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Recent research: 3 studies on internet-delivered therapy, 2 on speed of antidepressant response, and 1 on therapy effectiveness

Here are three studies (for all abstracts & links see below) highlighting the increasingly encouraging results being reported for internet-delivered psychological interventions.  Van't Hof, Cuijpers et al report on " ... a systematic review of meta-analyses on the efficacy of self-help interventions, including internet-guided therapy, for depression and anxiety disorders". They conclude that the 13 meta-analyses indicate "self-help methods are effective in a range of different disorders, including depression and anxiety disorders. Most meta-analyses found relatively large effect sizes for self-help treatments, independent of the type of self-help, and comparable to effect sizes for face-to-face treatments" (see below for abstracts and links to the six research papers mentioned).  Riper, Kramer et al describe how an experimental internet-delivered self-help alcohol reduction intervention transferred well to being made more generally available.  The authors conclude that " ... web-based self-help without therapeutic guidance is feasible, well accepted, and effective for curbing adult problem drinking in the community".  Crow, Mitchell, et al describe a study comparing therapist-delivered (not self-help) internet cognitive therapy for eating disorders with the same therapy delivered via the more traditional face-to-face format.  They conclude "In this study, CBT delivered face-to-face and via telemedicine were similarly effective, and telemedicine delivery cost substantially less. These findings underscore the potential applicability of telemedicine approaches to eating disorder treatment and psychiatric treatment in general".

There are then a couple of studies adding to the increasing literature showing antidepressants act more quickly than we have previously thought.  So Murphy, Norbury, et al describe how a single standard 20mg dose of the antidepressant citalopram produced reductions in brain amygdala response to fearful facial expressions on assessment within 3 hours using functional magnetic resonance imaging. They conclude "Such an immediate effect of an SSRI on amygdala responses to threat supports the idea that antidepressants have an earlier onset of therapeutically relevant effects than conventionally thought".  In a much bigger report, Szegedi, Jansen, et al performed a meta-analysis involving about 6,500 patients involved in trials of antidepressants for depression.  They showed that " ... early improvement (>or= 20% reduction in depression rating score within 2 weeks) with antidepressant medication can predict subsequent treatment outcome with high sensitivity in patients with major depressive disorder. The high negative predictive values indicate little chance of stable response or stable remission in the absence of improvement within 2 weeks. A lack of improvement during the first 2 weeks of therapy may indicate that changes in depression management should be considered earlier than conventionally thought". 

The last of the six papers I'm describing in this blog post is by Cuijpers, van Straten, et al.  After all the publicity earlier this year suggesting that antidepressants aren't as powerful an intervention as we have tended to think, here is a meta-analysis making a similar claim for psychotherapy.  The authors write "No meta-analytical study has examined whether the quality of the studies examining psychotherapy for adult depression is associated with the effect sizes found. This study assesses this association".  After a thorough examination of 115 randomized controlled trials in which 178 psychotherapies for adult depression were compared to a control condition, the authors state "We found strong evidence that the effects of psychotherapy for adult depression have been overestimated in meta-analytical studies. Although the effects of psychotherapy are significant, they are much smaller than was assumed until now, even after controlling for the type of control condition used".  This ties in with the panel discussion at the recent Exeter cognitive behavioural psychotherapy conference on "Having your cake and eating it: integrating therapist and therapy effects to maximise clinical outcomes" exploring how, in many situations, there are major differences both between the best and worst therapists and also between the best and worst therapies.  However it is also very clear that whether we use pharmacotherapy, psychotherapy, or both, there is plenty of room for improvement in the results that we as therapists are typically achieving.     

Van't Hof, E., P. Cuijpers, et al. (2009). "Self-help and Internet-guided interventions in depression and anxiety disorders: a systematic review of meta-analyses." CNS Spectr 14(2 Suppl 3): 34-40.  [PubMed]  
There is a growing database of research on self-help and internet-guided interventions in the treatment of common mental disorders, and a number of meta-analyses have now been published. This article provides a systematic review of meta-analyses on the efficacy of self-help interventions, including internet-guided therapy, for depression and anxiety disorders. Searches were conducted in PubMed, PsychINFO, EMBASE, and the Cochrane database for statistical meta-analyses of randomized, controlled trials of self-help or internet-guided interventions for depression or anxiety disorders published in English. Reference lists were also used to find additional studies. Effect sizes were tabulated; 13 meta-analyses reported medium to large effect sizes for self-help interventions. Studies included in the meta-analyses differed in samples, type of self-help (eg, computer-aided, internet-guided), control conditions, and study design. The meta-analyses indicate that self-help methods are effective in a range of different disorders, including depression and anxiety disorders. Most meta-analyses found relatively large effect sizes for self-help treatments, independent of the type of self-help, and comparable to effect sizes for face-to-face treatments. However, further research is needed to optimize the use of self-help methods.

Riper, H., J. Kramer, et al. (2009). "Translating Effective Web-Based Self-Help for Problem Drinking Into the Real World." Alcohol Clin Exp Res.  [PubMed]  
Background: Drinking Less (DL) is a 24/7 free-access anonymous interactive web-based self-help intervention without therapeutic guidance for adult problem drinkers in the community. In a randomized controlled trial (referred to here as DL-RCT), DL has been shown effective in reducing risky alcohol consumption. Objective: To assess whether the findings of DL-RCT are generalizable to a naturalistic setting (DL-RW) in terms of ability to reach the target group and alcohol treatment response. Methods: Pretest-posttest study with 6-month follow-up. An online survey was conducted of 378 of the 1,625 people who used DL-RW from May to November 2007. Primary outcome measures were (1) problem drinking, defined as alcohol consumption in the previous 4 weeks averaging >21 or >14 standard units (male/female) per week or >/=6 or >/=4 units (m/f) on 1 or more days per week; and (2) mean weekly alcohol consumption. DL-RW and DL-RCT data were compared and pooled. Intention-to-treat (ITT) analysis was performed to analyze and compare changes in drinking from baseline to follow-up. Results: In the DL-RW group, 18.8% (n = 71) were drinking successfully within the limits of the Dutch guideline for low-risk drinking (p < 0.001) 6 months after baseline (ITT). The DL-RW group also decreased its mean weekly alcohol intake by 7.4 units, t(377) = 6.67, p < 0.001, d = 0.29. Drinking reduction in DL-RW was of a similar magnitude to that in the DL-RCT condition in terms of drinking within the guideline [chi(2)(1) = 1.83, CI: 0.82-3.00, p = 0.18, RD = 0.05, OR = 1.55] and mean weekly consumption (a negligible difference of d = 0.03 in favor of DL-RW group). Conclusion: The results from DL-RCT and DL-RW were similar, and they demonstrate that web-based self-help without therapeutic guidance is feasible, well accepted, and effective for curbing adult problem drinking in the community.

Crow, S. J., J. E. Mitchell, et al. (2009). "The cost effectiveness of cognitive behavioral therapy for bulimia nervosa delivered via telemedicine versus face-to-face." Behaviour Research and Therapy 47(6): 451-453.  [Extract/Full Text]  
Objective A number of effective treatments for bulimia nervosa have been developed, but they are infrequently used, in part due to problems with dissemination. The goal of this study was to examine the cost effectiveness of telemedicine delivery of cognitive behavioral therapy for bulimia nervosa. Method A randomized controlled trial of face-to-face versus telemedicine cognitive behavioral therapy for bulimia nervosa. One hundred twenty eight women with DSM-IV bulimia nervosa or eating disorder, not otherwise specified subsyndromal variants of bulimia nervosa were randomized to 20 sessions of treatment over 16 weeks. A cost effectiveness analysis from a societal perspective was conducted. Results The total cost per recovered (abstinent) subject was $9324.68 for face-to-face CBT, and $7300.40 for telemedicine CBT. The cost differential was accounted for largely by therapist travel costs. Sensitivity analyses examining therapy session costs, gasoline costs and telemedicine connection costs yielded fundamentally similar results. Discussion In this study, CBT delivered face-to-face and via telemedicine were similarly effective, and telemedicine delivery cost substantially less. These findings underscore the potential applicability of telemedicine approaches to eating disorder treatment and psychiatric treatment in general.

Murphy, S. E., R. Norbury, et al. (2009). "Effect of a single dose of citalopram on amygdala response to emotional faces." The British Journal of Psychiatry 194(6): 535-540.  [Abstract/Full Text
Background Selective serotonin reuptake inhibitors (SSRIs) are typically thought to have a delay of several weeks in the onset of their clinical effects. However, recent reports suggest they may have a much earlier therapeutic onset. A reduction in amygdala responsivity has been implicated in the therapeutic action of SSRIs. Aims To investigate the effect of a single dose of an SSRI on the amygdala response to emotional faces. Method Twenty-six healthy volunteers were randomised to receive a single oral dose of citalopram (20 mg) or placebo. Effects on the processing of facial expressions were assessed 3 h later using functional magnetic resonance imaging. Results Volunteers treated with citalopram displayed a significantly reduced amygdala response to fearful facial expressions compared with placebo. Conclusions Such an immediate effect of an SSRI on amygdala responses to threat supports the idea that antidepressants have an earlier onset of therapeutically relevant effects than conventionally thought.

Szegedi, A., W. T. Jansen, et al. (2009). "Early improvement in the first 2 weeks as a predictor of treatment outcome in patients with major depressive disorder: a meta-analysis including 6562 patients." J Clin Psychiatry 70(3): 344-53.  [PubMed]  
OBJECTIVE: New evidence indicates that treatment response can be predicted with high sensitivity after 2 weeks of treatment. Here, we assess whether early improvement with antidepressant treatment predicts treatment outcome in patients with major depressive disorder (MDD). DATA SOURCES: Forty-one clinical trials comparing mirtazapine with active comparators or placebo in inpatients and outpatients (all-treated population, N = 6907; intent-to-treat population, N = 6562) with MDD (DSM-III-R or DSM-IV Criteria) were examined for early improvement (>or= 20% score reduction from baseline on the 17-item Hamilton Rating Scale for Depression [HAM-D-17] within 2 weeks of treatment) and its relationship to treatment outcome. STUDY SELECTION: Data were obtained from a systematic search of single- or double-blind clinical trials (clinical trials database, Organon, a part of Schering-Plough Corporation, Oss, The Netherlands). All included trials (a total of 41) employed antidepressant treatment for more than 4 weeks and a maximum of 8 weeks. The studies ranged from March 1982 to December 2003. Trials were excluded if there were no HAM-D-17 ratings available, no diagnosis of MDD, or if the study was not blinded. Trials were also excluded if HAM-D-17 assessments were not available at week 2, week 4, and at least once beyond week 4. DATA SYNTHESIS: Early improvement predicted stable response and stable remission with high sensitivity (>or= 81% and >or= 87%, respectively). Studies utilizing rapid titration vs. slow titration of mirtazapine demonstrated improved sensitivity for stable responders (98%, [95% CI = 93% to 100%] vs. 91% [95% CI = 89% to 93%]) and stable remitters (100%, [95% CI = 92% to 100%] vs. 93% [95% CI = 91% to 95%]). Negative predictive values for stable responders and stable remitters were much higher (range = 82%-100%) than positive predictive values (range = 19%-60%). CONCLUSIONS: These results indicate that early improvement with antidepressant medication can predict subsequent treatment outcome with high sensitivity in patients with major depressive disorder. The high negative predictive values indicate little chance of stable response or stable remission in the absence of improvement within 2 weeks. A lack of improvement during the first 2 weeks of therapy may indicate that changes in depression management should be considered earlier than conventionally thought.

Cuijpers, P., A. van Straten, et al. (2009). "The effects of psychotherapy for adult depression are overestimated: a meta-analysis of study quality and effect size." Psychol Med: 1-13.  [PubMed]  
BACKGROUND: No meta-analytical study has examined whether the quality of the studies examining psychotherapy for adult depression is associated with the effect sizes found. This study assesses this association.  Method: We used a database of 115 randomized controlled trials in which 178 psychotherapies for adult depression were compared to a control condition. Eight quality criteria were assessed by two independent coders: participants met diagnostic criteria for a depressive disorder, a treatment manual was used, the therapists were trained, treatment integrity was checked, intention-to-treat analyses were used, N50, randomization was conducted by an independent party, and assessors of outcome were blinded. RESULTS: Only 11 studies (16 comparisons) met the eight quality criteria. The standardized mean effect size found for the high-quality studies (d=0.22) was significantly smaller than in the other studies (d=0.74, p<0.001), even after restricting the sample to the subset of other studies that used the kind of care-as-usual or non-specific controls that tended to be used in the high-quality studies. Heterogeneity was zero in the group of high-quality studies. The numbers needed to be treated in the high-quality studies was 8, while it was 2 in the lower-quality studies. CONCLUSIONS: We found strong evidence that the effects of psychotherapy for adult depression have been overestimated in meta-analytical studies. Although the effects of psychotherapy are significant, they are much smaller than was assumed until now, even after controlling for the type of control condition used.

 

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