Major Review Finds Limited Effectiveness for Medication and Therapy

Most mental health treatments are marginally better than placebo; therapy for OCD seems to be the exception.

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A new study aimed to assess the efficacy of medication, therapy, and combined treatments. The researchers analyzed data from thousands of studies across a comprehensive range of psychiatric disorders. They found that both medication and therapy had limited efficacy in treating these problems.

The researchers write, “Across disorders and treatments, the majority of effect sizes for target symptoms were small.”

The only treatment with a large effect size was psychotherapy for OCD.

The study was published in World Psychiatry. The researchers included renowned Stanford statistician and methodologist John Ioannidis, who, in his influential paper “Why Most Published Research Findings Are False,” found that “for most study designs and settings, it is more likely for a research claim to be false than true.”

Female psychologist consulting pensive man during psychological therapy sessionAccording to the researchers, biases in the psychiatric research literature could lead to an overestimation of treatment efficacy. For instance, a treatment that is just marginally better than a placebo might meet the criteria for statistical significance while failing to be clinically significant. Publication bias and other problems can inflate this problem further. Positive findings are much more likely to be published. When researchers find that a treatment is ineffective, their study may never see the light of day.

For that reason, the current study focused on effect size, which measures how effective a treatment is, rather than just signifying whether it is effective or not effective.

The researchers describe the data that was included in their study: “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.”

They focused on studies that compared medication or therapy with placebo or treatment as usual (TAU). They did not include studies that used a waiting list comparator since this can artificially inflate effect sizes. They also assessed the risk of bias in the included studies, which is often ignored in other meta-analyses.

Their analysis found that, on average, psychotherapy had an effect size of 0.34, and medication had an effect size of 0.36 when compared with placebo or TAU. They note that this is considered a small effect.

When comparing therapy with medication, the researchers found that their efficacy was about the same (no statistically significant difference). Combined treatment (therapy plus medication) had an effect size of 0.31 above monotherapy.

To put these effect sizes in context: The researchers suggest that for depression, an effect size of 0.88 is needed before the improvement would be clinically noticeable. For schizophrenia, an effect size of 0.73 is required.

There were some exceptions. Cognitive-behavioral therapy (CBT) for OCD had a large effect size, reaching 1.03. However, most patients were also taking medication, so this could be considered a combined treatment.

Medication alone for OCD had a medium effect size (0.56), as did CBT for PTSD (0.54) and therapy for borderline personality disorder (0.57), although this last relied on a single meta-analysis with a high risk of bias.

Another interesting exception was that CBT was far better than medication for PTSD (effect size 0.83, considered a large effect).

One compelling negative finding was that antipsychotic drugs were not very effective at treating schizophrenia. The researchers write, “For the acute treatment of schizophrenia with pharmacotherapy, differences in response rates in comparison with placebo were small (23% vs. 14%).”

In many cases, specific drugs were found to decrease specific aspects or symptoms but did not have much of an effect on the overall diagnosis. These findings were also often based on a few studies with a high risk of bias, so they may not be reliable.

The researchers also found that the included meta-analyses had a high risk of bias. Forty-eight percent of the meta-analyses failed to account for bias, and 47% failed to register their studies. This was true for both medication studies and therapy studies.

They also note that most of the included studies were short-term and that data on long-term efficacy is lacking.

In conclusion, they write,

“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.”

 

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Leichsenring, F., Steinert, C., Rabung, S., & Ioannidis, J. P. A. (2022). The efficacy of psychotherapies and pharmacotherapies for mental disorders in adults: An umbrella review and meta-analytic evaluation of recent meta-analyses. World Psychiatry, 21, 133–145 (Link)

9 COMMENTS

  1. THERE ARE:- Other Options that work successfully even with “Schizophrenia” and “Bipolar”and “everything else”. It’s just a question of finding one that suits.

    Psychologist Dr Rufus May (labelled with “Schizophrenia” as a youngster) has some very good ideas:-
    http://compassionatementalhealth.co.uk/speaker/rufus_may

    Twelve Step Fellowship
    Has as a very good track record of success.
    It’s for free and it works.

    The Hearing Voices Network
    Has proven success with the (so called) strongest “Schizophrenic” Association.
    It’s for free and it works.

    GROW Peer Group welcomes people from all backgrounds and has success with ALL the Big Diagnoses. One of the members conducted a PHD on this:-
    https://youtu.be/g08yo4Phwic
    It’s for free and it works.

    The “Power of Now” by Eckhart Tolle ,
    contains brilliant advice that I believe can free people from terrible mental suffering.
    https://youtu.be/Fzj7R9IB48s
    It’s for Free and it Works

    The Buddhist Approach worked for me in successfully withdrawing from “Schizophrenic Medication”. I also engaged in the other methods mentioned.

    • CBT though it might have a ‘bad name’ in terms of commodification, has similarities with Buddist Philosophy. My Recovery wasn’t a short process but I could see light at the end of the tunnel, even at the start.

      Drug Withdrawal “High Anxiety”, as described by Robert Whitaker, nearly disabled me; but I was able to get a picture of how my Anxiety worked and to do something about it. During this process I suffered from “Catastrophisation” and “Emotional Reasoning” which are perfect human descriptions.

      The medical explanation I believe, for Withdrawal “High Anxiety” is that during medicating “the brain” becomes more sensitive, and when medication is withdrawn the person can as a result, become overwhelmed and breakdown.

      Naturally, it can take time for a persons Head to balance off.

        • It is also often a gross oversimplification. Yes, thinking about your mother having abandoned you IS painful, and it IS over, and you are not benefiting yourself by thinking about it over and over. But there are reasons why we are attracted to events in the past that are painful – we are still looking for some compassionate person to step in and make it RIGHT. And telling a person, “Just think of something else” when there is that much emotional charge on an event, be it fear, anger, grief, apathy, confusion, or whatever, is often counterproductive, leaving the client feeling like a failure for continuing to think “wrong thoughts” and feeling blamed for having “reacted badly” to the very real trauma they experienced. It also adds insult to injury if the “counselor” tells the client which feelings/thoughts need to be changed and/or what they need to tell themselves to change them.

          I certainly used CBT techniques when I used to be a counselor, but only at times when the client appeared to be able to process the past experiences attached first, or was dealing with fairly recent material. I would never try to ‘change the thinking’ of a person to the thoughts I believed they should have, nor would I ever blame their suffering on their own need to process harmful things that happened to them before being able to ‘let go’ of thoughts and feelings they may at one time have felt essential for their survival.

          Nobody should do CBT as a primary therapy approach in my book. It’s a set of techniques that have their place when carefully applied, but therapy had better be a whole lot more than that if you want your client to get anywhere close to where they want to go.

          • Well I don’t think CBT (when done well) is about convincing the person to simply think of something else, rather it’s coming up with alternative explanations which relieve suffering while also being plausible enough to be intellectually satisfying (i.e., not “oh they just did out of love”, etc.)

          • That is true, it should not be. Yet that is all too often what is on offer. My point is that it has to be done in the context of a bigger process of self-discovery. How to create a scenario which is “intellectually satisfying” is, indeed, the challenge. For some, it’s pretty natural, for others, it is quite a foreign concept and a lot of processing needs to happen before this is a reality to them. For others, it simply doesn’t work very well. I think a good therapist has a wide range of tools available, and CBT should just be one of them, and “tool selection” should be based on the needs of the client, not the need of the therapist to feel superior or skilled or whatever their needs may be.

  2. In this large, meta-analytic study of medication and therapy I think we have a good understanding of the medication side (e.g., antidepressants, antipsychotics, etc.) but what was the variable “therapy”? For example, is a Ph.D. psychologist with a CBT orientation to treatment the same or equivalent to a nurse doing CBT (after attending two workshops on CBT) or a counselor with two years of graduate education doing CBT? I don’t think so. In my 5 year doctoral program in clinical as well as other branches of psychology the first two years consist exclusively in the study of normal human behavior, which I think is necessary for those who want to go on to diagnosing and treating the full range of the mental disorders. I would like to see some sound efficacy research on medication vs. well trained psychotherapists.

    • Eh, I still think you’re talking about rearranging deck chairs on the Titanic. “Effectiveness” is a very problematic term when your “diagnoses” are voted on by committees and there is no objective way to create any kind of legitimate study groupings. Beyond that, the concept of a treatment “working” requires some agreement on desired outcomes, and no such agreement exists in psychiatry/psychology, nor probably ever can or will. For instance, is the goal of working with an “ADHD” child to make them “less hyperactive, distractible, impulsive?” If so, then stimulants seem to “work” pretty well. But if the goal is to have them become more academically competent, stimulants are a complete bust, may actually make things worse in some cases. So what’s the goal? We all know that in practice, the goal is to make the kids more compliant (dosing studies bear this out in every case). Is that really a legitimate measure of “working?” If it is, gagging and tying someone to a chair would also be judged to “work.”

      Psychiatry has massive philosophical conflicts preventing it from successfully studying anything it its realm of interest. I don’t see that changing any time soon.

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