Keywords
psychotherapy, cognitive-behavioral therapy (CBT), outcome studies, blinding, clinical trials
psychotherapy, cognitive-behavioral therapy (CBT), outcome studies, blinding, clinical trials
The validity of cognitive-behavioral therapy (CBT) efficacy for major depressive disorder (MDD) is widely accepted and is based largely on clinical intervention studies of CBT in MDD. However, clinical trials for CBT cannot be carried out under double-blind conditions as would be required of pharmacotherapy (or other somatic therapies), thus the rigor of CBT interventional studies is quite different from those modalities that can be studied under double-blinded conditions1,2.
Treatment allocation cannot be blinded in CBT studies because the subjects have to actively participate in cognitive restructuring tasks. More than just saying a study was “blinded”, absolute concealment of what treatment was allocated is crucial in order to avoid bias3.
CBT trials are sometimes stated to be, “single-blind” because the persons who rate the symptoms that subjects report are blind to the treatment allocation of the subject. The term “single-blind”, however, should be used with caution as single-blind is defined as the condition when subjects are blind, not the raters4. Blind (or “masked”) raters only record whatever bias may be in the subjective reports of the subjects that can be swayed by the unblinded conditions. Emphasizing that raters are blind in a CBT study can distract from the issue that subjects and treaters are not blind.
Allocation concealment is crucial for indications with subjective outcomes as in MDD3. During a clinical trial, subjects with MDD report changes in the severity of subjective depressive symptoms that may be influenced by an expectation or hope for improvement3. Only interventional studies for indications with objective endpoints can ignore potential bias from lack of blinding. For example, mortality rates, MI incidence, stroke, etc. where random error is small1. In this line, a meta analysis of CBT trials that controlled for blinding found treatment effects to be small in MDD5.
However, studies continue to report positive results of unblinded trials without voicing strong caution on the validity of the results. Hollon et al. in the October 2014 issue of JAMA Psychiatry compared an antidepressant medication only arm with a combined cognitive therapy/antidepressant arm6. All the subjects who received antidepressants did so under unblinded conditions. The cognitive therapy subjects and their treaters were also unblind to the treatment given. The study concluded that the cognitive therapy/antidepressant combination enhanced the rate of recovery compared with antidepressant alone, and that the magnitude of this increment nearly doubled for patients with more severe depression with little evidence of benefit for patients with less severe MDD. Only one line at the end of the discussion noted that the unblinded conditions could be a limitation.
An alternative conclusion could just as easily be that patients with greater severity MDD may have included more patients with a medication-responsive depression7. For those subjects with greater severity, there could have been both antidepressant efficacy as well as more hope and expectation in the group who knew they had received combined cognitive therapy/medication leading to an erroneous conclusion of greater efficacy for the combined group. A large sample size (N) as in this study is not necessarily a sign of robust results. A large N can create a significant finding on statistical testing as a small amount of bias in the subjects adds-up1. Our alternative conclusion may also be incorrect, the important issue is that the lack of allocation concealment in the study design does not allow any valid conclusion to be made either way. The antidepressant in each arm of the study provides the same amount of hope and expectation; the CBT arm has the added potential for bias from hope and expectation.
In addition, combining and comparing antidepressants that have market approval based on double-blinded placebo controlled outcome research with CBT, heretofore never studied under double-, or single-blinded conditions, in the same unblinded study is a serious problem. Handicapping one intervention group (antidepressants without the double-blinded placebo control needed for proof of efficacy), while providing advantage to another intervention group (unblinded CBT with no psychotherapy placebo which allows bias in one arm) which is then mixed with the handicapped group, confounds the study conditions and invalidates the design logic of a clinical trial.
To be sure, interventional studies for somatic therapies such as medications may also have elements of allocation non-concealment requiring caution in their interpretation. While medications can feasibly be blinded, side-effects may expose a subject to the fact that they are in the active-drug arm of a study. An exit analysis on the proportion of subjects in a study that correctly guessed the treatment arm they were in should be done, and the results of any study in an indication with subjective endpoints such as MDD that has evidence of unblinding should be suspect to have bias. Psychotherapy treatment, on the other hand, is virtually impossible to hide from the subject who is openly given the treatment. Whether medication, psychotherapy, or other intervention, no valid scientific assessment of efficacy can be made if a hurdle such as double-blinding in the study design of an indication with subjective endpoints is not rigorously implemented.
Authors must state clearly when an intervention cannot be studied with rigor, and conclusions need to be given with great caution when studies with subjective endpoints are unblinded. There is no regulatory authority like the FDA to review and approve a psychotherapeutic intervention for MDD, so that both professionals and society at large alike are dependent on the sound-bite conclusions made by authors and commentators on the results reported.
The critical problem of the inability to double-blind CBT clinical trials for MDD requires further evaluation by research groups who do not have a vested interest in CBT or related therapies. The validity of CBT (and its derivatives such as dialectical behavioral therapy) for indications other than MDD is part of a larger problem in the inability to blind outcome for these interventions.
No competing interests were disclosed. The author has no financial interests, activities, relationships, and affiliations other than those affiliations listed in the title page of the manuscript. There was no data collected or analyzed for this paper.
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References
1. Khan A, Faucett J, Lichtenberg P, Kirsch I, et al.: A systematic review of comparative efficacy of treatments and controls for depression.PLoS One. 2012; 7 (7): e41778 PubMed Abstract | Publisher Full TextCompeting Interests: No competing interests were disclosed.
Competing Interests: No competing interests were disclosed.
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We noticed that Dr. Hollon is actually one of the authors of the paper we quoted from ... Continue reading Directive psychotherapies are not more effective than non-directive psychotherapies when controlled for researcher allegiance.
We noticed that Dr. Hollon is actually one of the authors of the paper we quoted from 2012, that concluded that directive psychotherapies were not more effective than non-directive psychotherapies when controlled for researcher allegiance, and that the majority of the effect of therapy for adult depression is realized by non-specific factors[ref-1].
This is the abstract of this paper [our bolding]:
“The effects of non-directive supportive therapy (NDST) for adult depression have been examined in a considerable number of studies, but no meta-analysis of these studies has been conducted. We selected 31 studies on NDST from a comprehensive database of trials, examining psychotherapies for adult depression, and conducted meta-analyses in which NDST was compared with control groups, other psychotherapies and pharmacotherapy. We found that NDST is effective in the treatment of depression in adults (g = 0.58; 95% CI: 0.45–0.72). NDST was less effective than other psychological treatments (differential effect size g = − 0.20; 95% CI: − 0.32 to − 0.08, p < 0.01), but these differences were no longer present after controlling for researcher allegiance. We estimated that extra-therapeutic factors (those processes operating in waiting-list and care-as-usual controls) were responsible for 33.3% of the overall improvement, non-specific factors (the effects of NDST compared with control groups) for 49.6%, and specific factors (the effects of NDST compared with other therapies) for 17.1%. NDST has a considerable effect on symptoms of depression. Most of the effect of therapy for adult depression is realized by non-specific factors, and our results suggest that the contribution of specific effects is limited at best.”
Although Hollon and his coauthors are admitting in the above paper that the unblinded nature of therapists who have some allegiance to the therapy they are trained in can be the cause of positive findings, Hollon et al. now opine in their comment to us that blinding is not important for validation of CT efficacy, and that CT is superior to non-directive supportive therapies by referencing papers published the following year in 2013.[ref-2],[ref-3]
We are not sure why/how Dr. Hollon views these spins of his own conclusions over this short period of one year, nor how Dr. Hollon can state that psychotherapy studies do not require double-blinding to filter out bias.
We also noted Parker, et al.[ref-4] did a systematic literature search and could not find evidence that CBT was distinctively superior than other psychotherapies for major depression.
However, regardless of the issue of directiveness of a therapy, there is no way to get around the problem of not being able to blind the subjects or the treaters in any psychotherapy trial, directive or not.
That researcher allegiance is a cause of bias as concluded by a paper by Dr. Hollon himself, it is clear that conclusions must be seriously tempered in CBT trials where neither subjects nor treaters can be blinded, and where the majority of treaters trained in CBT would likely believe in CBT if they continued to be providers of this treatment.
[References]
[[1|title=The efficacy of non-directive supportive therapy for adult depression: A meta-analysis|authors=Cuijpers/P;Driessen/E;Hollon/SD;van Oppen/P;Barth/J;Andersson/G|source=Clin Psychol Rev.|vol=32|issue=4|year=2012|fpage=280|lpage=291|type=journal|doi=10.1016/j.cpr.2012.01.003|pmid=22466509|url=http://www.ncbi.nlm.nih.gov/pubmed/22466509]]
[[2|title=Comparative efficacy of seven psychotherapeutic interventions for patients with depression: a network meta-analysis|authors=Barth/J;Munder/T;Gerger/H;Nüesch/E;Trelle/S;Znoj/H;Jüni/P;Cuijpers/P|source=PLoS Med|vol=10|issue=5|year=2013|fpage=e1001454|type=journal|doi=10.1371/journal.pmed.1001454|pmid=23723742|pmcid=PMC3665892|url=http://www.ncbi.nlm.nih.gov/pubmed/23723742]]
[[3|title=Comparing bona fide psychotherapies of depression in adults with two meta-analytical approaches|authors= Braun/SR;Gregor/B;Tran/US|source=PLoS One|vol=8|issue=6|year=2013|fpage=e68135|type=journal|doi=10.1371/journal.pone.0068135|pmid=23840824|pmcid=PMC3695954|url=http://www.ncbi.nlm.nih.gov/pubmed/?term=Comparing+bona+fide+psychotherapies+of+depression+in+adults+with+two+meta-analytical+approaches]]
[[4|title=Treating depression with the evidence-based psychotherapies: a critique of the evidence|authors=Parker/G;Fletcher/K|source=Acta Psychiatr Scand|vol=115|issue=5|year=2007|fpage=352|lpage=359|type=journal||pmid=17430412|url=http://www.ncbi.nlm.nih.gov/pubmed/17430412]]
We noticed that Dr. Hollon is actually one of the authors of the paper we quoted from 2012, that concluded that directive psychotherapies were not more effective than non-directive psychotherapies when controlled for researcher allegiance, and that the majority of the effect of therapy for adult depression is realized by non-specific factors1.
This is the abstract of this paper [our bolding]:
“The effects of non-directive supportive therapy (NDST) for adult depression have been examined in a considerable number of studies, but no meta-analysis of these studies has been conducted. We selected 31 studies on NDST from a comprehensive database of trials, examining psychotherapies for adult depression, and conducted meta-analyses in which NDST was compared with control groups, other psychotherapies and pharmacotherapy. We found that NDST is effective in the treatment of depression in adults (g = 0.58; 95% CI: 0.45–0.72). NDST was less effective than other psychological treatments (differential effect size g = − 0.20; 95% CI: − 0.32 to − 0.08, p < 0.01), but these differences were no longer present after controlling for researcher allegiance. We estimated that extra-therapeutic factors (those processes operating in waiting-list and care-as-usual controls) were responsible for 33.3% of the overall improvement, non-specific factors (the effects of NDST compared with control groups) for 49.6%, and specific factors (the effects of NDST compared with other therapies) for 17.1%. NDST has a considerable effect on symptoms of depression. Most of the effect of therapy for adult depression is realized by non-specific factors, and our results suggest that the contribution of specific effects is limited at best.”
Although Hollon and his coauthors are admitting in the above paper that the unblinded nature of therapists who have some allegiance to the therapy they are trained in can be the cause of positive findings, Hollon et al. now opine in their comment to us that blinding is not important for validation of CT efficacy, and that CT is superior to non-directive supportive therapies by referencing papers published the following year in 2013.2,3
We are not sure why/how Dr. Hollon views these spins of his own conclusions over this short period of one year, nor how Dr. Hollon can state that psychotherapy studies do not require double-blinding to filter out bias.
We also noted Parker, et al.4 did a systematic literature search and could not find evidence that CBT was distinctively superior than other psychotherapies for major depression.
However, regardless of the issue of directiveness of a therapy, there is no way to get around the problem of not being able to blind the subjects or the treaters in any psychotherapy trial, directive or not.
That researcher allegiance is a cause of bias as concluded by a paper by Dr. Hollon himself, it is clear that conclusions must be seriously tempered in CBT trials where neither subjects nor treaters can be blinded, and where the majority of treaters trained in CBT would likely believe in CBT if they continued to be providers of this treatment.
References
1. Cuijpers P, Driessen E, Hollon SD, van Oppen P, et al.: The efficacy of non-directive supportive therapy for adult depression: A meta-analysis. Clin Psychol Rev.2012; 32 (4): 280-291 PubMed Abstract | Publisher Full Text | Reference Source
2. Barth J, Munder T, Gerger H, Nüesch E, et al.: Comparative efficacy of seven psychotherapeutic interventions for patients with depression: a network meta-analysis. PLoS Med. 2013; 10 (5): e1001454 PubMed Abstract | Free Full Text | Publisher Full Text | Reference Source
3. Braun SR, Gregor B, Tran US: Comparing bona fide psychotherapies of depression in adults with two meta-analytical approaches. PLoS One. 2013; 8 (6): e68135 PubMed Abstract | Free Full Text | Publisher Full Text | Reference Source
4. Parker G, Fletcher K: Treating depression with the evidence-based psychotherapies: a critique of the evidence. Acta Psychiatr Scand. 2007; 115 (5): 352-359 PubMed Abstract | Reference Source