PsycARTICLES - A Multidimensional Meta-Analysis of Treatments for Depre... Empirical Examination of the Status of Empirically Supported Therapies

نویسنده

  • Drew Westen
چکیده

The authors report a meta-analysis of high-quality studies published from 1990–1998 on the efficacy of manualized psychotherapies for depression, panic disorder, and generalized anxiety disorder (GAD) that bear on the clinical utility and external validity of empirically supported therapies. The results suggest that a substantial proportion of patients with panic improve and remain improved; that treatments for depression and GAD produce impressive short-term effects; that most patients in treatment for depression and GAD do not improve and remain improved at clinically meaningful follow-up intervals; and that screening procedures used in many studies raise questions about generalizability, particularly in light of a systematic relation across studies between exclusion rates and outcome. The data suggest the importance of reporting, in both clinical trials and metaanalyses, a range of outcome indices that provide a more comprehensive, multidimensional portrait of treatment effects and their generalizability. These include exclusion rates, percent improved, percent recovered, percent who remained improved or recovered at follow-up, percent seeking additional treatment at follow-up, and data on both completer and intent-to-treat samples. The past decade has seen increasing efforts to create evidence-based practice guidelines in both clinical psychology and psychiatry (see Nathan, 1998). Spurred in part by the publication of a task force report by the Division of Psychotherapy (Division 12) of the American Psychological Association (APA) in 1995, many researchers have called for psychotherapy practice and training to be limited to treatments that have demonstrated efficacy in randomized controlled trials (Calhoun, Moras, Pilkonis, & Rehm, 1998; Chambless & Hollon, 1998; Persons & Silberschatz, 1998). These treatments, typically referred to as empirically validated therapies, or empirically supported therapies (ESTs; Kendall, 1998), differ substantially from treatments conducted by many practicing clinicians. A major shift in training is nearing completion in university-based clinical psychology programs, as advocates of traditional psychotherapies retire and have in large part passed the torch to younger, more empirically informed colleagues who share the sentiment of Calhoun et al. (1998) that the longer-term, more exploratory therapies of a previous era are “less essential and outdated” (p. 151). That psychotherapy training and practice in the 21st century will, and should, be evidence-based is indisputable (Kopta, Lueger, Saunders, & Howard, 1999; Nathan et al., 2000; Roth & Fonagy, 1996). The fact that many clinicians are content to practice without reference to research that might refine their therapeutic technique, as well as widely held beliefs in the popular culture and in many circles in psychiatry that medication should be the first-line treatment for disorders such as panic and depression (see DeRubeis, Gelfand, Tang, & Simons, 1999), provided a powerful and appropriate impetus for the efforts of the Division 12 task force to create procedures for separating the therapeutic wheat from the chaff. The question is not whether practice should be evidence-based but what kind of evidence should be the basis of practice. Although the APA task force did not exclude designs other than randomized controlled trials from their 1995 report, over the past 20 years psychotherapy researchers have come to a consensus that the gold standard in treatment research is a straightforward application of experimental method as used in other areas of psychology, aimed at allowing researchers to draw causal inferences. In this design, patients are screened for inclusion to maximize homogeneity and minimize the presence of co-occurring conditions that could render findings difficult to interpret. Treatments are designed for a single disorder, typically an Axis I condition such as major depression, panic, or social phobia, rather than for nonspecific or multiple problems. Treatments are relatively brief, of fixed duration, and manualized, so that within-treatment variance can be minimized, allowing tight experimental control. In many respects, these characteristics exemplify good science. Recently, however, a number of researchers have begun to express concern file:///C|/Debbie/mutlidimart.htm (1 of 23) [5/16/2003 10:30:00 AM] PsycARTICLES A Multidimensional Meta-Analysis of Treatments for Depre... Empirical Examination of the Status of Empirically Supported Therapies about some of the limitations of this method, particularly regarding the balance between internal and external validity (e.g., Goldfried & Wolfe, 1995, 1998; Ingram, Hayes, & Scott, 2000; Seligman, 1995). In this article, we address some of these concerns empirically, by examining the findings of high-quality studies of three highly prevalent disorders, focusing on variables that bear on clinical utility and external validity. We describe the results of what we will call a multidimensional meta-analysis, which presents a range of statistics bearing on outcome, including but not limited to effect size, that we believe are important in assessing the strengths and limitations of treatments of psychological disorders.

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تاریخ انتشار 2001