Efficacy of Pharmacotherapy and Psychotherapy for Adult Psychiatric Disorders

Abstract

IMPORTANCEThere is debate about the effectiveness of psychiatric treatments and whether pharmacotherapy or psychotherapy should be primarily used.OBJECTIVES To perform a systematic overview on the efficacy of pharmacotherapies and psychotherapies for major psychiatric disorders and to compare the quality of pharmacotherapy and psychotherapy trials. EVIDENCE REVIEWWe searched MEDLINE, EMBASE, PsycINFO, and the Cochrane Library (April 2012, with no time or language limit) for systematic reviews on pharmacotherapy or psychotherapy vs placebo, pharmacotherapy vs psychotherapy, and their combination vs either modality alone. Two reviewers independently selected the meta-analyses and extracted efficacy effect sizes. We assessed the quality of the individual trials included in the pharmacotherapy and psychotherapy meta-analyses with the Cochrane risk of bias tool.FINDINGS The search yielded 45 233 results. We included 61 meta-analyses on 21 psychiatric disorders, which contained 852 individual trials and 137 126 participants. The mean effect size of the meta-analyses was medium (mean, 0.50; 95% CI, 0.41-0.59). Effect sizes of psychotherapies vs placebo tended to be higher than those of medication, but direct comparisons, albeit usually based on few trials, did not reveal consistent differences. Individual pharmacotherapy trials were more likely to have large sample sizes, blinding, control groups, and intention-to-treat analyses. In contrast, psychotherapy trials had lower dropout rates and provided follow-up data. In psychotherapy studies, wait-list designs showed larger effects than did comparisons with placebo.CONCLUSIONS AND RELEVANCE Many pharmacotherapies and psychotherapies are effective, but there is a lot of room for improvement. Because of the multiple differences in the methods used in pharmacotherapy and psychotherapy trials, indirect comparisons of their effect sizes compared with placebo or no treatment are problematic. Well-designed direct comparisons, which are scarce, need public funding. Because patients often benefit from both forms of therapy, research should also focus on how both modalities can be best combined to maximize synergy rather than debate the use of one treatment over the other.

The Generalizability of Randomized Controlled Trials of Self-Guided Internet-Based Cognitive Behavioral Therapy for Depressive Symptoms: Systematic Review and Meta-Regression Analysis (Preprint)

“…The search was limited to studies in Eligibility in psychotherapy vs. antidepressant studies 8 which antidepressants or face-to-face psychotherapy were compared with a control condition, so studies of multiple treatments (e.g., two psychotherapies) were compared were only included if a control condition was employed. There are systematic differences between antidepressant and face-to-face pharmacotherapy studies regarding the type of controls employed [34]. Virtually all pharmacotherapy studies use a pill placebo whereas the efficacy of face-to-face psychotherapy, as well as self-guided iCBT, is tested with a more diverse mix of controls including: a waiting list (WL), treatment as usual (TAU), pill placebos, and other conditions (e.g., relaxation) that are intended as control for non-specific effects (e.g., attention).…”

¡Enjaulad a Dodo, por favor! El cuento de que todas las psicoterapias son igual de eficaces

“…Por ejemplo, está claro que en psicoterapia es más difícil aplicar procedimientos de enmascaramiento que en el estudio con fármacos, particularmente el doble ciego. Pero sólo aproximadamente el 45% de los ensayos de psicoterapia (en contraste con el 98% en los ensayos de medicamentos) se aplica una evaluación ciega de los resultados (Huhn et al, 2014). Los pocos meta-análisis que examinan la aplicación de doble o simple ciego han constatado la existencia de sesgos en el sentido de que, por ejemplo, los ensayos que aplican procedimientos de enmascaramiento tienen tamaños del efecto más bajos que aquellos estudios que no han procurado encubrir de algún modo durante el estudio qué tratamiento era el eficaz.…”

Evaluating the economic impact of screening and treatment for depression in the workplace

“…For example, some research suggests that methodological issues such as a nocebo effect associated with wait list controls, difficulty in blinding and small study bias may be associated with a higher effect size for psychotherapy compared to pharmacotherapy studies (Furukawa et al, 2014;Huhn et al, 2014). Additionally, our findings may not be relevant for individuals with highly recurrent depressive disorder as the length of maintenance treatment needed for these individuals may be longer than 21 months; however, our upper bound was also driven by the economic case of the maximum amount of time for which the insurance company would pay.…”