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Barth, J., Munder, T., Gerger, H., Nuesch, E., Trelle, S. et al. (2013) Comparative efficacy of seven psychotherapeutic Interventions for patients with depression: A network meta-analysis. PLoS Med 10(5): e1001454. doi:10.1371/journal.pmed.1001454

As I wrote about in the June, 2014 blog, depression is a highly burdensome disorder and is the third leading cause of disability worldwide after lower respiratory infections and diarrhoeal diseases. Depression occurs in 4.4% of the world population. Identifying effective treatment for depression is critical to reduce its health and economic burden. There is broad based consensus that psychotherapy is effective for depression, but there remains ongoing debate about which therapies are more effective. Establishing the relative efficacy of psychotherapy for depression is important because many patients do not respond to any one type of treatment – and so they may benefit from different options. Although some meta-analyses have synthesized research that compared pairs of treatments against one another within studies, these meta analyses do not allow one to pool these comparisons of treatments across studies in a comprehensive way. The study by Barth and colleagues uses a relatively new method called network meta analysis in which many treatments can be compared to each other at once by pooling comparisons of treatments to alternate treatments across a number of studies. As a result the authors were able in one meta analysis to compare the relative efficacy of seven different treatments for depression. The seven therapies were defined as follows: (1) Interpersonal Psychotherapy: a brief and structured therapy that focuses on interpersonal issues in depression; (2) Behavioral Activation: raises the patient’s awareness of pleasant activities and seeks to increase the patient’s positive interactions with the environment; (3) Cognitive Behavioral Therapy: focuses on a patient’s negative beliefs, how they affect current and future behavior, and restructures the beliefs; (4) Problem Solving Therapy: defines a patient’s problems, proposes solutions for each problem, and then selects the best solution; (5) Psychodynamic Therapy: focuses on unresolved conflicts and relationships and the impact they have on a patient’s current functioning; (6) Social Skills Therapy: teaches skills that help to build and maintain healthy relationships; and (7) Supportive Counseling: aims to help patients talk about their experiences and emotions, and offers empathy. The network meta analysis included 198 clinical trials that represented 15,118 patients in which the seven psychotherapies were compared to each other or to a control condition. All seven psychotherapies were better than wait list controls or usual care, with moderate to large differences. That is, the average patient receiving psychotherapy was better off than about half those in a control condition. Researchers found small or no differences when the seven therapies were compared to each other. Treatments worked equally well for different patient groups (e.g., younger vs older; post natal depression; etc.), and in different modalities (individual vs group).

Practice Implications

All seven therapies were effective in reducing depression and none of the seven therapies in this network meta analysis stood out as superior to the others. The findings suggest that patients have a number of viable options for psychotherapeutic treatment for depression. This is important because, about 40% of patients do not benefit from the treatments they do receive, though they may benefit from another approach and will require other options. Client preferences may play a critical role in determining outcomes for some. If possible, patients should be given the option of the type treatment they may prefer or the option of the type of therapist with which they may be most comfortable.

Keefe, J.R., McCarthy, K.S., Dinger, U., Zilcha-Mano, S., Barber, J.P. (2014). A meta analytic review of psychodynamic therapies for anxiety disorders. Clinical Psychology Review, http://dx.doi.org/10.1016/j.cpr.2014.03.004.

Anxiety disorders are one of the most prevalent psychiatric conditions, with combined lifetime prevalence near 17%. Anxiety disorders have high rates of comorbidity with other Axis I and II psychiatric disorders, and are associated with substantial physical and mental health burden. Several well-established treatments for anxiety disorders exist, including cognitive-behavioral therapies (CBT). However, not all patients with anxiety disorders benefit from current treatments, and there is some evidence that some aspects of CBT are not well tolerated leading to patient non-compliance with therapist directives. Hence, other treatment options such as psychodynamic therapies (PDTs). Should be tested for efficacy with patents with anxiety problems. PDTs have been studied and found to be efficacious for other types of disorders especially for depression. As Keefer and colleagues note, psychodynamic theory conceptualizes anxiety symptoms as originating from relational contexts that give rise to painful feelings (e.g., feelings of loss or abandonment, a wish to express anger or assert oneself). The patient engages in disavowal defenses against these intense, negative feelings and desires, and so avoids their experiences, and develops anxiety symptoms (e.g., panic attack triggered by experiences of loss or anger). Psychodynamic therapists encourage the patient to discuss the contexts in which their symptoms arise in order to understand the occurrence of symptoms. Therapists help the patient make connections between prior interpersonal and intrapsychic events that lead to negative feelings and anxiety-producing defenses. The goal is to allow the patient to try new ways of getting their needs met without anxiety while using more adaptive defenses. Exposure to feared or avoided situations during therapy sessions or in real life may also be encouraged by therapists. PDT may be less directive that CBT in treating anxiety disorders, and this may be useful for patients who do not respond well to directive interventions. Keefe and colleagues conducted a meta analysis of PDT for anxiety disorders and included 14 controlled studies of 1,037adults. Most of the treatments to which PDT was compared were CBT. PDT was significantly more effective than no treatment control conditions and the effect was medium. PDT did not differ significantly from alternative treatments like CBT at post-treatment, one year follow-up, and follow up beyond one year. Almost half of patients who received PDT were no longer symptomatic at post-treatment, and the drop out rate from PDT was 17%.

Practice Implications

The findings of this meta analysis suggests that psychodynamic therapy (PDT) is effective in treating anxiety disorders including generalized anxiety disorder, social phobia, panic disorder and others. PDT was well tolerated by patients as the drop out rate was relatively low at 17%. PDT was as effective as CBT when the two treatments were compared to each other. PDT provides therapists and patients with a primary or alternative approach to treatment of anxiety disorders, and should be considered for those patients who do not respond well to the more highly directive nature of CBT.

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.

Cuijpers, P., Huibers, M., Ebert, D.D., Koole, S.L., & Andersson, G. (2013). How much psychotherapy is needed to treat depression? A metaregression analysis. Journal of Affective Disorders, 147, 1-13.

The question of the number of psychotherapy sessions and of frequency sessions (i.e., number of sessions per week) that are optimal for good outcomes could have implications for how psychotherapy is practiced and how it is reimbursed. In my August 2013 PPRNet Blog, I reported on research that indicated half of patients recover after 21 sessions of psychotherapy. However, that also means that half do not recover in that number of sessions. Many of those who do not recover require another 29 sessions to recover. Research and practice in psychotherapy is largely based on a “one-session-per-week” model. Some researchers, however, have found that an increase in the frequency sessions per week could improve or speed up outcomes. Cuijpers and colleagues (2013) did a meta-regression to assess these questions for short-term psychotherapies for depression. (Meta-regression is a type of meta-analysis in which predictors from many studies are aggregated and their averaged effects on the aggregated outcome are assessed. This produces much more reliable findings than are possible from a single study.) The authors assessed predictors such as the number and frequency of sessions, and they looked at symptom outcomes for depression. The authors found 70 controlled studies that included 5403 patients. More than two-thirds of the studies included CBT as the psychotherapy. Average length of treatment was 11 sessions, and the maximum number of sessions was 24. The number of sessions across studies ranged from .44 to 2 per week, and the average per week was 1. The overall effect size for the treatment was medium sized (g = .59), though the effect became smaller (g = .40) when publication bias was corrected. (Publication bias refers to the likelihood that some less favorable studies or results were not published thus creating an overestimation of the effect of the treatment. See my May 2013 PPRNet Blog). Cuijper and colleagues’ meta-regression showed a small but significant association between greater number of sessions and outcomes for depression; but more importantly, a greater number of sessions per week had a considerably larger positive influence on the effects of psychotherapy for depression.

Practice Implications

The findings from Cuijpers and colleagues (2013) meta-regression are particularly relevant to time limited treatment of depression with CBT. The total number of sessions was less important than the frequency of sessions per week. The results suggest that increasing the intensity or frequency of CBT sessions per week might result in a more efficient therapy and faster relief for patients with depression.

Author email: p.cuijpers@vu.nl

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