Practice-Based Psychotherapy Research
To Improve The Wellbeing Of Our Community
PPRNet Blog: April 2015
At the PPRNet conference in November 2012 over 100 psychotherapy clinicians, researchers, and educators were very keen to receive ongoing information about psychotherapy research that is practice-oriented and presented in an easily readable format. And so the PPRNet Blog was born.
About once a month I will review and summarize two or three published psychotherapy research articles. As part of the summary, I will highlight the practice implications of the research.
Because of copyright issues, we cannot post the full text of the articles, but we will provide a link to the abstract on the publisher's web site. I will also post the author's email address. Most authors are very happy to share their work. So if you want a copy of the article send the author an email with a request for a pdf or reprint.
At the bottom of each review you can post a comment, and comment on your colleagues' comments. I will update these as frequently as possible.
If you have ideas for an article to review or a topic you would like to see covered, please send me an email at firstname.lastname@example.org.
Giorgio A. Tasca
The Great Psychotherapy Debate
Starting in April, 2015 I will review parts of The Great Psychotherapy Debate that focus on efficacy of treatments, therapist effects, common factors, and more. This is the second edition of this landmark and sometimes controversial book that provides a historical and current survey of the evidence for what makes psychotherapy work. Since this is a book I will not provide the author email. However, you can view parts of the book in Google Books: The Great Psychotherapy Debate on Google Books.
Is Psychotherapy Provided in Clinical Settings Effective?
Wampold, B.E. & Imel, Z.E. (2015). The Great Psychotherapy Debate: The evidence for what makes psychotherapy work (2nd edition). New York: Routledge.
In this part of the chapter on efficacy, Wampold and Imel provide convincing evidence from numerous reviews of meta analyses that the average effect size of psychotherapy across diverse treatments and patients is about d = .80. This is a reliable figure and is considered a “large” effect by commonly accepted standards. Put another way, the average psychotherapy patient is better off than 79% of untreated clients, psychotherapy accounts for 14% of the outcome variance, and for every 3 patients who receive psychotherapy, one will have a better outcome than had they not received psychotherapy. In other words, psychotherapy is remarkably efficacious. These effect size estimates are mostly drawn from randomized clinical trials that are highly controlled (i.e., therapist are highly trained and supervised, patients are sometimes selected to have no co-morbid problems, treatment fidelity to a manual is closely monitored, etc.). Some argue that the context of these trials renders them artificial, and their findings say little about real world settings and patients. How do findings from controlled clinical trials compare to everyday clinical practice? Wampold and Imel review the evidence from three areas of research: clinical representativeness, benchmarking, and comparisons to treatment as usual. With regard to clinical representativeness, a meta-analysis (k > 1,000 studies) coded the studies for treatment setting, therapist characteristics, referral sources, use of manuals, client heterogeneity, etc. The meta-analysis found that clinically representative psychotherapy, that is therapies that were most representative of typical practice, had similar effects to what is observed in highly controlled studies. With regard to benchmarking, a large study (N > 5,700 patients) compared treatment effects observed in naturalistic settings to clinical trial benchmarks. Benchmarks were defined as score on an outcome (e.g., on a depression scale) that are within 10% of those scores reported in clinical trial research. Treatment effects in naturalistic settings were equivalent to and sometimes better than those achieved using clinical trial benchmarks, and therapists in practice settings achieved the same outcomes in fewer sessions than in clinical trials. With regard to comparisons to treatment as usual, a meta-analysis for personality disorders (k = 30 studies) looked at studies that compared evidence-based treatments tested in clinical trials to treatment as usual. The meta-analysis found that evidence-based treatments were significantly more effective than treatment as usual with moderate effects. These results suggest that special training and supervision for treating personality disorders, which is common in clinical trials, might be beneficial.
Wampold and Imel argue that psychotherapy as tested in clinical trials is remarkably effective such that the average treated patient being better off than 79% of untreated controls. The evidence also suggests that psychotherapy practiced in clinical settings is effective and probably as effective as psychotherapy tested in clinical trials. It is possible that therapists who treat those with personality disorders may benefit from training and supervision that is often characteristic of treatments provided in clinical trials.
Cuijpers, P., Koole, S.L., van Dijke, A., Roca, M., Li, J., & Reynolds, C.F. (2014). Psychotherapy for subclinical depression: A meta-analysis. British Journal of Psychiatry, 205, 268-274.
Subclinical depression refers to someone having relevant depressive symptoms but without meeting standard diagnostic criteria for a depressive disorder. Cuijpers and colleagues indicate that subclinical depression can be defined as meeting at least one but not more than four DSM core symptoms for depression. Subclinical depression is highly prevalent. About 50% of individuals with major depression have had a subclinical depressive disorder, and so subclinical depression may be a risk for developing major depression later on. Depression in general is associated with a high level of health and economic burden worldwide (see my June 2014 blog). Antidepressant medications are likely not more effective than a placebo in treating subclinical depression. Cuijpers and colleagues examined whether psychotherapy is effective in treating subclinical depression, and whether psychotherapy reduces the subsequent occurrence of major depression. Cuijpers and colleagues report on a meta-analysis of 18 studies of psychotherapy for subclinical depression representing 1,913 patients. Most of the studies were based on cognitive behavioral therapy (CBT). In order to compare the effects of psychotherapy for subclinical depression versus psychotherapy for major depression, they also included 56 studies of psychotherapy for major depression. Psychological treatments had a small to moderate effect on subclinical depression (g = .35) that was statistically significant. Treatments significantly reduced the incidence of major depressive episodes by 39% at 6 months follow up, and by 26% at 12 months follow. The effect of psychotherapy for major depression (g = .63) was significantly larger than the effect of psychotherapy for subclinical depression (g = .35). No differences were found between CBT and other forms of psychotherapy for subclinical depression.
The results of this meta analysis indicates that psychological treatment of subclinical depression is moderately effective, and may reduce the incidence of major depression in the longer term for some. Effect sizes of psychotherapy for subclinical depression were likely underestimated because the type of control groups used in these studies affected study quality. However, even after controlling for study quality, the effects of psychotherapy for subclinical depression were still smaller than effects for psychotherapy of major depression. Although the number of studies comparing CBT to other therapies is small, the findings are similar to other meta-analyses that indicate that several psychotherapies are effective treatment options for depressive symptoms.
View the Psychotherapy for Subclinical Depression article abstract.
Author email: email@example.com.
Xie, C.L., Wang, X.D., Chen, J., Lin, H.Z., Chen, Y.H., Pan, J.L., & Wang, W.W. (2015). A systematic review and meta-analysis of cognitive behavioral and psychodynamic therapy for depression in Parkinson’s disease patients. Neurological Sciences, 1-11.
Parkinson’s disease (PD) is a neurodegenerative brain disorder that progresses slowly in most people. When dopamine producing cells in the brain are damaged or do not produce enough dopamine, motor symptoms of PD appear. Non-motor symptoms including depression, apathy, and sleep disorders are also common so that in clinical settings about a 40% of patients with PD may have a depressive disorder. Depression is a top predictor of poor quality of life in patients with PD. Depression in PD is not well understood but may be due to neurobiological vulnerability and to psychological factors. Antidepressant medications are often prescribed for depression in PD but their efficacy is questionable. Xie and colleagues argue that long term use of some antidepressants may lead to worsening of some PD motor symptoms. In this meta-analysis, Xie and colleagues examine the efficacy of brief psychological interventions, including cognitive behavioral therapy (CBT) and psychodynamic psychotherapy for depressive symptoms in PD. Twelve eligible studies were included in the meta analysis representing 766 patients with a mean age of 62 years (48% men). As an interesting note, 9 of the 12 studies were conducted in China and 3 were from the US or UK. Six of the studies used CBT for depression, and the remaining used psychodynamic therapy for depression in PD patients. Control conditions were often “treatment as usual”, and varied from antidepressant medication (e.g., Citalopram), nursing care, telephone calls, or no treatment for the depression. The effects of psychological interventions compared to control conditions on depressive symptoms were large, and remained large even after removing outlier studies. Outcomes for psychodynamic psychotherapy were better than for CBT, although both interventions resulted in large effects. There were also significant positive effects of brief psychotherapies on cognitive functioning, but not on quality of life. The authors were concerned that the quality of studies was variable and that many studies demonstrated a risk of bias. Further, most did not report outcomes at follow up periods.
Significant depressive symptoms commonly occur in patients with Parkinson’s disease (PD). As a result, their overall quality of life may be reduced. Medications for depression may be complicated by the neurodegenerative nature of PD – that is, effects of medications on depressive symptoms may be small and their neuro-motor side effects may be intolerable for some patients. This meta-analysis by Xie and colleagues of 12 studies suggests that better research on psychotherapy for depression in PD needs to be conducted with adequate follow ups. Nevertheless, the findings suggest that brief psychological interventions may represent viable and effective alternatives for patients with PD who have a depressive disorder.