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McPherson, S., Wicks, C. & Tercelli, I. (2020). Patient experiences of psychological therapy for depression: A qualitative metasynthesis. BMC Psychiatry, 20, 313. https://doi.org/10.1186/s12888-020-02682-1

Many times, researchers choose what to study in psychotherapy trials without really consulting patients who are receiving the care. For example, researchers are often primarily interested in how well psychotherapies reduce symptoms in patients with a particular disorder, or researchers might be interested in certain constructs that might affect patient outcomes (e.g., therapeutic alliance, therapist empathy). But are these the things that patients are really interested in when they seek psychological therapy? Although many treatment guidelines emphasize patient choice and experience, none of them take research of patient experiences into account to develop the guidelines. When presented with findings from randomized controlled trials of psychotherapy, patients reported that the research was of limited value in helping them make an informed choice about therapy. In this metasynthesis of qualitative studies, McPherson and colleagues aimed to bring together qualitative evidence concerning adult patients’ experiences of psychotherapy for depression. Qualitative research typically involves interviewing patients and systematically categorizing their responses into meaningful themes. The authors found 38 qualitative studies involving patient interviews of their experiences in receiving psychotherapy for depression. Several key themes emerged from the analysis. First, many people who receive remote therapy primarily from a computer program felt dissatisfied because of the lack of or limited contact with a real person therapist. Most patients did not feel connected to the computerized therapy and so their motivation waned quickly. Second, patients found psychological models and techniques to be less relevant than their need for help with their immediate family or social problems that likely triggered their depressive symptoms. This points to the primary importance of quality of life and of the social and cultural context for patients, despite that many psychological therapies tend to focus on symptoms almost exclusively. Third, this metasynthesis pointed to reports of negative effects of therapy, in which some therapeutic techniques like body scans induced flashbacks in some patients. Other patients had mixed or sometimes negative feelings about requirements for homework, which sometimes felt overwhelming, culturally out of step, or irrelevant.

Practice Implications

This metasynthesis of patient experiences in psychotherapy point to the importance of asking patients about their goals, expectations, and preferences in therapy. The findings highlight the importance of some common factors across therapies (e.g., therapist warmth and humanness, collaborative agreement on tasks and goals, and patient factors like culture and individual differences). Patients prefer human connection with therapists, and they tend to place less value on techniques of therapy. Patients also tend to value outcomes related to quality of life, social connection, and they want therapy consistent with their cultural values. Patients should be fully involved in a collaborative discussion about which therapy you offer them, how you provide the therapy, and what they want to achieve in therapy.

Effectiveness and Adherence of Telephone-Administered Psychotherapy

Castro, A., Gili, M., Ricci-Cagello, I., Roca, M., Gilbody, S., Perez-Ara, A., Segui, A., & McMillan, D. (2020). Effectiveness and adherence of telephone-administered psychotherapy for depression: A systematic review and meta-analysis. Journal of Affective Disorders, 260, 514-526.

The COVID-19 pandemic has resulted in psychotherapy providers moving to online and telephone-delivered interventions. But questions remain about the efficacy of delivering psychotherapy in these formats to patients with depression. Depression is highly prevalent as it affects about 320 million people around the world and causes serious disability and lowered quality of life. Psychotherapy is effective in treating depression, however there are significant barriers to people accessing face-to-face psychotherapy including cost, stigma, distance, and disability. Telephone-delivered psychotherapy may minimize these barriers. One potential question that may arise is whether patients will adhere to telephone-delivered psychotherapy. That is, will patients find telephone sessions acceptable as indicted by the rate of starting therapy and of attending sessions? In this systematic review and meta-analysis, Castro and colleagues evaluated whether telephone-delivered psychotherapy for depression is as effective as other active treatments and more effective than no-treatment. The authors also examined the level of adherence/acceptability to telephone administered treatment, determined by the percent of scheduled sessions actually attended by a patient. The sample of studies was small such the authors only found a total of 11 direct comparison randomized controlled trials. These trials represented almost 1400 patients. The only treatment tested in these trials were CBT-oriented. Four studies found that telephone-delivered therapy produced significantly larger reductions in depressive symptoms when compared to no treatment controls (mean SMD = -0.48; 95% CI: -0.82 to -0.14). In four other studies telephone-administered therapy was just as effective as an active control (e.g., medication or self-help). The weighted average percentage of scheduled telephone sessions that patients attended was 73%, and the percent of patients who started telephone therapy after the initial referral was about 90%. These percentages indicating adherence and acceptability are similar to findings reported from individual psychotherapy studies.

Practice Implications

There are few randomized controlled trials that assess the efficacy of telephone-administered psychotherapy, and these studies were limited to only one type of intervention. However, the findings from this meta-analysis suggested that telephone-delivered psychotherapy may be efficacious and as effective as some other active treatments. Further, telephone therapy may be acceptable to patients in that they start and attend sessions at a rate similar to face-to-face therapy. These preliminary findings provide clinicians who provide telephone psychotherapy during this period of physical distancing due to COVID-19 with some evidence for the utility of telephone delivered treatment.

Once-Weekly or Twice-Weekly Sessions of Psychotherapy?

Bruijniks, S., Lemmens, L., Hollon, S.D., Peeters, F.P., ….Huibers, M.J. (2020). The effects of once- versus twice-weekly sessions on psychotherapy outcomes in depressed patients. The British Journal of Psychiatry, doi: 10.1192/bjp.2019.265. [Epub ahead of print].

Some research has suggested that the number of sessions per week, not the total number of sessions received, is correlated with patient outcomes. It is possible that higher session frequency per week might lead clients to better recall the content of sessions, which in turn may lead to better treatment outcomes. Or perhaps, higher frequency of sessions might lead to a better therapeutic alliance and higher client motivation thus leading to better outcomes. Although previous research has suggested that more sessions per week is better, no study has ever directly assessed this issue until now. Bruijniks and colleagues conducted a large randomized controlled trial of 200 adults with depression seen across nine specialized clinics in the Netherlands. Researchers randomly assigned clients to receive either cognitive-behavioral therapy (CBT) or interpersonal psychotherapy (IPT) for a maximum of 20 sessions. Half of the clients in either type of therapy received the 20 sessions on a twice a week basis, and half of clients in each type of therapy received the 20 sessions on a once a week basis. The therapies were manualized, therapists were trained and supervised, and clients were carefully selected to meet criteria for depression. More patients dropped out of weekly (31%) compared to twice weekly (17%) therapy. There were no differences between CBT and IPT in depression outcomes. However, there was a significant effect of session frequency on patient outcomes in favor of twice weekly sessions (d = 0.55). Using a strict criteria of “recovery” from depression at 6 months post treatment, 19.6% of patients receiving once weekly therapy “recovered” compared to 29.5% of patients receiving twice weekly therapy.

Practice Implications

This large multi-site study has intriguing implications for practice. More frequent sessions per week may result in significantly better patient outcomes regardless of the type of therapy offered. Not surprisingly, IPT and CBT were equally effective. However, their effectiveness was limited in that only between 20% to 30% of patients recovered from depression. This finding is similar to the results previous trials, and speaks to the limitations of time-limited manual-based therapies for depression. Nevertheless, it appears that more frequent therapy per week may be a better option for some clients.

Torous, J., Lipschitz, J., Ng, M., & Firth, J. (2020). Dropout rates in clinical trials of smartphone apps for depressive symptoms: A systematic review and meta-analysis. Journal of Affective Disorders, 263, 413-419.

Depression is a leading cause of disability worldwide, and yet more than 50% of people do not have access to adequate therapy. One solution might be to provide individuals with smartphone apps to help screen, monitor, or provide treatment. Smart phones are ubiquitous, and depression apps are one of the most downloaded categories of apps by the public. Research seems to suggest that smartphone apps provide some positive results for members of the public, but these findings are compromised by the high drop-out rates reported in the primary studies. Further, one study found that although many people download the apps, only about 4% actually use them. Whereas smartphone apps appear attractive to the consumer, very few actually make use of and therefore benefit from them. In this systematic review, Torous and colleagues conduct a meta-analysis of drop-out rates from studies that test the use of smart phone apps. They found 18 independent studies representing data from 3,336 participants who received a psychological intervention for depression via a cell phone app, or who were in a placebo control condition. A total of 22 different apps were tested in the studies. Initially, the pooled drop-out rate from the depression app treatment arms appeared to be about 26.2% (95% C.I.=11.34% to 46.75%), which would be in line with average drop-out rates from randomized controlled trials of face to face psychotherapy. But, the authors noted two things. First, the drop-out rate from the placebo control conditions (14.2%; 95% C.I. = 8.236 to 23.406) was almost half as high as that found for the apps. Second, through some sophisticated statistical analyses, they found evidence of “publication bias” in this research area. This means that a number of studies testing these apps likely were completed but never published (i.e., these might be studies funded by an app manufacturer that demonstrated negative findings or high drop-out rates). When the authors statistically adjusted for publication bias, they found that the actual drop-out rate from the apps was about 47.8%. That is, almost half of users did not complete or dropped out of the studies. There were no differences in drop-out between types of interventions (CBT, mindfulness, or others), and studies with larger sample sizes (i.e., better quality studies) had higher drop-out rates.

Practice Implications

Although smartphone apps appear really attractive and may be potentially useful as an adjunct to face to face psychotherapy for depression, their utility is plagued by extremely low usage rates (4%) and high drop-out rates from studies (almost 50%). Leading writers and researchers define psychotherapy as primarily a healing relationship that also includes specific interventions. The key ingredient is the human relationship. Depressed or otherwise troubled individuals cannot (because of feeling demoralized) or will not interact with a machine for healing. One way or another, when it comes to smartphone apps, depressed individuals are voting with their feet. Given these findings, health care providers should consider the ethics of giving a depressed individual only e-therapy as the primary mode of treatment.

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.

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.