The efficacy of psychotherapies and pharmacotherapies for mental disorders in adults: an umbrella review and meta‐analytic evaluation of recent meta‐analyses

Abstract

Mental disorders represent a worldwide public health concern. Psychotherapies and pharmacotherapies are recommended as first line treatments. However, evidence has emerged that their efficacy may be overestimated, due to a variety of shortcomings in clinical trials (e.g., publication bias, weak control conditions such as waiting list). We performed an umbrella review of recent meta‐analyses of randomized controlled trials (RCTs) of psychotherapies and pharmacotherapies for the main mental disorders in adults. We selected meta‐analyses that formally assessed risk of bias or quality of studies, excluded weak comparators, and used effect sizes for target symptoms as primary outcome. We searched PubMed and PsycINFO and individual records of the Cochrane Library for meta‐analyses published between January 2014 and March 2021 comparing psychotherapies or pharmacotherapies with placebo or treatment‐as‐usual (TAU), or psychotherapies vs. pharmacotherapies head‐to‐head, or the combination of psychotherapy with pharmacotherapy to either monotherapy. One hundred and two meta‐analyses, encompassing 3,782 RCTs and 650,514 patients, were included, covering depressive disorders, anxiety disorders, post‐traumatic stress disorder, obsessive‐compulsive disorder, somatoform disorders, eating disorders, attention‐deficit/hyperactivity disorder, substance use disorders, insomnia, schizophrenia spectrum disorders, and bipolar disorder. Across disorders and treatments, the majority of effect sizes for target symptoms were small. A random effect meta‐analytic evaluation of the effect sizes reported by the largest meta‐analyses per disorder yielded a standardized mean difference (SMD) of 0.34 (95% CI: 0.26‐0.42) for psychotherapies and 0.36 (95% CI: 0.32‐0.41) for pharmacotherapies compared with placebo or TAU. The SMD for head‐to‐head comparisons of psychotherapies vs. pharmacotherapies was 0.11 (95% CI: –0.05 to 0.26). The SMD for the combined treatment compared with either monotherapy was 0.31 (95% CI: 0.19‐0.44). Risk of bias was often high. After more than half a century of research, thousands of RCTs and millions of invested funds, the effect sizes of psychotherapies and pharmacotherapies for mental disorders are limited, suggesting a ceiling effect for treatment research as presently conducted. A paradigm shift in research seems to be required to achieve further progress.

Effect of antidepressants on functioning and quality of life outcomes in children and adolescents with major depressive disorder: a systematic review and meta-analysis

“…However, a sensitivity analysis excluding these studies showed no significant difference. Seventh, based on the evidence from a recent study in adults [ 46 ], the effects of antidepressants on functioning and QOL in children and adolescents with MDD might be also overestimated due to potential observers’ bias of functioning and QOL outcomes in our included trials, which would be an interesting topic in further study. Finally, to reduce heterogeneity across studies, we excluded patients with treatment-resistant depression, which may have led to an overestimation of effects because of the omission of a difficult-to-treat population.…”

Psychological interventions for adult PTSD: A network and pairwise meta-analysis of short and long-term efficacy, acceptability and trial quality

“…Psychological interventions for adult PTSD appear more effective than psychological interventions more generally, that is, across mental disorders. A recent umbrella review and meta-analysis 80 summarized findings of 3,782 RCTs (N = 650,514 patients) on the efficacy of psychological interventions and pharmacotherapies for the treatment of various mental disorders and found a pooled SMD of 0.34 (95% CI: 0.26-0.42) for psychological interventions as monotherapy compared to placebo or treatment-as-usual, which is substantially below the SMDs found for psychological interventions in the present NMA (e.g., SMD of TF-CBT vs active control conditions at post-treatment assessment = 0.60).Similar results have been reported elsewhere. For instance, psychological interventions for PTSD produce larger treatment effects than psychological interventions for other anxiety-related disorders 81 .…”

Functional Coding System for Verbal Interaction in Clinical Contexts

“…Empirically Supported Treatments (EST) movement has helped clinical psychologists to reach an agreement on the efficacy of psychological treatments for specific problems (Nathan & Gorman, 2015). However, after all the resources invested in clinical research, the effect sizes of psychological interventions are limited and researchers are starting to suggest a ceiling effect for clinical research as presently conducted (Leichsenring et al, 2022). Probably these results are generated by pervasive problems in clinical research psychology as the undying influence of the latent disease model of psychiatry, manualized treatment for specific diagnostic labels, and the separation between therapeutic processes and clinical outcomes (Hofmann & Hayes, 2019;Tolin et al, 2015).…”