Can new approaches to synthesising evidence help achieve a consensus in psychotherapy research?

OBJECTIVE

The recent debate around the College's Clinical Practice Guidelines on mood disorders have highlighted differences in opinion on interpreting evidence from randomised control trials (RCTs) for psychodynamic psychotherapy. This paper discusses new techniques of synthesising research evidence (e.g., umbrella reviews) that may help minimise disagreements in the interpretation of RCTs and foster greater consensus on treatment guidelines.

CONCLUSIONS

Findings from the latest umbrella review suggest that psychodynamic therapy is an evidence-based approach, among several, for common mental disorders.

The lived experience of depression: a bottom-up review co-written by experts by experience and academics

We provide here the first bottom-up review of the lived experience of depression, co-written by experts by experience and academics. First-person accounts within and outside the medical field were screened and discussed in collaborative workshops involving numerous individuals with lived experience of depression, family members and carers, representing a global network of organizations. The material was enriched by phenomenologically informed perspectives and shared with all collaborators in a cloud-based system. The subjective world of depression was characterized by an altered experience of emotions and body (feeling overwhelmed by negative emotions, unable to experience positive emotions, stuck in a heavy aching body drained of energy, detached from the mind, the body and the world); an altered experience of the self (losing sense of purpose and existential hope, mismatch between the past and the depressed self, feeling painfully incarcerated, losing control over one's thoughts, losing the capacity to act on the world; feeling numb, empty, non-existent, dead, and dreaming of death as a possible escape route); and an altered experience of time (experiencing an alteration of vital biorhythms, an overwhelming past, a stagnation of the present, and the impossibility of the future). The experience of depression in the social and cultural context was characterized by altered interpersonal experiences (struggling with communication, feeling loneliness and estrangement, perceiving stigma and stereotypes), and varied across different cultures, ethnic or racial minorities, and genders. The subjective perception of recovery varied (feeling contrasting attitudes towards recovery, recognizing recovery as a journey, recognizing one's vulnerability and the need for professional help), as did the experience of receiving pharmacotherapy, psychotherapy, and social as well as physical health interventions. These findings can inform clinical practice, research and education. This journey in the lived experience of depression can also help us to understand the nature of our own emotions and feelings, what is to believe in something, what is to hope, and what is to be a living human being.

Comparative effectiveness of psychotherapies in adults with posttraumatic stress disorder: a network meta-analysis of randomised controlled trials

BACKGROUND

Evidence on the long-term comparative effectiveness of posttraumatic stress disorder (PTSD) psychotherapies in adults remains unknown. Therefore, we performed an extensive network meta-analysis of randomised controlled trials (RCTs) to determine the comparative effectiveness of psychotherapies for people diagnosed with PTSD.

METHODS

A comprehensive search was conducted in Cochrane library, Embase, Medline-OVID, PubMed, Scopus, and Psych-Info until March 2021. Studies on the effectiveness of cognitive processing therapy (CPT), cognitive therapy (CT), eye movement desensitisation reprocessing (EMDR), narrative exposure therapy (NET), prolonged exposure (PE), cognitive behavioural therapy (CBT), present-centred therapy (PCT), brief eclectic psychotherapies (BEP), psychodynamic therapy (PDT) or combination therapies compared to no treatment (NT) or treatment as usual (TAU) in adults with PTSD were included. Frequentist and Bayesian approaches were used for analysis in R-software.

RESULTS

We included 98 RCTs with 5567 participants from 18 897 studies. CPT, EMDR, CT, NET, PE, CBT, and PCT were significant to reduce PTSD symptoms (SMD range: -1.53 to -0.75; Certainty: very low to high) at immediate post-treatment and ranked accordingly. Longitudinal analysis found EMDR (1.02) and CPT (0.85) as the significant therapies with large effect size in short-term and long-term follow-up, respectively. NET and CPT showed higher proportion of loss of PTSD diagnosis (RR range: 5.51-3.45) while there were no significant psychotherapies for retention rate compared to NT.

CONCLUSIONS

Our findings provide evidence for improving current guidelines and informing clinical decision-making for PTSD management. However, the best PTSD treatment plan should be tailored to patients' needs, characteristics, and clinician expertise.

REGISTRATION

PROSPERO CRD42020162143.

The status of psychodynamic psychotherapy as an empirically supported treatment for common mental disorders - an umbrella review based on updated criteria

To assess the current status of psychodynamic therapy (PDT) as an empirically supported treatment (EST), we carried out a pre-registered systematic umbrella review addressing the evidence for PDT in common mental disorders in adults, based on an updated model for ESTs. Following this model, we focused on meta-analyses of randomized controlled trials (RCTs) published in the past two years to assess efficacy. In addition, we reviewed the evidence on effectiveness, cost-effectiveness and mechanisms of change. Meta-analyses were evaluated by at least two raters using the proposed updated criteria, i.e. effect sizes, risk of bias, inconsistency, indirectness, imprecision, publication bias, treatment fidelity, and their quality as well as that of primary studies. To assess the quality of evidence we applied the GRADE system. A systematic search identified recent meta-analyses on the efficacy of PDT in depressive, anxiety, personality and somatic symptom disorders. High quality evidence in depressive and somatic symptom disorders and moderate quality evidence in anxiety and personality disorders showed that PDT is superior to (inactive and active) control conditions in reducing target symptoms with clinically meaningful effect sizes. Moderate quality evidence suggests that PDT is as efficacious as other active therapies in these disorders. The benefits of PDT outweigh its costs and harms. Furthermore, evidence was found for long-term effects, improving functioning, effectiveness, cost-effectiveness and mechanisms of change in the aforementioned disorders. Some limitations in specific research areas exist, such as risk of bias and imprecision, which are, however, comparable to those of other evidence-based psychotherapies. Thus, according to the updated EST model, PDT proved to be an empirically-supported treatment for common mental disorders. Of the three options for recommendation provided by the updated model (i.e., "very strong", "strong" or "weak"), the new EST criteria suggest that a strong recommendation for treating the aforementioned mental disorders with PDT is the most appropriate option. In conclusion, PDT represents an evidence-based psychotherapy. This is clinically important since no single therapeutic approach fits all psychiatric patients, as shown by the limited success rates across all evidence-based treatments.

Cognitive behavior therapy vs. control conditions, other psychotherapies, pharmacotherapies and combined treatment for depression: a comprehensive meta-analysis including 409 trials with 52,702 patients

Cognitive behavior therapy (CBT) is by far the most examined type of psychological treatment for depression and is recommended in most treatment guide-lines. However, no recent meta-analysis has integrated the results of randomized trials examining its effects, and its efficacy in comparison with other psychotherapies, pharmacotherapies and combined treatment for depression remains uncertain. We searched PubMed, PsycINFO, Embase and the Cochrane Library to identify studies on CBT, and separated included trials into several subsets to conduct random-effects meta-analyses. We included 409 trials (518 comparisons) with 52,702 patients, thus conducting the largest meta-analysis ever of a specific type of psychotherapy for a mental disorder. The quality of the trials was found to have increased significantly over time (with increasing numbers of trials with low risk of bias, less waitlist control groups, and larger sample sizes). CBT had moderate to large effects compared to control conditions such as care as usual and waitlist (g=0.79; 95% CI: 0.70-0.89), which remained similar in sensitivity analyses and were still significant at 6-12 month follow-up. There was no reduction of the effect size of CBT according to the publication year (<2001 vs. 2001-2010 vs. >2011). CBT was significantly more effective than other psychotherapies, but the difference was small (g=0.06; 95% CI: 0-0.12) and became non-significant in most sensitivity analyses. The effects of CBT did not differ significantly from those of pharmacotherapies at the short term, but were significantly larger at 6-12 month follow-up (g=0.34; 95% CI: 0.09-0.58), although the number of trials was small, and the difference was not significant in all sensitivity analyses. Combined treatment was more effective than pharmacotherapies alone at the short (g=0.51; 95% CI: 0.19-0.84) and long term (g=0.32; 95% CI: 0.09-0.55), but it was not more effective than CBT alone at either time point. CBT was also effective as unguided self-help intervention (g=0.45; 95% CI: 0.31-0.60), in institutional settings (g=0.65; 95% CI: 0.21-1.08), and in children and adolescents (g=0.41; 95% CI: 0.25-0.57). We can conclude that the efficacy of CBT in depression is documented across different formats, ages, target groups, and settings. However, the superiority of CBT over other psychotherapies for depression does not emerge clearly from this meta-analysis. CBT appears to be as effective as pharmacotherapies at the short term, but more effective at the longer term.

Current and Emerging Treatments for Methamphetamine-use Disorder

Almost two decades have passed since the last methamphetamine (METH) abuse epidemic. In recent years, METH abuse in the United States has been rapidly increasing and is currently one of the leading causes of death in our country. Available statistical data indicates re-emergence of METH popularity and suggest an impending third epidemic of METH abuse. Alarmingly, there is no FDA-approved medication for METH use disorder (MUD). This disorder is currently treated with behavioral therapies; however, these therapies have limitations and would benefit from the addition of a MUD pharmacotherapy. Unfortunately, clinical trials have not yet found consistently effective pharmacotherapy for MUD. This review outlines the history of METH use, provides information on current prevalence of METH abuse and MUD, describes medications that have been in clinical trials for MUD, and addresses current as well as potential new treatments for MUD.

Efficacy and acceptability of pharmacological, psychosocial, and brain stimulation interventions in children and adolescents with mental disorders: an umbrella review

Top-tier evidence on the safety/tolerability of 80 medications in children/adolescents with mental disorders has recently been reviewed in this jour-nal. To guide clinical practice, such data must be combined with evidence on efficacy and acceptability. Besides medications, psychosocial inter-ventions and brain stimulation techniques are treatment options for children/adolescents with mental disorders. For this umbrella review, we systematically searched network meta-analyses (NMAs) and meta-analyses (MAs) of randomized controlled trials (RCTs) evaluating 48 medications, 20 psychosocial interventions, and four brain stimulation techniques in children/adolescents with 52 different mental disorders or groups of mental disorders, reporting on 20 different efficacy/acceptability outcomes. Co-primary outcomes were disease-specific symptom reduction and all-cause discontinuation ("acceptability"). We included 14 NMAs and 90 MAs, reporting on 15 mental disorders or groups of mental disorders. Overall, 21 medications outperformed placebo regarding the co-primary outcomes, and three psychosocial interventions did so (while seven outperformed waiting list/no treatment). Based on the meta-analytic evidence, the most convincing efficacy profile emerged for amphetamines, methylphenidate and, to a smaller extent, behavioral therapy in attention-deficit/hyperactivity disorder; aripiprazole, risperidone and several psychosocial interventions in autism; risperidone and behavioral interventions in disruptive behavior disorders; several antipsychotics in schizophrenia spectrum disorders; fluoxetine, the combination of fluoxetine and cognitive behavioral therapy (CBT), and interpersonal therapy in depression; aripiprazole in mania; fluoxetine and group CBT in anxiety disorders; fluoxetine/selective serotonin reuptake inhibitors, CBT, and behavioral therapy with exposure and response prevention in obsessive-compulsive disorder; CBT in post-traumatic stress disorder; imipramine and alarm behavioral intervention in enuresis; behavioral therapy in encopresis; and family therapy in anorexia nervosa. Results from this umbrella review of interventions for mental disorders in children/adolescents provide evidence-based information for clinical decision making.

Paradigms and parallels: A commentary on the transformation of the self East and West

Ways of gaining enhanced self understanding have developed in every culture. A modern way of referring to this understanding is insight, defined as the individual's understanding of associations between past and present, typical relationship patterns and their vicissitudes, emotional experiences, and psychological symptoms. This paper explores the similarities and differences among the approaches developed in Europe, the United States, and Asia. An example of evolving changes in psychoanalytic theory and practice in the United States, embodied in the body of work called "self psychology" is described as an illustration of how "western" approaches may be incorporating wisdom from "eastern" practice.

Practitioner Review: Therapeutics of unipolar major depressions in adolescents

BACKGROUND

Over the past two decades new and key randomized controlled trials have reported the efficacy, clinical and cost effectiveness of psychological and pharmacological treatments for adolescents with major depression.

METHODS

The literature was searched through pubmed, psychinfo, scopus and web of science for randomized controlled trials of current major depression together with meta-analyses and systematic reviews of trials between 2000 and 2017. Those specific to the adolescent years (11-18 years) were taken as the primary source for this narrative review. Additional selected studies in adults were used to illustrate methodological issues.

RESULTS

Manualized psychological therapies and the SSRI fluoxetine are more effective than active placebo in the treatment of major depressions. Mild to moderate illnesses attending community-based services are likely to benefit from psychological treatment alone. Moderately to severely ill patients attending clinic and hospital services are likely to benefit from monotherapies or combining psychological and pharmacological treatment. Antidepressants carry a small but significant side-effect risk including increased suicidality. Side effects from psychotherapies are somewhat lower but specific negative consequences remain less well characterized. There is some evidence that CBT-based approaches prevent onset of major depression episode in well adolescents at high-risk. Other psychological interventions have not been adequately studied. There has been only limited identification of treatment moderators and no clear understanding of therapeutic mechanisms.

CONCLUSIONS

There is now a range of clinically effective treatments for depressed adolescents. Future research needs to reveal moderators of and mechanisms for individual differences to treatment response, determine psychotherapies of value for milder depressions, enhance our understanding of safety and side-effects for all treatments, and consider how to reduce and treat treatment-resistant cases.

The role of the gut microbiota in schizophrenia: Current and future perspectives

OBJECTIVES

Schizophrenia is a poorly understood chronic disease. Its pathophysiology is complex, dynamic, and linked to epigenetic mechanisms and microbiota involvement. Nowadays, correlating schizophrenia with the environment makes sense owing to its multidimensional implications: temporal and spatial variability. Microbiota involvement and epigenetic mechanisms are factors that are currently being considered to better understand another dimension of schizophrenia.

METHODS

This review summarises and discusses currently available information, focussing on the microbiota, epigenetic mechanisms, technological approaches aimed at performing exhaustive analyses of the microbiota, and psychotherapies, to establish future perspectives.

RESULTS

The connection between the microbiota, epigenetic mechanisms and technological developments allows for formulating new approaches objectively oriented towards the development of alternative psychotherapies that may help treat schizophrenia.

CONCLUSIONS

In this review, the gut microbiota and epigenetic mechanisms were considered as key regulators, revealing a potential new aetiology of schizophrenia. Likewise, continuous technological advances (e.g. culturomics), aimed at the microbiota-gut-brain axis generate new evidence on this concept.

The current status of culturally adapted mental health interventions: a practice-focused review of meta-analyses

In recent years, there has been a steadily increasing recognition of the need to improve the cultural competence of services and cultural adaptation of interventions so that every individual can benefit from evidence-based care. There have been attempts at culturally adapting evidence-based interventions for mental health problems, and a few meta-analyses have been published in this area. This is, however, a much debated subject. Furthermore, there is a lack of a comprehensive review of meta-analyses and literature reviews that provide guidance to policy makers and clinicians. This review summarizes the current meta-analysis literature on culturally adapted interventions for mental health disorders to provide a succinct account of the current state of knowledge in this area, limitations, and guidance for the future research.

PATTERNS OF CHANGE IN RESPONSE TO PROLONGED EXPOSURE: IMPLICATIONS FOR TREATMENT OUTCOME

BACKGROUND

Assessment of response to Prolonged Exposure (PE) suggests some patients may experience discontinuous change involving sudden symptom reductions and/or temporary exacerbations. The current study looked to (1) isolate profiles of PE response among treatment-seeking veterans and (2) identify factors associated with unique patterns of change.

METHODS

Archival records were examined for veterans receiving PE through a specialty Veterans Affairs Medical Center (VAMC) clinic (N = 109). Latent profile analysis was used to extract response trajectories defined by change in weekly PTSD Checklist (PCL) scores. Associations with provider status (staff vs. intern), setting (in-person vs. telehealth), initial severity (PTSD; depression), and eventual treatment gains were examined.

RESULTS

Three profiles were observed. Rapid Responders (18.3%) evidenced sharp reductions at Week 2 and again between Weeks 5 and 6. Linear Responders (40.4%) demonstrated gradual reductions throughout the 10-week assessment window. Delayed Responder (41.3%) scores were relatively stable over the evaluation period although final session outcomes indicated reliable change (PCLΔ > 10) in 40% of patients. Profiles were similar with respect to provider status, treatment setting, and initial symptom severity. Rapid Responders evidenced lower final session scores relative to Linear (g = 1.13) and Delayed (g = 1.85) groups, with Linear Responders reporting lower end scores than Delayed Responders (g = 1.02).

CONCLUSIONS

Anticipating patterns of recovery and their association with therapeutic outcome is of immense clinical value. Sudden gains emerged as a strong predictor of enhanced response. Data also suggest potential benefits of extending standard intervention for patients who fail to demonstrate an immediate response to PE.

Differential efficacy of cognitive behavioral therapy and psychodynamic therapy for major depression: a study of prescriptive factors

BACKGROUND

Minimal efficacy differences have been found between cognitive behavioral therapy (CBT) and psychodynamic therapies for depression, but little is known about patient characteristics that might moderate differential treatment effects. We aimed to generate hypotheses regarding such potential prescriptive factors.

METHOD

We conducted post-hoc model-based recursive partitioning analyses alongside a randomized clinical trial comparing the efficacy of CBT and short-term psychodynamic supportive psychotherapy (SPSP). Severely depressed patients received additional antidepressant medication. We included 233 adults seeking treatment for a major depressive episode in psychiatric outpatient clinics, who completed post-treatment assessment. Post-treatment mean Hamilton Depression Rating Scale scores constituted the main outcome measure.

RESULTS

While treatment differences (CBT v. SPSP) were minimal in the total sample of patients (d = 0.04), model-based recursive partitioning indicated differential treatment efficacy in certain subgroups of patients. SPSP was found more efficacious among moderately depressed patients receiving psychotherapy only who showed low baseline co-morbid anxiety levels (d = -0.40) and among severely depressed patients receiving psychotherapy and antidepressant medication who reported a duration of the depressive episode of ⩾1 year (d = -0.31), while CBT was found more efficacious for such patients reporting a duration <1 year (d = 0.83).

CONCLUSIONS

Our findings are observational and need validation before they can be used to guide treatment selection, but suggest that knowledge of prescriptive factors can help improve the efficacy of psychotherapy for depression. Depressive episode duration and co-morbid anxiety level should be included as stratification variables in future randomized clinical trials comparing CBT and psychodynamic therapy.

WPA guidance on mental health and mental health care in migrants

The purpose of this guidance is to review currently available evidence on mental health problems in migrants and to present advice to clinicians and policy makers on how to provide migrants with appropriate and accessible mental health services. The three phases of the process of migration and the relevant implications for mental health are outlined, as well as the specific problems of groups such as women, children and adolescents, the elderly, refugees and asylum seekers, and lesbian, gay, bisexual and transgender individuals. The concepts of cultural bereavement, cultural identity and cultural congruity are discussed. The epidemiology of mental disorders in migrants is described. A series of recommendations to policy makers, service providers and clinicians aimed to improve mental health care in migrants are provided, covering the special needs of migrants concerning pharmacotherapies and psychotherapies.