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Have psychotherapies been overhyped?

Professor David Nutt believes that psychological therapies lack the evidence base required for licensing drugs and carry hidden risks. But his views are opposed by NICE advisor Dr Stephen Pilling, who insists psychological therapies have been rigorously evaluated as safe and effective.

Professor David Nutt believes that psychological therapies lack the evidence base required for licensing drugs and carry hidden risks. But his views are opposed by NICE advisor Dr Stephen Pilling, who insists psychological therapies have been rigorously evaluated as safe and effective.

Yes

In recent years, there have been a series of attacks by the media and some doctors on the value and safety of antidepressants, especially SSRIs.

Underpinning much of this seems to be the belief that any benefits of these drugs can readily be achieved by non-pharmacological treatments such as counselling or psychotherapy, and that such treatments would be safer.

National surveys have shown the general public shares these opinions. During the Defeat Depression Campaign, most of those who said Yes to the question ‘is depression a brain disorder?' also said they would prefer psychotherapy to drug treatment.

But it is hard to say for certain whether psychotherapy is effective.

What is clear is that I know of no psychotherapy trial that meets the criteria currently necessary for a drug treatment to be licensed – evidence of efficacy from two multi-centre, double-blind, randomised placebo-controlled trials.

Most psychotherapy trials are compared against controls that get no treatment and are just left on a waiting list.

This maximises the apparent effect of interventions and leads to claims that the effect size for psychotherapy can be much bigger than for drug treatment.

Where the best form of psychotherapy, CBT, has been put head-to-head with antidepressants in the treatment of depression, it has barely been better than placebo, and less good than drug treatment1,2.

We can presume psychological interventions less founded in psychotherapy theory, such as non-specific counselling, would perform even less well. In many ways they equate to the placebo in antidepressant drug therapy studies.

But are psychotherapies safe? To many this will seem a bizarre question – how can talking harm anyone? On closer inspection, though, there are many hazards, often conveniently ignored.

A key issue is that of dependence on the therapist.

So many patients become dependent on their therapists that a large proportion of later sessions – up to one half – are used to help the patient disengage from treatment and minimise the distress this can cause.

There are examples of abrupt termination of psychotherapy precipitating suicide.

Psychotherapy can also promote suicide, by raising difficult and painful issues, or if therapists bully their patients.

The recent scare over suicidal ideation in adolescents with SSRIs has been shown to be a feature of measurement of mood, and is also seen in a psychotherapy trial for depression3.

Psychotherapy can even exacerbate symptoms in anxiety disorders, leaving patients worse off than they were before

Hidden danger

Another hidden danger of psychotherapy is that of sexual abuse by the therapist.

Each year a few doctors are struck off for inappropriate relations with patients, and the incidence of this is higher for therapists who are not subject to strict regulation.

We can imagine the prevalence of such abuse is grossly under-reported – anonymous surveys of therapists have revealed up to 40% admitting to sex with patients4.

I have argued elsewhere that the frequency of such damaging interactions is such that if a drug had similarly severe adverse effects it would probably be taken off the market.

Moreover, there is no way for patients to record these adverse effects – hence my suggestion of a Pink Card scheme to mirror the Yellow Card scheme for drug therapy4.

Most of the support for psychotherapy is based on a mixture of the desire for it to work and the false supposition that it does. It is doubtful if any form of psychotherapy has yet fulfilled the stringent criteria required for licensing drug treatments.

We must currently assume it is at best a form of placebo, albeit one with high patient satisfaction. But psychotherapy is not inevitably safe and doctors must be vigilant that their patients are not suffering through ineffective treatment or abuse.

Professor Nutt is professor of psychopharmacology at the University of Bristol and a former member of the Committee on Safety of Medicines

No

David Nutt is right that the simplistic presentation of the evidence for SSRIs in the media is unhelpful, often ill-informed and partial in its coverage of the evidence.

Fortunately this has not been the case with the evidence underpinning expansion of psychotherapies in the Government's Improving Access to Psychological Therapies (IAPT) programme.

The evidence points to real benefits and draws on NICE guidelines for depression and anxiety, which have identified a range of effective psychological as well as pharmacological interventions.

NICE and IAPT provide the evidence, and for the first time the proper resources, for provision of psychological therapies. This has to be welcomed by all interested in the effective treatment of mental disorders.

The methods used by NICE are robust and subject to wide consultation (including with the pharmaceutical industry). In many ways the criteria are more stringent than those adopted by drug licensing bodies (NICE recommendations rarely rely on just two trials).

David Nutt is simply incorrect when he asserts that no psychotherapy trial meets the criterion of two randomised trials showing superiority to placebo (or even better than active treatments).

High-quality randomised clinical trials in depression and anxiety have established the superior efficacy of psychological treatments (predominantly CBT).

Routinely, the assessors in such studies are blind to treatment allocation. Naturally, the therapists know which treatment they are delivering – it is difficult to see how it could be otherwise!

Going beyond placebo, trials have established equivalence to medication in depression. More importantly, the psychotherapies recommended by NICE and IAPT have demonstrated two other key attributes.

First, they have been shown to be superior to other active psychological treatments – CBT is more effective than counselling or relaxation in treatment of post-traumatic stress disorder, obsessive-compulsive disorder, panic disorder and social phobia.

Secondly, psychotherapy trials are typically of longer duration than many purely pharmacological trials and so there is evidence of long-term outcomes.

These trials show enduring benefits for psychological interventions not found for drugs; for example, CBT reduces the risk symptoms will return after terminating treatment in depression, panic disorder, social phobia and OCD.

The evidence also shows some patients, often the severely depressed, benefit by combining psychological therapies and medications.

Professor Nutt is right to raise concerns about the possible harms associated with psychotherapies.

Use of inappropriate treatments, both psychological and pharmacological, can do harm. Single-session debriefing for PTSD may well be harmful, and so will not feature in IAPT.

Inadequately delivered treatments (be they psychological or pharmacological) may at best provide no benefit, but could do harm.

Rigorous assessment

IAPT explicitly addresses this risk with an extensive training programme focused on rigorous assessment of clinical outcomes using standardised measures of symptoms every session (unusual in drug treatment).

As for dependency, its management is not a central feature of therapies recommended by IAPT, no doubt because the collaborative approach that characterises effective treatments renders it unnecessary.

Sexual abuse of patients is a risk but not one that remotely approaches 40%, nor is this risk confined to psychological therapies. Again, IAPT supports a rigorous approach to supervision that should ensure the risk of harm to patients is significantly reduced.

Let us move beyond rhetoric and focus on delivering an effective evidence-based programme of psychological treatments that complements pharmacological interventions, is delivered by competent professionals, is rigorously evaluated and offers real choice to patients.

Dr Pilling is joint director of the National Collaborating Centre for Mental Health and a consultant clinical psychologist based at University College London

Depression David Nutt

Most support for psychotherapy is based on a desire for it to work

Stephen Pilling

Psychotherapy trials show enduring benefits not found in drugs

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