Psychotherapy for depression 25% less effective than the published literature would have you believe

[Sidereal]

A new meta-analysis published in PLoS One of publication bias in NIMH-funded trials of psychological therapies for depression shows that once unpublished studies are included in the meta-analysis, the effect size for psychotherapy drops from 0.52 to 0.39. You'll note that the confidence interval for the new effect size estimate very nearly crosses zero (0.08~0.70).

Does Publication Bias Inflate the Apparent Efficacy of Psychological Treatment for Major Depressive Disorder? A Systematic Review and Meta-Analysis of US National Institutes of Health-Funded Trials

Ellen Driessen, Steven D. Hollon, Claudi L. H. Bockting, Pim Cuijpers, Erick H. Turner

Abstract
Background
The efficacy of antidepressant medication has been shown empirically to be overestimated due to publication bias, but this has only been inferred statistically with regard to psychological treatment for depression. We assessed directly the extent of study publication bias in trials examining the efficacy of psychological treatment for depression.

Methods and Findings
We identified US National Institutes of Health grants awarded to fund randomized clinical trials comparing psychological treatment to control conditions or other treatments in patients diagnosed with major depressive disorder for the period 1972–2008, and we determined whether those grants led to publications. For studies that were not published, data were requested from investigators and included in the meta-analyses. Thirteen (23.6%) of the 55 funded grants that began trials did not result in publications, and two others never started. Among comparisons to control conditions, adding unpublished studies (Hedges’ g = 0.20; CI95% -0.11~0.51; k = 6) to published studies (g = 0.52; 0.37~0.68; k = 20) reduced the psychotherapy effect size point estimate (g = 0.39; 0.08~0.70) by 25%. Moreover, these findings may overestimate the "true" effect of psychological treatment for depression as outcome reporting bias could not be examined quantitatively.

Conclusion
The efficacy of psychological interventions for depression has been overestimated in the published literature, just as it has been for pharmacotherapy. Both are efficacious but not to the extent that the published literature would suggest. Funding agencies and journals should archive both original protocols and raw data from treatment trials to allow the detection and correction of outcome reporting bias. Clinicians, guidelines developers, and decision makers should be aware that the published literature overestimates the effects of the predominant treatments for depression.

It's good to see big names in the field authoring a paper like this.

It's important to also keep in mind that outcome measures in depression studies are questionnaires. Only a small number of items on the Hamilton Depression Rating Scale are objectively observable by the clinician (things like psychomotor agitation or retardation) who is doing the rating while the remaining items are rated on the basis of what the patient tells you. Some scales like the Beck Depression Inventory are self-report scales. An unknown % of that improvement is therefore likely to be due to the effects of psychological brainwashing on the patients' reporting of subjective symptoms.

Personally, I've suspected for a long time that psychotherapy is worthless even for problems conventionally classified as psychiatric.

 

[Beyond]

Psychotherapy = awfully expensive delusion...

Off I go to my psych appointment now *sigh*

 

[anciendaze]

I'd like to point out that there are multiple studies showing psychotherapy is just as effective as psychopharmacology. This revision causes me to question both. I noticed some years ago that drugs which produced a response lasting months in 30% of patients could be FDA approved. Most antidepressants are being prescribed for longer periods than any research has demonstrated effectiveness. With the discovery that very popular antidepressants (so popular they can be measured in municipal sewage) strongly inhibit certain enteroviruses in vivo, I'm left with the suspicion an entire profession has been treating an infectious disease without beginning to understand what they were doing.

 

[ahmo]

The efficacy of psychological interventions for depression has been overestimated in the published literature, just as it has been for pharmacotherapy. Both are efficacious but not to the extent that the published literature would sugge

Toxic food, treadmill work life, pace of living....Put people into soul-destroying conditions, and, surprise, they get depressed. Or anxious. Or murderous.

 

[Effi]

Does anyone know if in these kinds of studies the cyclic nature of depression (or are they called flare-ups?) is taken into account? i.e.: if a patient gets better, do these studies automatically assume that this was thanks to their treatment and not due to the ending of a flare-up? I understand that this is hardly measureable, but this would make the overestimate of treatment even bigger... I'd be interested to hear some thoughts about this.

 

[A.B.]

So, about that CBT for car engine problems study... can we convince some people that their car doesn't really have any problems despite the strange noises and then claim that CBT can fix car engine problems?

 

[Sidereal]

Does anyone know if in these kinds of studies the cyclic nature of depression (or are they called flare-ups?) is taken into account? i.e.: if a patient gets better, do these studies automatically assume that this was thanks to their treatment and not due to the ending of a flare-up? I understand that this is hardly measureable, but this would make the overestimate of treatment even bigger... I'd be interested to hear some thoughts about this.

The effect of spontaneous remission due to relapsing-remitting nature of depression, passage of time, regression toward the mean - whatever you wanna call this issue - is factored into study design by having a placebo group. The improvement in depression in the placebo group is not just due to administration of the placebo itself but also incorporates all those other nebulous factors that can result in people getting better during the study period. So when you are measuring the effect of psychotherapy or meds, you're really looking at the improvement over and above the improvement in the placebo group, thus partialling out the effect of placebo + that other stuff like passage of time.

 

[IreneF]

Once you get into the world of meds and psychotherapy, you realize how little the docs and the therapists know, and how ineffective their treatments are. I found effective treatment after decades of trial-and-error. Yeah, depression can be treated, but for many (most?) people thetreatments don't work.

 

[whodathunkit]

Neither anti-depressants or talk therapy really worked for me. Plus, I believe anti-depressants actually helped make my already-deteriorating physical health worse. I tried them several times over the years before my energy went completely in the tank. Each time after coming off them I was a little bit different, and not in the good way.

Talk therapy would help me for a little while to blow off steam in acute situations, but then I'd get all "talked out" and reach an impasse. I gradually realized that any cognitive or behavioral changes of the kind that are the goal of talk therapy were going to have to come spontaneously when I was ready to work them, and not on a timeline set by someone else. And it turns out that my physical health had a lot to do with my readiness to effect CB changes.

I do think cognitive measures are beneficial (I have experienced that), but again, on a therapy timeline, which is usually very finite due to lack of funds, not so much. Even when I was depressed I've gotten more out of reading self-help books than out of any strategies that a therapist ever gave me. Part of that could be because I'm a reader and a visual person, not auditory, but I think some of it is just the inherent weakness of talk therapy as a longer-term wellness strategy.

Toxic food, treadmill work life, pace of living....Put people into soul-destroying conditions, and, surprise, they get depressed. Or anxious. Or murderous.

Honestly, I think it's *mostly* about toxic food and proper nutrition. Cognitive/intellectual/mental resiliency to the other stressors of life is vastly improved when we have the proper physiological foundation from which to form neurotransmitters and thus cogitate.

Case in point is that my treadmill hasn't changed a bit from when I hit PR a couple years ago, but thanks the the improvement in physiological function my depression has pretty much lifted and I'm much better able to cope with the idea that I'm actually a hamster.

Of course, that's aside from whatever is needed to recover from any acute illnesses that are causing depression. But we're talking here about studies concerned with the effects of antidepressants on "idiopathic" modern depression, not depression caused by acute health conditions (viruses, snps, or other complex morbities).

Also worth noting is that it really wasn't until I resolved the physiological foundation of my depression that cognitive strategies have been truly beneficial. This is a very recent development. When I was depressed, the strategies were mostly just intellectual curios. Never anything I could sustain any lasting benefit from.

Sadly, now and then I do still take a ride on the crazy train. But I think that's to be expected at my time of life. Thankfully, I'm not a constant passenger any more, and again, I'm much better able to cope with the stress of travel when I do jump on board. Thanks in large measure to @Freddd and the stuff I've learned here on PR.

 

[Sean]

Neither anti-depressants or talk therapy really worked for me. Plus, I believe anti-depressants actually helped make my already-deteriorating physical health worse. I tried them several times over the years before my energy went completely in the tank. Each time after coming off them I was a little bit different, and not in the good way.

Tried both too, including several rounds of different types of anti-depressants, and a year with a psychologist.

Benefits from them? Not so much. Mostly boiled down to learning that neither was of much use, and the 'side-effects' of ADs were, um, a bit more serious than the prescribers led me to believe. Like, ED.

(Not having a go at GPs, or frontline staff in general, they are caught in the middle of all this.)