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.

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.

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.

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.

September 2016

No Added Value to Adding Antidepressants to Psychotherapy

Karyotaki, E., Smit, Y., Henningsen, H., Huibers, M.J.H., Robays, J., de Beurs, D., & Cuijpers, P. (2016). Combining pharmacotherapy and psychotherapy or monotherapy for major depression? A meta-analysis on the long-term effects. Journal of Affective Disorders, 194, 144-152.

Depression is a highly prevalent disorder and is expected to become the second largest cause of disability by 2020. Part of the reason for this high level of burden is that depression tends to be a recurrent disorder with high rates of mortality and morbidity. The post-treatment effects of psychotherapy and pharmacotherapy for treating mild to moderate depression are comparable, and combining the two interventions appears to result in better outcomes. Treatment guidelines recommend pharmacotherapy for at least six months to prevent relapse of depressive symptoms. But to what extent does combined antidepressants with psychotherapy result in a different response than pharmacotherapy or psychotherapy alone in the longer term? The meta analysis by Karotaki and colleagues was conducted to address this question. They defined psychotherapy to include any psychological intervention between a therapist and patient that was verbal in nature, and that included in-person, internet-based, telephone, or bibliotherapy components. Types of psychotherapy included CBT, interpersonal, dynamic, and problem solving therapy. Only studies with outcomes at six months or longer (up to 48 months) after the start of treatment were included. The meta analysis included 23 studies with a total of 2164 patients with major depression who receive combined therapy in at least one arm of the study. Antidepressants included SSRIs, SNRIs, and tricyclic medications. In the acute phase treatment (i.e., in studies of treatment during the occurrence of depressive symptoms), combining antidepressants with psychotherapy was more effective than antidepressants alone. But combined treatment was not more effect than psychotherapy alone at six months or longer after the start of treatment. In maintenance treatment (i.e., in studies to prevent relapse of depression) psychotherapy with antidepressants was more effective that pharmacotherapy alone. Type of psychotherapy or medication did not affect any of the results.

Practice Implications

The meta analysis suggests that in the treatment of patients who currently have depressive symptoms (acute phase) psychotherapy alone is as effective in the long run as combining psychotherapy with antidepressants. However combination treatment is more effective that antidepressants alone, presumably because of the added value of psychotherapy. To prevent relapse (maintenance phase), combined treatment of pharmacotherapy and psychotherapy was more effective than antidepressants alone. Psychotherapy may be a viable alternative to combined treatment with medications for treatment of current active depressive symptoms. Psychotherapy often results in patients improving their interpersonal skills and coping mechanisms which they can then use to sustain their improvements in the longer term.

August 2016

Psychotherapy That is Culturally Congruent for Chinese Clients

Xu, H. & Tracey, T.J.G. (2016). Cultural congruence with psychotherapy efficacy: A network meta-analytic examination in China. Journal of Counseling Psychology, 63, 359-365.

Cultural congruence refers to providing psychotherapy that is consistent with the client’s cultural context in its description of the etiology of symptoms and in its therapeutic procedures. In general, congruence of treatments with clients’ expectation, preferences, and beliefs is related to greater psychotherapy efficacy. And specifically identifying culturally appropriate or adapted treatments is important because this is often related to better therapy outcomes for ethnic and racial minorities. Psychotherapy as a professional practice developed recently in China. Cognitive-behavioral, existential-humanistic, and psychodynamic therapies have taken their place along side indigenous therapies including Naikan therapy, Taoism cognitive therapy, and Morita therapy. Historically in China mental health problems were seen as a disturbance in ying-yang or a sin committed in a previous life. Healing practices included engaging in altruism or religious practices to achieve redemption. Xu and Tracey argue that Chinese culture strongly endorses an experiential and subjective orientation and is less aligned with analytic and objective orientations. Using this understanding, the authors expected that experiential-humanistic and indigenous therapies would be more congruent and therefore more effective than cognitive-behavioral education or psychodynamic therapy in alleviating mental health issues. In this meta analysis, Xu and Tracey reported on 235 studies conducted in China that compared the various treatments to a control condition or to each other. There were too few studies of psychodynamic therapy, so it was not included in the analyses. All treatments were effective compared to a control condition with large effect sizes (g = .85 to 1.18). However, whereas experiential-humanistic and indigenous therapies were equally effective, each was significantly more effective (g = .34) than cognitive-behavioral psychoeducation.

Practice Implications

The three modalities, experiential-humanistic, indigenous, and cognitive-behavioral psychoeducation were effective. However the two therapies that were more experiential and subjective in nature were more effective to reduce Chinese clients’ symptoms. When working with Chinese clients, therapists may achieve better outcomes if they work on more experiential components (e.g., feelings and therapeutic relationship) and focus on subjective experiences (e.g., introspection and reflection). The results of the meta analysis suggest that when working with Chinese clients interpersonal processes and emotions should be the clinical focus and take priority over dysfunctional cognitions and psychoeducation.

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April 2017

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January 2017

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December 2016

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October 2016

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September 2016

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August 2016

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Psychotherapy Practice Research Network (PPRNet)