Performance of Evidence-Based Youth Psychotherapies Compared With Usual Clinical Care: A Multilevel Meta-analysis

Abstract

IMPORTANCE: Research across more than 4 decades has produced numerous empirically tested evidence-based psychotherapies (EBPs) for psychopathology in children and adolescents. The EBPs were developed to improve on usual clinical interventions. Advocates argue that the EBPs should replace usual care, but this assumes that EBPs produce better outcomes than usual care. OBJECTIVE: To determine whether EBPs do in fact produce better outcomes than usual care in youth psychotherapy. We performed a meta-analysis of 52 randomized trials directly comparing EBPs with usual care. Analyses assessed the overall effect of EBPs vs usual care and candidate moderators; we used multilevel analysis to address the dependency among effect sizes (ES) that is common but typically unaddressed in psychotherapy syntheses. DATA SOURCES: We searched the PubMed, PsychINFO, and Dissertation Abstracts International databases for studies from January 1, 1960, through December 31, 2010. STUDY SELECTION: We identified 507 randomized youth psychotherapy trials. Of these, the 52 studies that compared EBPs with usual care were included in the meta-analysis. DATA EXTRACTION AND SYNTHESIS: Sixteen variables (participant, treatment, outcome, and study characteristics) were extracted from studies, and ESs were calculated for all comparisons of EBP vs usual care. We used an extension of the commonly used random-effects meta-analytic model to obtain an overall estimate of the difference between EBP and usual care while accounting for the dependency among ESs. We then fitted a 3-level mixed-effects model to identify moderators that might explain variation in ESs within and between studies by adding study or ES characteristics as fixed predictors. MAIN OUTCOMES AND MEASURES: Primary outcomes of our meta-analysis were mean ES estimates across all studies and for levels of candidate moderators. These ES values were based on measures of symptoms, functioning, and other outcomes assessed within the 52 randomized trials. RESULTS: Evidence-based psychotherapies outperformed usual care. Mean ES was 0.29; the probability was 58% that a randomly selected youth would have a better outcome after EBP than a randomly selected youth after receiving usual care. The following 3 variables moderated treatment benefit: ESs decreased for studies conducted outside North America, for studies in which all participants were impaired enough to qualify for diagnoses, and for outcomes reported by informants other than the youths and parents in therapy. For certain key groups (eg, studies of clinically referred samples and youths with diagnoses), significant EBP effects were not demonstrated. CONCLUSIONS AND RELEVANCE: Evidence-based psychotherapies outperform usual care, but the EBP advantage is modest and moderated by youth, location, and assessment characteristics. The EBPs have room for improvement in the magnitude and range of their benefit relative to usual clinical care.