Absolute and relative outcomes of psychotherapies for eight mental disorders: a systematic review and meta‐analysis

Summary & key facts

Researchers pooled results from many clinical trials to see how often psychotherapy cuts symptoms by half or more for eight common mental disorders. They looked at 441 trials with about 34,000 people, comparing psychotherapies to things like waiting list, usual care, or a placebo pill. They found that therapy usually works better than those controls, but the share of people who got much better was modest: for example, about 42% with depression and about 38% with PTSD, OCD, or panic disorder had large improvements, while only about 24% with borderline personality disorder did. The main takeaway is that psychotherapy helps many people, but a lot of patients still do not get a strong benefit, so better or additional treatments are needed for those who don’t respond.

Key facts:

• The researchers combined results from 441 randomized trials that together included about 34,000 people.
• They measured response as a drop of at least half in symptoms between the start of treatment and the end of therapy.
• About 42% of people with major depression had that level of improvement after psychotherapy.
• Around 38% of people with PTSD, OCD, or panic disorder had large improvements after psychotherapy.
• About 36% of people with generalized anxiety disorder and about 32% with social anxiety or specific phobia had large improvements.
• Only about 24% of people with borderline personality disorder reached that level of symptom reduction.
• Psychotherapies were generally better than control conditions (like waitlist or usual care) for all disorders except borderline personality disorder, where the advantage was not clear.
• Most sensitivity checks of the data supported these overall results, but the authors say more effective treatments are still needed for people who don’t respond to first-line psychotherapy.

Abstract

Psychotherapies are first-line treatments for most mental disorders, but their absolute outcomes (i.e., response and remission rates) are not well studied, despite the relevance of such information for health care users, providers and policy makers. We aimed to examine absolute and relative outcomes of psychotherapies across eight mental disorders: major depressive disorder (MDD), social anxiety disorder, panic disorder, generalized anxiety disorder (GAD), specific phobia, post-traumatic stress disorder (PTSD), obsessive-compulsive disorder (OCD), and borderline personality disorder (BPD). We used a series of living systematic reviews included in the Metapsy initiative (www.metapsy.org), with a common strategy for literature search, inclusion of studies and extraction of data, and a common format for the analyses. Literature search was conducted in major bibliographical databases (PubMed, PsycINFO, Embase, and the Cochrane Register of Controlled Trials) up to January 1, 2023. We included randomized controlled trials comparing psychotherapies for any of the eight mental disorders, established by a diagnostic interview, with a control group (waitlist, care-as-usual, or pill placebo). We conducted random-effects model pairwise meta-analyses. The main outcome was the absolute rate of response (at least 50% symptom reduction between baseline and post-test) in the treatment and control conditions. Secondary outcomes included the relative risk (RR) of response, and the number needed to treat (NNT). Random-effects meta-analyses of the included 441 trials (33,881 patients) indicated modest response rates for psychotherapies: 0.42 (95% CI: 0.39-0.45) for MDD; 0.38 (95% CI: 0.33-0.43) for PTSD; 0.38 (95% CI: 0.30-0.47) for OCD; 0.38 (95% CI: 0.33-0.43) for panic disorder; 0.36 (95% CI: 0.30-0.42) for GAD; 0.32 (95% CI: 0.29-0.37) for social anxiety disorder; 0.32 (95% CI: 0.23-0.42) for specific phobia; and 0.24 (95% CI: 0.15-0.36) for BPD. Most sensitivity analyses broadly supported these findings. The RRs were significant for all disorders, except BPD. Our conclusion is that most psychotherapies for the eight mental disorders are effective compared with control conditions, but absolute response rates are modest. More effective treatments and interventions for those not responding to a first-line treatment are needed.

Topics

Anxiety, Depression, Psychometrics, Treatment, Cognitive Processes Psychosomatic Disorders and Their Treatments Treatment of Major Depression

Categories

Health Sciences Medicine Pharmacology

Tags

Agoraphobia Anxiety Borderline personality disorder Clinical psychology Confidence interval Internal medicine Law Major depressive disorder Medicine MEDLINE Mental health Meta-analysis Mood Number needed to treat Panic disorder Political science Psychiatry Psychology PsycINFO Randomized controlled trial Relative risk Systematic review

Conditions & symptoms

Anxiety Depression Obsessive-Compulsive Disorder Panic disorder and phobias PTSD Anxiety or worry Panic Poor sleep Sadness or low mood