Abstracts: Psychotherapy: New Evidence and New Approaches

Am J Psychiatry 2014; 171:523–538

Objective: Meta-analyses have demonstrated the efficacy of various interventions for psychosis, and a small number of studies have compared such interventions. The aim of this study was to provide further insight into the relative efficacy of psychological interventions for psychosis. Methods: Forty-eight outcome trials comparing psychological interventions for psychosis were identified. The comparisons included 3,295 participants. Categorization of interventions resulted in six interventions being compared against other interventions pooled. Hedges’ g was calculated for all comparisons. Risk of bias was assessed using four items of the Cochrane risk of bias tool, and sensitivity analyses were conducted. Researcher allegiance was assessed, and sensitivity analyses were conducted for robust significant findings. Results: Cognitive-behavioral therapy (CBT) was significantly more efficacious than other interventions pooled in reducing positive symptoms (g=0.16). This finding was robust in all sensitivity analyses for risk of bias, but lost significance in sensitivity analyses for researcher allegiance, which suffered from low power. Social skills training was significantly more efficacious in reducing negative symptoms (g=0.27). This finding was robust in sensitivity analyses for risk of bias and researcher allegiance. Significant findings for CBT, social skills training, and cognitive remediation for overall symptoms were not robust after sensitivity analyses. CBT was significantly more efficacious when compared directly with befriending for overall symptoms (g=0.42) and supportive counseling for positive symptoms (g=0.23). Conclusions: There are small but reliable differences in efficacy between psychological interventions for psychosis, and they occur in a pattern consistent with the specific factors of particular interventions.

PLoS One 2014; 9:e98118

Background: Greater access to evidence-based psychological treatments is needed. This review aimed to evaluate whether Internet-delivered psychological treatments for mood and anxiety disorders are efficacious, noninferior to established treatments, safe, and cost-effective for children, adolescents, and adults. Methods: We searched the literature for studies published through March 2013. Randomized controlled trials (RCTs) were considered for the assessment of short-term efficacy and safety and were pooled in meta-analyses. Other designs were also considered for long-term effect and cost-effectiveness. Comparisons against established treatments were evaluated for noninferiority. Two reviewers independently assessed the relevant studies for risk of bias. The quality of the evidence was graded using an international grading system. Results: A total of 52 relevant RCTs were identified whereof 12 were excluded because of a high risk of bias. Five cost-effectiveness studies were identified and three were excluded because of a high risk of bias. The included trials mainly evaluated Internet-delivered cognitive behavioral therapy (I-CBT) against a waiting list in adult volunteers, and 88% were conducted in Sweden or Australia. One trial involved children. For adults, the quality of evidence was graded as moderate for the short-term efficacy of I-CBT versus the waiting list for mild/moderate depression (d=0.83; 95% CI 0.59, 1.07) and social phobia (d=0.85; 95% CI 0.66, 1.05), and moderate for no efficacy of Internet-delivered attention bias modification versus sham treatment for social phobia (d=−0.04; 95% CI −0.24, 0.35). The quality of evidence was graded as low/very low for other disorders, interventions, children/adolescents, noninferiority, adverse events, and cost-effectiveness. Conclusions: I-CBT is a viable treatment option for adults with depression and some anxiety disorders who request this treatment modality. Important questions remain before broad implementation can be supported. Future research would benefit from prioritizing adapting treatments to children/adolescents and using noninferiority designs with established forms of treatment.

PLoS Med 2013; 10:e1001454

Background: Previous meta-analyses comparing the efficacy of psychotherapeutic interventions for depression were clouded by a limited number of within-study treatment comparisons. This study used network meta-analysis, a novel methodological approach that integrates direct and indirect evidence from randomized controlled studies, to re-examine the comparative efficacy of seven psychotherapeutic interventions for adult depression. Methods and findings: We conducted systematic literature searches in PubMed, PsycINFO, and Embase up to November 2012, and identified additional studies through earlier meta-analyses and the references of included studies. We identified 198 studies, including 15,118 adult patients with depression, and coded moderator variables. Each of the seven psychotherapeutic interventions was superior to a waitlist control condition with moderate to large effects (range d=−0.62 to d=−0.92). Relative effects of different psychotherapeutic interventions on depressive symptoms were absent to small (range d=0.01 to d=−0.30). Interpersonal therapy was significantly more effective than supportive therapy [d=−0.30, 95% credibility interval (CrI) (−0.54 to −0.05)]. Moderator analysis showed that patient characteristics had no influence on treatment effects, but identified aspects of study quality and sample size as effect modifiers. Smaller effects were found in studies of at least moderate [Δd=0.29 (−0.01 to 0.58); p=0.063] and large size [Δd=0.33 (0.08 to 0.61); p=0.012], and those that had adequate outcome assessment [Δd=0.38 (−0.06 to 0.87); p=0.100]. Stepwise restriction of analyses by sample size showed robust effects for cognitive-behavioral therapy, interpersonal therapy, and problem-solving therapy (all d>0.46) compared with waitlist. Empirical evidence from large studies was unavailable or limited for other psychotherapeutic interventions. Conclusions: Overall, our results are consistent with the notion that different psychotherapeutic interventions for depression have comparable benefits. However, the robustness of the evidence varies considerably between different psychotherapeutic treatments.

Can J Psychiatry 2013; 58:376–385

Objective: No recent meta-analysis has examined the effects of cognitive-behavioral therapy (CBT) for adult depression. We decided to conduct such an updated meta-analysis. Methods: Studies were identified through systematic searches in bibliographical databases (PubMed, PsycINFO, Embase, and the Cochrane library). We included studies examining the effects of CBT compared with control groups, other psychotherapies, and pharmacotherapy. Results: A total of 115 studies met inclusion criteria. The mean effect size (ES) of 94 comparisons from 75 studies of CBT and control groups was Hedges’ g=0.71 (95% CI 0.62 to 0.79), which corresponds with a number needed to treat of 2.6. However, this may be an overestimation of the true ES, because we found strong indications for publication bias (ES after adjustment for bias was g=0.53), and because the ES of higher-quality studies was significantly lower (g=0.53) than for lower-quality studies (g=0.90). The difference between high- and low-quality studies remained significant after adjustment for other study characteristics in a multivariate meta-regression analysis. We did not find any indication that CBT was more or less effective than other psychotherapies or pharmacotherapy. Combined treatment was significantly more effective than pharmacotherapy alone (g=0.49). Conclusions: There is no doubt that CBT is an effective treatment for adult depression, although the effects may have been overestimated until now. CBT is also the most studied psychotherapy for depression, and thus has the greatest weight of evidence. However, other treatments approach its overall efficacy.

Psychotherapy (Chic) 2011; 48:9–16 (PsycINFO Database Record © 2011 APA, all rights reserved)

This article reports on a research synthesis of the relation between alliance and the outcomes of individual psychotherapy. Included were over 200 research reports based on 190 independent data sources, covering more than 14,000 treatments. Research involving five or more adult participants receiving genuine (as opposed to analog) treatments, where the author(s) referred to one of the independent variables as “alliance,” “therapeutic alliance,” “helping alliance,” or “working alliance” were the inclusion criteria. All analyses were done using the assumptions of a random model. The overall aggregate relation between the alliance and treatment outcome (adjusted for sample size and nonindependence of outcome measures) was r=0.275 (k=190); the 95% confidence interval for this value was 0.25–0.30. The statistical probability associated with the aggregated relation between alliance and outcome is p<0.0001. The data collected for this meta-analysis were quite variable (heterogeneous). Potential variables such as assessment perspectives (client, therapist, observer), publication source, types of assessment methods, and time of assessment were explored.

Am J Psychiatry 2008; 165:1559–1565

Objective: Recent studies demonstrate the poor psychosocial outcomes associated with bipolar disorder. Occupational functioning, a key indicator of psychosocial disability, is often severely affected by the disorder. The authors describe the effect of acute treatment with interpersonal and social rhythm therapy on occupational functioning over a period of approximately 2.5 years. Methods: Patients with bipolar I disorder were randomly assigned to receive either acute and maintenance interpersonal and social rhythm therapy, acute and maintenance intensive clinical management, acute interpersonal and social rhythm therapy and maintenance intensive clinical management, or acute intensive clinical management and maintenance interpersonal and social rhythm therapy, all with appropriate pharmacotherapy. Occupational functioning was measured with the UCLA Social Attainment Scale at baseline, at the end of acute treatment, and after 1 and 2 years of maintenance treatment. Results: The main effect of treatment did not reach conventional levels of statistical significance; however, the authors observed a significant time by initial treatment interaction. Participants initially assigned to interpersonal and social rhythm therapy showed more rapid improvement in occupational functioning than those initially assigned to intensive clinical management, primarily accounted for by greater improvement in occupational functioning during the acute treatment phase. At the end of 2 years of maintenance treatment, there were no differences between the treatment groups. A gender effect was also observed, with women who initially received interpersonal and social rhythm therapy showing more marked and rapid improvement. There was no effect of maintenance treatment assignment on occupational functioning outcomes. Conclusions: In this study, interpersonal and social rhythm therapy, with its emphasis on amelioration of interpersonal and role functioning, improved occupational functioning significantly more rapidly than did a psychoeducational and supportive approach with no such emphasis on functional capacities.

Am J Psychiatry 2007; 164:739–752.

Objective: The authors compared the effectiveness of cognitive therapy and pharmacotherapy as second-step strategies for outpatients with major depressive disorder who had received inadequate benefit from an initial trial of citalopram. Cognitive therapy was compared with medication augmentation and switch strategies. Methods: An equipoise-stratified randomization strategy was used to assign participants to either augmentation of citalopram with cognitive therapy (N=65), or medication [N=117; either sustained-release bupropion (N=56) or buspirone (N=61)], or a switch to cognitive therapy (N=36) or another antidepressant [N=86; sertraline (N=27), sustained-release bupropion (N=28), or extended-release venlafaxine (N=31)]. Treatment outcomes and the frequency of adverse events were compared. Results: Less than one-third of the participants consented to randomization strata that permitted comparison of cognitive therapy and pharmacotherapy. Among participants who were assigned to second-step treatment, those who received cognitive therapy (either alone or in combination with citalopram) had a similar response and remission rates to those assigned to medication strategies. For those who continued on citalopram, medication augmentation resulted in significantly more rapid remission than augmentation with cognitive therapy. Among those who discontinued citalopram, there were no significant differences in outcome, although those who switched to a different antidepressant reported significantly more side effects than those who received cognitive therapy alone. Conclusions: After an unsatisfactory response to citalopram, patients who consented to random assignment to either cognitive therapy or alternative pharmacologic strategies had generally comparable outcomes. Pharmacologic augmentation was more rapidly effective than cognitive therapy augmentation of citalopram, whereas switching to cognitive therapy was better tolerated than switching to a different antidepressant.