common Factors
- Depression and Depressive Symptoms
- Efficacy of Treatments
- Feedback and Progress Monitoring
- Group Psychotherapy
- Illness and Medical Comorbidities
- Interpersonal Psychotherapy (IPT)
- Long-term Outcomes
- 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
- Therapist Factors
- Transference and Countertransference
- Trauma and/or PTSD
- Treatment Length and Frequency
Long-Term Outcome of Psychodynamic Therapy and CBT in Social Anxiety Disorder
Leichsenring, F., Salzer, S., Beutel, M.E., Herpertz, S., Hiller, W. et al. (2014). Long-term outcome of psychodynamic therapy and cognitive-behavioral therapy in social anxiety disorder. American Journal of Psychiatry, Advance online publication: doi:10.1176/appi.ajp.2014.13111514.
Social anxiety disorder is a highly prevalent mental disorder, with lifetime prevalence of about 12% in the population. As Leichsenring and colleagues note, the disorder has an early onset and can have a chronic course leading to many psychosocial impairments. Also, social anxiety disorder often is comorbid with depression. There is good evidence for the efficacy of cognitive behavioral therapy (CBT) for social anxiety disorder and some evidence for psychodynamic therapy (PDT), but most studies have only assessed short term outcomes. In this large mulit-center randomized controlled trial comparing CBT and PDT for social phobia, Leichsenring and colleagues report on outcomes up to 2 years post treatment. The study had 416 adult patients randomly assigned to one of the treatments, and 79 randomly assigned to a waiting list. Outcomes were reported at post, 6 months, 12 months, and 24 months post treatment, and included remission of social phobia, depression levels, and interpersonal problem scores. The CBT intervention for social phobia was based on the model by Clark and Wells. The PDT was based on Luborsky’s model but specifically adapted for social phobia. Participants received 25 sessions of individual therapy, and therapists received advanced training in the models. CBT resulted in significantly greater remission of social phobia than PDT at post treatment, but the difference was small. Remission rates at 6, 12, and 24 months post treatment were not different between treatments. At 2 years post treatment 39% of those receiving CBT and 38% of those receiving PDT no longer had clinical symptoms of social phobia. Results were similar for interpersonal problems in which CBT showed an earlier response, but the two treatments were equivalent at each follow up. Depression scores improved for both interventions at post and follow ups.
The findings of this large study suggest that both CBT and PDT are effective treatments for social phobia. Although CBT had a small advantage at post treatment, PDT appeared to have an “incubation effect” in which patients continued to work on interpersonal problems and symptoms of social phobia over the longer term. Despite these positive outcomes, Leichsenring and colleagues suggest that there remains room for improvement in treating social phobia. Those who do not respond to these interventions may require different forms of treatment that is more specific, intense, or of longer duration. Leichsenring and colleagues also suggest integrating elements of the effective treatments within a single protocol. Although intuitively appealing, this integrated approach has not been tested.
Global Burden of Depression
Ferrari, A.J., Charlson, F.J., Norman, R.E., Patten, S.B., Freedman, G., et al. (2013). Burden of depressive disorders by country, sex, age, and year: Findings from the global burden of disease study 2010. PLoS Medicine, 10(11): e1001547. doi:10.1371/journal.pmed.1001547.
Depressive disorders are among the most common mental disorders that previously were described as a leading cause of burden in the world. In epidemiological literature, burden is defined in several ways. One common metric is “disability adjusted life years” (DALYs) which represents loss of a healthy year of life. DALYs can be aggregated into the “years of life lived with disability” (YLD). Another metric is the “years of life lost due to premature mortality” (YLL). Each of these metrics of burden can be estimated from aggregating data from a number of studies and meta analyses that assess burden world wide. Such epidemiologic studies can also look at relative burden across countries, ages, and sex. In the 2000 Global Burden of Disease report, depressive disorders were the third leading cause of burden after lower respiratory infections and diarrhoeal diseases. Depression was also the leading cause of disability, responsible for 13.4% of years of life living with disability in women and 8.3% in men. In this study by Ferrari and colleagues, the authors provide a 2010 update to the Global Burden of Disease report for major depressive disorder and dysthymia. Major depressive episode is the experience of depressed mood almost all day, every day, for at least 2 weeks. Dysthymia involves a less severely depressed mood with duration of at least 2 years, a chronic rather than episodic course, but with low rates of remission. Ferrari and colleagues reviewed over 700 studies from 1980 to 2010. Prevalence (i.e., current rate) of major depression and dysthymia in the world population is 5.95%, representing nearly 400 million people. Major depression (4.4%) occurs more frequently than dysthymia (1.55%). Major depression occurs more frequently among women (5.5%) than men (3.2%). Major depression accounted for 8.2% of all years lost to disability, making it the second leading cause after low back pain. The percent of years lost due to disability increased since 1990, largely due to population increases and aging of the world population. The highest level of burden due to depression was seen in Afghanistan and the lowest in Japan. In terms of world regions, North Africa and Latin America showed the highest levels of burden due to depression. The authors also reported that 2.9% of disability adjusted life years from ischemic heart disease can be attributed to major depression.
This study joins others in past decades to define depression as a leading cause of years lost to disability worldwide, with over 400 million people suffering from a depressive disorder. The increasing burden of depression is partly due to decreasing mortality caused by other diseases in developing countries and population aging. Countries that have recently experienced conflict (e.g., Afghanistan, North Africa, Middle East) were particularly burdened by depression. But research has also linked depression to intimate partner violence and child sexual abuse. Mortality is elevated with major depression, as is disability related to other medical problems like heart disease. This epidemiological research points to the importance of identifying and treating depression in the population. Psychotherapeutic interventions provide highly effective treatments for depression.
Medication Versus Psychotherapy for Depressive and Anxiety Disorders
Cuijpers P, Sijbrandij M, Koole SL, Andersson G, Beekman AT, Reynolds III CF (2013). The efficacy of psychotherapy and pharmacotherapy in treating depressive and anxiety disorders: A meta-analysis of direct comparisons. World Psychiatry, 12, 137-148.
Both psychotherapy and antidepressant medications are efficacious treatments for depression and anxiety disorders. However, there remains some debate about whether they are equally effective for all disorders, and whether psychotherapy and antidepressants are equally efficacious for each disorder. As I indicated in the March 2014 blog, antidepressant medications alone have become the first line of treatment for many who have depressive and anxiety disorders. However, a recent meta analysis concluded that monotherapy with medication alone was not optimal treatment for most patients, and that adding psychotherapy results in clinically meaningful improvement for most patients. Cuijpers and colleagues (2013) reported on an overall meta analysis of the studies in which psychotherapy and medication were directly compared to each other in adults with depressive disorders, panic disorder, generalized anxiety disorder (GAD), social anxiety disorder (SAD), or post-traumatic stress disorder (PTSD). They combined the effects of 67 studies including 5,993 patients. Forty studies included depressive disorders and 27 included anxiety disorders. Most therapies (49 of 78) were characterized as cognitive behavioral therapy (CBT), and the others included interpersonal psychotherapy, psychodynamic therapy, and non-directive counselling. Most patients were seen in individual treatment for 12 to 18 sessions. The most commonly prescribed medications were selective serotonin reuptake inhibitors (SSRI). The overall mean effect size for the difference between psychotherapy and medications was almost zero, indicating no significant difference. Regarding specific disorders and treatments, pharmacotherapy was more effective for dysthymia, but the effect size was small. By contrast, psychotherapy was more effective for OCD, and the effect size was moderately large. SSRI had similar effects to psychotherapy, but non-directive counselling was less effective than pharmacotherapy, though the effect was small.
This meta analysis by Cuijpers and colleagues found that the differences between psychotherapy and antidepressant medications were non-existent for major depression, panic disorder, and SAD. Although antidepressants were more effective for dysthymia, the difference was small and disappeared when study quality was controlled, and so this finding is not reliable. Psychotherapy was clearly more effective for OCD even after adjusting for study quality and other factors. This is the first meta analysis to show the relative superiority of psychotherapy for OCD, and suggests psychotherapy as a first line treatment. The meta analysis only looked at post treatment results and not at longer term effects. There is evidence from other research showing that antidepressants do not have strong effects after patients stop taking them, whereas psychotherapy’s effects tend to be sustained in the longer term.
Barriers to Conducting CBT for Social Phobia
McAleavey, A.A., Castonguay, L.G., & Goldfried, M.R. (2014). Clinical experiences in conducting cognitive-behavioral therapy for social phobia. Behavior Therapy, 45, 21-35.
It might come as a surprise to some that social phobia (also called social anxiety disorder) is the most commonly diagnosed anxiety disorder, with a lifetime prevalence of about 12%. Symptoms include negative self-view, fear of embarrassment or criticism, and fear and/or avoidance of social situations. Cognitive behavioral therapy (CBT) is an effective treatment for social phobia with effects as large as pharmacotherapies. Despite this, there are several potential barriers to implementing CBT for social phobia in clinical practice. CBT involves exposure to feared situations (in vivo or simulated), identifying and altering maladaptive thoughts during exposure, producing testable hypotheses, and identifying cognitive errors. CBT is not uniformly effective for all patients with social phobia, exposure techniques are linked to dropping out and failure to initiate treatment, and there can be an increase in missed sessions and non-completion of homework related to avoidance. In this study, McAleavy and colleagues surveyed 276 psychotherapists who provided CBT for social phobia to assess problems or barriers clinicians encountered when applying CBT in practice. Possible barriers listed in the survey were derived from extensive interviews with experts who developed and researched CBT interventions for anxiety disorders. Survey respondents were mostly Ph.D. level clinical psychologists (59%), women (61%), who practiced in outpatient clinics or private practice, and had on average 12 years of post-degree experience. Many therapists reported using behavioral interventions, including developing a fear/avoidance hierarchy, in-session exposures, focusing on behavior in social situations, and specifically focusing on behavioral avoidance. Most also used cognitive homework (i.e., interventions focused on exploring or altering attributions or cognitions). The most frequent therapist endorsed barriers to implementing CBT for social phobia included: patient symptoms (i.e., severity, chronicity, and poor social skills); other patient characteristics (i.e., resistance to directiveness of treatment, inability to work independently between sessions, avoidant personality disorder, limited premorbid functioning, poor interpersonal skills, depressed mood); patient expectations (i.e., that therapist will do all the work; pessimism regarding therapy); patient specific beliefs (i.e., belief that fears are realistic, or that social anxiety is part of their personality); patient motivation (i.e., premature termination, attribution that gains are due to medications); and patient social system (i.e., social system endorses dependency, social isolation). A minority of CBT therapists endorsed a weak therapeutic alliance or aspects of the CBT intervention itself as posing a barrier.
CBT therapists identified a number of barriers, mainly patient related, that might impede the implementation of CBT for social phobia. Given these barriers the authors suggested that therapists: (1) consider more intense, longer, or more specific treatments for more severe cases; (2) incorporate assessment of patient severity to guide decisions; (3) consider tailoring the level of treatment directiveness based on patient characteristics – i.e., more resistant patients may require a less directive approach and more control over the type and pace of interventions; (4) prepare patients on what to expect in the treatment before therapy begins; (5) find a balance between validating/accepting patients’ problematic beliefs that their fears might be realistic with encouragement to change; (6) add motivational interviewing for patients who are less motivated; (6) complete a thorough functional analysis of patients’ social systems at the start of therapy. McAleavey and colleagues noted that while therapeutic alliance difficulties was an infrequently endorsed barrier by therapists, such difficulties remain clinically important, especially in light of findings that indicate that negative reactions to patients are under-reported by therapists. Developing and maintaining a good alliance remains a key aspect of CBT for panic disorder.
Adding Psychotherapy to Medications for Depression and Anxiety
Cuijpers, P., Sijbrandij, E.M., Koole, S.L., Andersson, G., Beekman, A.T. & Reynolds, C.F. (2014). Adding psychotherapy to antidepressant medication in depression and anxiety disorders: A meta-analysis. World Psychiatry, 13(1), 56-67.
Anxiety and depressive disorders occur at a high rate and are very burdensome to those who suffer. These disorders are also related to high levels of health care costs, loss of productivity, and lower quality of life. Both pharmacological and psychotherapeutic interventions are effective, yet in recent years there has been a trend for patients to receive psychotropic interventions alone rather than psychotherapy. Cuijpers and colleagues (2014) conducted a meta analysis comparing pharmacotherapy alone versus pharmacotherapy combined with psychotherapy. Studies in the meta analysis included a variety of disorders such as depressive disorders and anxiety disorders. (Meta analysis is an important tool to review and combine the effects of interventions across a large number of studies. Rather than simply counting studies with positive, neutral, or negative findings, meta analysis allows one to calculate an effect size, average the effect sizes across different studies, and look at predictors or moderators of the effects. Aggregated effect sizes in a meta analysis are much more reliable [i.e., dependable] than any single study result). Cuijpers and colleagues’ meta analysis included 52 studies with 3,623 patients. Most studies tested cognitive behavioral therapy, though a large minority also included interpersonal psychotherapy and psychodynamic therapy. Most studies used selective serotonin reuptake inhibitors (SSRI), though some included tricyclic antidepressants and others. There was a moderately large overall difference between pharmacotherapy versus combined pharmacotherapy plus psychotherapy for major depression, panic disorder, and obsessive compulsive disorder (OCD). That is, adding psychotherapy resulted in a clinically meaningful improvement above and beyond pharmacotherapy alone. There were no significant differences found for type of antidepressant medication or for type of psychotherapy. Eleven studies included a placebo control condition to which medication alone vs medication plus psychotherapy was compared. The effect of combining medication and psychotherapy was twice as large as the effect of medication alone when compared to a placebo control condition. Nineteen studies followed patients after treatment (from 3 to 24 months post treatment), and the superiority of combined treatment versus medication alone remained strong and significant well into follow up.
There has been a trend over the past decade to provide medication as a first line of treatment for depression and anxiety disorders. However, the results of this meta analysis indicate that monotherapy with medication alone is not optimal treatment for most patients, and that psychotherapy results in additive clinically meaningful improvement for most patients. The additive effects of psychotherapy are especially pronounced for major depression, panic disorder, and OCD.
Separation Anxiety in Childhood is Related to Adult Panic and Anxiety Disorders
Kossowsky, J., Pfaltz, M., Schneider, S., Taeymans, J., Locher, C., & Gaab, J. (2013). The separation anxiety hypothesis of panic disorder: A meta-analysis. American Journal of Psychiatry, 170, 768-781.
The concept of separation anxiety is intimately tied to attachment theory. Problematic early attachments have negative consequences for adults’ ability to experience and internalize positive relationships which help to develop mental capacities to self sooth, tolerate anxiety, and modulate affect. Separation anxiety is the persistent, excessive, and developmentally inappropriate fear of separation from major attachment figures, like parents. It is one of the most frequently diagnosed childhood anxiety disorders, with a lifetime prevalence of 4.1% to 5.1%. If we knew that separation anxiety is truly related to or causes adult psychopathology, then we would have a better understanding of the development of adult mental disorders and greater reason to quickly and aggressively treat childhood separation anxiety. A meta analysis by Kossowsky and colleagues (2013) begins to address this relationship between separation anxiety and adult disorders. They looked at case-control, prospective, and retrospective studies comparing children with and without separation anxiety disorder with regard to future panic disorder, major depressive disorder, any anxiety disorder, and substance use disorders. The meta analysis included 25 studies of 14, 855 participants. Children with separation anxiety were 3.45 times more likely to develop a panic disorder later on; and 5 studies suggested that children with separation anxiety were 2.19 times more likely to develop future anxiety disorders. Childhood separation anxiety disorder did not increase the risk of future depressive disorders or of future substance use disorders. In a subsequent paper, Milrod and colleagues (2014) reviewed the literature on separation anxiety and psychotherapy outcomes of adult anxiety and mood disorders. Separation anxiety is associated with poor response to treatment of adult anxiety and mood disorders possibly because separation anxiety disrupts the therapeutic relationship. Separation anxiety also predicted non-response to antidepressant medications.
As Kossowsky and colleagues (2013) indicate, it is possible that children suffering from separation anxiety disorder may be hindered early on in developing skills to help cope with anxiety and strong emotions. Nevertheless, the findings draw our attention to the importance of recognizing and treating separation anxiety as early as possible. A few psychological treatment studies show that disorder-specific parent-child cognitive behavioral therapy is successful in treating separation anxiety in children. For adults, poorer treatment response may reflect difficulty forming and maintaining attachments, including the therapeutic relationship. Milrod and colleagues (2014) suggest that psychotherapies that focus on relationships and separation anxiety by using the dyadic therapist-patient relationship to revisit earlier problematic parent-child relationships may benefit adults with separation anxiety.