Christiane Steinert

The prospective long-term course of adult depression in general practice and the community. A systematic literature review

BACKGROUND Findings about the prospective long-term course of depression are usually derived from clinical populations while knowledge about the course in community and primary care samples is rarer. As depressive disorders are highly prevalent and associated with considerable disability and costs, this information is needed to identify the percentages of subjects with a favorable or unfavorable prognosis. Therefore our aim was to summarize the available evidence on the prospective longitudinal course of depression in both general practice and the community. METHODS We conducted a systematic, computerized search of Medline and PsycINFO. Main selection criteria were (a) adults with observer assessed depressive disorder recruited in the community or in general practice and (b) naturalistic study with follow-up length of at least three years. As primary outcome the percentages of stable recovery, recovery during or at follow-up, recurrence and chronic course were used. RESULTS We identified 12 cohorts, with 4009 followed-up individuals. Follow-up intervals ranged between three and 49 years. Between 35% and 60% of participants experienced a stable recovery with no (further) recurrences, while 70-85% recovered at least once during follow-up. A consistent percentage of 10-17% had a chronic course. Recurrence rates varied considerably ranging between 7% and 65%. Significant predictors of an unfavorable course appear to be mainly those variables that lie within the course of depression itself, i.e. history of depression, baseline severity, and comorbidity. LIMITATIONS Use of broad inclusion criteria heightened study heterogeneity and hampered comparability. CONCLUSION Regarding stable recovery, the long-term course within general practice and community samples seems more favorable than within clinical samples. Further research applying a standardized methodology is required.

Psychodynamic therapy meets evidence-based medicine: a systematic review using updated criteria

Psychodynamic therapy (PDT) is an umbrella concept for treatments that operate on an interpretive-supportive continuum and is frequently used in clinical practice. The use of any form of psychotherapy should be supported by sufficient evidence. Efficacy research has been neglected in PDT for a long time. In this review, we describe methodological requirements for proofs of efficacy and summarise the evidence for use of PDT to treat mental health disorders. After specifying the requirements for superiority, non-inferiority, and equivalence trials, we did a systematic search using the following criteria: randomised controlled trial of PDT; use of treatment manuals or manual-like guidelines; use of reliable and valid measures for diagnosis and outcome; adults treated for specific mental problems. We identified 64 randomised controlled trials that provide evidence for the efficacy of PDT in common mental health disorders. Studies sufficiently powered to test for equivalence to established treatments did not find substantial differences in efficacy. These results were corroborated by several meta-analyses that suggest PDT is as efficacious as treatments established in efficacy. More randomised controlled trials are needed for some mental health disorders such as obsessive-compulsive disorder and post-traumatic stress disorder. Furthermore, more adequately powered equivalence trials are needed.

Relapse rates after psychotherapy for depression – stable long-term effects? A meta-analysis

BACKGROUND Depression is the most common mental disorder. Effective psychotherapeutic treatments for depression exist; however, data on their long-term effectiveness beyond a time span of two years is still scarce. Our aim was to perform a meta-analysis, investigating (a) overall rates of relapse more than two years after psychotherapy (meta-analysis 1), and (b) if psychotherapy has more enduring effects than non-psychotherapeutic comparison conditions (e.g. pharmacotherapy, treatment as usual), again beyond a time span of two years post-therapy (meta-analysis 2). METHODS We searched electronic databases Medline, PsycINFO and the COCHRANE Library. Main selection criteria were (i) RCT of psychotherapy with follow-up interval of more than 2 years, (ii) primary diagnosis of depression, assessed by observer ratings, (iii) report of relapse at follow-up. RESULTS We identified 11 studies, 6 of which included a non-psychotherapeutic comparison condition. Together they comprised long-term data of 966 patients. Mean follow-up duration was 4.4 years. The overall relapse rate at long-term follow-up was 0.39 (95% CI 0.29, 0.50). Psychotherapy resulted in significantly less relapses (53.1% vs. 71.1%, OR 0.51; 95% CI 0.32, 0.82, p=0.005) than comparison treatments. This finding corresponded to a number needed to treat (NNT) of 5.55. LIMITATIONS Results can only be preliminary as data was sparse and studies differed methodologically. Heterogeneity in the first meta-analysis was high (I(2)=82%). Results indicated publication bias. CONCLUSIONS The relapse rate more than two years after psychotherapy is relatively high, but significantly lower compared to non-psychotherapeutic treatments. Multiannual follow-ups should routinely be included in future psychotherapy RCTs.

The course of PTSD in naturalistic long-term studies: High variability of outcomes. A systematic review

Abstract Background: With a lifetime prevalence of 8% posttraumatic stress disorder (PTSD) is one of the most common mental disorders; nevertheless, its longitudinal course is largely unknown. Aims: Our aim was to conduct a systematic review summarizing available findings on the prospective, naturalistic long-term course of PTSD and its predictors. Methods: Databases MEDLINE and PsycINFO were searched. Main selection criteria were: 1) naturalistic cohort study with a follow-up period of at least 3 years, 2) adult participants with observer-rated or probable PTSD at baseline. Results: Twenty-four cohorts (25 studies) were retrieved (14 with observer-assessed, 10 with probable PTSD). In total, they comprised about 10,500 participants with PTSD at baseline that were included in the long-term follow-ups. Studies investigating patient populations with observer-assessed PTSD found that between 18% and 50% of patients experienced a stable recovery within 3–7 years; the remaining subjects either facing a recurrent or a more chronic course. Outcomes of community studies and studies investigating probable PTSD varied considerably (remission rates 6–92%). Social factors (e.g. support) as well as comorbid physical or mental health problems seem to be salient predictors of PTSD long-term course and special focus should be laid on these factors in clinical settings. Conclusions: Included studies differed notably with regard to applied methodologies. The resulting large variability of findings is discussed. More standardized systematic follow-up research and more uniformed criteria for remission and chronicity are needed to gain a better insight into the long-term course of PTSD.

What do we know today about the prospective long-term course of social anxiety disorder? A systematic literature review

While we know that social anxiety disorder (SAD) is todays most common anxiety disorder knowledge on its prospective long-term course is sparse. We conducted a systematic literature search using databases Medline and PsycINFO for naturalistic and psychotherapy outcome studies with follow-up durations of at least 24 months. Four naturalistic cohorts and nine psychotherapy trials were included in the review. The naturalistic course in clinical was less favorable than in non-clinical samples (27% vs. 40% recovery rate after 5 years). Psychotherapy trials, all applying (cognitive) behavioral methods, yielded stable outcomes with overall large pre- to follow-up effect sizes on self-report scales. Observer rated remission rates varied considerably (36% to 100%) depending on study design and follow-up length. The results of psychotherapy trials and that of naturalistic studies can hardly be compared due to differences in methodology. More standardized remission and recovery criteria are needed to enhance the understanding of the longitudinal course.

Is Cognitive Behavioral Therapy the Gold Standard for Psychotherapy?: The Need for Plurality in Treatment and Research

Mental disorders are common and associated with severe impairments and high societal costs, thus representing a significant public health concern. About 75% of patients prefer psychotherapy over medication.1 For psychotherapy of mental disorders, several approaches are available such as cognitive behavioral therapy (CBT), interpersonal therapy, or psychodynamic therapy. Pointing to the available evidence, CBT is usually considered the gold standard for the psychotherapeutic treatment of many or even most mental disorders.2,3 For example, the American Psychological Association’s Division 12 Task Force on Psychological Interventions currently lists CBT as the only treatment with “strong research support” in almost 80% of all mental disorders included in its listing.2 For a treatment to be considered the gold standard requires that substantial supporting evidence exists. Recently, however, additional research findings have emerged that question the prominent status of CBT. In this Viewpoint, we review some of the most important findings.

Biases in research: risk factors for non-replicability in psychotherapy and pharmacotherapy research

Replicability of findings is an essential prerequisite of research. For both basic and clinical research, however, low replicability of findings has recently been reported. Replicability may be affected by research biases not sufficiently controlled for by the existing research standards. Several biases such as researcher allegiance or selective reporting are well-known for affecting results. For psychotherapy and pharmacotherapy research, specific additional biases may affect outcome (e.g. therapist allegiance, therapist effects or impairments in treatment implementation). For meta-analyses further specific biases are relevant. In psychotherapy and pharmacotherapy research these biases have not yet been systematically discussed in the context of replicability. Using a list of 13 biases as a starting point, we discuss each biass impact on replicability. We illustrate each bias by selective findings of recent research, showing that (1) several biases are not yet sufficiently controlled for by the presently applied research standards, (2) these biases have a pernicious effect on replicability of findings. For the sake of research credibility, it is critical to avoid these biases in future research. To control for biases and to improve replicability, we propose to systematically implement several measures in psychotherapy and pharmacotherapy research, such as adversarial collaboration (inviting academic rivals to collaborate), reviewing study design prior to knowing the results, triple-blind data analysis (including subjects, investigators and data managers/statisticians), data analysis by other research teams (crowdsourcing), and, last not least, updating reporting standards such as CONSORT or the Template for Intervention Description and Replication (TIDieR).

The Effects of Waiting for Treatment: A Meta‐Analysis of Waitlist Control Groups in Randomized Controlled Trials for Social Anxiety Disorder

Social anxiety disorder (SAD) is a highly prevalent mental disorder. However, little is known about how SAD changes in subjects who do not receive treatment. Waitlist control groups (WLCGs) are frequently included in randomized controlled trials (RCTs) on the treatment of mental disorders. Data from WLCGs are of value as they provide information on the untreated short-term course of a disorder and may serve as disorder-specific norms of change (benchmarks) against which treatment outcomes of SAD can be compared. Thus, we performed a meta-analysis focusing on the effects occurring in WLCGs of RCTs for SAD. Our study was conducted along the PRISMA guidelines. Thirty RCTs (total n = 2460) comprising 30 WLCGs and 47 treatment groups were included. Mean waiting time was 10.6 weeks. The pooled effect of waiting on SAD measures was g = 0.128 (95% CI: 0.057-0.199). Effects regarding other forms of anxiety, depression and functioning were of similarly small size. In contrast, change in the treatment groups was large, both within (g = 0.887) and between groups (g = 0.860). Our results show that for SAD, changes occurring in WLCGs of RCTs are small. The findings may serve as benchmarks in pilot studies of a new treatment or as an additional comparison in studies comparing two active treatments. For psychotherapy research in general, the small effect sizes found in WLCGs confirm that testing a treatment against a waiting list is not a very strict test. Further research on WLCGs in specific mental disorders is required, for example examining the expectancies of patients randomized to waiting. Copyright

Psychotherapy Versus Pharmacotherapy of Depression: What’s the Evidence?

OBJECTIVES Depression may be treated by psychotherapy or pharmacotherapy or their combination. There is an ongoing debate whether one of these approaches is possibly superior. A recent meta-analysis reported results in favour of pharmacotherapy. METHODS Individual studies and meta-analyses on the comparative efficacy of psychotherapy vs. pharmacotherapy were reviewed. RESULTS Evidence suggests that psychotherapy and pharmacotherapy are equally efficacious in the short-term, but psychotherapy is superior in the long-term. For the recently stated hypothesis that pharmacotherapy is superior to psychotherapy in studies without a pill placebo condition, which implies equally including a positive expectancy effect for both pharmacotherapy and psychotherapy no evidence was found. CONCLUSION Depression may be treated by psychotherapy or pharmacotherapy with equivalent results in the short-term and advantages for psychotherapy in the long-term. As the rates of response and remission are still limited in both treatments, further improvement of treatments is required.

Psychoanalytic-Interactional Therapy versus Psychodynamic Therapy by Experts for Personality Disorders: A Randomized Controlled Efficacy-Effectiveness Study in Cluster B Personality Disorders

Background: With regard to cluster B personality disorders, most psychotherapeutic treatments focus on borderline personality disorder. Evidence-based treatments for patients with other cluster B personality disorders are not yet available. Psychoanalytic-interactional therapy (PIT) represents a transdiagnostic treatment for severe personality disorders. PIT has been applied in clinical practice for many years and has proven effective in open studies. In a randomized controlled trial, we compared manual-guided PIT to nonmanualized pychodynamic therapy by experts in personality disorders (E-PDT) in patients with cluster B personality disorders. Methods: In an inpatient setting, patients with cluster B personality disorders were randomly assigned to manual-guided PIT (n = 64) or nonmanualized E-PDT (n = 58). In addition, a quasi-experimental control condition was used (n = 46) including both patients receiving treatment as usual and patients waiting for treatment. Primary outcomes were level of personality organization and overall psychological distress. As secondary outcomes, depression, anxiety and interpersonal problems were examined. Results: No significant improvements were found in the control patients. Both PIT and E-PDT achieved significant improvements in all outcome measures and were superior to the control condition. No differences were found between PIT and E-PDT in any outcome measure at the end of treatment. The type of cluster B personality disorder had no impact on the results. Conclusions: In an inpatient setting, both PIT and E-PDT proved to be superior to a control condition in cluster B personality disorders. In a head-to-head comparison, both treatments appeared to be equally effective. Further research on the treatment of cluster B personality disorders is required.