So says a new American Journal of Psychiatry paper that could prove controversial.
CBT is widely perceived as having a better evidence base than other therapies. The "creation myth" of CBT (at least as I was taught it) is that it was invented by a psychoanalyst who got annoyed at the unscientific nature of psychodynamic i.e. Freudian-influenced therapy. CBT has always looked on clinical trials more favorably than the dynamic school.
However, the authors of this meta-analysis found that while there are certainly lots of published CBT trials for depression, they're actually no better quality than the psychodynamic trials.
"Surprisingly" (their word), they found no difference between the CBT for depression trials, and the psychodynamic trials, on a rating score of trial methodology.
Trials got better over time, but the two groups improved equally (see above). The mean score was 25.5 for CBT and 25.1 for dynamic, on a scale that goes from 0 to 48. Anything over 24 points is deemed acceptable but this is clearly an arbitrary cut-off.
The RCTP-QRS scale is relatively new and it was developed by the people who wrote this paper (albeit with the input of other experts.) There's 24 items and each gets a score from 0 (bad) to 2 (good). Items are things like "Adaquate sample size", "Patients randomly assigned to group", etc.
Worryingly, better CBT trials tended to find smaller benefits of CBT over the comparison treatment. The overall results showed that while CBT was clearly better than doing nothing, it was pretty much the same as antidepressants, and other psychotherapies, in adults with depression:
The article follows one from the same group, Gerber et al, who reviewed the evidence for psychodynamic therapy in more detail. And last year, another team reported evidence of publication bias in psychotherapy trials. In this study, the authors report possible publication bias, but they don't go into detail.
Overall this is interesting stuff, and a reminder that while CBT has the most evidence of any psychotherapy, this is not the same thing as saying that it has the best evidence...
Nathan C. Thoma et al (2011). A Quality-Based Review of Randomized Controlled Trials of Cognitive-Behavioral Therapy for Depression: An Assessment and Metaregression American Journal of Psychiatry
16 comments:
Thank you for another fascinating post. Was wondering whether it may be more accurate to title the post CBT vs Psychodynamic Psychotherapy though? Psychoanalysis is generally associated with more traditional form of psychoanalytic treatment and is usually more frequent than once a week. The Shedler paper (http://nvpp.nl/JonathanShedlerStudy20100202.pdf) is also an interesting read.
Pay wall on that American journal for poor I and I can't discuss that paper
But NS recently exposed how easy it is to fraud in psychology papers anyway.
I would be grateful to learn of any trend toward CBT teams finding CBT superior to psychodynamic approach more often than neutral clinical researchers.
Anyone knows about a Pr Thomas F. Babor, Farmington, CT article from a huge Veteran alcoholism treatments trial comparing in different centers alcoholic anonymous, behavioral therapy, psychodynamic therapy founding that the three treatment groups were not different on efficacy criteria? I heard him lecture on that in 2010.
With a huge center effect inside each therapy suggesting that the quality of the therapist might be more important that the school of thinking any therapist belongs to?
Plus, what can you expect when psychiatric illnesses definition and criteria are elected by an American Psychiatric Association money making DSM committees?
It probably does have better evidence than the other treatments because it is scientifically reproducible hence an efficacy worth marketing and the 'best' for society at large. The others suggest you help yourself, pump drugs etc. whereas CBT specifically targets changes in the way you think - correct me if I'm wrong.
Your circumstances still suck and the world is falling apart regardless of what anyone thinks but at least it teaches you to meditate on rainbows like with the colors and stuff instead of just talking about rainbows, you can be a druggy to see rainbows or punching you in the eye to see rainbows in the case of military torture.
Ivana, what you can do is walk into your library and read it. Lots of university libraries have access to these articles and you don't have to do PhD to access it.
I say there should be universal access to articles paid for by govts - information vetoed by the UN. I believe this is in the works as we speak..
http://www.unesco.org/new/en/communication-and-information/access-to-knowledge/open-access-to-scientific-information/
There are too many information laws, jurisdiction issues, confidentiality issues, internet laws, on and on red tape, opening a pandora of loops to make open access fully-fledged viable under the laws of one nation-state.
Perhaps individuals like yourself should consider working for the UNESCO. They're located in Paris.
Ivana, what you can do is walk into your library and read it. Lots of university libraries have access to these articles and you don't have to do PhD to access it.
I say there should be universal access to articles paid for by govts - information vetoed by the UN. I believe this is in the works as we speak..
http://www.unesco.org/new/en/communication-and-information/access-to-knowledge/open-access-to-scientific-information/
There are too many information laws, jurisdiction issues, confidentiality issues, internet laws, on and on red tape, opening a pandora of loops to make open access fully-fledged viable under the laws of one nation-state.
Perhaps individuals like yourself should consider working for the UNESCO. They're located in Paris.
It is necessarily true that in the world of small effects, smaller studies will show larger effect sizes. So while it is not ideal that this is the case all it shows is that there is a small effect size, which we already knew. Zero is small too, that is a worry, but this pattern of data doesn't show anything dodgy prima facie.
This is not surprising given the so-called "common factors" evidence. I suggest The Heart and Soul of Change: What Works in Therapy as a beginning resource.
omg,
I do not know if UNESCO should consider to take in people like me but I know for certain that they are not.
Their recruitment criteria is highly political and their work very politicaly correct- unless you have a Nobel prize on your CV ( The man who demonstrated that AIDES is due to a virus had an office there and bought me lunch once in 2009 in front of it to discuss homeopathy and that is te closest I will ever be to UNESCO).
Thanks anyway for the compliment.
omg
You are right about what seems to me your comprehension of wha CBT is :
To help people put minds over moods
in the depression CBT therapies
About your advice for me to go to the library:
It is just unpractical to ask busy isolated physicians to walk to a library every time they think an article would be worth reading improve their practice.
To give you an example, my good friend Bernard Fleming -from Autism Researh - excellent work supplies me through my mail box with a reading list of around 30 very well selected papers a week...
The Norvegian governement is - to my knowledge- the only one who poses the problem of the high cost for physicians to an access online to medical litterature.
Until that acess is easy and cheap enough - the cost of ne article only is marketting racket- Big Pharma will run the show in contiuous medical education.
And to forbid sexy goodies delivering medical visitors from Big Pharma to penetrate practises ground will solve nothing.
Because of cost of medical conferences ( close to 1000 pounds registering fees to attend for example the yearly Royal Psyc Ass plus lodging and eating on the cheap to attend medical meetings cost a fortune in money or in transportatiopn time often.
Because of expensive premises in sexy cities like the Sheraton in BUENOS AIRES for the last WPA meeting meaning long tranport twice a day in crowded subte.
- if you are an adept of : http://www.nograziepagoio.it/
It is easier tobe part of a group taken are of by Big Pharma who will lodge, feed and amuse you: on the last EPA in VIENNA march 2011 ou could see luxiourious buses with several Big Pharma labels on th windows waiting for their presribers to come in for free transportation to free evening restaurants and after that free confortable hotels...
Anonymous 29 November 2011 10:54 comment is fundamental:
"(...)more accurate to title the post CBT vs Psychodynamic Psychotherapy (...)"
Psychodynamic Psychotherapy do exist indeed
and do more good than many a CBT or ABA prescriber or practicing person will be ready to admit.
But a lot of people are just pretending to be psychoanalysts in action
–and charge clients accordingly (often in cash in France at least) to get back the funds invested in years of at least twice costly sessions to become psychoanalyst plus sessions to keep up with their lack of penises for the women and fear of loosing it for the men presumably in somebody else soft hole of some sort-
But Psychodynamic Psychotherapy is not giving general advices or even using CBT plus prescribing Big Pharma drugs with disreguard for side effects.
And many a psychoanalyst does that at least in France.
Not even always like the XVII century Molière character, Mr JOURDAIN, who is delighted and proud to realize - paying an expensive teacher of good manners and general culture- that he had been able to speak in prose without metrical structure and without even knowing it before that expensive ig session.
PS: Don't panic Aonymouses it will be my last comment on that post.
Mostly because my two PhD candidate children do not want to maintain me in my old age and keep telling me that I should make some money and spend less time on the internet.
Anytime I advise them to spend more of their time in the libraries to complete sooner their PhD.
thanks to the healthy and competitive air one inhale in a good academic library: A French Nobel laureate (medicine) F Jacob said in an interview that the most difficult thing for a researcher is when competitors discover something of some worth.
and right now they advice that keeping on reading Nicole X propaganda on the Oct NS post on packing is no good for me.
Although there is much to discuss on that topic and NS has a talent to ask good questions.
Erratum on Ivana Fulli 11h38 last comment on that NS post:
Of course psychoanalytic training impose (in theory at least) paying your master in the art twice sessions
per week
for years- if your master is in town that is.
Yeah I second The Heart and Soul of Change. This finding isn't really new, Bruce Wampold published a book length treatment of meta-analyses on the efficacy and effectiveness of psychotherapy in 2001 (The Great Psychotherapy Debate), which provides a wealth of evidence for the conclusion that there are no differences in terms of effectiveness between various psychotherapy techniques.
As to points about the components of the treatment, like targeting behaviors in CBT, or analyzing the transference in PDT, the evidence shows that those techniques don't make a difference. In essence, all roads lead to Rome. Psychotherapy is effective no matter the manner in which it is conducted.
I hadn't heard of the Great Psychotherapy Debate, will take a look.
But the idea that all therapies are equal is very old, I remember reading an old medical textbook from 1990 or something which said, roughly, "Psychologists have all kinds of arcane debates but basically they're all the same"
Jim and neuroskeptic,
I think what counts really might be the quality of the relationship between the psychotherapist and the client.
Hence the hudge center factor reported in an oral presentation
(IF 29 November 2011 12:42:)
from Pr Thomas F. Babor, Farmington, CT, from a huge Veteran alcoholism treatments trial comparing in different centers alcoholic anonymous, behavioral therapy, psychodynamic therapy; suggesting that the quality of the therapist might be more important that the school of thinking any therapist belongs to.
It is my clinical experience that some psychiatrists and psychotherapists are better than others and it is very true also for homeopaths...
Beware also that for psychotherapy,
the psychoanalysts working "face to face with the client" in short term psychodynamic therapies
can do behaviour therapy without even noticing it like the XVII century Molière character, Mr Jourdain, who spoke not in verse but in prose.
idem for the cognitiviste when the clinet discover a repetition (like Whaou! I married a man so like my father and I am finding myself in the ackward difficult position my mother was trapped in !)
Actually I paid 250 pounds to learn from psychoanalyst from the Maudsley hospital what was their tretment for borderline personality disorder and:
1) hard to tell the concrete difference with the cognitist therapy for borderline personality disorder (no kidding really)
2) two British colleagues told me afterward that they had been doing just what was taught in that day for years without knowing it was called "Mentalization".
3) sometimes a good sensitive aunt, teacher, supervicor at work, friend or chaplain or whatever might have the same positive influence plus healing of time...
4) the "mindfullness" techniques can be considered third wawe CBT but -honestly- they are little more than oriental "religious" philosophy outside the temples.
like:
http://www.ncbi.nlm.nih.gov/pubmed/14756612
http://www.pnas.org/content/108/50/20254
5) the clients not being labs rats have lives. Living their lives as miserable at times as it can be interferes with the results of any psychotherapy in trial: As an example, a story from the New York Times of a schizophrenic man, who during a snow tempest, asked his woman neighbor if she needed help and cooked diner for her and her children. He ended married with the single mother of three and his symptoms improved dramatically over the months. he also meditates...
What seems important to my mind, is that clever academics are proposing that may be a trauma at a young age is a good indication to treat depression by psychotherapy.
The link to the paper does not work any more. Here is the DOI link (it's better to use DOI Links instead of copying the browser URL because they are stable): http://dx.doi.org/10.1176/appi.ajp.2011.11030433
Thanks, well spotted.
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