Practice-Based Psychotherapy Research
To Improve The Wellbeing Of Our Community
PPRNet Blog: June 2014
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
Handbook of Psychotherapy and Behavior Change
Starting in March 2013 I will review one chapter a month from the Handbook of Psychotherapy and Behavior Change in addition to reviewing psychotherapy research articles. Book chapters have more restrictive copy right rules than journal articles, so I will not provide author email addresses for these chapters. If you are interested, the Handbook table of content and sections of the book can be read on Google Books:
Cognitive Therapy for Depression
Hollon, S.D. & Beck, A.T. (2013). Cognitive and cognitive-behavioral therapies. In M.E. Lambert (Ed.), Bergin and Garfield’s Handbook of Psychotherapy and Behavior Change, 6th Edition (pp. 393-442). New York: Wiley.
Cognitive (CT) and cognitive behavioural therapies (CBT) are among the most empirically supported and widely practiced psychological interventions. CT emphasizes the role of meaning in their models of depression and CT interventions emphasise testing the accuracy of beliefs. More behavioural approaches like CBT see change in terms of classical or operant conditioning of behaviours, in which cognitive strategies are incorporated to facilitate behavioural change. In this section of their chapter, Hollon and Beck review research on CT for depression. Depression is the single most prevalent mental disorder and is a leading cause of disability in the world (see this month’s blog entry on the global burden of depression). Most patients have multiple episodes of depression (i.e., recurrent) and about 25% have episodes that last for 2 years or more (i.e., chronic). CT posits that depressed individuals have negative automatic thoughts that are organized into depressogenic automatic beliefs (or underlying assumptions) that put them at risk for relapse. Automatic beliefs can be organized in latent (or unconscious) schemas often laid down in childhood and activated by later stress that influence the way information is organized. In CT patients are taught to evaluate their beliefs (also called empirical disconfirmation), conduct “experiments” to test their accuracy and to modify core beliefs and reduce maladaptive interpersonal behaviours. Most reviews show that CT for depression is superior to no treatment (with large effects) and at least as effective as alternative psychological or pharmacological interventions. Most patients show a good response to CT with about one third showing complete remission. Although some practice guidelines have concluded that medications are preferred to CBT (or any psychotherapy) for severe depression, more recent meta analyses show that CT is as efficacious as medications and is likely better in the long term. CT also has an enduring effect that protects clients against symptoms returning. Medications, on the other hand suppress depressive symptoms only as long as the patient continues to take the treatment, but medications do not reduce underlying risk. As a result, relapse rates for medication treatment of depression are much higher than for CT. These findings suggest that patients who receive CT learn something that reduces risk for recurrence, which is the single biggest advantage that CT has over medications. Further, CT is free from problematic side effects that may occur with medications.
CT and CBT are the most tested psychological treatments for depression and the evidence indicates that many patients benefit. CT and CBT are as effective as medications for reducing acute distress related to depression, and even for those with more severe depression when implemented by experienced therapists. CT has an enduring effect not found in medications, may also help prevent future episodes of depression, and may prevent relapse after medications are discontinued.
Ferrari, A.J., Charlson, F.J., Norman, R.E., Patten, S.B., Freedman, G., et al. (2013). Burden of depressive disorders by country, sex, age, and year: Findings from the global burden of disease study 2010. PLoS Medicine, 10(11): e1001547. doi:10.1371/journal.pmed.1001547.
Depressive disorders are among the most common mental disorders that previously were described as a leading cause of burden in the world. In epidemiological literature, burden is defined in several ways. One common metric is “disability adjusted life years” (DALYs) which represents loss of a healthy year of life. DALYs can be aggregated into the “years of life lived with disability” (YLD). Another metric is the “years of life lost due to premature mortality” (YLL). Each of these metrics of burden can be estimated from aggregating data from a number of studies and meta analyses that assess burden world wide. Such epidemiologic studies can also look at relative burden across countries, ages, and sex. In the 2000 Global Burden of Disease report, depressive disorders were the third leading cause of burden after lower respiratory infections and diarrhoeal diseases. Depression was also the leading cause of disability, responsible for 13.4% of years of life living with disability in women and 8.3% in men. In this study by Ferrari and colleagues, the authors provide a 2010 update to the Global Burden of Disease report for major depressive disorder and dysthymia. Major depressive episode is the experience of depressed mood almost all day, every day, for at least 2 weeks. Dysthymia involves a less severely depressed mood with duration of at least 2 years, a chronic rather than episodic course, but with low rates of remission. Ferrari and colleagues reviewed over 700 studies from 1980 to 2010. Prevalence (i.e., current rate) of major depression and dysthymia in the world population is 5.95%, representing nearly 400 million people. Major depression (4.4%) occurs more frequently than dysthymia (1.55%). Major depression occurs more frequently among women (5.5%) than men (3.2%). Major depression accounted for 8.2% of all years lost to disability, making it the second leading cause after low back pain. The percent of years lost due to disability increased since 1990, largely due to population increases and aging of the world population. The highest level of burden due to depression was seen in Afghanistan and the lowest in Japan. In terms of world regions, North Africa and Latin America showed the highest levels of burden due to depression. The authors also reported that 2.9% of disability adjusted life years from ischemic heart disease can be attributed to major depression.
This study joins others in past decades to define depression as a leading cause of years lost to disability worldwide, with over 400 million people suffering from a depressive disorder. The increasing burden of depression is partly due to decreasing mortality caused by other diseases in developing countries and population aging. Countries that have recently experienced conflict (e.g., Afghanistan, North Africa, Middle East) were particularly burdened by depression. But research has also linked depression to intimate partner violence and child sexual abuse. Mortality is elevated with major depression, as is disability related to other medical problems like heart disease. This epidemiological research points to the importance of identifying and treating depression in the population. Psychotherapeutic interventions provide highly effective treatments for depression.
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 dropout rate from PDT was 17%.
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.