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Negative Effects of Psychotherapy

Cuijpers, P., Reijnders, M., Karyotaki, E., de Wit, L., & Ebert, D.D. (2018). Negative effects of psychotherapy for adult depression: A meta-analysis of deterioration rates. Journal of Affective Disorders, 239, 138-145.

Several types of psychotherapy are effective to treat depression, and there appears to be very little difference among the treatments in term of their effectiveness. Despite the documented effectiveness of psychotherapies to treat depression, there is also a growing interest in the clinical and research community about negative effects. Negative effects refer to the deterioration or worsening of depressive symptoms during treatment. Some may also refer to drop-out or non-response as a negative effect because these events are demoralizing and may prevent a patient from seeking more adequate care. Some researchers estimated that 5% to 10% of patients deteriorate during therapy. Deteriorations may not be due solely to the therapy itself, but instead may reflect the natural course of depression. In this meta-analysis, Cuijpers and colleagues examined studies in which a psychotherapy for depression was compared to a control condition in which patients did not receive an active treatment. In such studies, one might expect the control condition to represent what would happen in terms of symptoms if the patient received no treatment. Despite over 100 randomized controlled trials of a psychotherapy versus a non-active treatment control condition for depression, only 18 studies reported enough information to estimate negative effects. There was a median deterioration rate in the psychotherapy groups of about 4%, whereas the risk of deterioration in the control groups was about 11%. There were no differences in deterioration rates among types of psychotherapy (CBT vs others), treatment format (group vs individual), or type of control group (wait-list vs care as usual).

Practice Implications

Only 6.2% of research studies reported enough information to estimate negative effects, making it difficult to get a good estimate that represents all studies and patients. Nevertheless, receiving psychotherapy reduced deterioration rates by more than 61% compared to untreated control conditions, suggesting that psychotherapy can help some patients who might get worse with no treatment. Therapists should work to recognize and evaluate deterioration rates in therapy because they do occur for an important minority of patients. Some have suggested ongoing progress monitoring as a means of reducing the number of patients who might get worse during 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.

Mental Health Disorders Increase Health Care Utilization in Adults with Chronic Disease

Sporinova B, Manns B, Tonelli M, et al. (2019). Association of mental health disorders with health care utilization and costs among adults with chronic cisease. JAMA Network Open. Published online: 2(8):e199910. doi:10.1001/jamanetworkopen.2019.9910

Chronic diseases like diabetes, heart disease, chronic obstructive pulmonary disease (COPD), chronic kidney disease are common and represent a major burden on the individual and on society. So much so that chronic diseases represent about 60% of global disease burden. There is also a documented association between mental and physical health, such that mortality in cancer, diabetes, and following a heart attack is significantly higher in those with depression. The cost of chronic disease to the Canadian economy represents about 60% of the annual health care budget, and depression alone has a $32.3 billion impact on the Canadian economy. In this economic study, Sporinova and colleagues sought to quantify the impact of having a mental disorder on health care utilization and cost for those with chronic diseases. The study used a large data base of adults from Alberta, Canada who had at least one chronic disease including asthma, COPD, heart failure, myocardial infarction, diabetes, epilepsy, and chronic kidney disease. Mental disorders were defined as a concurrent diagnosis of depression, schizophrenia, or substance use disorder. Factors like sex, income, and rural residency were controlled in the analyses. Of the cohort with a chronic illness, 15.8% had a mental disorder, with depression as the most common mental disorder at 11.2%. People with chronic illness and a mental disorder tended to be younger, women, with a lower socio-economic status, and they tended to die at a higher rate during the study period. The mean total 3-year health costs of those with a chronic illness was $20,210 (95% CI: $19,674, $20,750) Canadian dollars, whereas for those with a concurrent mental disorder the cost was significantly higher at $38,250 (95% CI: $36,476, $39,935). Higher costs were driven by greater hospitalizations, prescription drug use, and physician visits. Costs were higher for older people, and for those with more than one mental disorder.

Practice Implications

The results clearly indicated that an important proportion of those with chronic illnesses were also diagnosed with a mental disorder. Further, a diagnosis of a mental disorder drove up the burden of the chronic illness significantly, both for the individual and for the health care system. Past research indicated improved medical outcomes when treating depression in medical patients. And so, although the physical symptoms of chronic illness may appear prominent, clinicians must treat mental health problems when they exist concurrently, if they want to improve patient medical and mental health outcomes.

Fonagy, P., Lemma, A., Target, M., O'Keeffe, S., Constantinou, M., Ventura Wurman, T., . . . Pilling, S. (2019). Dynamic interpersonal therapy for moderate to severe depression: A pilot randomized controlled and feasibility trial. Psychological Medicine, 1-10. Online first publication. doi:10.1017/S0033291719000928

Most psychotherapies are equally effective when it comes to treating depression. However, no single therapy is uniformly effective, so that about 50% of patients might improve when it comes to symptom reduction. So, although there is a large evidence base for treatments like CBT, therapists and patients need access to a range of available treatments. There is less research on psychodynamic therapies, although a number of trials and meta-analyses indicate their effectiveness to treat depression. In the United Kingdom (UK), the health system may offer a stepped care program that provides patients with low intensity guided self-help based on a CBT model followed by more intensive treatment with CBT or IPT if patients did not benefit from self-help. The UK health system rarely offers Dynamic Interpersonal Therapy (DIT), and DIT has never been studied in a randomized controlled trial within the UK health system. Fonagy and colleagues designed this randomized controlled trial to test the efficacy of DIT when compared to the CBT-oriented self-help program as offered in the UK. The study also included a smaller randomized sample of those who received the intensive version of CBT for depression. In total, 147 participants with moderate to severe depression were randomly assigned to DIT, CBT guided self-help, or the intensive version of CBT. The DIT is informed by attachment theory and by mentalization theory, and it views depressive symptoms as responses to interpersonal difficulties or perceived attachment threats. The results of the trial showed a significantly greater effect of DIT compared to guided self-help with regard to depressive symptoms, overall symptom severity, social functioning, and quality of life at post-treatment. The patients receiving DIT maintained these gains up to 1-year post-treatment. Over half of DIT patients showed clinically significant improvements, but only 9% who received the CBT-based guided self-help achieved such improvement. There were no significant differences on any of the outcomes between DIT and the more intensive version of CBT.

Practice Implications

One of the benefits of DIT, according to the authors, is that it offers a treatment manual and curriculum that enables those without a lot of background in psychodynamic therapies to deliver it. This makes DIT potentially widely-applicable in publicly funded health systems like in the UK, Canada, and others. DIT may offer yet another effective option of psychotherapy to therapists and their patients who experience depressive symptoms. The study also points to the limits of offering only guided self-help to those with moderate to severe depression.

Author email: p.fonagy@ucl.ac.uk

Jennissen, S., Huber, J., Ehrenthal, J.C., Schauenburg, H., & Dinger, U. (2018). Association between insight and outcome of psychotherapy: Systematic review and meta-analysis. The American Journal of Psychiatry. Published Online: https://doi.org/10.1176/appi.ajp.2018.17080847

For many authors, one of the purported mechanisms of change in psychotherapy is insight. In fact, the utility of insight for clients with mental health problems was first proposed over 120 years ago by Freud and Breuer. Briefly, insight refers to higher levels of self-understanding that might result in fewer negative automatic reactions to stress and other challenges, more positive emotions, and greater flexibility in cognitive and interpersonal functioning. Although insight is a key factor in some psychodynamic models, it also plays a role in other forms of psychotherapy. Experiential psychotherapy emphasises gaining a new perspective through experiencing, and for CBT insight relates to becoming more aware of automatic thoughts. Jennissen and colleagues defined insight as patients understanding: the relationship between past and present experiences, their typical relationship patterns, and the associations between interpersonal challenges, emotional experiences, and psychological symptoms. In this study, Jennissen and colleagues conducted a systematic review and meta analysis of the insight-outcome relationship, that is the relationship between client self-understanding and symptom reduction. They reviewed studies of adults seeking psychological treatment including individual or group therapy. The predictor variable was an empirical measure of insight assessed during treatment but prior to when final outcomes were evaluated. The outcome was some reliable and empirical measure related to symptom improvement, pre- to post- treatment. The review turned up 22 studies that included over 1100 patients mostly with anxiety or depressive disorders who attended a median of 20 sessions of therapy. The overall effect size of the association between insight and outcome was r = 0.31 (95% CI=0.22–0.40, p < 0.05), which represents a medium effect. Moderator analyses found no effect of type of therapy or diagnosis on this mean effect size, though the power of these analyses was low.

Practice Implications

The magnitude of the association between insight and outcome is similar to the effects of other therapeutic factors such as the therapeutic alliance. When gaining insight, patients may achieve a greater self-understanding, which allows them to reduce distorted perceptions of themselves, and better integrate unpleasant experiences into their conscious life. Symptoms may be improved by self-understanding because of the greater sense of control and master that it provides, and by the new solutions and adaptive ways of living that become available to clients.

Author email: Simone.Jennissen@med.uni-heidelberg.de

Munder, T., Fluckiger, C., Leichsenring, F, Abbass, A.A., Hilsenroth, M.J., … Wampold, B.E. (2018). Is psychotherapy effective? A re-analysis of treatments for depression. Epidemiology and Psychiatric Sciences, 1-7.

Based on a deeply flawed review in 1952, Hans Eysenck declared that psychotherapy was no more effective than custodial care for treating mental disorders. Later, he qualified this by stating that behaviour therapy was effective and other forms of psychotherapy were not. These statements touched off decades of angst and debate in the psychotherapy community, and also resulted in a great deal of research about psychotherapy’s effectiveness. By the 1970s the new research technique of meta-analysis was developed and was applied to psychotherapy research. In their seminal meta analysis of controlled studies, Smith and Glass found that psychotherapy was useful and with large effects compared to no treatment. And yet the debate continues. In 2018, Cuijpers argued that waitlist control groups (i.e., a common control condition in psychotherapy studies in which patients receive no treatment) are an inappropriate comparison leading to exaggerated estimates of the effects of psychotherapy. Recently, Munder and colleagues argued that waitlist controls are a way of estimating the natural course of the disorder (what would happen with no treatment) plus the effect of expecting to receive treatment (client expectations of receiving treatment tend to have a positive impact on symptoms). In fact, research shows that pre- to post-study effect sizes for the waiting period is approximately g = .40, or a medium effect. In other words, waiting for therapy in a study results in a moderate proportion of individuals getting better on their own without treatment. Therefore, Munder and colleagues argued that comparing psychotherapy to a waitlist control is appropriate and may be a conservative estimate of psychotherapy’s effects (i.e., psychotherapy has to outperform the effects of clients expecting treatment to help them). In their meta analysis, Munder and colleagues re-analysed 71 studies of psychotherapy for depression compared to a waitlist control condition. They found that the effect size in favour of psychotherapy was g = 0.75 (SE = 0.09) indicating a moderate to large effect. Psychotherapy was also more effective than care as usual (i.e., compared to another intervention that was not psychotherapy), g = 0.31 (SE = 0.11). There were no differences between types of psychotherapy (CBT, IPT, PDT, etc.) for depression outcomes.

Practice Implications

Despite various attempts during the history of psychotherapy to downplay or disparage its efficacy, research continues to show that psychotherapy is in fact effective. The average effect size compared to the natural history of depression is moderate to large (and that is likely an under-estimate). Again, there is no evidence that one type of psychotherapy is superior to another for treating depression. It is time for the field to move beyond questions of efficacy of psychotherapy and of the relative efficacy of different treatments, and look to understanding therapist interpersonal stances, client characteristics, and relationship factors that may improve outcomes from psychotherapy.