From the Editor
Cognitive behavioural therapy is widely used for the treatment of depression – but the last significant meta-analysis was published a decade ago. What’s the latest evidence?
In the first selection, Pim Cuijpers (of the Vrije Universiteit Amsterdam) and his co-authors try to answer this question with a new meta-analysis including more than 400 randomized trials with almost 53 000 patients (yes, you read that correctly). In this World Psychiatry paper, they compare the therapy with controls, other therapies, and medications. They write: “We can conclude that CBT is effective in the treatment of depression with a moderate to large effect size, and that its effect is still significant up to 12 months.” We consider the paper and its clinical implications.
Beck: the father of CBT
In the second selection, Dr. John Torous (of Harvard University) and his co-authors look at digital mental health. Despite widespread use of smartphones – perhaps 80% of the world’s population now has access to one – “digital mental health is not transforming care.” In this Editorial for World Psychiatry, they wonder why. They also point a way forward: “Developing a new generation of digital mental health tools/services to support more accessible, effective and equitable care is the true innovation ready to be stoked today by each person who becomes empowered to connect, set up, engage, start/stop, and demand more from mental health technology.”
Finally, in the third selection, Dr. Karla Castro-Frenzel (of the University of Central Florida) writes about a patient with advanced lung cancer. As it turns out, she’s that patient. In this personal essay published in JAMA, she writes about being a doctor and a patient. “My ultimate hope… is that we can create space for illness as well as wellness. In helping our colleagues feel safe and supported when they become patients, we rehumanize our environments and our very selves.”
Selection 1: “Cognitive behavior therapy vs. control conditions, other psychotherapies, pharmacotherapies and combined treatment for depression: a comprehensive meta-analysis including 409 trials with 52,702 patients”
Pim Cuijpers, Clara Miguel, Mathias Harrer, et al.
World Psychiatry, February 2023
Cognitive behavior therapy (CBT) is by far the most examined type of psychological treatment for depression and is recommended in most treatment guidelines. Several hundreds of randomized controlled trials have tested the effects of CBT. Previous meta-analyses have found that CBT is significantly more effective in the treatment of depression than various control conditions, whereas its effectiveness in comparison with other psychotherapies, pharmacotherapies and combined treatment at the short and longer term, as well as its impact on specific populations of patients and in different formats, remain uncertain.
The last comprehensive meta-analysis of CBT for depression was published in 2013, while the number of trials has increased exponentially over the years, and many new trials have been published since then.
So begins a paper by Cuijpers et al.
Here’s what they did:
- “We searched PubMed, PsycINFO, Embase and the Cochrane Library to identify studies on CBT…” The search included studies up to 1 January 2022.
- “[W]e selected randomized controlled trials in which CBT for people with depression was compared with control conditions (care as usual, waitlist, others), other psychotherapies, pharmacotherapies, or combined treatment.”
- Several sub-sets were used, including for unguided self-help CBT.
- The meta-analyses were conducted using pooled effect sizes, calculated different ways.
Here’s what they found:
- 3,584 full-text papers were considered with 409 trials selected including 52,702 patients (27,000 in CBT and 25,702 in control groups).
- Demographics. Patients tended to be female (69.0%), with a mean age of 40.1; many were adults (39.1%).
- CBT versus control. “CBT had moderate to large effects compared to control conditions such as care as usual and waitlist (g=0.79…), which remained similar in sensitivity analyses and were still significant at 6-12 month follow-up.”
- CBT versus other psychotherapies. “CBT was significantly more effective than other psychotherapies, but the difference was small (g=0.06…) and became non-significant in most sensitivity analyses.”
- CBT versus pharmacotherapies and combined treatment. “Combined treatment was more effective than pharmacotherapies alone at the short (g=0.51…) and long term (g=0.32…), but it was not more effective than CBT alone at either time point.”
- On the quality of the literature. “The quality of the trials was found to have increased significantly over time (with increasing numbers of trials with low risk of bias, less waitlist control groups, and larger sample sizes).”
A few thoughts:
1. Wow. This is a major study in an important journal.
2. Our summary here doesn’t capture the detail and nuance of this meta-analysis paper.
3. The main finding in a sentence: CBT had a moderate to large effect size. To put that in perspective: “A total of 42% of patients receiving CBT responded to treatment, while the response rate was only 19% in control groups, with a NNT of 4.7 in favor of CBT. The remission rate was 36% in patients receiving CBT, compared to 15% in control conditions, with a NNT of 3.6.”
4. The results aren’t exactly surprising as this study supports past work in the area. From a clinical perspective, it provides clinicians with even more evidence to discuss psychotherapy.
5. What do the findings say about current controversies? Controversy 1: CBT is the superior psychotherapy. Maybe, maybe not, but CBT is effective. Controversy 2: CBT bests medications. Yes. Controversy 3: CBT in combination with meds get better outcomes. Maybe not. Controversy 4: Self-help works. Yes.
6. Of course, this paper’s great strength – pulling together so many studies covering different populations – is its great weakness in that it provides a big but crude view.
The full World Psychiatry paper can be found here:
Selection 2: “The need for a new generation of digital mental health tools to support more accessible, effective and equitable care”
John Torous, Keris Myrick, Adrian Aguilera
World Psychiatry, February 2023
The potential of digital mental health to increase access to and quality of care has gained traction with the rise of smartphones and accelerated with the spread of telehealth during the COVID-19 pandemic. With at least 80% of the global population now owning a device able to capture digital phenotyping signals, analyze data, and run mental health apps, excitement about the imminent arrival of personalized, preventive and precision psychiatry is understandable.
Yet, by nearly all outcome metrics, digital mental health is not transforming care. Whether measured in global trends of deaths from suicide or rising rates of depression, especially among younger people who are often the first to use digital tools, it is clear that the proclaimed paradigm shift is paused. The very people who require mental health care the most, underserved populations, have not experienced a rise in access or boon in outcomes, and the burden of mental illness in low- and middle-income countries remains as high as ever.
So begins a new Editorial by Torous et al.
Why haven’t digital mental health tools transformed care? “As smartphone penetration has accelerated in all countries around the world, blaming the digital divide on a lack of access to devices has become untenable. This narrative now covers lack of Internet access, especially in rural areas. While this is indeed a barrier still requiring work today, it is one that can and will probably be quickly addressed. But, behind access to the Internet, lies a more challenging first inequity – that concerning digital self-determination.”
They write: “Just as self-determination theory highlights the need for autonomy, competence and connection for psychological thriving, the same is necessary for any digital mental health tools, be they anything from smartphone apps to virtual reality headsets.”
The authors focus on three areas.
“A leading reason why people often say ‘no’ is that today digital mental health tools have privacy practices compounded by limited evidence of efficacy. One of the clearest examples of inequity is the lack of privacy offered by most mental health apps. A report by the Mozilla Foundation in March 2022 highlighted ongoing privacy risks among well-known mental health apps. Around the same time in 2022, the suicide hotline service Crisis Textline agreed to stop sharing users’ text messages with an outside company after public outcry…”
“[D]espite bold claims of efficacy on their websites, most studies in the mental health field do not recruit or sample from the patients with the highest unmet health care needs. This clear lack of representativeness may explain why many digital technologies fail to offer impressive results in the real world when deployed outside clinical trial conditions. Digital mental health tools need not be perceived as second-class treatments to be utilized when a clinician is not available, but should strive for excellence that exceeds current standards of care.”
“The full potential of remote monitoring innovations, such as digital phenotyping and wearable sensors, as well as digital behavioral interventions, can only be realized when these are well integrated into care and treatment plans. That means that apps, devices and programs must transfer data to and from electronic medical records and that health workers and their workflow must be part of the design process… Yet, less than 25% of apps today even allow such interoperability, and, when supported at one major academic hospital, only 1% of people chose to link their app to their electronic health record…”
A few thoughts:
1. This is a well written and argued Editorial.
2. They do a good job of weighing the great potential and not-so-great reality of digital mental health.
3. Of course, things are evolving very quickly. The technological advances that allow ChatGPT to generate clever poetry may soon translate into excellent (if non-human) therapy.
The full World Psychiatry Editorial can be found here:
Selection 3: “Physician-as-Patient—Vulnerabilities and Strengths”
JAMA, 20 December 2022
The late afternoon sun reached deep into the preoperative holding area. On call days like this one, the floor-to-ceiling windows that wrapped around the surgical suite provided a visual respite. Even on the most demanding days, one could at least gaze out onto the serene celestial landscape where pillowy clouds floated by bathed in the pinkish light of the disappearing day.
On such an afternoon, with an evening of call looming and the staff dwindling, my left hand absently fiddled with the rose quartz bead of my necklace as I rearranged the evening operating room assignments. As my fingertips grazed my clavicle, they were startled by the peculiar sensation of a firm, marble-like structure.
So begins an essay by Dr. Castro-Frenzel.
She talks about the testing and then the phone call: “Immediately after anesthetizing my first patient, my surgeon called to tell me I had advanced stage lung cancer – ‘Does anyone, other than a doctor, receive a terminal diagnosis while working?’”
Though she had assumed she would die after two years, it’s now been four years. She notes that “physicians are… uniquely positioned to act as the greatest adversaries to our own patient-selves.” Still, she takes a more nuanced view: “physicians possess distinct strengths and vulnerabilities when we become patients.”
She discusses the vulnerabilities. “Shame is common among physicians-as-patients. We might wonder if we contributed to the illness by something we did or failed to do. Yet when the cloak of responsibility is wound so tightly, we may struggle to recognize when something is not our fault. Because the core work of medicine is to restore health, and indeed this is the public role we serve in our communities, physicians may feel embarrassment or guilt, as if they are not allowed to experience illness.” She notes the need to recognize these vulnerabilities. “Fostering an awareness of the vulnerabilities physicians might face both as patients themselves and as physicians treating physicians-as-patients might help future physicians facing serious illness. At any moment, we can become patients.”
But she also notes strengths. “The thought of becoming a patient does not immediately conjure images of strength, but physicians are, in fact, among the most resilient patients. High intelligence and a working knowledge of the medical system also benefit the physician-as-patient. Not only are diseases and their treatments more comprehensible, but physicians can share their understanding with lay members of support groups who might otherwise struggle to understand treatment options.”
She writes about the support she has received. “I discovered the best of my colleagues when I revealed my diagnosis. Their faith in me is what saved me from despair, restored hope, and ultimately rebuilt the faith I needed to live with terminal cancer. I saw how they cared for me and felt how much they loved me…”
A few thoughts:
1. This is a beautiful essay.
2. Every physician should read it.
3. “Physicians are… uniquely positioned to act as the greatest adversaries to our own patient-selves.” That comment is true for those of us who struggle with cancer – or depression or substance or even burnout.
The full JAMA paper by found here:
Reading of the Week. Every week I pick articles and papers from the world of Psychiatry.