Article Text
PDF
Statistics from Altmetric.com
Question
Question: Are evidence-based psychotherapies better than usual care for treating psychopathology in children and adolescents?
Outcomes: Improvement in psychopathology (symptoms, functioning or other outcomes) as assessed by the included studies.
Methods
Design: Systematic review and meta-analysis.
Data sources: PubMed, PsychoINFO and the Dissertation Abstracts International Database (search from 1 January 1960 to 31 December 2010), supplemented by hand search of reference lists of reviews and meta-analyses of youth psychotherapy and contact with investigators in the field.
Study selection and analysis: Randomised controlled trials (RCTs) that compared evidence-based psychotherapies (EBPs, defined as treatments listed in at least one systematic review of EBPs for youths) with usual care for psychopathology in children and adolescents (age 3–18 years). Usual care included psychotherapy, counselling or other non-medical intervention provided through outpatient clinics, public programmes and agencies or residential facilities. Psychopathology included internalising as well as externalising disorders, either meeting Diagnostic and Statistical Manual (DSM) criteria or showing elevated behavioural/emotional symptoms. Effect sizes (reflecting standardised mean difference between EBP and usual care) were calculated for each trial, and combined using a random effects model with a multilevel model extension to account for the fact that the majority of the studies reported multiple outcome measures and/or outcomes at multiple time points. A mixed-effect model was used to identify moderators that might explain variation in effect sizes within and between studies, including participant, characteristics, timing of assessments, geographical location and study year. Publication bias was assessed by comparing effect sizes in published and unpublished studies, funnel plot and by calculating a classic fail-safe N value.
Main results
Fifty-two RCTs (n=5101) met the inclusion criteria. These trials contained 341 effect sizes comparing EBP with usual care. EBP was more effective than usual care for the treatment of psychopathology (mean effect size across studies 0.29, 95% CI 0.19 to 0.38). A randomly selected child or adolescent had a 58% probability of a better outcome with EBP than with usual care. Effect sizes differed significantly between studies. Moderator analyses found no significant effect of treatment setting, mode of treatment delivery, child/adolescent age or ethnicity, study year or timing of outcome assessment (effect sizes at follow-up assessments a mean 31 weeks after treatment were similar to effect sizes immediately post-treatment). However, effect sizes were lower: 1) in studies performed outside North America; 2) in studies where participants had a DSM diagnosis of psychopathology; and 3) when outcomes were reported by teachers and therapists rather than youths and parents. There was no evidence of publication bias.
Conclusions
Evidence-based psychotherapies have a small effect on child or adolescent psychopathology compared with usual care, but the effect is dependent on location, the severity of psychopathology and who reports the outcomes.
Abstracted from
Commentary
Many evidence-based psychotherapies (EBPs) for young people have been devised over recent decades. These are labelled as EBPs due to outperforming some sort of control group, such as a waitlist or a psychological placebo, in randomised controlled trials (RCTs). However, superiority to a control group does not necessarily equate to better outcomes than usual clinical care (UC). Close examination of trials comparing EBP to UC is needed to investigate whether the substantial expense and effort required to widely disseminate EBP is a worthy endeavour.
The review by Weisz and colleagues included by far the largest number of RCTs to date. Their thorough and sophisticated meta-analysis included 52 RCTs comparing EBP versus UC for youth. They found a statistically significant but small advantage (effect size (d)=0.29) for EBP overall. However, the effects were very small and statistically non-significant when examining only clinically referred samples or only children who met the criteria for a Diagnostic and Statistical Manual of Mental Disorders diagnosis. In other words, EBP fared no better than UC for children who have the greatest need for treatment. Interestingly, EBP also failed to outperform UC under the following conditions: (1) studies conducted outside North America, (2) studies with child (as opposed to adolescent) participants, (3) studies in which treatment dosage was equal or favoured UC.
The authors rightly note that UC was often poorly described and yielded widely diverging outcomes across trials. In some cases, UC represented little psychotherapeutic or psychiatric treatment while in other studies, UC provided fairly intensive treatment. Furthermore, likely due to poor reporting in the underlying trials, Weisz and colleagues did not report on differences in clinical supervision, therapist caseload or prestudy therapist training between EBP and UC. EBP likely had an advantage over UC on at least one of these variables in most included studies, possibly biasing the results.
Despite the authors’ detailed analysis, they could not rectify the questionable design and reporting of the underlying studies. Additionally, EBP did not outperform UC among clinically referred or DSM-diagnosed youth. There is currently not sufficient evidence to justify widespread implementation of EBP for the youth.
Footnotes
-
Sources of funding The Norlien Foundation, the US National Institute of Mental Health, the Annie E Casey Foundation and the Research Foundation, Flanders, Belgium.
Footnotes
-
Competing interests None.