Elsevier

Clinical Psychology Review

Volume 31, Issue 8, December 2011, Pages 1304-1312
Clinical Psychology Review

Evidence-based treatments for depression and anxiety versus treatment-as-usual: A meta-analysis of direct comparisons

https://doi.org/10.1016/j.cpr.2011.07.012Get rights and content

Abstract

Objective

The aim of this study was to examine the relative efficacy of evidence-based treatments (EBTs) versus treatment-as-usual (TAU) in routine care for anxiety and depression in adults.

Method

A computerized search of studies that directly compared an EBT with a TAU was conducted. Meta-analytic methods were used to estimate effectiveness of EBTs relative to TAU and to model how various confounding variables impacted the results of this comparative research.

Results

A total of 14 studies were included in the final meta-analysis. There was significant heterogeneity in the TAU conditions, which ranged from unknown and/or minimal mental health treatment to psychotherapeutic interventions provided by trained professionals. Although the effect for EBT vs. TAU was significantly greater than zero, the effect for EBT vs. TAUs that were psychotherapeutic interventions was not statistically different from zero.

Conclusions

Heterogeneity of TAU conditions in this meta-analysis highlight the importance of clarifying the research questions being asked when investigating and drawing conclusions from EBT–TAU comparisons. Researchers need to clarify if they are comparing an EBT to psychotherapeutic services in routine care or to minimal mental health services. Extant research on EBT versus TAU reveals that there is insufficient evidence to recommend the transportation of EBTs for anxiety and depression to routine care, particularly when the routine care involves psychotherapeutic services.

Highlights

► Compared evidence-based treatments and treatment-as-usual for anxiety and depression. ► Implementing evidence-based treatments could improve the quality of care. ► The definition of treatment-as-usual varies considerably. ► Evidence-based treatments are superior to treatment-as-usual without psychotherapy. ► Evidence-based treatments are not superior to psychotherapy services.

Introduction

Anxiety and depressive disorders are among the most common psychiatric diagnoses in the United States. Lifetime prevalence for Major Depressive Disorder (MDD) is 16.6%, resulting in an economic cost to society of roughly $83.1 billion (Greenberg et al., 2003, Kessler et al., 2005). Instead of being seen as an acute mental health concern, MDD is seen as a chronic disorder that is projected to be the second overall cause of disability by the year 2020 (Murray & Lopez, 1997). In addition, 28.8% of the general population has been diagnosed with an anxiety disorder at least once in their lifetime (Kessler et al., 2005). The total yearly economic burden of anxiety disorders is estimated to be around $46.6 billion (Rosenblatt, 2010).

In response to the pervasive nature of depression and anxiety in the general population, psychotherapy researchers have focused on identifying efficacious treatments for these disorders (Westen & Morrison, 2001). Over the past four decades, this emphasis has led to identification of Empirically Supported Treatments (ESTs), which was an official designation of Division 12 of the American Psychological Association's Task Force for the Promotion and Dissemination of Psychological Procedures (Chambless and Hollon, 1998, Task Force on Promotion and Dissemination of Psychological Procedures, 1995). The field has moved to “evidence-based treatments” (EBTs) to describe therapies that have been demonstrated to be efficacious in randomized clinical trials (RCTs), the design that is the “gold standard” for establishing the viability of a treatment (Westen, Novotny, & Thompson-Brenner, 2004). Several treatments for anxiety and depression have been identified as evidence-based, establishing the value of these treatments for anxiety and depression (e.g., Interpersonal Therapy for depression, Cognitive Behavioral Therapy for generalized anxiety disorder, and Prolonged Exposure for post traumatic stress disorder; see APA Division 12, Society of Clinical Psychology, website for a complete list, http://www.div12.org/PsychologicalTreatments/index.html).

Once efficacy of a treatment has been established in controlled settings (i.e., RCTs), the next logical step to improve the quality of care is to test the effect of the treatment on anxiety and depression in routine care. The primary method for investigating the effect of EBTs in naturalistic settings for anxiety and depression involves a direct comparison of EBTs with services that are currently being delivered in routine care, which are often referred to as treatment-as-usual (TAU). Implementation of this strategy has resulted in mixed findings. On the one hand, for example, Meuser et al. (2008) compared cognitive behavioral treatment (CBT) with TAU for PTSD and found that patients in the CBT condition improved more than patients in TAU. Similarly, Grote et al. (2009) found that EBT outperformed TAU for the treatment of depression. In contrast, Cuijpers, van Lier, van Straten, and Donker (2005) directly compared CBT to TAU for depressed patients and concluded, “On average, patients in both test conditions improved significantly from baseline to posttest, and no significant difference was found between the conditions” (p. 137). These contradictory findings may be attributable to sampling error or systematic differences between studies (e.g., levels of training, supervision, treatment dose, type or nature of the TAU; see Spielmans, Gatlin, & McFall, 2010 for a discussion in the youth treatment literature).

One well-established method of synthesizing seemingly inconsistent results from a corpus of studies is meta-analysis (Cooper et al., 2009, Hunt, 1997, Mann, 1994) Recently, Weisz, Jensen-Doss, and Hawley (2006) conducted a meta-analysis in which EBTs and TAU were directly compared for child and adolescent populations. Their findings indicated that EBTs were more effective than TAU, but they noted aspects of the research design that posed significant confounds: “EBT descriptions were significantly more likely than [TAU] descriptions to note the use of pretherapy training, treatment manuals, and adherence checks” (p. 681). Moreover, several studies in the meta-analysis included EBT therapists who had specialized training and expertise (e.g., trained extensively in the EBT for particular disorders or had training about the disorder itself) vis-à-vis the TAU therapists who received no training. In addition, the heterogeneity of TAU conditions was problematic:

We considered studies in which participants received medications in addition to therapy, studies in which the EBT was administered in addition to UC [usual care, which is used synonymously with TAU], studies in which a psychotherapy placebo was administered in addition to UC, and studies in which UC involved case management services (e.g., probation and referral) that may or may not have included significant doses of psychotherapy (Weisz et al., 2006, p. 683).

To model the confounds noted in Weisz et al., 2006, Spielmans et al., 2010 conducted a replication of the Weisz et al. meta-analysis and found that EBTs and TAU had similar outcomes when the confounds were controlled. Essentially, Spielmans et al. found that many design operations in the studies favored the EBT (e.g., a greater dose of therapy for EBT patients or supervision of EBT therapists only), which attenuated the magnitude of the effect.

Heterogeneity of TAU conditions in the Weisz et al. meta-analysis highlights the importance of clarifying the research questions being asked when investigating and drawing conclusions from EBT–TAU comparisons. Presumably, researchers are interested in two different research questions: (a) does the implementation of an EBT into existing mental health systems that are delivering psychotherapeutic services by trained professionals improve outcomes (psychotherapy TAU)? or (b) does the implementation of an EBT into existing mental health services, where little or no psychotherapy is provided, improve outcomes (non-psychotherapy TAU)?

A comparison of an EBT to a psychotherapy TAU delivered by mental health therapists with comparable training to the EBT therapists (psychotherapy TAU) provides evidence about the viability of transporting EBTs into existing mental health systems that deliver psychotherapy, whereas EBT–non-psychotherapy TAU comparisons do not. The latter comparison, that is, the comparison of an EBT with other types of services that do not involve psychotherapy (e.g., a referral to a primary care physician), provides evidence related to the question of whether instituting EBTs improves the quality of care of mental health services that do not provide psychotherapy. Consequently, the latter does not provide evidence about the viability of transporting EBTs into existing mental health systems that deliver psychotherapy. Interpretation of EBT–TAU comparisons requires an in-depth examination of the nature of the TAU to understand what conclusions can be drawn from the evidence.

The purpose of the present study was to examine the relative efficacy of EBTs when compared to TAU for anxiety and depression in adults, while examining possible confounds, including the type of services provided in the TAU (i.e., the proximity of the TAU to psychotherapeutic interventions). We hypothesized that EBT would be superior to TAU (i.e., the overall effect would be significantly greater than zero), but that the various confounds would moderate the effect. In particular, we hypothesized that the EBT–TAU effect would be smaller when the TAU was psychotherapy than when the TAU involved little or no psychotherapy.

Section snippets

Inclusion criteria

In order to be selected for this analysis, studies needed to meet the following criteria: (a) the study directly compared an EBT with TAU; (b) participants were diagnosed with either a depressive or anxiety disorder; (c) the study did not primarily focus on reduction of suicidality; (d) the treatment modality was either group or individual; (e) the article reporting the results was published between the years 1995 and 2009, inclusive, in peer reviewed English language journals; (f) the

Results

Results are presented in two parts: (a) study variables and (b) meta-analytic synthesis.

Discussion

Given prevalence of anxiety and depression in the United States, developing strategies for improving quality of services for these disorders is clearly an imperative. One method for improving mental health services is to transport EBTs established in RCTs to practice settings. Such a decision at the service level, or enactment of a policy that would require such action, should be based on scientific evidence. Comparisons of EBTs with TAU in routine care would provide useful evidence for those

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