Welcome to my blog, a place to explore and learn about the experience of running a psychiatric practice. I post about things that I find useful to know or think about. So, enjoy, and let me know what you think.

Thursday, October 1, 2015

Does Talk Therapy Work?

Take a look at the article in today's NY Times, Effectiveness of Talk Therapy Is Overstated, a Study Says.  

It's about a study published in PLOS one,

Does Publication Bias Inflate the Apparent Efficacy of Psychological Treatment for Major Depressive Disorder? A Systematic Review and Meta-Analysis of US National Institutes of Health-Funded Trials

Well, it's all very interesting. They were trying to look at publication bias in studies about talk therapy, and they found it. Of the 57 studies that met their inclusion criteria, 13 were never published-they learned about them by contacting the study authors.

And by their estimation, talk therapy is 25% less effective than previously believed.

The study looked at NIH grants between 1972 and 2008, and tried to match the grants to published studies. They were pretty thorough in their search terms:

(1) “depression” (depression, depressive, major depressive disorder, mood disorder, affective disorder, melancholic, melancholia) and (2) “psychological treatment” (cognitive therapy, behavior therapy, behavioral therapy, interpersonal therapy, psychodynamic therapy, dynamic therapy, humanistic therapy, therapy, supportive therapy, experiential therapy, [self-] control therapy, [problem-] solving therapy, [supportive-] expressive therapy, family therapy, group therapy, marital therapy, couples therapy, aversive therapy, exposure therapy, psychotherapy, psychotherapies, psychotherapeutic, counseling, disease management, psychoanalytic, behavioral activation, cognitive behavioral analysis system, desensitization, relaxation techniques, and progressive muscle relaxation). 

Of note to me is that they included "psychoanalytic", but not "psychoanalysis".

Inclusion criteria were:

(1) a randomized clinical trial examining (2) psychological treatment for (3) acute depression in (4) adults

This is a diagram of how they selected studies:

It bothers me a little that they started out with 4073 studies, and ended up with 57. But they seem to have been pretty thorough in how they went about it.

This is the table of the 57 varieties of studies they looked at:

Sorry,  I meant:

Of note again to me is that 5 of the studies are in Short Term Psychodynamic/Psychoanalytic Psychotherapy (STPP).

I'm not terribly surprised by their results. I don't put that much stock in the long-term effects of short term therapy. You may recall my post, Analytic Evidence, probably worth a shifty in this context. I've never been a big fan of CBT, except in very specific presentations, but admittedly, I think my CBT training was inadequate.

What I don't like about the study, and the Times article, is the overall message to the uninitiated. These were short-term treatments, and they were heterogeneous in type. These limitations are not addressed in the discussion section of the study. So the message is that all "Talk Therapy" doesn't work as well as we thought, with no differentiation between type or duration of therapy. And this is misleading and may keep people from seeking help.


  1. I think that you are referring to is what I am going to refer to from now on as Clinical Trials bias, or the idea that randomized, double blind, placebo controlled clinical trials have something to do with the reality of clinical practice. That is a fallacy whether we are applying it to medical treatments or psychotherapy. In my experience the most frequent variable that determines the success of therapy had little to do with the method. It has to do with the patient - therapist match and whether the patient believes they are getting anything out of it. There is nothing in psychotherapy research that I have read that gets to this. Standardized training and observation based on a manualized version of the therapy certainly doesn't. The assumptions that these trials are the best way to figure out if something "works" whether it is medication or therapy seems fairly naive to me and is basically a reworking of "well it is currently the best we have." Things won't improve until we greatly improve the trials. In the meantime, publication bias trials may be headline grabbers, but I am not impressed.

  2. Agreed with this conclusion: So the message is that all "Talk Therapy" doesn't work as well as we thought, with no differentiation between type or duration of therapy. And this is misleading and may keep people from seeking help.

    But also want to point out that such validation may help those stuck in highly ineffective, unethical (and expensive) long term psychodynamic/psychoanlytical treatments. (For clarification: I have been in long term psychodynamic treatment that was highly effective and highly ethical (but still expensive.) But I also spent tens of thousands of dollars on a long term ineffective, unethical, and medically negligent treatment with elements of malpractice (verified and adjudicated by attorneys and the state licensing board, no Im' not exaggerating.)....because when you point out that nothing's working or even getting better at all over the course of YEARS, they tell you it's supposed to be that way, and they're the experts....) If even one person reads this article, is validated, and gets out of abusive, unethical and negligent treatment with the MD/psychoanalyst I saw, this article will be more then worth it.