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Cited by 105Psychotherapy Techniques and ApplicationsAnxiety, Depression, Psychometrics, Treatment, Cognitive ProcessesMental Health Treatment and Access

Negative effects of psychotherapies for adult depression: A meta-analysis of deterioration rates

Open access
Cuijpers, Pim, Reijnders, Mirjam, Karyotaki, Eirini, de Wit, Leonore, Ebert, David D.·2018·Journal of Affective Disorders
DOI 10.1016/j.jad.2018.05.050
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Abstract

Background The risk for deterioration in patients receiving psychotherapy for adult depression has not been examined extensively and it is not clear whether psychotherapy reduces this risk or may even increase it in some patients. We conducted a meta-analysis of trials comparing these psychotherapies with control conditions that report deterioration rates.Methods We used an existing database of randomized trials on psychotherapies for adult depression which was updated up to 1/1/2017, through systematic searches in bibliographic databases. We included trials that reported clinically significant deterioration rates.Results We included 18 studies with 23 comparisons between therapy and control groups. The pooled risk ratio of deterioration was 0.39 (95% CI: 0.27∼0.57), indicating that patients in the psychotherapy groups have a 61% lower chance to deteriorate than patients in the control groups. We found that 20 patients need to be treated with psychotherapy in order to avoid one case of deterioration, compared to the control conditions. The median deterioration rate in the therapy groups was 4%, and in some studies more than 10%, indicating that clinicians should always be aware of the risk of deterioration.Limitations The results should be considered with caution because most studies had at least some risk of bias. Only 6% of all trials comparing psychotherapy with a control condition reported deterioration rates, using different ways to define deterioration which made pooling the prevalence rates across treatments and control groups impossible.Conclusions Psychological treatments of adult depression may reduce the risk for deterioration, compared to control groups, but this should be considered with caution because of the small proportion of studies reporting deterioration rates.

Integrity signals

Registry

Crossref · 10.1016/j.jad.2018.05.050

Cites

48 of 48 references verified0 citation errors · 0 not checkable

Statistics

Nothing to recompute.

Claims the paper makes

0 of 20 cited sources checked · 0 supported · 0 flagged

  • Findingown data

    Only three of 23 comparisons showed significant differences in deterioration between treatment and control groups.

    “Only three of the 23 comparisons were significant”
    Quote in the paperNot a substantial claim
  • Findingown data

    Heterogeneity across the 23 comparisons was zero (I2 = 0; 95% CI 0-40).

    “with zero heterogeneity (I 2 = 0; 95% CI: 0-40).”
    Quote in the paperNot a substantial claim
  • Findingown data

    Only a small fraction of psychotherapy trials for adult depression report deterioration rates.

    “The first limitation is that only a small fraction of trials on psychotherapy report deterioration rates.”
    • Also stated in: § 4. Discussion · plain
      “this study showed that only a small number of studies have examined deterioration rates”
    Quote in the paperSubstantial claim
  • Findingown data

    The pooled risk ratio was not associated with type of therapy (CBT vs others).

    “We found no indications that the RR was associated with the definition of depression (according to a diagnostic interview versus a high score on a self-rating depression measure), type of therapy (CBT versus others), treatment format (individual, group, guided self-help), and type of control group (waiting list, care as usual, other).”
    Quote in the paperNot a substantial claim
  • Findingown data

    The pooled risk ratio was not associated with treatment format (individual, group, guided self-help).

    “We found no indications that the RR was associated with the definition of depression (according to a diagnostic interview versus a high score on a self-rating depression measure), type of therapy (CBT versus others), treatment format (individual, group, guided self-help), and type of control group (waiting list, care as usual, other).”
    Quote in the paperNot a substantial claim
  • Classified as probably not a substantial claim. 8
  • May combine two claims. 12

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Findingown data

    Deterioration was measured using Jacobson and Truax criteria in 11 studies and another definition in 7 studies.

    “Deterioration was measured using the criteria for clinically significant deterioration by Jacobson and Truax (1991) in 11 studies, while 7 studies used another definition (such as moving to another symptom category or scoring a number of points lower on a depression scale).”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites Jacobson and Truax (1991) source

      Not checked in the free run.

  • May combine two claims.

    Findingown data

    Median deterioration rate in psychotherapy groups was 4%, with range 0-25%.

    “The deterioration rates in the psychotherapy groups ranged from 0 to 25%, with a median of 4%.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingown data

    The meta-analysis included 18 randomized trials with 23 comparisons between psychotherapy and control groups.

    “We included 18 studies with 23 comparisons between therapy and control groups.”
    • Also stated in: § 3.1. Selection and inclusion of studies · plain
      “A total of 18 studies with 23 comparisons between a therapy and a control group met inclusion criteria for this meta-analysis (Table 1).”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Findingown data

    Median deterioration rate in control conditions was 11%, with range 1-44%.

    “The deterioration rates in the control conditions ranged from 1 to 44% with a median of 11%.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Interpretationown data

    Psychological treatments for adult depression may reduce the risk of deterioration compared with control groups, but this conclusion is cautious because few trials reported deterioration rates.

    “Psychological treatments of adult depression may reduce the risk for deterioration, compared to control groups, but this should be considered with caution because of the small proportion of studies reporting deterioration rates.”
    Quote in the paperSubstantial claim
    • Rests on an assumption: The control conditions used in the included trials function as valid untreated comparators for estimating the effect of psychotherapy on deterioration.

  • May combine two claims.

    Interpretationown data

    The number of studies with low risk of bias was small, and the lack of a significant difference may be related to low statistical power.

    “although the number of studies with low risk of bias was small and not finding a significant difference may be related to low statistical power.”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation

    The need for research on negative effects of psychotherapy has been acknowledged for several years.

    “The need for research on negative effects has been acknowledged for several years now (Barlow, 2010;Foulkes, 2010;Peterson et al., 2013)”
    Quote in the paperNot a substantial claim0 of 3 sources checked
    • cites Barlow, 2010 source

      Not checked in the free run.

    • cites Foulkes, 2010 source

      Not checked in the free run.

    • cites Peterson et al., 2013 source

      Not checked in the free run.

  • May combine two claims.

    Premisecitation

    Deterioration rates are typically not reported in titles and abstracts of trials, but only in full papers, because deterioration is typically not the primary outcome.

    “these deterioration rates are typically not reported in titles and abstracts of studies, but only reported in the full papers because this is typically not the primary outcome of trials”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites Hautzinger et al. 2004

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation

    An earlier estimate put the proportion of patients who worsen during therapy at 5-10%.

    “It has been estimated that 5-10% of patients deteriorate during therapy (Lambert, 2007).”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites Lambert, 2007 source

      Not checked in the free run.

  • May combine two claims.

    Study design and conductreasoning

    The results are uncertain because of the limited number of trials and the high proportion of studies with risk of bias.

    “A second limitation is the small number of trials and the considerable proportion of studies with risk of bias, making the results uncertain.”
    Quote in the paperSubstantial claim
    • Rests on an assumption: The risk of bias assessment using the four criteria adequately captures study quality.

  • May combine two claims.

    Study design and conductown data

    Publication bias analyses found no indication of missing studies; trim-and-fill adjusted RR equaled original, Egger's test p > 0.1.

    “We found no indication for publication bias.”
    • Also stated in: § 3.4. Deterioration rates of psychotherapies compared to control groups · hedged
      “Duvall and Tweedie's trim and fill procedure did not indicate that studies were missing (the adjusted RR was identical to the original RR), and Egger's test of the intercept was not significant (p > 0.1).”
    Quote in the paperNot a substantial claim

  • Classified as probably not a substantial claim.

    Study design and conductreasoning

    The meta-analysis used a random-effects pooling model because heterogeneity was expected.

    “Because we expected considerable heterogeneity among the studies, we employed a random effects pooling model in all analyses.”
    Quote in the paperSubstantial claim

  • Classified as probably not a substantial claim.

    Interpretationown data

    The results should be interpreted with caution because most studies had at least some risk of bias.

    “The results should be considered with caution because most studies had at least some risk of bias.”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Study design and conductcitation

    The validity of included studies was assessed using four Cochrane-inspired risk-of-bias criteria.

    “We assessed the validity of included studies using four criteria inspired by the 'Risk of bias' assessment tool, developed by the Cochrane Collaboration (Higgins et al., 2011).”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites Higgins et al., 2011 source

      Not checked in the free run.

  • May combine two claims.

    Interpretationcitation

    Those earlier studies also back the conclusions that deterioration is uncommon and that psychotherapy lowers its frequency.

    “However, these studies also support the findings that deterioration rates are low and that psychological treatment reduces these rates.”
    Quote in the paperNot a substantial claim0 of 2 sources checked
    • cites Vittengl et al., 2016 source

      Not checked in the free run.

    • cites Ebert et al., 2016 source

      Not checked in the free run.

    • Rests on an assumption: The measures of deterioration used in the included trials validly capture negative effects of psychotherapy.
    • Rests on an assumption: The control conditions in the included trials provide a valid counterfactual for what would have happened without psychotherapy.

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Study design and conductown data

    Two independent researchers screened records and resolved disagreements by discussion.

    “All records were screened by two independent researchers”
    • Also stated in: § 2.1. Identification and selection of studies · plain
      “disagreements were solved through discussion.”
    Quote in the paperNot a substantial claim

  • Classified as probably not a substantial claim.

    Interpretationreasoning

    The trials that reported deterioration rates may not represent the full population of psychotherapy trials for adult depression.

    “It is very well possible, therefore, that these studies are not a representative sample of all studies on psychotherapy for adult depression.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Interpretationreasoning

    Not every patient benefits from therapy, and some may not improve.

    “It cannot be expected that therapies work for everyone and that all patients improve during therapy.”
    Quote in the paperSubstantial claim
    • Rests on an assumption: The measures of deterioration used in the included trials validly capture negative effects of psychotherapy.
    • Rests on an assumption: The control conditions in the included trials provide a valid counterfactual for what would have happened without psychotherapy.
18 of 18

  • The paper relies on this without support.

    The control conditions used in the included trials function as valid untreated comparators for estimating the effect of psychotherapy on deterioration.

    “compared with a control group (waiting list, care-as-usual, placebo, other inactive treatment)”

  • The paper relies on this without support.

    The measures of deterioration used in the included trials validly capture negative effects of psychotherapy.

    “Deterioration rates are low in most studies, but it depends on how it is measured.”

  • The paper relies on this without support.

    The risk ratios for deterioration from studies using different definitions of deterioration are comparable enough to be pooled.

    “Another limitation is that the studies used different ways to define deterioration, making it impossible to pool the prevalence rates across treatments and control groups.”

  • The paper relies on this without support.

    The control conditions in the included trials provide a valid counterfactual for what would have happened without psychotherapy.

    “While the mean risk for deterioration was reduced compared to the control group”

  • The paper relies on this without support.

    The risk of bias assessment using the four criteria adequately captures study quality.

    “A second limitation is the small number of trials and the considerable proportion of studies with risk of bias, making the results uncertain.”
5 of 5

Claims other papers make about this one

Each is checked against this paper’s own text: does it say what the citing paper says it does?

  • The proportion of individuals experiencing symptom deterioration during face-to-face psychological interventions is estimated to range between 3-14%, comparable to deterioration rates for online interventions.

    “Although deterioration rates are infrequently reported in the literature, the proportion of individuals experiencing symptom deterioration during face-to-face psychological interventions is estimated to range between 3-14% (Ebert et al., 2016; Cujipers et al., 2018; Ronk et al., 2013), which is comparable to deterioration rates for online interventions (Ebert et al., 2016).”

    From A randomised trial comparing a brief online delivery of mindfulness-plus-values versus values only for symptoms of depression: Does baseline severity matter? (2020) · cites this paper as Cujipers et al., 2018

    Section 3.4 reports symptom deterioration in psychotherapy groups, supporting the general point, but gives a range of 0–25% (median 4%), not 3–14%. The study-characteristics table in the Discussion includes internet-based as well as face-to-face treatments, so that range is not an estimate specifically for face-to-face interventions. The citing sentence attributes the comparison with online interventions to Ebert et al., not to this paper. (LLM, conf=0.88)

    Experimental — accuracy not yet measured

  • Deterioration rates (3.2% depression, 3.1% anxiety) were slightly lower but within the 95% CI of RCT findings for internet-based guided self-help (3.36% depression, 5.8% anxiety) and comparable with face-to-face psychotherapy for depression.

    “The results of deterioration rates (3.2% in depression and 3.1% in anxiety studies) were slightly lower, but within the 95% CI of findings based on RCTs for internet-based guided self-help interventions (3.36%) for depression [164] and anxiety (5.8% [165]), and also comparable with deterioration rates in face-to-face psychotherapy for depression [166].”

    From Effects of Internet-based cognitive behavioral therapy in routine care for adults in treatment for depression and anxiety: systematic review and meta-analysis (2020) · cites this paper as [166]

Self-check

Percentages, sums and reported differences re-computed from the paper’s own numbers.

Each contradiction between two passages listed here was confirmed by an independent check.

  • Wuthrich risk difference has the opposite sign

    Minor

    The Wuthrich comparison has one deterioration in each group, but the psychotherapy group is smaller (27 versus 35), so its deterioration risk is higher. Under the paper's definition of control risk minus psychotherapy risk, the risk difference is negative, not positive 0.01.

  • Watt study risk difference does not match its event counts

    Minor

    Both Watt comparisons report zero deteriorations among nine psychotherapy patients and two among nine controls. With zero events in psychotherapy, the stated risk difference should equal the control risk, 2/9 = 0.222, rather than 0.28.

    Reported 0.28 · recomputed 0.222222

  • Table 3 reverses the reporting-group columns

    Minor

    Table 3 identifies the first group as the 23 comparisons reporting negative effects and the second as the 346 that do not. Its first numerical column nevertheless contains 156 community comparisons, which cannot belong to a group of 23; the numerical columns appear reversed.

  • Table 3 assigns too many comparisons to general-adult studies

    Minor

    The text says six of the 18 studies targeted adults in general. Since the 18 studies produced only 23 comparisons in total, those six studies could produce at most 11 comparisons, not the 14 assigned to the Adults category in Table 3.

4 of 4

Cites

Flagged first, then by citations

1 of the 49 references couldn’t be matched to a known paper.

Research works printed but not linked: 1

  1. Hautzinger, 2004, Cognitive behavioral therapy for depressed elderly outpatients - a controlled randomized trial, Verhaltensth. Psychosoz. Prax., 36, 789

Cited by

Sorted by citations

Related

Authors
Cuijpers, P., Reijnders, M., Karyotaki, E., de Wit, L., & Ebert, D. D.
Affiliations
  • Amsterdam Public Health (NL)
  • Friedrich-Alexander-Universität Erlangen-Nürnberg (DE)
Corresponding author
Cuijpers, Pim
ORCID
Venue
Journal of Affective Disorders
Publisher
Elsevier BV
Published
2018-10
Volume
239
Pages
138-145
ISSN
0165-0327 (ISSN-L)
DOI
10.1016/j.jad.2018.05.050
OpenAlex
W2810254134
Cited by
105
References
49
Citations by year
2026: 11 · 2025: 8 · 2024: 10 · 2023: 11 · 2022: 14 · 2021: 14 · 2020: 29 · 2019: 6 · 2017: 1
FWCI
2.08
Type
journal article
Language
en
Open access
Licence
www.elsevier.com/tdm/userlicense/1.0/ (tdm)
Locations
  • Journal of Affective Disorders (publishedVersion)
  • PubMed (publishedVersion)
  • Data Archiving and Networked Services (DANS) (submittedVersion, other-oa)
  • VU Research Portal (submittedVersion, other-oa)
  • Digital Academic REpository of VU University Amsterdam (Vrije Universiteit Amsterdam) (submittedVersion)
  • VU Research Portal (submittedVersion)
Topics
  • Social Sciences › Psychology › Clinical Psychology › Psychotherapy Techniques and Applications
  • Social Sciences › Psychology › Experimental and Cognitive Psychology › Anxiety, Depression, Psychometrics, Treatment, Cognitive Processes
  • Social Sciences › Psychology › Social Psychology › Mental Health Treatment and Access
Keywords
adult depression, psychotherapy, treatment deterioration, relapse, psychological intervention
MeSH terms
Adult, Depression, Depressive Disorder, Humans, Psychotherapy, Group, Cognitive Behavioral Therapy

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