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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.

This month...

Giorgio A. Tasca

…I blog about how the therapeutic alliance works, psychotherapy with Indigenous Peoples, and th efficacy of psychotherapy and psychopharmacology

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Topics

April 2017

  • Efficacy of Psychotherapies for Borderline Personality Disorder

    Cristea, I.A., Gentili, C., Cotet, C.D., Palomba, D., Barbui, C., & Cuijpers, P. (2017). Efficacy of psychotherapies for borderline personality disorder: A systematic review and meta-analysis. JAMA Psychiatry. doi:10.1001/jamapsychiatry.2016.4287.

    Borderline personality disorder (BPD) is a debilitating disorder characterized by: severe instability of emotions, relationships, and behaviors. More than 75% of those with BPD have engaged in deliberate self-harm, and suicide rates are between 8% and 10%. BPD is the most common of the personality disorders with a high level of functional impairment. Several psychotherapies have been developed to treat BPD. Most notably, dialectical behavior therapy (DBT), cognitive behavioral therapy (CBT), and psychodynamic treatments like mentalization-based and transference-focused psychotherapy. This meta-analysis by Cristea and colleagues examined the efficacy of psychotherapy for BPD. Studies included in the meta-analysis (33 trials of 2256 clients) were randomized controlled trials in which a psychotherapy was compared to a control condition for adults with BPD. For all borderline-relevant outcomes (combined borderline symptoms, self-harm, parasuicidal and suicidal behaviors) yielded a significant but small effect of the psychotherapies over control conditions at post treatment (g = 0.35; 95%CI: 0.20, 0.50). At follow up, there was again a significant effect of the psychotherapies over control conditions with a moderate effect (g = 0.45; 95% CI: 0.15, 0.75). When the different treatment types were looked at separately, DBT (g = 0.34; 95% CI: 0.15, 0.53) and psychodynamic approaches (g = 0.41; 95% CI: 0.12, 0.69) were more effective than control interventions, while CBT (g = 0.24; 95% CI: −0.01, 0.49) was not. The authors also reported a significant amount of publication bias, suggesting that published results may be positively biased in favor of the psychotherapies.

    Practice Implications

    The results indicate a small effect of psychotherapies at post-treatment and a moderate effect at follow-up for the treatment of BPD. DBT and psychodynamic treatment were significantly more effective than control conditions, whereas CBT was not. However, all effects were likely inflated by publication bias, indicating a tendency to publish only positive findings. Nevertheless, various independent psychotherapies demonstrated efficacy for symptoms of self harm, suicide, and general psychopathology in BPD.

January 2017

  • Individual versus Group Psychotherapy

    Burlingame, G.M., Seebeck, J.D., Janis, R.A., Whitcomb, K.E., Barkowski, S., Rosendahl, J., & Strauss, B. (2016). Outcome differences between individual and group formats when identical and nonidentical treatments, patients, and doses are compared: A 25-year meta-analytic perspective. Psychotherapy, 53, 446-461.

    With increasing service demands being put on mental health systems, clinicians and administrators are looking to more efficient ways of providing care to more patients. One option is group therapy in which more patients can be treated with fewer resources. However, are groups as effective as individual therapy for mental disorders? This meta-analysis by Burlingame and colleagues addresses this question by examining 67 studies in which group and individual therapy were directly compared within the same study. The majority of studies included adults with anxiety, mood, or substance use disorders, with some studies focusing on medical conditions, eating or personality disorders. Two-thirds of studies were of cognitive-behavioral therapy, but other treatment types like interpersonal, psychodynamic, and supportive therapy were also tested. Groups were defined as having at least 3 patients per group. The average number of sessions for group and individual therapy were equivalent (group M = 14.67, SD = 8.75; individual 15.94, SD = 14.37)), and as expected group therapy sessions were longer in minutes (M = 100.39, SD = 30.87) than individual therapy sessions (M = 56.55, SD = 14.37) given the multi-person demands of groups. Groups were primarily closed to new members after starting, they tended to have homogenous membership based on diagnosis, and groups tended to be co-led by 2 therapists. Individual and group therapy were not significantly different for all disorders and outcomes at post-treatment (g = -0.03; 95%CI = -0.10, 0.04), short-term follow-up (g = 0.01; 95% CI = -0.13, 0.11), and long-term follow-up (g = 0.00; 95% CI= -0.12, 0.13). Drop out rates for group therapy (17.28%) and individual therapy (14.96%) were not significantly different (OR = 1.10; 95% CI = 0.90, 1.33), and patients were likely to accept group therapy (88.76%) as often as they accepted individual therapy (84.83%) when one or the other was offered. Pre- to post-treatment effect sizes were moderately large for both interventions (group: g = 0.60, 95% CI = 0.48, 0.72; individual: g = 0.53, 95% CI = 0.42, 0.65). Patients presenting with depression, substance us, anxiety, or eating disorders had the highest level of improvement.

    Practice Implications

    When identical treatments, patients, and doses are compared, individual and group therapy resulted in equivalent outcomes across of a variety of disorders. This is good news for clinicians and agencies looking to maximize resources to treat more patients. However, running a group is more complex than providing individual therapy. Finding a sufficient number of patients to start a group, assessing and preparing each patient prior to starting a group, writing a note per patient per session, and managing attrition is logistically more challenging. Further, most therapists are not formally trained to provide group interventions and so they may find the task of managing a substantially larger amount of within-session group process information to be complex. Finally, as Burlingame and colleagues indicate, there are institutional considerations so that group programs require a milieu that supports group referrals and flexibility in scheduling. Nevertheless the findings of this meta analysis indicate the potential for group therapy to provide efficacious treatments for mental disorders.

  • Comparing Three Psychotherapies for Adolescents with Major Depression

    Goodyear, I.M., Reynolds, S., Barrett, B., Byford, S., Dubicka, B., ….Fonagy, P. (2016). Cognitive behavioural therapy and short-term psychoanalytical psychotherapy versus a brief psychosocial intervention in adolescents with unipolar major depressive disorder (IMPACT): A multicentre, pragmatic, observer-blind, randomised controlled superiority trial. Lancet Psychiatry, Online first publication: http://dx.doi.org/10.1016/S2215-0366(16)30378-9.

    Major depression affects a large proportion of adolescents worldwide. The Global Burden of Disease Study Found that depressive disorders accounted for over 40% of disease burden caused by all mental and substance use disorders, with the highest burden occurring for those between the ages of 10 and 29. Although there is good evidence for cognitive-behavioral therapy (CBT) to treat depression in adolescents, data is scarce for long term outcomes – which is an important issue because maintaining treatment gains reduces the risk for relapse. There is also little research on alternative treatments to CBT and their long term effects. In this large study, Goodyear and colleagues (2016) randomly assigned 470 adolescents with major depression to receive CBT, short-term psychoanalytical therapy (STPT), or a brief psychosocial intervention (BPI). CBT was based on a commonly used model but adapted to include parents and emphasized behavioural techniques. The STPT model emphasized the child – therapist relationship in which the therapist emphasized understanding feelings and difficulties in ones life. STPT also included some family meeting. BPI on the other hand focused on psychoeducation about depression, was task and goal oriented, and emphasized interpersonal activities. The study also compared cost-effectiveness of the three treatments – that is, whether the treatments’ costs relative to their effectiveness were different. There were some advantages in terms of reduced depression to both CBT and STPT compared to BPI at 36 weeks and 52 weeks post treatment, but these advantages disappeared by 86 weeks follow-up. Across all three treatments, about 77% of adolescents with depression were in remission (i.e., no longer depressed) by 86 weeks post-treatment. There were no differences between the three treatments in terms of cost-effectiveness.

    Practice Implications

    This is one of those rare studies that is large enough to adequately compare the efficacy of alternative treatments for adolescents with major depression. CBT, STPT, and BPI were all associated with reduced depression in adolescents, and with maintenance of these improvements 1 year after the start of treatment. Both BPI and STPT provide alternative choices to CBT for patients and therapists.

December 2016

  • Effects of Combining Psychotherapy and Pharmacotherapy on Quality of Life in Depression

    Kamenov, K., Twomey, C., Cabello, M., Prina, A.M., & Ayuso-Mateos, J.L. (2016). The efficacy of psychotherapy, pharmacotherapy, and their combination on functioning and quality of life in depression: A meta-analysis. Psychological Medicine, doi: 10.1017/S0033291716002774.

    Both psychotherapy and pharmacotherapy are efficacious for reducing symptoms of depression. Some studies suggest that functioning (i.e., the ability to engage in work, school, and social activities) and quality of life (i.e., satisfaction with these activities and perception of one’s health) are just as important to depressed patients as is reducing their symptoms. In fact, many patients place greater priority on improving functioning compared to reducing symptoms. In this meta analysis, Kamenov and colleagues assess the relative efficacy of psychotherapy vs pharmacotherapy in improving functioning and quality of life. They also evaluate if combining psychotherapy and pharmacotherapy is efficacious relative to either treatment alone. The meta analysis included k = 153 studies of over 29,000 participants. Psychotherapies often included CBT and interpersonal psychotherapy. Compared to control groups (k = 37 to 52) both psychotherapy (g = 0.35, 95% CI = 0.24, 0.46) and medications (g = 0.27, 95% CI = 0.21, 0.32) significantly improved functioning. Also, compared to controls both psychotherapy (g = 0.35, 95% CI = 0.26, 0.44) and medications (g = 0.31, 95% CI = 0.24, 0.38) significantly improved quality of life in depressed participants. In studies that directly compared psychotherapy and medications, there were no significant differences when it came to improving functioning, but there was a small significant advantage to psychotherapy over medication for improving quality of life (g = 0.21, 95% CI = 0.01, 0.43). Combined psychotherapy and medications (k = 19) was more effective to improve functioning compared to pharmacotherapy alone (g = 0.34, 95% CI = 0.18, 0.50) and compared to psychotherapy alone (g = 0.32, 95% CI = 0.14, 0.49). Combined treatment was also more efficacious for improved quality of life compared to medications alone (g = 0.36, 95% CI = 0.11, 0.62) and to psychotherapy alone (g = 0.39, 95% CI = 0.19, 0.58).

    Practice Implications

    Combined treatment of medications and psychotherapy is more effective than either treatment alone for improving functioning and quality of life. However, most patients prefer psychotherapy to medications, and some studies indicate that many patients choose not to get treated at all rather than receive medications. Further, quality of life can be substantially compromised by medication side effects. Clinicians should take these factors into account when considering monotherapy with antidepressant medications or combined treatment of pharmacotherapy and psychotherapy for depression.

November 2016

  • When Clients and Therapists Agree on Client Functioning

    Bar-Kalifa, E., Atzil-Slonim, D., Rafaeli, E., Peri, T., Rubel, J., & Lutz, W. (2016, October 24). Therapist–client agreement in assessments of clients’ functioning. Journal of Consulting and Clinical Psychology. Advance online publication. http://dx.doi.org/10.1037/ccp0000157.

    There has been a lot of research in the past decade on progress monitoring (i.e., regularly providing reliable feedback to therapists on client outcomes, the alliance, and client functioning). This research indicates that client outcomes can be enhanced if therapists have ongoing information on how their client or the relationship is progressing. In this innovative research by Bar-Kalifa and colleagues, the authors studied 77 therapists who saw a total of 384 clients. The therapists were experienced at providing cognitive-behavioral therapy. Clients for the most part had a depressive or anxiety disorder and were seen for an average of 36 sessions. Client outcomes were measured pre- and post-treatment. Emotional and psychological functioning during the past week was rated by the client before each session, and the same measure was given to the therapist to rate their client at the end of each session. After therapists made their rating, they were given ongoing feedback (i.e., progress monitoring) about how their clients’ rated their own functioning during the past week. Did clients and therapists agree on level of client functioning, was this agreement stable over time, and was this agreement or disagreement related to client outcomes? The authors used sophisticated statistical modeling to separate the effects of client ratings of their functioning from therapists’ ratings, and to examine the impact of the changing relationship between therapist and client ratings over time on client outcomes. The authors found little difference in the level of client and therapist ratings of client functioning, and they found that therapists tended to be accurate (i.e., congruent with clients) in tracking client functioning over time. More importantly, the ability of therapists to accurately track client functioning from session to session was related to better client outcomes in terms of key symptoms of depression and anxiety.

    Practice Implications

    The ability of therapists to accurately track client functioning over time was related to better client outcomes. This means that therapists who were aware of their clients’ functioning through feedback methods were better equipped to help their clients. In particular, information about how client functioning was changing from session to session might have allowed therapists to take corrective action for clients who were not doing well from one session to another. This information might have allowed therapists to reconsider a treatment formulation for a particular client, for example. Therapists should be aware of how a client is doing at a particular session, but more importantly therapists should be sensitive to fluctuations in client functioning across sessions. This might be best achieved with ongoing progress monitoring.

October 2016

  • The Quality of Psychotherapy Research Affects The Size of Treatment Effects for CBT

    Cuijpers, P., Cristea, I.A., Karyotaki, E., Reijnders, M., Huibers, M.J.J. (2016). How effective are cognitive behavior therapies for major depression and anxiety disorders? A meta-analytic update of the evidence. World Psychiatry, 15, 245-258.

    You might think that an esoteric topic like study quality should not really be of interest or concern to clinicians – but it is an important topic with practice implications. In this meta analysis Pim Cuijpers and his research group updated the meta analytic evidence for the efficacy of cognitive behavioral therapy (CBT) for a variety of disorders (major depressive disorder [MDD], generalized anxiety disorder [GAD], panic disorder [PAD], and social anxiety disorder [SAD]). The important thing about meta analyses is that the method combines the effect sizes from all relevant studies into a single metric – an average effect size. These average effect sizes are much more reliable than findings from any one single study. In fact, whenever possible, clinical decision-making should be based on a meta analysis and systematic review and not on a single study. Meta analyses also allow one to give more weight to those studies that have larger sample sizes, and that employ better methodologies. Even more, meta analytic techniques allow one to adjust the averaged effect size by taking into account publication bias (i.e., an indication of the effects from studies that might have been completed but were never published, likely because they had unfavorable findings). Usually, average effect sizes are lower when they are adjusted for study quality and publication bias. Cuijpers and colleagues’ meta analyses found that the unadjusted average effects of CBT were large for each of the disorders (ranging from g = .75 to .88 [confidence intervals not reported]). However adjusting for publication bias reduced the effects to medium-sized for MDD (g = .65) and GAD (g = .59). Only 17.4% of the individual studies of CBT were considered to be of “high quality” (i.e., studies that use the best methodology to reduce bias, like random allocation, blinding, using all the available data, etc.). After adjusting for study quality, the effects of CBT for SAD (g = .61) and PAD (g = .76) were also reduced to medium-sized. Not surprisingly, the effects of CBT were largest when the treatment was compared to a wait-list no-treatment control group. The effects were small to moderate when CBT was compared to treatment as usual or to a placebo.

    Practice Implications

    Even when adjusting for study quality and publication bias, the average effects of CBT were medium-sized for a variety of common disorders compared to control conditions. Unfortunately, the quality of the studies was not high for most trials, reducing the effect sizes and lowering our confidence in the efficacy of the treatment. Nevertheless, the findings of this meta analysis suggest that CBT will likely have moderate effects for the average patient with MDD, SAD, PAD, and GAD.

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