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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.

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.

Practice Implications

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.

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.

Practice Implications

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.

McHugh, K.R., Whitton, S.W., Peckham, A.D., Welge, J.A., & Otto, M.W. (2013). Patient preference for psychological vs pharmacological treatment of psychiatric disorders: A meta-analytic review. Journal of Clinical Psychiatry, 74, 595-602.

For the most part psychotherapy and pharmacological interventions have equivalent positive effects on depression in the short term, and psychotherapy has better outcomes in the long term (see my May, 2013 blog).  There is also evidence that the effects of medications for depression are overestimated (also in the May 2013 blog). Despite all of this evidence, psychotherapy use has remained the same or declined slightly over the past 10 years (currently at about 3.4% of the population), whereas medication use for depression has doubled to over 10% of the population. At the same time, guidelines for evidenced based practice emphasize incorporating patient preferences when there is an absence of evidence-based decision rules for treatment selection. Providing patients with their preferred treatment is associated with better treatment uptake and outcomes (see June, 2013 blog). McHugh and colleagues conducted a meta analysis to review the literature on patient preferences for psychological versus pharmacological interventions for mental health disorders among adults. They included studies with treatment and non-treatment seeking samples of patients with a variety of disorders. (A quick note about meta-analysis. Meta analysis is a way of statistically combining the effect sizes from a number of studies into a common metric so that an average effect size can be calculated. Meta analysis is now the standard by which studies are reviewed. Meta analysis results are much more reliable than any single study and so represent the best way to inform clinical practice from research findings). McHugh and colleagues identified 34 studies representing over 90,000 participants. Most studies were of depressive disorders and anxiety disorders. When given a preference, 75% of participants preferred psychotherapy over medication to treat their mental health problem. In treatment seeking samples, the percentage was lower at 69%, but still significantly in favour of psychotherapy. Younger people and women were more likely to prefer psychotherapy, though the findings still showed a preference for psychotherapy among older people and men. The availability of combining psychotherapy and medication did not affect the results, so that even when given the option of both psychotherapy and medication people still preferred psychotherapy alone.

Practice Implications:

In all subsamples, participants were 3 times more likely to prefer psychotherapy to medication for their mental disorder. Patient preference for treatment is a core component of evidence based mental health practice that improves outcome and reduces drop outs. Without evidence for superiority for one treatment over another, patients should be given their preference, and on average patients overwhelmingly prefer psychotherapy. To optimize outcomes in clinical settings, providers should consider patient preferences, including their preference for psychotherapy over medication.

Author email: kmchugh@mclean.harvard.edu

Niemeyer, H., Musch, J., & Pietrowsky, R. (2013). Publication bias in meta-analyses of the efficacy of psychotherapeutic interventions for depression. Journal of Consulting and Clinical Psychology, 81, 58-74.

Meta-analyses are important ways of summarizing effects of medical and psychological interventions by aggregating effect sizes across a large number of studies. (Don’t stop reading, I promise this won’t get too statistical). The aggregated effect size from a meta analysis is more reliable than the findings of any individual study. That is why practice guidelines almost exclusively rely on meta analyses when making practice recommendations (see for example the Resources tab on this web site). However meta analyses are only as good as the data (i.e., studies) that go into them (hence, the old adage: “garbage in, garbage out”). For example, if the studies included in a meta analysis are a biased representation of all studies, then the meta analysis results will be unreliable leading to misleading practice guidelines. One problem that leads to unreliable meta analyses is called publication bias. Publication bias often refers to the tendency of peer reviewed journals not to publish studies with non-significant results (e.g., a study showing a treatment is no better than a control condition). Publication bias may also refer to active suppression of data by researchers or industry. Suppression of research results may occur because an intervention’s effects were not supported by the data, or the intervention was harmful to some study participants. In medical research, publication bias can have dire public health consequences (see this TED Talk). There is lots of evidence that publication bias has lead to a significant over-estimation of the effects of antidepressant medications (see Turner et al (2008) New England Journal of Medicine). Does publication bias exist in psychotherapy research, and if so does this mean that psychotherapy is not as effective as we think? A recent study by Niemeyer and colleagues (2013) addressed this question with the most up to date research and statistical techniques. They collected 31 data sets each of which included 6 or more studies of psychotherapeutic interventions (including published and unpublished studies) for depression. The majority of interventions tested were cognitive behavioral therapy, but interpersonal psychotherapy, and brief psychodynamic therapy were also included. The authors applied sophisticated statistical techniques to assess if publication bias existed. (Briefly, there are ways of assessing if the distribution of effect sizes across data sets fall in a predictable pattern called a “funnel plot” – specific significant deviations from this pattern indicate positive or negative publication bias). Niemeyer and colleagues found minimal evidence of publication bias in published research of psychotherapy for depression. This minimal bias had almost no impact on the size of the effect of psychotherapy for depression.

Practice Implications

This is a very important result indicating that despite a minor tendency toward a selective publication of positive results, the efficacy of all reviewed psychotherapy interventions for depression remained substantial, even after correcting for the publication bias. Niemeyer and colleagues’ findings demonstrate that publication bias alone cannot explain the considerable efficacy of psychotherapy for depression. Psychotherapeutic interventions can still be considered efficacious and recommended for the treatment of depression.

Author email address: helen.niemeyer@hhu.de