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.
This month...
…I blog about how the therapeutic alliance works, psychotherapy with Indigenous Peoples, and th efficacy of psychotherapy and psychopharmacology
Type of Research
Topics
- ALL Topics (clear)
- Adherance
- Alliance and Therapeutic Relationship
- Anxiety Disorders
- Attachment
- Attendance, Attrition, and Drop-Out
- Client Factors
- Client Preferences
- Cognitive Therapy (CT) and Cognitive-Behavioural Therapy (CBT)
- Combination Therapy
- Common Factors
- Cost-effectiveness
- Depression and Depressive Symptoms
- Efficacy of Treatments
- Empathy
- Feedback and Progress Monitoring
- Group Psychotherapy
- Illness and Medical Comorbidities
- Interpersonal Psychotherapy (IPT)
- Long-term Outcomes
- Medications/Pharmacotherapy
- Miscellaneous
- 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
- Termination
- Therapist Factors
- Training
- Transference and Countertransference
- Trauma and/or PTSD
- Treatment Length and Frequency
November 2015
The Logic of Placebos in Medicine and Psychotherapy
The Great Psychotherapy Debate: Since April, 2015 I review parts of The Great Psychotherapy Debate (Wampold & Imel, 2015) in the PPRNet Blog. This is the second edition of a landmark and sometimes controversial book that surveys the evidence for what makes psychotherapy work. You can view parts of the book in Google Books.
A couple of decades ago Martin Seligman famously said: “Whenever you hear someone demanding a double-blind study of psychotherapy, hold on to your wallet.” In this chapter, Wampold and Imel continue their examination of the Medical Model versus the Contextual Model for psychotherapy by discussing the viability of double-blind placebo control designs in psychotherapy. This topic sounds a little esoteric, but it’s not – this issue reaches into the very core of the definition of psychotherapy. A placebo-controlled trial in medicine often involves comparing a medication that contains an active biochemical ingredient versus a “sugar pill” that is exactly like the medication but without the active biochemical ingredient. Key to the placebo controlled design is that the health care provider, the patient, nor the researcher/evaluator knows which patient received which pill (i.e., the classic “double-blind” design). However, double-blinding is impossible in psychotherapy – the therapist must know what they are providing, which means that they know which treatment is expected to be effective, and which treatment is favoured by the researchers. Further, the researchers know which patients are getting which intervention of study condition. This affects a critical aspect of psychotherapy, that is, the therapist’s ability to provide a good rationale for the disorder and for the efficacious actions of the therapy. Additionally, patients are often aware that they are getting a pseudo-treatment in the placebo, and so their expectation of outcomes is also lowered (actually, this is often true in medical trials as well as most medications have side effects, and the absence of a side effect signals to the patient and the researcher that the patient is receiving the placebo). Wampold and Imel argue that common factors like emotional arousal, an acceptable explanation of the disorder, an understanding and empathic therapist, a structure to the treatment, and therapist and client expectations and hope are integral to the effectiveness of psychological therapies. They further argue that these are the very factors that medical trials try to control with a double-blind placebo controlled trial. Nonetheless placebo-like controls have been tried in psychotherapy to test the active or specific ingredients of a therapy – that is, to isolate the effects of active ingredients from the relationship context of the therapy. Placebo-like controls in psychotherapy have been called: minimal treatment, supportive counselling, non-directive counselling, etc. However, as mentioned, these placebo control conditions often contain elements that are integral to the effectiveness of psychotherapy, like: emotional arousal, an empathic therapist, and client expectations. And so not surprisingly, after reviewing meta-analyses of placebo-like conditions in psychotherapy research, Wampold and Imel conclude that when the studies are well constructed, these placebo-like conditions perform nearly as well as evidence-based treatments.
Practice Implications
What is the take home message for the clinician of this seemingly esoteric topic about research design? Although the placebo-controlled double-blind randomized design is the gold standard in medical research, this design is not possible or even logical for psychotherapy. The relationship, therapist factors, expectations, and contextual factors that one tries to control in a placebo-controlled trial are some of the very ingredients that are active in psychotherapy. The technical and specific ingredients of psychotherapies (e.g., transference interpretations, cognitive restructuring, two-chair techniques, etc.) are also part of the mix; but in the end, one cannot separate contextual relationship factors from techniques when it comes to providing psychotherapy.
May 2015
Effects of Antidepressants in Treating Anxiety Disorders Are Overestimated
Roest, A.M., de Jonge, P., Williames, G.D., de Vries, Y.A., Shoevers, R.A., & Turner, E.H. (2015). Reporting bias in clinical trials investigating second-generation antidepressants in the treatment of anxiety disorders: A report of 2 meta-analyses. JAMA Psychiatry, doi:10.1001/jamapsychiatry.2015.15.
Previous research has shown that the effects of antidepressant medications for treating depression may be over estimated by as much as 35%. This occurs because of publication bias, which refers to the tendency among researchers and editors to prefer to publish positive findings, and also occurs due to the occasional practice of the pharmaceutical industry to suppress negative findings. In these meta analyses, Roest and colleagues assess publication bias in the research of antidepressant medications to treat anxiety disorders (i.e., generalized anxiety disorder [GAD], panic disorder [PD), social anxiety disorder [SAD], post traumatic stress disorder [PTSD], and obsessive compulsive disorder [OCD]). Anxiety disorders are very common in the population, with an estimated year-prevalence of 12%. Second generation antidepressants (i.e., selective serotonin reuptake inhibitors and serotonin-norepinephrine reuptake inhibitors) are the primary pharmacologic treatment for anxiety disorders. Roest and colleagues were also interested in outcome reporting bias, which refers to mis-reporting non-positive findings as if they were positive findings, and spin which refers to interpreting non-positive results as beneficial findings. Positive findings refer to the pharmacological agent significantly outperforming a placebo, and non-positive findings refer to pharmacological agents not significantly outperforming a placebo. Pharmaceutical companies in the US must register any trial with the Food and Drug Administration (FDA) prior to starting the trial if the company wishes to apply for US marketing approval. And so, all medication trials and their findings, whether positive or non-positive must be listed in the FDA register. Despite being listed with the FDA, not all trials and findings get published in peer reviewed journals. This causes a problem for reviews and meta analyses that tend only to focus on published trials, and prescribing physicians tend only to read published trials and reviews. In their meta analyses Roest and colleagues compared findings from all FDA registered medication trials to those that were published in peer reviewed journal. Fifty seven trials were registered with the FDA but only 48 were published. Regarding publication bias, the proportion of studies with positive findings indicating efficacy of antidepressant medications in FDA trials was 72%, whereas the proportion of studies with positive findings in trials published in a journal was 96%. Overall, trials were 5 times more likely to be published if they were positive than if they were non-positive. Regarding outcome reporting bias, 3 of 16 trials that were non-positive in the FDA review were reported as positive in journal publications. Regarding spin, an additional 3 of the 16 non-positive trials interpreted non-positive results as if they were positive. Effect sizes in the FDA data was g = .33 indicating a small average effect size of the medications for anxiety disorders, but the effect size in published journals was g = .38 indicating a small to moderate effect. This represents a 15% over estimation of the effects of the antidepressant medications for anxiety disorders in the published literature.
Practice Implications
The effects of antidepressant medications for anxiety disorders appear to be over estimated by 15% in the published literature. This inflation is not as large as the 35% over estimation in the published literature of the effects of antidepressant medications for depression. By contrast, as I reported in a previous PPRNet Blog, publication bias in psychotherapy trials is small and has little impact on the overall estimate of psychotherapy’s efficacy. Effect sizes for psychological interventions for anxiety disorders are moderate to large, g = .73. Combining medications and psychotherapy only modestly improves efficacy of treatments, and medications may interfere with the efficacy of psychological interventions.
February 2015
Placebo Response is Increasing in Trials of Antipsychotic Medications
Rutherford, B.R., Pott, E., Tandler, J.M., Wall, M.M., Roose, S.P., & Lieberman, J.A. (2014). Placebo response in antipsychotic clinical trials: A meta-analysis. JAMA Psychiatry, doi:10.1001/jamapsychiatry.2014.1319.
The placebo response refers to improvements in symptoms among participants in medication trials that cannot be specifically attributed to the active ingredient of the intervention. For this reason, it is common to have a placebo control condition in trials of medications. In these trials, some participants are randomly assigned to the medication condition, and some are randomly assigned to a placebo control condition. Typically, the placebo is a pill that looks exactly like the medication but that has no active ingredient. Both patients and providers are blind or unaware of whether the patient is receiving the active medication or the placebo. The placebo response is usually attributed to a number of sources: (1) the patient’s expectation of receiving benefit, (2) the patient’s contact with a caring provider and the healing effect of factors like therapeutic alliance and provider empathy, (3) statistical and measurement error, and (4) random changes in patient symptoms that are unrelated to the medication or the placebo. The first two sources are psychological factors that are often specifically active and purposefully enhanced in psychotherapies. That is, some psychotherapists actively work to develop an alliance with the patient and to align therapeutic interventions with patient expectations and preferences. (For a broader discussion, see my review of Common Factors in this month’s PPRNet blog.) The placebo response can sometimes be quite powerful such that antidepressant medications, and antipsychotic medications for example, only tend to be modestly superior to placebo. People with schizophrenia have cognitive difficulties that may reduce their expectations of receiving benefits from treatment. These patients also have significant interpersonal difficulties so that their alliance with health care providers may be significantly hampered. For these reasons, it may be possible that the placebo response may play a smaller role in the medical treatment of patients with schizophrenia. Rutherford and colleagues conducted a meta analysis of 105 studies of over 24,000 participants from 1960 to the present. Their goal was to examine if the average drug-placebo difference decreased significantly over time (i.e. across years of publication). They found that the placebo response significantly increased from 1960 to the present. That is, the average placebo patient tended to get worse in the 1960s, but by the 2000s the average placebo participant tended to get better. The effect of this trend was large (r = .52). By contrast, treatment change associated with antipsychotic medications decreased over time, and the effect of this trend was moderate (r = -.26). The authors suggested possible explanations for this trend. The average participant in drug trials in the 1960s was more severely ill than the average patient enrolled in drug trials in the 2000s. It is possible that the placebo response is more powerful in less severely ill individuals. Also, the authors suggested that a number of study design factors (e.g., multi site vs single site trials, financial incentives to recruit more patients may result in less severely ill and younger samples) may also contribute to this trend.
Practice Implications
One of the practical implications of these findings is that drug companies may be less inclined to fund research and development of new medications for mental illnesses if the research is increasingly showing only modest benefits over control conditions. On the other hand, health care workers who provide: support and empathy, a positive therapeutic alliance, positive expectations about benefits of treatment, attention to patient preferences, and a coherent narrative to understand their patient’s illness may help to enhance the effects of interventions including antipsychotic medications. This may be especially true for younger and less severely ill individuals with schizophrenia.
December 2014
Does Cognitive Therapy Have an Enduring Effect Superior to Keeping Patients on Medication?
Cuijpers, P., Hollon, S. D., van Straten, A., Bockting, C., Berking, M., & Andersson, G. (2013). Does cognitive behaviour therapy have an enduring effect that is superior to keeping patients on continuation pharmacotherapy? A meta-analysis. BMJ open, 3(4).
In another in a series of meta analyses by this primarily Dutch group, Cuijpers and colleagues tackle the question of whether the longer term effects of cognitive behavioral therapy (CBT; a short time-limited treatment for depression) outweighs the long term effects of continuation on anti depression medications. CBT is considered an efficacious treatment for depression (see my June 2014 Blog). CBT also has comparable effects as antidepressant medications, but CBT tends to have lower rates of treatment drop outs. What is not clear is whether short term CBT leads to lasting change that is comparable to long term use of medications for depression. One could argue for example, that short term CBT or other comparable psychological interventions teaches patients skills or changes psychological functioning such that future recurrences of depression are less likely. That is, psychological interventions may cause changes that eventually will prevent relapse. Pharmacotherapy on the other hand, may not result in psychological change or acquisition of new skills to forestall a relapse. In fact, patients with chronic depression tend to be kept on medications indefinitely, and patients who recently remit (i.e., no longer have symptoms of depression) are typically kept on pharmacotherapy for another 6 to 12 months to reduce the risk of recurrence. Information about the relative longer term effects of short term treatment with a psychological intervention like CBT versus longer term maintenance on pharmacotherapy can help practitioners and patients decide on the best course of action depending on patient preferences. Cuijpers and colleagues asked: is short term CBT without continuation of treatment as effective as short term treatment of pharmacotherapy with and without long term continuation? They conducted a meta analysis in which the effects of short term CBT were compared to pharmacotherapy in adults diagnosed with depression across follow up periods of 6 to 18 months. Nine studies representing 506 patients were included in the meta analysis. There was a non-significant trend showing that short term CBT outperformed continuation pharmacotherapy at one-year post treatment. On the other hand, CBT resulted in better long term outcomes compared to pharmacotherapy that was discontinued at post treatment. The odds of dropping out of treatment were significantly higher for those receiving pharmacotherapy compared to CBT. There were no differences in any of the findings for type of antidepressant medications.
Practice Implications
The findings reaffirm CBT as a first-line treatment of depressive disorders. It also suggests that equally effective other psychological treatments may also have similar enduring effects compared to pharmacotherapy. Patients and providers need to consider all of the evidence when weighing the pros and cons of psychotherapy or medications for the treatment of depression. Although pharmacotherapy might be more widely available to patients through primary care physicians, the research is suggesting that enduring effects and treatment compliance are higher among those who have access to psychological interventions.
Attitudes Toward Seeking Mental Health Care Have Become Increasingly Negative in the Past 40 Years
Mackenzie, C. S., Erickson, J., Deane, F. P., & Wright, M. (2014). Changes in attitudes toward seeking mental health services: A 40-year cross-temporal meta-analysis. Clinical Psychology Review, 34(2), 99-106.
Rates of treatment for mental disorders in developed countries have increased over time and this is largely due to the dramatic rise in the use of medications, such as antidepressants over the past 30 years. Concurrently the proportion of people receiving outpatient psychotherapy has declined. Despite the increase of pharmacological interventions, many mental health services in the US do not meet evidence based guidelines, and most people with mental disorders in the US and Canada are not receiving care. Barriers to accessing care include: lack of knowledge (not knowing where to get help); structural barriers (financial costs), and attitudes (stigma, belief that one should handle the problem oneself, and belief that treatment will not help). There is a great deal of evidence that negative attitudes about seeking and receiving help are the most consistent reasons related to low service utilization in Canada and the US. Efforts to reduce stigma, in part, have attempted to define mental illness as a medical or biological disorder likely with the intent of reducing blame of the individual for his or her problems. As Mackenzie and colleagues indicate, this coincided with an aggressive direct-to-consumer advertising of psychotropic medications for mental disorders. And so the perception that mental disorders are biological and that require biological treatments became entrenched in the population. However, as I summarized in the PPRNet October 2013 Blog endorsing neurobiological causes of mental illness is associated with seeing the disorder as persistent, unchangeable, and serious. This increases social distance, which is an aspect of stigma. In their meta analysis, Mackenzie and colleagues reviewed all published studies over the past 40 years that used the Attitudes Toward Seeking Professional Help Scale. They analysed 22 studies with a total sample size of 6,796. They used cross-temporal meta-analysis to correlate year of the study with total scores on the scale. The correlation was large and negative (r = -.53) indicating that participants’ help-seeking attitudes have become significantly more negative over time.
Practice Implications
Attitudes toward seeking mental health services have become increasingly negative over the past four decades, which is consistent with worsening public stigma about mental health. This has coincided with an increase in the use of psychotropic medications and a decline in psychotherapy during the same period, despite evidence that psychotherapy is as effective as medications and preferred by patients. As Mackenzie and colleagues suggest, it is possible that attitudes toward mental health care have become increasingly negative due to efforts to convince the public that mental disorders have a neurobiolobic etiology and require biological treatments. When appropriate, clinicians should not promote biological explanations at the expense of psychosocial explanations for mental disorders. Psychological explanations and treatments may result in patients experiencing a greater sense of optimism about change, and greater personal control over the treatments they receive.
June 2014
Cognitive Therapy for Depression
Hollon, S.D. & Beck, A.T. (2013). Cognitive and cognitive-behavioral therapies. In M.E. Lambert (Ed.), Bergin and Garfield’s Handbook of Psychotherapy and Behavior Change, 6th Edition (pp. 393-442). New York: Wiley.
Cognitive (CT) and cognitive behavioural therapies (CBT) are among the most empirically supported and widely practiced psychological interventions. CT emphasizes the role of meaning in their models of depression and CT interventions emphasise testing the accuracy of beliefs. More behavioural approaches like CBT see change in terms of classical or operant conditioning of behaviours, in which cognitive strategies are incorporated to facilitate behavioural change. In this section of their chapter, Hollon and Beck review research on CT for depression. Depression is the single most prevalent mental disorder and is a leading cause of disability in the world (see this month’s blog entry on the global burden of depression). Most patients have multiple episodes of depression (i.e., recurrent) and about 25% have episodes that last for 2 years or more (i.e., chronic). CT posits that depressed individuals have negative automatic thoughts that are organized into depressogenic automatic beliefs (or underlying assumptions) that put them at risk for relapse. Automatic beliefs can be organized in latent (or unconscious) schemas often laid down in childhood and activated by later stress that influence the way information is organized. In CT patients are taught to evaluate their beliefs (also called empirical disconfirmation), conduct “experiments” to test their accuracy and to modify core beliefs and reduce maladaptive interpersonal behaviours. Most reviews show that CT for depression is superior to no treatment (with large effects) and at least as effective as alternative psychological or pharmacological interventions. Most patients show a good response to CT with about one third showing complete remission. Although some practice guidelines have concluded that medications are preferred to CBT (or any psychotherapy) for severe depression, more recent meta analyses show that CT is as efficacious as medications and is likely better in the long term. CT also has an enduring effect that protects clients against symptoms returning. Medications, on the other hand suppress depressive symptoms only as long as the patient continues to take the treatment, but medications do not reduce underlying risk. As a result, relapse rates for medication treatment of depression are much higher than for CT. These findings suggest that patients who receive CT learn something that reduces risk for recurrence, which is the single biggest advantage that CT has over medications. Further, CT is free from problematic side effects that may occur with medications.
Practice Implications
CT and CBT are the most tested psychological treatments for depression and the evidence indicates that many patients benefit. CT and CBT are as effective as medications for reducing acute distress related to depression, and even for those with more severe depression when implemented by experienced therapists. CT has an enduring effect not found in medications, may also help prevent future episodes of depression, and may prevent relapse after medications are discontinued.