Psychotherapy doesn’t improve depression outcomes?

[4AM123]

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Hi all. I’m wondering what you guys make of the research i’ve linked below. To quote the medscape article: “Results of a cross-sectional, naturalistic, multicenter European study showed there were no significant differences in response rates between patients with major depressive disorder (MDD) who received combination treatment with psychotherapy and antidepressant medication in comparison with those who received antidepressant monotherapy”

Medscape article: No Added Benefit of Adjunctive Psychotherapy in Severe Depression?

Link to paper: Combining psychopharmacotherapy and psychotherapy is not associated with better treatment outcome in major depressive disorder - evidence from the European Group for the Study of Resistant Depression

As a student interested in psychiatry this is a little disappointing to me, as the ability to practice psychotherapy is a part of why i’m interested in the field

What do you all think?

 

[birchswing]

<Not a doctor or medical student>

This is my opinion—but given that mental illnesses are conceptualizations, I'm not sure it's so unusual to have an opinion. But again see the disclaimer above. I see severe MDD as a different disease state than mild to moderate depression. Even studies looking at architecture changes in the brain post-SSRI show differences between people who have severe MDD and those who do not (those with severe MDD tend to improve on SSRIs whereas those with mild-moderate do not so much).

If you're not depressed about something but more suffering from an ill-defined physical disease known as severe MDD, it's not that I don't think psychotherapy could help. But I think you should have expectations for it the way you would for psychotherapy helping a person with any other syndrome. In fact, I think the idea of placing too much agency on the person to fix the issue with changing thoughts etc when it's extremely ingrained in some not-understood way could be quite demoralizing when it fails to work.

Also:

Just reading the abstract (I read nothing but the abstract), the group that did not receive therapy had higher severity of depression which is already known to respond better to antidepressants, so that could skew the results. And the type of therapy was something I had not heard of before (manual driven therapy), which it turns out is what it sounds like, and I've always heard it's more the quality of the relationship with a therapist than the treatment modality, and manual driven therapy sounds like something that could be conducted entirely without a therapist. I didn't read further, but if you're just using a manual to guide someone through (I assume something like CBT), it sounds rather cold. Based on the little I read, I personally (again see the disclaimer above) would not put much into this study. It sounds very observational and like the headline is a pretty sweeping generalization based on fairly heterogeneous groups.

Edit:

If you want to be depressed about a future in psychiatry, disregard the results of this study. Regard instead the footnote with the declaration of competing interests. They make prostitution look respectable. I'm not saying there was a conflict of interest in reaching those results, but you couldn't work any harder in making there appear to be one if you wanted to.

 

[splik]

It’s a cross-sectional study. These aren’t really designed to tell you anything about the efficacy of treatments at all. I don't think this study tells us anything about whether psychotherapy improves outcomes in depression. Conversely there is a robust database that a range of psychotherapies are efficacious in the treatment of depression, often similar or superior to pharmacotherapy. In general, the combination of pharmacotherapy and psychotherapy is recommended as optimal treatment for more significant depressive states. This study does nothing to change this. Instead, it highlights many patients do not receive psychotherapy, and the disparities between those who do and do not.

Psychotherapy is an indispensable tool in psychiatric practice. I do not think my work would be as interesting or rewarding if I were not able to think about patients from a psychological perspective or provide psychotherapeutic interventions. Even when I am just seeing patients once, or primarily for pharmacotherapy, I am still providing therapeutic interventions, and thinking about psychosocial and relational factors. We also know that medications are more effective when prescribed by psychiatrists who have a stronger therapeutic alliance with their patients and maximize expectancy effects and contextual healing.

It is also worth stating that psychotherapy is an operator-dependent procedure. It requires skill on the part of the therapists and there are lots of bad therapists out there who do not know what they are doing and aren't providing quality care. I assume this is why people are still willing to pay a premium for high quality psychotherapy despite a glut of therapists providing services on the cheap.

 

[Orgone]

The title is science clickbait. It was not a study meant to address the effectiveness of therapy, as splik said.

They also found this correlation: "In our sample, MDD patients treated with psychopharmacotherapy and additional MDP, that was CBT in the most cases, were younger and, concurrently, more often suffered from migraine and asthma as comorbid conditions than patients lacking this treatment option. "

By the same reasoning, they could have written the title "CBT shrinks are causing your ASTHMA and MIGRAINES!!!"

I also found the writing style stilted and barely readable, which is probably beside the point, and might be a "second language" issue, but still.

 

[PsyDr]

It doesn't say that.

1) No control group
2) Psychotherapy vs No psychotherapy samples were exceedingly different.
3) The authors stated their exclusion criteria included comorbidities such as PTSD. Those same diagnoses were shown in the study results.
4) response rates were essentially the same between no treatment, medication alone, and medication plus psychotherapy
5) Psychotherapies included any manualized psychotherapy, not CBT alone.
6) There are group differences in terms of symptoms, with the authors explaining that maybe MDD samples with psychosis will do less well with psychotherapy, than MDD samples without psychosis. No kidding .
7) The SES is different, which affects everything.

 

[4AM123]

Thank you all for the very thorough responses. I think I need to make it a point of emphasis to think a little more critically about papers I read!

 

[singasongofjoy]

My first thought when I saw that headline earlier was “what type of psychotherapy.” I get the sense approach to therapy is often quite different “across the pond” from those of us in North America. Much more variance and more psychoanalysis (I went on a frustrating deep dive into psychoanalysis approach to treating autism a few years ago…). Disclaimer though I haven’t actually read the article - the title was so click-baity that I didn’t even bother.