Review articleNegative effects of psychotherapies for adult depression: A meta-analysis of deterioration rates
Introduction
It is well-established that several types of psychotherapies are effective in the treatment of adult depression, including cognitive behavior therapy (Cuijpers et al., 2016a), behavioral activation therapy (Ekers et al., 2014), interpersonal psychotherapy (Cuijpers et al., 2016b), problem-solving therapy (Malouff et al., 2007), and possibly brief psychodynamic therapy (Driessen et al., 2015) and non-directive counseling (Cuijpers et al., 2012). There is also considerable evidence that the effects of these therapies do not or only marginally differ from each other (Barth et al., 2013).
Apart from the average positive effects these therapies can have on depressed patients, it is also important to examine whether these therapies may have negative effects on some individual patients (Barlow, 2010, Foulkes, 2010, Peterson et al., 2013). Although the importance of negative effects of psychotherapies has been described for several decades (Hadley and Strupp, 1976, Mohr, 1995), it is relatively recent that this is considered one of the core issues that should be prioritized in research on psychotherapies (Barlow, 2010, Lilienfeld, 2007). At the moment, it can be said that there is consensus in the field of psychotherapy research that (1) negative effects should be examined better and (2) has mostly been neglected in much of this research up to now (Barlow, 2010, Dimidjian and Hollon, 2010).
How negative effects should be defined is less clear (Boisvert, 2010, Dimidjian and Hollon, 2010). It is clear that an increased risk of deterioration during therapy is one of the core types of negative effects. However, there are other types of negative effects that are also important to consider, such as serious adverse events (Rozental et al., 2014). Also non-response and drop-out can be considered as negative effects as they could have prevented the patient from receiving adequate care or spontaneous remission (Dimidjian and Hollon, 2010). In this paper we will focus on the negative effects of psychotherapies in terms of clinically relevant deterioration, because this is one of the most important type of negative outcomes, it has not been examined in conventional meta-analyses before.
Although there is a considerable number of randomized trials that report deterioration rates, to the best of our knowledge these have not been integrated in meta-analytic research. There are some “individual patient data” meta-analyses that have reported deterioration rates in psychotherapies (Ebert et al., 2016, Vittengl et al., 2016). However, these meta-analyses are aimed at only one type of treatment (internet-based treatment of depression; (Ebert et al., 2016)), or focus on the difference in deterioration rates between cognitive behavior therapy and pharmacotherapy for depression (Vittengl et al., 2016). No meta-analysis has examined deterioration rates in psychotherapy versus untreated control groups.
One important reason why no meta-analysis on deterioration rates in psychotherapies has been conducted is that these deterioration rates are typically not reported in titles and abstracts of studies, but only reported in the full papers because this is typically not the primary outcome of trials (only one of the 18 studies included in the current meta-analysis reported negative outcomes in the abstract; (Hautzinger et al. 2004)). At the same time only a relatively small proportion of trials do report deterioration rates. Therefore, all papers on trials in a certain field have to be collected and examined to determine whether they report relevant data. In the current study we solved this by using an existing database of randomized trials on psychotherapies for adult depression that is updated every year and record whether they report deterioration rates.
It has been estimated that 5–10% of patients deteriorate during therapy (Lambert, 2007). However, that does not necessarily have to be the result of the therapy, but may be related to other causes (Dimidjian and Hollon, 2010). Therefore when assessing deterioration rates in psychotherapy, it is important to compare these rates with those in control groups.
In the current meta-analysis, we selected studies in which psychotherapies for adult depression were compared with control conditions (waiting list, care as usual, placebo, other inactive control group), and examined whether they reported the number of patients who deteriorated (using any measure for deterioration). We then pooled the results of these studies to estimate whether psychotherapy resulted in lower or higher deterioration rates than the control conditions. We also compared the characteristics of the patients, therapies and designs of the studies that report deterioration rates with those that do not.
Section snippets
Identification and selection of studies
We used an existing database of studies on the psychological treatment of depression. This database has been described in detail elsewhere (Cuijpers et al., 2008b), and has been used in a series of earlier published meta-analyses (Cuijpers, 2017). For this database we searched four major bibliographical databases (PubMed, PsycInfo, Embase and the Cochrane Library) by combining terms (both index terms and text words) indicative of depression and psychotherapies, with filters for randomized
Selection and inclusion of studies
After examining a total of 18,500 abstracts during the building of the database described in the Methods section (14,290 after removal of duplicates), we retrieved 2092 full-text papers for further consideration. We excluded 2074 of the retrieved papers. The PRISMA flowchart describing the inclusion process, including the reasons for exclusion, is presented in Fig. 1. A total of 18 studies with 23 comparisons between a therapy and a control group met inclusion criteria for this meta-analysis (
Discussion
In this meta-analysis we pooled the deterioration rates reported in randomized trials of psychotherapies for adult depression. We found that psychotherapy significantly reduces deterioration rates of patients compared to patients in control conditions. Overall, we found that the risk of deterioration in the psychotherapy groups was reduced by 61% compared to untreated control conditions. We found that 20 patients need to be treated with psychotherapy in order to avoid one case of deterioration,
Funding sources
This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.
Conflicts of interest
None.
Contributors
PC had the idea for this paper with input from all authors. PC also did the analyses and wrote the first draft. The searches were done by PC and EK, data extraction was done by PC, EK and MR. All authors have contributed to the next versions of the paper revising it critically for important intellectual content, and have agreed that this version is submitted for publication.
Acknowledgments
None.
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