Practice-Based Psychotherapy Research
To Improve The Wellbeing Of Our Community
PPRNet Blog: July 2017
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
Maljanen, T., Knekt, P., Lindfors, O., Virtala, E., Tillman, P., et al. (2016). The cost-effectiveness of short-term and long-term psychotherapy in the treatment of depressive and anxiety disorders during a 5-year follow-up. Journal of Affective Disorders, 190, 254-263.
There is substantial evidence that short-term psychotherapy is effective for depressive and anxiety disorders, including at follow-up. There are also a few meta-analyses showing the effectiveness of longer term therapy. Although there is research indicating the cost-effectiveness of short-term treatments, less research has evaluated the cost-effectiveness of longer term therapy, and even less research at long term follow-ups. In this study from the Helsinki Psychotherapy Study Group, the authors evaluated the cost-effectiveness of short-term therapy (solution-focused therapy [12 sessions] or short-term dynamic therapy [20 sessions]) versus long term dynamic psychotherapy (2-3 sessions weekly for up to 3 years). Participants (N = 326) with anxiety or mood disorders were randomized to one of the three therapies. Symptoms and work ability were assessed at pre-treatment, post-treatment, and several times during a 5 year follow-up period. A previous publication with this sample showed that long-term treatment resulted in greater recovery with regard to symptoms and work ability (recovery for both outcomes exceeding 60%) compared to short-term treatment (50% recovered). For this study the authors asked: is long-term treatment cost-effective – in other words, is the better outcome from long-term treatment justified by greater cost? Both direct costs (health care utilization) and indirect costs (lost productivity) were calculated in this study using standard econometrics. Long-term therapy cost 3 times as much as short-term treatments. This amount was smaller than expected because those who received short-term treatments had higher auxiliary costs (i.e., the need for other treatments after the short term therapy ended). Shorter therapies were equally cost-effective, but both were more cost-effective than the longer treatment. That is, despite being more effective and requiring less auxiliary treatment, the longer-term therapy was more costly per unit of improvement with regard to symptoms and productivity compared to the shorter treatments.
From an economic point of view, short-term treatments make the most sense. However, given that many patients needed other treatments after the end of short-term therapy, and given that on average the longer-term therapy was more effective in the long run, a clinician may want to weigh the economics with the specific needs and preferences of each patient.
Steinert, C., Munder, T., Rabung, S., Hoyer, J., & Leichsenring, F. (2017). Psychodynamic therapy: As efficacious as other empirically supported treatments? A meta-analysis testing equivalence of outcomes. American Journal of Psychiatry (AJP In Advance) https://doi.org/10.1176/appi.ajp.2017.17010057.
Mental disorders are an important health concern that confer high levels of personal and economic burden. Up to 45% of primary care patients have at least one mental disorder. Many practice guidelines indicate that cognitive behavioral therapy (CBT), interpersonal therapy (IPT) , and specific pharmacotherapy interventions as empirically supported for common mental disorders. However, many psychotherapists practice psychodynamic therapy (PDT), and a number of reviews have provided evidence for the efficacy of short-term PDT compared to wait-lists, treatment as usual, and other forms of psychotherapy for depression and anxiety disorders. However, there also have been inconsistent findings with regard to the efficacy of PDT. A particularly strict test of efficacy of a therapy involves a comparison of the treatment to a rival intervention that has established efficacy. Such comparisons in which no differences are expected are referred to as equivalence trials. The problem is that no single study in psychotherapy so far is large enough to test for equivalence (technically, this refers to studies being statistically underpowered to detect a small effect), but a meta-analysis that combines samples from many studies can represent a large enough sample and be adequately powered. In this study, Steinert and colleagues conducted a meta-analysis of randomized controlled trials in which PDT was compared to a treatment established in efficacy. Outcomes included target symptoms (anxiety, depression, etc.) measured with reliable instruments. The authors found 21 randomized controlled trials with 2,751 patients, and all of the comparisons included CBT. Based on predetermined accepted standards, the authors decided that an effect size of g = -0.25 to +0.25 would indicate equivalence (i.e., a small and clinically not meaningful difference). Post-treatment differences between PDT and comparison treatments was g = -0.153 (90%CI: -0.227 to -0.079), and similar results were found at follow-up. In other words there were small, non-significant, and clinically not meaningful differences between PDT and other established treatments with accepted efficacy. The studies were rated as high in quality, there was no effect of diagnosis on the results, and there was no evidence of publication bias.
This meta-analysis found PDT to be as efficacious as other treatments with established efficacy (i.e., CBT). The finding suggest that established practice guidelines may need to be revisited to include PDT. Response rates for anxiety disorders and depressive disorders (around 50%) for those receiving CBT, and even lower remission rates, indicate that there is room for improvement. Having other treatment options may be particularly important for patients who do not respond to one form of therapy and who may need to be switched to another type of intervention.
Click here for the article abstract.
Author email: email@example.com
Driessen, E., Hollon, S.D., Bockting, C.L.H., Cuijpers, P., Turner, E.H. (2015). Does publication bias inflate the apparent efficacy of psychological treatment for major depressive disorder? A systematic review and meta-analysis of US National Institutes of Health-funded trials. PLoS ONE 10(9): e0137864. doi:10.1371/journal.pone.0137864.
In 2008 Turner published a well-known study in which he found that almost 50% of antidepressant trials registered with the Food and Drug Administration in the US were never published or were positively “spun” (i.e., essentially negative findings were interpreted to be positive). Almost all of the unpublished trials showed unfavorable results for the antidepressants’ effects. By contrast, the published studies were almost always were positive. This is evidence of publication bias caused by selective publication of some data and suppression of other data. As you can imagine, this has important implications for treatment of depression as the published record appeared to over-inflate effects of antidepressants by 25% (the mean effect size decreased from g = .41 [CI95% 0.36~0.45] to 0.31 [0.27~0.35] when unpublished studies were included). Has the same type of publication bias occurred in the published record of psychotherapy’s efficacy? In this study by Driessen and colleagues, the authors reviewed all psychotherapy studies for depression funded by the National Institutes of Mental Health in the US between 1972 and 2008. They wanted to determine which ones were published, which were never published, and what the impact of nonpublication was on the mean effect size. Of the 55 grants that were funded, 13 (26.3%) were never published, and the authors were able to obtain data from 11 of those unpublished studies. The overall mean effect size (psychological treatment versus a control condition) of unpublished studies was g = 0.20 (CI95% -0.11~0.51) indicating a small non-significant effect. The overall mean effect size for published studies was g = 0.52 (CI95% 0.37~0.68) indicating a medium significant effect. Adding the unpublished studies to published studies resulted in a 25% decrease in effect size estimate to g = 0.39 (0.08~0.70), indicating a small but significant effect of psychotherapy.
This study indicated that psychotherapy is effective but that the effects are likely smaller than indicated in the published record. As in the case of antidepressant medication research, a minority of researchers may not publish findings that are not in line with their preconceived expectations or wished-for results. Regardless, there is certainly room for psychotherapy to improve. After decades of focusing largely on the efficacy of specific psychotherapies like CBT, psychodynamic therapies, and interpersonal therapy, perhaps it is time to shift to studying how and why therapies work, and which patients benefit from specific interventions. There are promising avenues such as research on: repairing therapeutic alliance tensions, enhancing therapist expertise, progress monitoring and feedback, client factors, and managing countertransference.