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Neurotherapeutics : the Journal of the... Jul 2017Evidence-based psychotherapies have been shown to be efficacious and cost-effective for a wide range of psychiatric conditions. Psychiatric disorders are prevalent... (Review)
Review
Evidence-based psychotherapies have been shown to be efficacious and cost-effective for a wide range of psychiatric conditions. Psychiatric disorders are prevalent worldwide and associated with high rates of disease burden, as well as elevated rates of co-occurrence with medical disorders, which has led to an increased focus on the need for evidence-based psychotherapies. This chapter focuses on the current state of evidence-based psychotherapy. The strengths and challenges of evidence-based psychotherapy are discussed, as well as misperceptions regarding the approach that may discourage and limit its use. In addition, we review various factors associated with the optimal implementation and application of evidence-based psychotherapies. Lastly, suggestions are provided on ways to advance the evidence-based psychotherapy movement to become truly integrated into practice.
Topics: Evidence-Based Medicine; Humans; Psychotherapy
PubMed: 28653278
DOI: 10.1007/s13311-017-0549-4 -
JAMA Psychiatry Feb 2021Several psychotherapy protocols have been evaluated as adjuncts to pharmacotherapy for patients with bipolar disorder, but little is known about their comparative... (Meta-Analysis)
Meta-Analysis
IMPORTANCE
Several psychotherapy protocols have been evaluated as adjuncts to pharmacotherapy for patients with bipolar disorder, but little is known about their comparative effectiveness.
OBJECTIVE
To use systematic review and network meta-analysis to compare the association of using manualized psychotherapies and therapy components with reducing recurrences and stabilizing symptoms in patients with bipolar disorder.
DATA SOURCES
Major bibliographic databases (MEDLINE, PsychInfo, and Cochrane Library of Systematic Reviews) and trial registries were searched from inception to June 1, 2019, for randomized clinical trials of psychotherapy for bipolar disorder.
STUDY SELECTION
Of 3255 abstracts, 39 randomized clinical trials were identified that compared pharmacotherapy plus manualized psychotherapy (cognitive behavioral therapy, family or conjoint therapy, interpersonal therapy, or psychoeducational therapy) with pharmacotherapy plus a control intervention (eg, supportive therapy or treatment as usual) for patients with bipolar disorder.
DATA EXTRACTION AND SYNTHESIS
Binary outcomes (recurrence and study retention) were compared across treatments using odds ratios (ORs). For depression or mania severity scores, data were pooled and compared across treatments using standardized mean differences (SMDs) (Hedges-adjusted g using weighted pooled SDs). In component network meta-analyses, the incremental effectiveness of 13 specific therapy components was examined.
MAIN OUTCOMES AND MEASURES
The primary outcome was illness recurrence. Secondary outcomes were depressive and manic symptoms at 12 months and acceptability of treatment (study retention).
RESULTS
A total of 39 randomized clinical trials with 3863 participants (2247 of 3693 [60.8%] with data on sex were female; mean [SD] age, 36.5 [8.2] years) were identified. Across 20 two-group trials that provided usable information, manualized treatments were associated with lower recurrence rates than control treatments (OR, 0.56; 95% CI, 0.43-0.74). Psychoeducation with guided practice of illness management skills in a family or group format was associated with reducing recurrences vs the same strategies in an individual format (OR, 0.12; 95% CI, 0.02-0.94). Cognitive behavioral therapy (SMD, -0.32; 95% CI, -0.64 to -0.01) and, with less certainty, family or conjoint therapy (SMD, -0.46; 95% CI, -1.01 to 0.08) and interpersonal therapy (SMD, -0.46; 95% CI, -1.07 to 0.15) were associated with stabilizing depressive symptoms compared with treatment as usual. Higher study retention was associated with family or conjoint therapy (OR, 0.46; 95% CI, 0.26-0.82) and brief psychoeducation (OR, 0.44; 95% CI, 0.23-0.85) compared with standard psychoeducation.
CONCLUSIONS AND RELEVANCE
This study suggests that outpatients with bipolar disorder may benefit from skills-based psychosocial interventions combined with pharmacotherapy. Conclusions are tempered by heterogeneity in populations, treatment duration, and follow-up.
Topics: Adult; Bipolar Disorder; Female; Humans; Male; Middle Aged; Network Meta-Analysis; Psychotherapy
PubMed: 33052390
DOI: 10.1001/jamapsychiatry.2020.2993 -
Annual Review of Clinical Psychology May 2021Research findings strongly suggest that cognitive behavioral therapy for the eating disorders (CBT-ED) is more effective than other treatments for bulimia nervosa (BN)... (Review)
Review
Research findings strongly suggest that cognitive behavioral therapy for the eating disorders (CBT-ED) is more effective than other treatments for bulimia nervosa (BN) and for binge eating disorder (BED), although interpersonal psychotherapy appears to be equally effective for BED. Evidence for the effectiveness of CBT-ED for the persistent (adult) form of anorexia nervosa (AN) is insufficient at present and is essentially absent for AN in adolescents except for some evidence from uncontrolled trials. This article begins with an overview of the early studies in the development of CBT-ED that showed a similar effectiveness of other symptom-focused psychotherapies-a finding that was neglected at the time. Later developments are then considered, including comparisons of CBT-ED with other psychotherapies, efforts to develop Internet-based training and treatment, and electronic applications for treatment. Finally, implications of the findings for future short- and long-term research and for clinical practice are considered.
Topics: Adolescent; Adult; Binge-Eating Disorder; Bulimia Nervosa; Cognitive Behavioral Therapy; Feeding and Eating Disorders; Humans; Psychotherapy; Treatment Outcome
PubMed: 33962536
DOI: 10.1146/annurev-clinpsy-081219-110907 -
Psychiatrike = Psychiatriki 2019The therapeutic relationship is the common place of all medical specialties in therapeutic practice. It is a professional relationship and consists of two components:... (Review)
Review
The therapeutic relationship is the common place of all medical specialties in therapeutic practice. It is a professional relationship and consists of two components: the work component and the interpersonal component. The focus of the studies aims to show the contribution of the dynamics of the therapist - patient interpersonal relationship as a therapeutic factor in achieving the therapeutic outcome. The issue of doctor-patient relationship has been studied since antiquity, in particular by Socrates and beyond. Hippocrates promotes and systematizes medical philosophy, bioethics and medical ethics, as seen in the well-known "Hippocratic Oath". In the new era, S. Freud continued the work of inductive dialectics of Socrates, while formulating the concept of transference and countertransference. The development of psychotherapies has provided enough evidence for the parameters that interact into a therapeutic relationship, as their techniques were merely dialectical. M. Balint supports the value of counter-transference and transference to the therapeutic relationship. G. Bibring & R. Kahana suggest that psychoanalytic techniques and personality types contribute to the understanding of the physical patient. C. Rogers suggested that the attitudes and the empathic understanding of the therapist, not the techniques, contribute primarily to therapeutic success. G. Engel (1970) promotes the patient's biopsychosocial approach. Since 1980, systematic studies have begun to support the value of the therapeutic relationship, believing that it is itself an autonomous therapeutic factor, confirming the views of M. Balint and C. Rogers. They conclude that the therapeutic effect is a function of the quality of the therapeutic relationship, regardless of any therapeutic technique, and that the therapeutic alliance has a significant effect on the clinical outcome for psychotherapies as well as for pharmacotherapy. Empathy, non-possessive warmth, positive respect and authenticity have a significant effect on the treatment results. The common factor model supports the dynamics of the interpersonal relationship contributing 85% to the therapeutic effect whereas the therapeutic techniques contribute 15%. It therefore seems that the dynamics of the interpersonal relationship, the therapist-patient, is an important therapeutic factor. Studies continue and more questions arise as to whether education is available, the dynamics of interpersonal relationships in the context of therapeutic relationships at undergraduate and postgraduate levels. Also, the development of dialectical techniques, as a response to the empathic therapeutic relationship, which contributes at the clinical level to the patient's approach and information within the general health area and not only to mental health.
Topics: Countertransference; Empathy; Ethics, Medical; Humans; Patients; Professional-Patient Relations; Psychotherapy
PubMed: 31425144
DOI: 10.22365/jpsych.2019.302.165 -
Psychology and Psychotherapy Jun 2019Fragmentation of processes and interventions plague the psychotherapies (Gilbert & Kirby, ). Part of the problem is that we have not agreed on a framework that could be... (Review)
Review
Fragmentation of processes and interventions plague the psychotherapies (Gilbert & Kirby, ). Part of the problem is that we have not agreed on a framework that could be the basis for integrating knowledge and the scientific enquiry of processes and interventions. This paper outlines an approach that brings together a variety of different disciplines in the service of consilience (Wilson, , Consilience: The unity of knowledge, Vintage, New York, NY; Siegel, ). It presents the importance of an evolutionary framework for understanding the proclivities and dispositions for mental suffering and antisocial behaviour, and how they are choreographed in different sociodevelopmental contexts. Building on earlier models (Gilbert, , Human nature and suffering, Routledge, London, UK; Gilbert, , Clin. Psychol. Psychother., 2, 135; Gilbert, , Br. J. Med. Psychol., 71, 353; Gilbert, , Case formulation in cognitive behaviour therapy: The treatment of challenging cases, Wiley, Chichester, UK, pp. 50-89) the call is for an integrative, evolutionary, contextual, biopsychosocial approach to psychology and psychotherapy. PRACTITIONER POINTS: Evolutionary functional analysis is part of an evolutionary, contextual, biopsychosocial approach to mental health that can serve as a scientific platform for the future developments of psychotherapy. Therapist skills and training will increasing need to focus on the multidimensional textures of mental states especially the context-social-body linkages. Therapies of the future will also focus more on the moral aspects of therapy and address the need to promote prosocial and ethical behaviour to self and others.
Topics: Clinical Competence; Humans; Mental Disorders; Psychotherapy; Social Behavior
PubMed: 30932302
DOI: 10.1111/papt.12226 -
Pharmacopsychiatry Jul 2021Psychedelics have shown great promise in modern clinical trials for treating various psychiatric conditions. As a transdiagnostic treatment that exerts its effects... (Review)
Review
Psychedelics have shown great promise in modern clinical trials for treating various psychiatric conditions. As a transdiagnostic treatment that exerts its effects through subjective experiences that leave enduring effects, it is akin to psychotherapy. To date, there has been insufficient discussion of how psychedelic therapy is similar to and different from conventional psychotherapy. In this article, we review the shared features of effective conventional psychotherapies and situate therapeutic psychedelic effects within those. We then discuss how psychedelic drug effects might amplify conventional psychotherapeutic processes-particularly via effects on meaning and relationship-as well as features that make psychedelic treatment unique. Taking into account shared features of conventional psychotherapies and unique psychedelic drug effects, we create a framework for understanding why psychedelics are likely to be effective with very diverse types of psychotherapies. We also review the formal psychotherapies that have been adjunctively included in modern psychedelic trials and extend the understanding of psychedelics as psychotherapy towards implications for clinical ethics and trial design. We aim to provide some common conceptual vocabulary that can be used to frame therapeutic psychedelic effects beyond the confines of any one specific modality.
Topics: Hallucinogens; Humans; Mental Disorders; Psychotherapy
PubMed: 33285578
DOI: 10.1055/a-1312-7297 -
The British Journal of Psychiatry : the... Sep 2022A recently updated Cochrane review supports the efficacy of psychotherapy for borderline personality disorder (BPD). (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
A recently updated Cochrane review supports the efficacy of psychotherapy for borderline personality disorder (BPD).
AIMS
To evaluate the effects of standalone and add-on psychotherapeutic treatments more concisely.
METHOD
We applied the same methods as the 2020 Cochrane review, but focused on adult samples and comparisons of active treatments and unspecific control conditions. Standalone treatments (i.e. necessarily including individual psychotherapy as either the sole or one of several treatment components) and add-on interventions (i.e. complementing any ongoing individual BPD treatment) were analysed separately. Primary outcomes were BPD severity, self-harm, suicide-related outcomes and psychosocial functioning. Secondary outcomes were remaining BPD diagnostic criteria, depression and attrition.
RESULTS
Thirty-one randomised controlled trials totalling 1870 participants were identified. Among standalone treatments, statistically significant effects of low overall certainty were observed for dialectical behaviour therapy (self-harm: standardised mean difference (SMD) -0.54, = 0.006; psychosocial functioning: SMD -0.51, = 0.01) and mentalisation-based treatment (self-harm: risk ratio 0.51, < 0.0007; suicide-related outcomes: risk ratio 0.10, < 0.0001). For adjunctive interventions, moderate-quality evidence of beneficial effects was observed for DBT skills training (BPD severity: SMD -0.66, = 0.002; psychosocial functioning: SMD -0.45, = 0.002), and statistically significant low-certainty evidence was observed for the emotion regulation group (BPD severity: mean difference -8.49, < 0.00001), manual-assisted cognitive therapy (self-harm: mean difference -3.03, = 0.03; suicide-related outcomes: SMD -0.96, = 0.005) and the systems training for emotional predictability and problem-solving (BPD severity: SMD -0.48, = 0.002).
CONCLUSIONS
There is reasonable evidence to conclude that psychotherapeutic interventions are helpful for individuals with BPD. Replication studies are needed to enhance the certainty of findings.
Topics: Adult; Borderline Personality Disorder; Cognitive Behavioral Therapy; Dialectical Behavior Therapy; Humans; Psychotherapy; Randomized Controlled Trials as Topic; Self-Injurious Behavior
PubMed: 35088687
DOI: 10.1192/bjp.2021.204 -
JAMA Psychiatry Apr 2017Borderline personality disorder (BPD) is a debilitating condition, but several psychotherapies are considered effective. (Meta-Analysis)
Meta-Analysis Review
IMPORTANCE
Borderline personality disorder (BPD) is a debilitating condition, but several psychotherapies are considered effective.
OBJECTIVE
To conduct an updated systematic review and meta-analysis of randomized clinical trials to assess the efficacy of psychotherapies for BPD populations.
DATA SOURCES
Search terms were combined for borderline personality and randomized trials in PubMed, PsycINFO, EMBASE, and the Cochrane Central Register of Controlled Trials (from database inception to November 2015), as well as the reference lists of earlier meta-analyses.
STUDY SELECTION
Included were randomized clinical trials of adults with diagnosed BPD randomized to psychotherapy exclusively or to a control intervention. Study selection differentiated stand-alone designs (in which an independent psychotherapy was compared with control interventions) from add-on designs (in which an experimental intervention added to usual treatment was compared with usual treatment alone).
DATA EXTRACTION AND SYNTHESIS
Data extraction coded characteristics of trials, participants, and interventions and assessed risk of bias using 4 domains of the Cochrane Collaboration Risk of Bias tool (independent extraction by 2 assessors). Outcomes were pooled using a random-effects model. Subgroup and meta-regression analyses were conducted.
MAIN OUTCOMES AND MEASURES
Standardized mean differences (Hedges g) were calculated using all outcomes reported in the trials for borderline symptoms, self-harm, suicide, health service use, and general psychopathology at posttest and follow-up. Differential treatment retention at posttest was analyzed, reporting odds ratios.
RESULTS
Thirty-three trials (2256 participants) were included. For borderline-relevant outcomes combined (symptoms, self-harm, and suicide) at posttest, the investigated psychotherapies were moderately more effective than control interventions in stand-alone designs (g = 0.32; 95% CI, 0.14-0.51) and add-on designs (g = 0.40; 95% CI, 0.15-0.65). Results were similar for other outcomes, including stand-alone designs: self-harm (g = 0.32; 95% CI, 0.09-0.54), suicide (g = 0.44; 95% CI, 0.15-0.74), health service use (g = 0.40; 95% CI, 0.22-0.58), and general psychopathology (g = 0.32; 95% CI, 0.09-0.55), with no differences between design types. There were no significant differences in the odds ratios for treatment retention (1.32; 95% CI, 0.87-2.00 for stand-alone designs and 1.01; 95% CI, 0.55-1.87 for add-on designs). Thirteen trials reported borderline-relevant outcomes at follow-up (g = 0.45; 95% CI, 0.15-0.75). Dialectical behavior therapy (g = 0.34; 95% CI, 0.15-0.53) and psychodynamic approaches (g = 0.41; 95% CI, 0.12-0.69) were the only types of psychotherapies more effective than control interventions. Risk of bias was a significant moderator in subgroup and meta-regression analyses (slope β = -0.16; 95% CI, -0.29 to -0.03; P = .02). Publication bias was persistent, particularly for follow-up.
CONCLUSIONS AND RELEVANCE
Psychotherapies, most notably dialectical behavior therapy and psychodynamic approaches, are effective for borderline symptoms and related problems. Nonetheless, effects are small, inflated by risk of bias and publication bias, and particularly unstable at follow-up.
Topics: Behavior Therapy; Borderline Personality Disorder; Humans; Psychotherapy; Psychotherapy, Psychodynamic; Randomized Controlled Trials as Topic; Self-Injurious Behavior; Suicide; Treatment Outcome; Suicide Prevention
PubMed: 28249086
DOI: 10.1001/jamapsychiatry.2016.4287 -
The Cochrane Database of Systematic... May 2018Antidepressants are a first-line treatment for adults with moderate to severe major depression. However, many people prescribed antidepressants for depression don't... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
Antidepressants are a first-line treatment for adults with moderate to severe major depression. However, many people prescribed antidepressants for depression don't respond fully to such medication, and little evidence is available to inform the most appropriate 'next step' treatment for such patients, who may be referred to as having treatment-resistant depression (TRD). National Institute for Health and Care Excellence (NICE) guidance suggests that the 'next step' for those who do not respond to antidepressants may include a change in the dose or type of antidepressant medication, the addition of another medication, or the start of psychotherapy. Different types of psychotherapies may be used for TRD; evidence on these treatments is available but has not been collated to date.Along with the sister review of pharmacological therapies for TRD, this review summarises available evidence for the effectiveness of psychotherapies for adults (18 to 74 years) with TRD with the goal of establishing the best 'next step' for this group.
OBJECTIVES
To assess the effectiveness of psychotherapies for adults with TRD.
SEARCH METHODS
We searched the Cochrane Common Mental Disorders Controlled Trials Register (until May 2016), along with CENTRAL, MEDLINE, Embase, and PsycINFO via OVID (until 16 May 2017). We also searched the World Health Organization (WHO) trials portal (ICTRP) and ClinicalTrials.gov to identify unpublished and ongoing studies. There were no date or language restrictions.
SELECTION CRITERIA
We included randomised controlled trials (RCTs) with participants aged 18 to 74 years diagnosed with unipolar depression that had not responded to minimum four weeks of antidepressant treatment at a recommended dose. We excluded studies of drug intolerance. Acceptable diagnoses of unipolar depression were based onthe Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR) or earlier versions, International Classification of Diseases (ICD)-10, Feighner criteria, or Research Diagnostic Criteria. We included the following comparisons.1. Any psychological therapy versus antidepressant treatment alone, or another psychological therapy.2. Any psychological therapy given in addition to antidepressant medication versus antidepressant treatment alone, or a psychological therapy alone.Primary outcomes required were change in depressive symptoms and number of dropouts from study or treatment (as a measure of acceptability).
DATA COLLECTION AND ANALYSIS
We extracted data, assessed risk of bias in duplicate, and resolved disagreements through discussion or consultation with a third person. We conducted random-effects meta-analyses when appropriate. We summarised continuous outcomes using mean differences (MDs) or standardised mean differences (SMDs), and dichotomous outcomes using risk ratios (RRs).
MAIN RESULTS
We included six trials (n = 698; most participants were women approximately 40 years of age). All studies evaluated psychotherapy plus usual care (with antidepressants) versus usual care (with antidepressants). Three studies addressed the addition of cognitive-behavioural therapy (CBT) to usual care (n = 522), and one each evaluated intensive short-term dynamic psychotherapy (ISTDP) (n = 60), interpersonal therapy (IPT) (n = 34), or group dialectical behavioural therapy (DBT) (n = 19) as the intervention. Most studies were small (except one trial of CBT was large), and all studies were at high risk of detection bias for the main outcome of self-reported depressive symptoms.A random-effects meta-analysis of five trials (n = 575) showed that psychotherapy given in addition to usual care (vs usual care alone) produced improvement in self-reported depressive symptoms (MD -4.07 points, 95% confidence interval (CI) -7.07 to -1.07 on the Beck Depression Inventory (BDI) scale) over the short term (up to six months). Effects were similar when data from all six studies were combined for self-reported depressive symptoms (SMD -0.40, 95% CI -0.65 to -0.14; n = 635). The quality of this evidence was moderate. Similar moderate-quality evidence of benefit was seen on the Patient Health Questionnaire-9 Scale (PHQ-9) from two studies (MD -4.66, 95% CI 8.72 to -0.59; n = 482) and on the Hamilton Depression Rating Scale (HAMD) from four studies (MD -3.28, 95% CI -5.71 to -0.85; n = 193).High-quality evidence shows no differential dropout (a measure of acceptability) between intervention and comparator groups over the short term (RR 0.85, 95% CI 0.58 to 1.24; six studies; n = 698).Moderate-quality evidence for remission from six studies (RR 1.92, 95% CI 1.46 to 2.52; n = 635) and low-quality evidence for response from four studies (RR 1.80, 95% CI 1.2 to 2.7; n = 556) indicate that psychotherapy was beneficial as an adjunct to usual care over the short term.With the addition of CBT, low-quality evidence suggests lower depression scores on the BDI scale over the medium term (12 months) (RR -3.40, 95% CI -7.21 to 0.40; two studies; n = 475) and over the long term (46 months) (RR -1.90, 95% CI -3.22 to -0.58; one study; n = 248). Moderate-quality evidence for adjunctive CBT suggests no difference in acceptability (dropout) over the medium term (RR 0.98, 95% CI 0.66 to 1.47; two studies; n = 549) and lower dropout over long term (RR 0.80, 95% CI 0.66 to 0.97; one study; n = 248).Two studies reported serious adverse events (one suicide, two hospitalisations, and two exacerbations of depression) in 4.2% of the total sample, which occurred only in the usual care group (no events in the intervention group).An economic analysis (conducted as part of an included study) from the UK healthcare perspective (National Health Service (NHS)) revealed that adjunctive CBT was cost-effective over nearly four years.
AUTHORS' CONCLUSIONS
Moderate-quality evidence shows that psychotherapy added to usual care (with antidepressants) is beneficial for depressive symptoms and for response and remission rates over the short term for patients with TRD. Medium- and long-term effects seem similarly beneficial, although most evidence was derived from a single large trial. Psychotherapy added to usual care seems as acceptable as usual care alone.Further evidence is needed on the effectiveness of different types of psychotherapies for patients with TRD. No evidence currently shows whether switching to a psychotherapy is more beneficial for this patient group than continuing an antidepressant medication regimen. Addressing this evidence gap is an important goal for researchers.
Topics: Adult; Aged; Antidepressive Agents; Cognitive Behavioral Therapy; Depression; Drug Resistance; Female; Humans; Male; Middle Aged; Psychotherapy; Psychotherapy, Group; Randomized Controlled Trials as Topic; Young Adult
PubMed: 29761488
DOI: 10.1002/14651858.CD010558.pub2 -
Der Nervenarzt Nov 2023
Topics: Humans; Psychotherapy; Psychiatry
PubMed: 37910315
DOI: 10.1007/s00115-023-01559-4