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The future of psychotherapy in the NHS

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Sandy Goldbeck-Wood at UiT The Arctic University of Norway
Sandy Goldbeck-Wood
Peter Fonagy at University College London
Peter Fonagy
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error. However, in diagnosing metastases with no
known primary, such as liver metastases as a first pres-
entation, consideration should be given to the need for
histological material. Cytology is ideal for confirming
metastasis from a clinically or radiologically suspected
primary site and distinguishing between limited
alternatives such as small cell or non-small cell lung
cancer. However, if there is no indication of a possible
primary site, core biopsy facilitates more thorough
assessment of a tumour’s architecture and immunohis-
tochemical profile, allowing better prediction of origin
and prognosis. The trauma and risks of biopsy are
greater than for fine needle aspiration,
11
and we need
to consider for each patient which technique is most
suitable and how the result of any invasive test would
alter management.
Used appropriately FNAC remains a powerful tool
in the diagnosis and management of patients with
malignancy. A realistic approach to what is achievable,
with clear communication between clinician and
cytopathologist, is vital.
Derek E Roskell consultant pathologist
(derek.roskell@orh.nhs.uk)
Ian D Buley consultant pathologist
Department of Cellular Pathology, John Radcliffe Hospital, Oxford
OX3 9DU
Competing interests: None declared.
1 Metcalfe MS, Bridgewater FHG, Mullin EJ, Maddern GJ. Useless and
dangerous
—
fine needle aspiration of hepatic colorectal metastases. BMJ
2004;328:507-8. (Also electronic responses at http://
bmj.bmjjournals.com/cgi/content/full/328/7438/507)
2 Brown LA, Coghill SB. Cost effectiveness of a fine needle aspiration
clinic. Cytopathology 1992;3:275-80.
3 Buley ID, Roskell DE. Fine needle aspiration cytology in tumour diagno-
sis: uses and limitations. Clin Oncol 2000;12:166-71.
4 Powers CN. Complications of fine needle aspiration biopsy: the reality
behind the myths. In Schmidt WA, ed. Cytopathology. Chicago: ASCP
Press, 1996:69-91.
5 Snead DRJ, Vryenhoef P, Pinder SE, Evans A, Wilson ARM, Blamey RW,
et al. Routine audit of breast fine needle aspiration (FNA) cytology speci-
mens and aspirator inadequate rates. Cytopathology 1997;8:236-47.
6 Singh N, Ryan D, Berney D, Calaminici, Sheaff MT, Wells CA. Inadequate
rates are lower when FNAC samples are taken by cytopathologists.
Cytopathology 2003;14:327-31.
7 Britton PD. Fine needle aspiration or core biopsy. Breast 1999;8:1-4.
8 Castro MR, Gharib H. Thyroid fine-needle aspiration biopsy: progress,
practice and pitfalls. Endocrine Pract 2003;9:128-36.
9 Orell SR, Phillips J, eds. The role of fine needle biopsy in the investigation
of thyroid disease and its diagnostic accuracy. In: The thyroid, fine needle
biopsy and cytological diagnosis of thyroid lesions. Monographs in clinical
cytology. Vol 14. Basel: Karger, 1997:8-16. (Chapter 3.)
10 Gharib H, Goellner JR: Fine-needle aspiration biopsy of the thyroid: an
appraisal. Ann Intern Med 1993;119:282-9.
11 Buscarini L, Fornari F, Bolondi L, Colombo P, Livraghi T, Magnolfi F, et
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The future of psychotherapy in the NHS
More evidence based services are taking shape to meet growing demand
T
he demand for psychological therapies in Brit-
ain has never been greater,
1
yet their claim on
scientific legitimacy and therefore on public
resources has never been under greater scrutiny.
2 w1-w4
At a meeting held by the UK Council for Psycho-
therapy in November 2003 to address the future of
psychotherapy in the NHS, the clearest messages were
conflicting ones
—
that although the taxpaying public
demands increased access to psychological therapies
and the government espouses both patient choice and
user centred services,
1
the evidence on the efficacy and
cost effectiveness of the many different psychothera-
pies is patchy. Randomised trials cover only a limited
number of treatments, and many treatments remain
unevaluated in relation to many conditions.
3
Exclusion
rates of 40-70% of presenting patients limit their gen-
eralisability to the treatment seeking population,
4
and a
dearth of long term data, data on quality of life, non
experimental evidence, user perspectives, and evidence
of the generalisability to NHS practice of studies
carried out in other settings hampers rational purchas-
ing decisions. Little is known about equity of access to
therapy across socioeconomic or ethnic groups, and
with neither a career structure nor a pay scale of its
own, psychotherapy is not even formally recognised as
an independent profession. The result is a lottery for
patients and piecemeal and ad hoc arrangements for
recruitment and supervision of staff.
One of the key obstacles has been a conflict of cul-
tures. The narrative based hermeneutic culture of post-
Freudian psychotherapy and the empirical culture that
dominates medicine have proved reluctant bedfellows.
Theoretical differences are reinforced by longstanding
political antagonisms and resentments. Analytic thera-
pists in particular have been defensive and suspicious
in the f ace of the evidence culture as though the very
idea of objective scrutiny represented a hostile
intrusion into a quasi sacred private world.
w5
Cognitive
behaviour therapy has done much better at embracing
the need for evidence and the requirements of
purchasers. As a result its strong research and dissemi-
nation strategy has found favour with service providers
and research funding bodies lost in a jungle of conflict-
ing claims and vested interests, regardless of whether it
is the most effective for any given indication.
5
Real difficulties exist in providing meaningful
evidence on psychotherapies.
w6
Although research is
legitimately and necessarily a public activity, much of
what is most important in psychotherapy is legiti-
mately and necessarily private.
w7
As with surgical
research, factors related to the individual practitioner
and patient are probably at least as important a part of
the “active ingredient” as the modality of therapy.
6w8
Individual, patient related factors such as coping style
may also be influential. A meta-analysis of 16 trials
showed that self reflective and introspective individuals
seem to benefit more from insight oriented therapies
Additional references w1-w13 are on bmj.com
Editorials
BMJ 2004;329:245–6
245BMJ VOLUME 329 31 JULY 2004 bmj.com
whereas impulsive and aggressive patients respond
better to symptom focused procedures.
6
In short, some
of the influences that randomised trials would
normally seek to exclude seem actually to be part of
the active ingredient of psychotherapy. It seems that a
good therapist can achieve results with the right
patient almost irrespective of his or her declared brand
of therapy.
6
To complicate matters, therapists them-
selves disagree over fundamentals such as relevant
outcome measures, and what constitutes a “therapeutic
dose.” Analytic therapists favour a long term view, in
which short term worsening of presenting symptoms
may be seen to play a necessary part and success is
measured less in terms of symptom relief than of self
understanding. All these represent real barriers to the
pursuit of evidence but barriers which are being
surmounted.
Evidence from randomised controlled trials now
exists for the efficacy of psychotherapy in depression,
panic, generalised anxiety disorder, eating disorder,
and personality disorder. Cognitive behaviour therapy,
family therapy, interpersonal therapy, cognitive ana-
lytic therapy, and some psychodynamic therapy have
variously been shown to reduce life impairing mood
states and behaviours substantially.
3
But with notable
exceptions, such as the use of cognitive behaviour
therapy for panic disorders, most trials still leave
patients with residual symptoms, and most participants
in trials relapse or seek further treatment within a year
or two of “successful treatment.”
3
Most patients
presenting at clinics are polysymptomatic, and
improvement is inversely proportional to the chronic-
ity and complexity of their presenting condition. Dura-
tion of treatment is also highly correlated with
comorbidity and chronicity, and we know that theoreti-
cally based therapies with a coherent theoretical
mechanism of action deliver better results than
interventions, such as simple interpersonal support,
which lack a coherent theoretical model.
7
But though the overall picture is diffuse, differences
between individual therapies in relation to specific dis-
orders are now emerging. The efficacy of cognitive
behaviour therapy in conditions such as panic
disorder, specific phobias, and obsessive compulsive
disorder is well established, although critics argue that
effect sizes have been overestimated because of
inappropriate controls.
8w9
Psychodynamic therapy has
been shown to be effective in severe personality disor-
der,
9
which responds poorly to cognitive behaviour
therapy.
w10-w12
Family therapy is effective in anorexia
nervosa,
10
and structured br ief psychological therapies
in depression
11
are generally effective at least in the
short term, although with no clear evidence of advan-
tage to any particular approach.
7
Again few trials have
extended follow up, and those that do show a clear ten-
dency for patients to relapse.
4 w13
Unlike medicine and allied professions, psycho-
therapy has established itself primarily outside the
state sector. From Freud’s fir st analyses of the Viennese
bourgeoisie to modern Britain, private provision still
exceeds state provision. Britain has no legal definition
of psychotherapy, so the British market is richly varied
in type of therapy, training, price, and quality.
Regulation with bodies such as the United Kingdom
Council for Psychotherapy, and the British Association
for Counselling and Psychotherapy, is still purely
voluntary. But if evidence based psychotherapy is to be
more than a private luxury for the wealthy, and if the
NHS is to meet growing demand for mental health
services, the internecine warfare between the cultures
of medicine and psychotherapy must stop. The NHS
needs to recognise psychotherapists as professionals
with proper career and pay structures, rather than
treating them as petitioners at the gate. Psychothera-
pists need to speak coherently and convincingly as a
profession in language that others can understand.
And the joint pursuit of rigorous, theory based, patient
centred, therapist led research into talking therapies
must go on. Only then will patients receive the accessi-
ble, affordable, and effective talking treatments they
need and want.
Sandy Goldbeck-Wood associate editor BMJ
(sgoldbeck-wood@bmj.com)
Peter Fonagy Freud Memorial professor of psychoanalysis
Psychoanalysis Unit, University College London, London WC1E 6BT
(p.fonagy@ucl.ac.uk)
Competing interests: SG-W has received training in psychody-
namic and humanistic therapies. She is not currently practising
as a therapist.
1 Department of Health. National service framework for mental health: modern
standards and service models. London. DOH, 1999. www.dh.gov.uk/
PublicationsAndStatistics/Publications/
PublicationsPolicyAndGuidance/
PublicationsPolicyAndGuidanceArticle/fs/
en?CONTENT_ID = 4009598&chk = jmAMLk (accessed 7 Apr 2004).
2 National Institute for Clinical Excellence. Depression: the management
of depression in primary and secondary care. Second consultation draft,
December 2003..
3 Roth, Fonagy P. What works for whom? A critical review of psychotherapy
research. 2nd ed. New York: Guilford Press (in press).
4 Westen D, Morrison K, Thompson-Brenner H. The empirical status of
empirically supported psychotherapies: assumptions, findings, and
reporting in controlled clinical trials. Psychol Bull (in press).
5 Holmes J. All you need is cognitive behaviour therapy? BMJ
2002;324:228-94.
6 Beutler LE, Machado PP, Neufeldt SA. Therapist variables. In: Bergin AE,
Garfield SL, eds. Handbook of psychotherapy and behavior change. New York:
Wiley, 2004.
7 Wampold B, Minami T, Baskin T, Callen Tierney S. A meta-(re)analysis of
the effects of cognitive therapy versus “other therapies” for depression. J
Affect Disord 2002;68:159-65.
8 Westen D, Morrison K. A multidimensional meta-analysis of treatments
for depression, panic, and generalized anxiety disorder: An empirical
examination of the status of empirically supported therapies. J Consult
Clin Psychol 2001;69:875-99.
9 Leichsenring F, Leibing E. The effectiveness of psychodynamic therapy
and cognitive behavior therapy in the treatment of personality disorders:
a meta-analysis. Am J Psychiatry 2003;160:1223-32.
10 Dare C, Eisler I, Russell G, Treasure J, Dodge L. Psychological therapies
for adults with anorexia nervosa: randomised controlled trial of
out-patient treatments. Br J Psychiatry 2001;178:216-21.
11 Churchill R, Corney R, Knapp M, McGuire H, Tylee A, Wessely S. A sys-
tematic review of controlled trials of the effectiveness and cost-
effectiveness of brief psychological treatments for depression: Health-
Technology Assessment 2002;5(35).
Editorials
246 BMJ VOLUME 329 31 JULY 2004 bmj.com
... There is no legal requirement for accreditation with any regulatory body and once accredited there is no common standard for ongoing accreditation. 1 This lack of a regulatory framework means that quality ABSTRACT Objectives To evaluate whether effective psychological therapies are being provided in an inner London population and to describe the ethnicity of clients in relation to estimated need in the population. Methods A questionnaire survey was sent to 78 providers of structured psychological therapy in the borough. ...
... 14 There are many problems with assessing the evidence base for psychological therapies. 1 We ensured that we related evidence of effectiveness to each of the common mental illnesses and used the best current evidence of effectiveness based on independent systematic reviews. The effectiveness grid was approved by a multidisciplinary steering group. ...
... There is now sufficient evidence to show that some types of therapy are more effective for different common mental health problems. 1,5,[7][8][9][10][11][12] We have no independent assessment of the effectiveness of therapy provided and have relied solely on therapists' own assessments of the treatment type they usually used for each common mental illness. None appeared to have any problems identifying the type of therapy they provided, and since respondents were not aware of the effectiveness grid there were no incentives to record other than their usual practice. ...
Psychological therapies for common mental illness: How effective and equitable is provision?
Article
  • Mar 2005
Objectives To evaluate whether effective psychological therapies are being provided in an inner London population and to describe the ethnicity of clients in relation to estimated need in the population.Methods A questionnaire survey was sent to 78 providers of structured psychological therapy in the borough.Results Fifty-nine (76%) providers of structured psychological therapy described the types of therapy they use for each of the common mental illnesses. At least one effective or likely to be effective therapy was used by 70% of voluntary sector providers, 61% of the primary care team, 59% of the primary care counselling service and 53% of private therapists. Twenty-five percent of the primary care team, 23% of voluntary sector providers and 5% of private therapists only used a therapy that was unlikely to be effective. A validated outcome measure was used by 100% of the primary care counsellors, 67% of the primary care team, 10% of private therapists and none of the voluntary sector providers. Twenty-three percent of the population of Greenwich are from a black and minority ethnic (BME) group. Only 15% of the client group for the primary care counselling service were from BME groups compared with 47% of clients of the private sector and 40% of voluntary sector clients.Conclusions Levels of use of treatment that is unlikely to be effective are unacceptably high for all provider groups. BME groups are more likely to access voluntary and private sector providers of psychological therapies, and services within the NHS should be developed appropriately to address this inequity of access.
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... Clearly these kinds of anxieties are not exclusive to the discipline of child psychoanalytic psychotherapy, but of particular interest was the lack of a formal evidence base as perceived by the medical establishment. (Goldbeck-Wood and Fonagy, 2004), which may put it at risk of becoming obsolete. Child psychoanalytic psychotherapy is an important part of the history of Child and Adolescent Mental Health Services and, some argue, an important part of the history of child psychiatry. ...
... There is an extensive literature on the history of psychoanalysis and a range of opinion about whether it is a science (Hale, 1995; Rustin, 2003; Strenger, 1991). However, to have a place in the UK NHS in the later part of the twentieth century, it became necessary for a treatment to have a strong evidence base ( Wood and Fonagy, 2004). Therefore, this review looks for signs that child psychoanalytic psychotherapy is positioning itself as a scientifi c discipline, in recognition that this is a necessary prerequisite to establishing an evidence-based practice. ...
Child psychoanalytic psychotherapy in the UK National Health Service: An historical analysis
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  • Dec 2009
This review developed from a discussion with the late Professor Richard Harrington about interventions in Child and Adolescent Mental Health services (CAMHS) that lacked an evidence base. Our aim is to investigate the literature for signs that child psychoanalysis is a declining paradigm within the Child and Adolescent Mental Health Services (CAMHS) in the United Kingdom (UK). We present the literature chronologically since the inception of the UK National Health Service. This study shows that there have been a number of threats to child psychoanalytic psychotherapy, but no significant consistent decline. The profession is beginning to develop the social profile of a scientific discipline. We conclude that child psychoanalytic psychotherapy does not consistently demonstrate features of a declining scientific paradigm.
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... A theory regarded as 'scientific' may eventually receive the legitimate status of a grand narrative. It should be also noted that, in the context of public health of which psychotherapy has become part, the scientific legitimacy of certain therapeutic models is reflected in access to public resources (Goldbeck-Wood and Fonagy, 2004). Therefore, it might be said that the system encourages and justifies seeking explanatory, scientific models that could be established as grand narratives in psychotherapy. ...
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This article presents an approach to refugee care that is based on a hermeneutic understanding of the meanings constituted by narratives in therapy. It proposes distinguishing psychotherapeutic models commonly used in therapy with refugees, such as post-traumatic stress disorder or post-traumatic growth theories, from an approach that involves many different narratives in the form of multi-voiced conversation within the therapeutic setting. Such a concept, called here the narrative matrix, is discussed and presented as an alternative and efficient way of providing therapeutic support for refugees and asylum seekers. It discusses family therapy with refugees as an example of the narrative-hermeneutic approach that involves not only different voices from members of a family but different psychotherapeutic models.
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This analysis identifies the significant problem of ambiguity, variation and vagueness in relation to the intervention described as ‘psychotherapy’. Its purpose is to raise international awareness of this problem and alternative solutions.
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When to offer cognitive behavioural or psychoanalytic psychotherapy in an integrated psychotherapy service: Are everyday allocation decisions theoretically congruent?
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  • Jun 2008
  • Counsell Psychother Res J
Different modes of psychotherapy can be an effective form of treatment for a range of mental health problems. Psychotherapy provision in the NHS is organised in a variety of ways, with patient entry to various modes of therapy determined by a range of factors including evidence-based guidelines and patient or referrer preference. The methods by which patients arrive at a particular mode of psychotherapy are largely unreported. This paper aims to describe this process in one UK NHS psychotherapy service offering cognitive behavioural and psychoanalytic psychotherapy, and provides data to inform a discussion on the theoretical congruence of these allocation decisions.
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Jack Tizard Lecture: Cognitive Behaviour Therapies for Children: Passing Fashion or Here to Stay?
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The aim of this article is to consider the current and likely future status of cognitive behaviour therapy (CBT) for disturbed children and adolescents. Two definitions of CBT, narrow and broad, are provided and their core components described. Subsequently the historical development of these therapies and their reception by psychotherapists with different orientations is discussed. Assessment and therapeutic CBT approaches are described and the strength of the evidence for their use is briefly reviewed. Finally the challenges these therapies are currently meeting that might enhance or diminish their value are outlined. It is concluded that CBTs offer a most promising approach in the child and adolescent field and are likely to establish and maintain an important place in the therapeutic armoury of the next generation of professionals concerned to help children and young people with psychiatric disorders.
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Future of psychotherapy in the NHS - Psychotherapists require more than evidence based services to be recognised as professionals
Article
  • Sep 2004
  • Br Med J
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Future of psychotherapy in the NHS - Control groups play important part
Article
Full-text available
  • Sep 2004
  • Br Med J
Editor—In discussing the future of psychotherapy, Goldbeck-Wood and Fonagy comment on the difficulties in providing meaningful evidence about efficacy.1 However, they do not explain that the specific problem is about the adequacy of control groups.2 Comparison of active with control treatment in psychotherapy cannot be conducted double blind as subjects inevitably know to which group they have been allocated. Drug trials may seem to have an advantage over psychotherapy trials in claims for scientific legitimacy because they can be conducted double blind by using placebo drugs. However, the degree of bias remaining in apparently double blind trials should not be underestimated.3,4 Goldbeck-Wood and Fonagy may have focused too much on evidence as factual without acknowledging the importance of interpretation and have therefore not spelt out the role of ideology in assessing efficacy. Evaluation of psychotherapy is controversial. Psychotherapy may be in conflict with biomedical psychiatry in its conceptualisation of mental illness. Moreover, statutory responsibilities under the Mental Health Act take precedence within mental health services over psychotherapy, which is a voluntary activity. Psychotherapy therefore struggles against the hegemony of biological psychiatry. For reasons such as this, psychotherapy has established itself primarily outside the state sector, as Goldbeck-Wood and Fonagy note. Their solution is for the NHS to create a proper career structure for psychotherapists. Politically this may be less likely to be successful than taking advantage of the government policy for choice in the NHS.5 Primary care trusts need to look for alternative providers to meet the public demand for psychological therapies. Psychotherapists could organise themselves into provider organisations. These alternative providers should meet standards of training approved by such bodies as the UK Council for Psychotherapy and the British Confederation of Psychotherapists.
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To test the hypotheses that: (1) Lumbar spine radiography in primary care patients with low back pain is not associated with improved patient outcomes, including pain, disability, health status, sickness absence, reassurance, and patient satisfaction or belief in the value of radiography. (2) Lumbar spine radiography in primary care patients with low back pain is not associated with changes in patient management, including medication use, and the use of primary and secondary care services, physical therapies and complementary therapies. (3) Participants choosing their treatment group (i.e. radiography or no radiography) do not have better outcomes than those randomised to a treatment group. (4) Lumbar spine radiography is not cost-effective compared with usual care without lumbar spine radiography. A randomised unblinded controlled trial. Seventy-three general practices in Nottingham, North Nottinghamshire, Southern Derbyshire, North Lincolnshire and North Leicestershire. Fifty-two practices recruited participants to the trial. Randomised arm: 421 participants with low back pain, with median duration of 10 weeks. Patient preference arm: 55 participants with low back pain, with median duration of 11 weeks. Lumbar spine radiography and usual care versus usual care without radiography. Roland adaptation of the Sickness Impact Profile, visual analogue pain scale, health status scale, EuroQol, use of primary and secondary care services, and physical and complementary therapies, sickness absence, medication use, patient satisfaction, reassurance and belief in value of radiography at 3 and 9 months post-randomisation. Participants randomised to receive an X-ray were more likely to report low back pain at 3 months (odds ratio (OR) = 1.56; 95% confidence interval (CI), 1.02 to 2.40) and had a lower overall health status score (p = 0.02). There were no differences in health or functional status at 9 months. A higher proportion of participants consulted the general practitioner (GP) in the 3 months following an X-ray (OR = 2.72; 95% CI, 1.80 to 4.10). There were no differences in use of any other services, medication use or sickness absence at 3 or 9 months. No serious spinal pathology was identified in either group. The commonest X-ray reports were of discovertebral degeneration and normal findings. Many patients did not perceive their information needs were met within the consultation. Satisfaction with care was greater in the group receiving radiography at 9 months. Participants randomised to receive an X-ray were not less worried, or more reassured about serious disease causing their low back pain. Satisfaction was associated with meeting participants' information needs and reduced belief in the necessity for investigations for low back pain, including X-rays and blood tests. In both groups, at 3 and 9 months 80% of participants would choose to have an X-ray if the choice was available. Participants in the patient preference group achieved marginally better outcomes than those randomised to a treatment group, but the clinical significance of these differences is unclear. Lumbar spine radiography was associated with a net economic loss at 3 and 9 months. Lumbar spine radiography in primary care patients with low back pain of at least 6 weeks duration is not associated with improved functioning, severity of pain or overall health status, and is associated with an increase in GP workload. Participants receiving X-rays are more satisfied with their care, but are not less worried or more reassured about serious disease causing their low back pain. CONCLUSIONS - RECOMMENDATIONS FOR FURTHER RESEARCH: Further work is required to develop and test an educational package that educates patients and GPs about the utility of radiography and provides strategies for identifying and meeting the information needs of patients, and the needs of patients and GPs to be reassured about missing serious disease. Guidelines on the management of low back pain in primary care should be consistent about not recommending lumbar spine radiography in patients with low back pain in the absence of red flags for serious spinal pathology, even if the pain has persisted for at least 6 weeks.
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All you need is cognitive behaviour therapy?
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Review of What works for whom? A critical review of psychotherapy research
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Reviews the book, What works for whom? A critical review of psychotherapy research by Anthony Roth and Peter Fonagy (see record 1996-98691-000). This book presents a comprehensive review of the status of psychotherapy research. The authors look at the evidence dealing with both efficacy and effectiveness of psychotherapy for the more common DSM-IV disorders. All of the chapters are geared toward the goal of providing the practitioner with a list of treatments for which there is empirical support. The reviewer notes that the amount of information covered in this text is extensive and provides sufficient evidence for the efficacy of psychotherapy for many of the diagnostic categories. Despite an overemphasis on cognitive/behavioral treatments, the authors do present the best of the research in psychodynamic therapy. The reviewer recommends this volume to both to researchers and practitioners. (PsycINFO Database Record (c) 2012 APA, all rights reserved)
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A multidimensional meta-analysis of treatments for depression, panic, and generalized anxiety disorder: An empirical examination of the status of empirically supported therapies
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  • Jan 2002
The authors report a meta-analysis of high-quality studies published from 1990-1998 on the efficacy of manualized psychotherapies for depression, panic disorder, and generalized anxiety disorder (GAD) that bear on the clinical utility and external validity of empirically supported therapies. The results suggest that a substantial proportion of patients with panic improve and remain improved; that treatments for depression and GAD produce impressive short-term effects: that most patients in treatment for depression and GAD do not improve and remain improved at clinically meaningful follow-up intervals: and that screening procedures used in many studies raise questions about generalizability, particularly in light of a systematic relation across studies between exclusion rates and outcome. The data suggest the importance of reporting, in both clinical trials and meta-analyses, a range of outcome indices that provide a more comprehensive, multidimensional portrait of treatment effects and their generalizability. These include exclusion rates, percent improved, percent recovered, percent who remained improved or recovered at follow-up, percent seeking additional treatment at follow-up, and data on both completer and intent-to-treat samples.
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The Place of Psychoanalytic Treatments Within Psychiatry
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  • Jul 2002
  • ARCH GEN PSYCHIAT
Psychoanalytic treatments may be necessary when other treatments are ineffective. An empirically grounded framework for the use of these treatments involves sources of evidence from both efficacy and effectiveness studies. Preliminary evidence suggests that psychoanalysis appears to be consistently helpful to patients with milder disorders and somewhat helpful to those with more severe disturbances. A greater number of controlled studies are necessary to confirm these impressions. A multisite process and outcome study is proposed.
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A meta-(re)analysis of the effect of cognitive therapy versus other therapies for depression
Article
  • May 2002
  • J AFFECT DISORDERS
Cognitive therapy (CT) for depression has been found to be efficacious for the treatment of depression. In comparison to other psychotherapies, CT has been shown to be approximately equal to behavior therapies, but sometimes superior to 'other therapies.' The latter comparison is problematic given that 'other therapies' contain bona fide treatments as well as treatments without therapeutic rationale for depression. A meta-analysis was conducted for studies that compared CT to 'other therapies' in an earlier meta-analysis, except that in this meta-analysis 'other therapies' were classified as bona fide and non-bona fide. The benefits of CT were found to be approximately equal to the benefits of bona fide non-CT and behavioral treatments, but superior to non-bona fide treatments. The results of this study fail to support the superiority of CT for depression. On the contrary, these results support the conclusion that all bona fide psychological treatments for depression are equally efficacious.
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