Practice-Based Psychotherapy Research
To Improve The Wellbeing Of Our Community
PPRNet Blog: December 2016
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
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).
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.
Furukawa, T.A., Cipriani, A., Atkinson, L.A., Leucht, S., Ogawa, Y., … Salanti, G. (2016). Placebo response rates in antidepressant trials: A systematic review of published and unpublished double-blind randomised controlled studies. Lancet Psychiatry, 3, 1059-1066.
The placebo response in medication trials is an interesting and important phenomenon. Placebo response refers to improvement in clients that is due to therapeutically powerful factors like client’s expectations that an intervention will be effective and to the therapeutic relationship with the health care provider. In medication trials, placebo is seen as problematic because researchers typically want to demonstrate the effectiveness of the active medication (e.g., selective serotonin re-uptake inhibitors) independent of any other factors. For this reason, randomized clinical trials of medications are often double-blind and placebo controlled (i.e., clients and clinicians are unaware of who received the active medication and who received the inert placebo pill). It has widely been suspected that over the years the placebo response has been increasing in antidepressant trials possibly due to the types of patients included in trials (i.e., more recently, patients with more severe symptoms are included) and to other methodological issues (e.g., use of multi-centre trials, dosing schedule). An increasing placebo response is suspected of contributing to the growing number of failed anti-depressant trials (i.e., trials that show little or no effectiveness of the medication). Using advanced statistical methods, Furukawa and colleagues evaluated in a meta analysis if placebo response in medication trials was increasing over time. They defined a response as a 50% or greater reduction in observer-rated depression scale scores from baseline to 8 weeks. Their review included 252 placebo controlled trials of antidepressants from 1978 to 2015. Placebo response rates ranged widely from 0% to 70% (I2 = 74.1%) with a mean placebo response of 35% to 40%. Year of publication was not significantly related to placebo response rate after controlling for methodological variables like length of the trial, multi-centre trials, and dose regimen. That is, once change in the methodology of conducting trials over time was accounted for, the placebo response appeared to remain largely the same from year to year.
The placebo response is very real and complicates our understanding of how and why antidepressants might work for some patients. About 35% to 40% of patients who benefit from antidepressants may be benefitting largely because of the expectation of getting better. Greater treatment response to antidepressants for a large proportion of patients appears to be dependent on the therapeutic features of supportive contact with a caring health professional.
Pomerville, A., Burrage, R.L., & Gone, J.P. (2016). Empirical findings from psychotherapy research with indigenous populations: A systematic review. Journal of Consulting and Clinical Psychology, 84, 1023-1038.
Indigenous people around the world have a higher incidence of mental illness compared to other ethnic or racial groups. These higher rates may be related to the historical effects of colonization and to current discrimination. Despite this, there is very little empirical research on psychotherapy provided to Indigenous peoples. Psychotherapy, as commonly practiced, has Eurocentric values by emphasizing individuality, independence, rationality, assertiveness, and by sometimes taking an ahistorical present-centered focus. These values may conflict with some Indigenous cultures that emphasize community, interdependence, mysticism, modesty, and the historical context of current functioning. Hence, psychotherapy as typically defined may require adaptations when used with Indigenous groups. In their review, Pomerville and colleagues examine what is currently known about psychotherapy with Indigenous populations. The populations studied in the existing research includes Indigenous peoples of the US, Australia, Canada, Pacific Islands, and New Zealand. There were no psychotherapy studies prior to 1986, and only 23 studies since then. Most studies emphasized some form of cultural adaptation of the treatment. The majority of studies focused on substance abuse, with only a few on anxiety and depression. Only two studies were controlled outcomes studies (i.e., randomized controlled trials considered by many to provide the best evidence from a single study). Research on individual therapy for Indigenous adolescents is completely lacking. The authors concluded that the efficacy of novel or adapted treatments or the generalizability of existing empirically supported treatments to Indigenous people are currently unknown.
The virtual absence of controlled outcome trials of psychotherapies for Indigenous populations is serious gap in the practice of mental health interventions. This state of the research is particularly problematic given the high rates of mental illness and alarming rates of suicide among adolescents in Indigenous populations. Some studies found discontent among Indigenous communities with the current application of empirically supported treatments, and others argue that Indigenous healing be given the same legitimacy despite no controlled outcome research. On the other hand some authors favour training cultural competence among clinicians who practice standard empirically supported treatments. Pomerville and colleagues suggest that in the absence of evidence, tailoring psychotherapy to address the needs of Indigenous clients by taking into account specific practices of their communities may improve retention and outcomes.