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Review
June 2014

Efficacy of Pharmacotherapy and Psychotherapy for Adult Psychiatric Disorders: A Systematic Overview of Meta-analyses

Author Affiliations
  • 1Department of Psychiatry and Psychotherapy, Technische Universität München, München, Germany
  • 2Department of Psychiatry, University of Oxford, Warneford Hospital, Oxford, England
  • 3Department of Hygiene and Epidemiology, School of Medicine, University of Ioannina, University Campus, Ioannina, Greece
  • 4Psychiatric Institute, University of Illinois at Chicago
  • 5Institute of Psychiatry, King’s College London, London, England
JAMA Psychiatry. 2014;71(6):706-715. doi:10.1001/jamapsychiatry.2014.112
Abstract

Importance  There is debate about the effectiveness of psychiatric treatments and whether pharmacotherapy or psychotherapy should be primarily used.

Objectives  To perform a systematic overview on the efficacy of pharmacotherapies and psychotherapies for major psychiatric disorders and to compare the quality of pharmacotherapy and psychotherapy trials.

Evidence Review  We searched MEDLINE, EMBASE, PsycINFO, and the Cochrane Library (April 2012, with no time or language limit) for systematic reviews on pharmacotherapy or psychotherapy vs placebo, pharmacotherapy vs psychotherapy, and their combination vs either modality alone. Two reviewers independently selected the meta-analyses and extracted efficacy effect sizes. We assessed the quality of the individual trials included in the pharmacotherapy and psychotherapy meta-analyses with the Cochrane risk of bias tool.

Findings  The search yielded 45 233 results. We included 61 meta-analyses on 21 psychiatric disorders, which contained 852 individual trials and 137 126 participants. The mean effect size of the meta-analyses was medium (mean, 0.50; 95% CI, 0.41-0.59). Effect sizes of psychotherapies vs placebo tended to be higher than those of medication, but direct comparisons, albeit usually based on few trials, did not reveal consistent differences. Individual pharmacotherapy trials were more likely to have large sample sizes, blinding, control groups, and intention-to-treat analyses. In contrast, psychotherapy trials had lower dropout rates and provided follow-up data. In psychotherapy studies, wait-list designs showed larger effects than did comparisons with placebo.

Conclusions and Relevance  Many pharmacotherapies and psychotherapies are effective, but there is a lot of room for improvement. Because of the multiple differences in the methods used in pharmacotherapy and psychotherapy trials, indirect comparisons of their effect sizes compared with placebo or no treatment are problematic. Well-designed direct comparisons, which are scarce, need public funding. Because patients often benefit from both forms of therapy, research should also focus on how both modalities can be best combined to maximize synergy rather than debate the use of one treatment over the other.

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    1 Comment for this article
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    Placebo effect a factor in results of pharmacotherapy v. psychotherapy trial?
    Dr. Eugene J. Koprowski | King's College, Institute of Psychiatry, University of London
    I'm curious to know why the placebo effect was not really considered important by the researchers in this systematic overview, particularly when it comes to the effectiveness of pharmacotherapies? The placebo effect is an important element in the healing process, especially for psychiatric disorders. One may even consider there to be a \"transference\" of sorts with healing power attributed to certain pharmacotherapies by certain patients. Freud and Jung did not prescribe anti-depressants or anxiolytics in their day, and yet they helped many patients, though they did use other modalities in addition to talk therapy (e.g. hydrotherapy). This study of the placebo effect of brand name anti-depressants and anxiolytics is something that should be investigated now and would be helpful to clinicians, who could combine the power of suggestion with the placebo effect in daily medication management situations.

    REFERENCES

    McQueen, D., Cohen, S., St John-Smith, P., & Rampes, H. (2013). Rethinking placebo in psychiatry: the range of placebo effects. Advances in psychiatric treatment, 19(3), 162-170.

    Moerman, D. E. (2013). Against the “placebo effect”: A personal point of view. Complementary therapies in medicine, 21(2), 125-130.

    CONFLICT OF INTEREST: None Reported
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