Additional Research Information on Person-Centred/Experiential (PCE) Therapy for Depression for SIGN Consultation

(Robert Elliott, version 2, 21 Sept 2008)
[Note: This is a consultation document prepared to provide input for the review process for the SIGN Guidelines on Mild-to-Moderate Depression. It is provided here as supporting documentation for the blog entry on the release of The Matrix guidelines documents on commissioning mental health services in Scotland.]

The purpose of this document is to provide additional evidence missing from the Draft SIGN Guideline for Non-pharmacological management of mild to moderate depression. Based on ongoing meta-analytic research being carried out at the University of Strathclyde (supported by a grant from the British Association for the Person-Centred Approach) we are proposing that the following information be added to the Guideline. Note that the draft guidelines refer only to generic counselling, without reference to the particular type of counselling. We summarize evidence specific to Person-centred/Experiential (PCE) therapy, including (a) general meta-analytic support for PCE therapies for depression, (b) strong RCT evidence for a particular form of PCE (Process-Experiential) to general clinical depression, and (c) strong RCT evidence for Person-centred therapy for a specific form of depression (postnatal). It is our view that this body of evidence warrants modification of the draft Guideline to include Person-Centred/Experiential therapy in its recommendations for psychosocial management of mild to moderate depression. I am happy to supply the supporting references cited in this document.

1. Person-Centred/Experiential therapies in general for Mild to Moderate Depression.
Meta-analytic evidence: A meta-analysis of 23 PCE therapy research studies (including 4 controlled and 16 comparative studies) reported large pre-post effect sizes and general and statistical equivalence to nonPCE therapies. The small number of controlled studies mostly involved small or unrepresentative samples. (An updated meta-analysis [Elliott & Freire, in preparation] includes 32 pre-post studies, 8 controlled studies, and 33 comparative outcome studies with comparable or more favourable results.) (Evidence level 1+)
(Grade of recommendation: A: Highly Recommended)

Reference:
Elliott, R., Greenberg, L.S., & Lietaer, G. (2004). Research on Experiential Psychotherapies. In M.J. Lambert (Ed.), Bergin & Garfield‘s Handbook of psychotherapy and behavior change (5th ed.) (pp. 493-539), New York: Wiley.

2. Person-Centred Therapy for Mild to Moderate Depression:

(1) Extrapolated evidence: There is one large well-designed RCT with 62% diagnosed depressed clients, and pre-therapy depression measure scores typical of depressed samples, showing comparable outcomes to CBT across 2 randomized comparisons and one preference comparison. Another source of extrapolated evidence is research on Person-centred therapy for postnatal depression, reviewed in section 3 below. (1+ or 1++)
(2) Cohort study: In one large, unpublished analysis of depressed patients taken from a very large published naturalistic study, the depressed subgroup analysis finds no difference between Person-Centred, CBT and Psychodynamic therapies. (2++)
(Grade of recommendation: B: Recommended)

References:
Elliott, R., Greenberg, L.S., & Lietaer, G. (2004). Research on Experiential Psychotherapies. In M.J. Lambert (Ed.), Bergin & Garfield‘s Handbook of psychotherapy and behavior change (5th ed.) (pp. 493-539), New York: Wiley.
King, M., Sibbald, B., Ward, E., Bower, P., Lloyd, M., Gabbay, M., & Byford, S. (2000). Randomised controlled trial of non-directive counselling, cognitive-behaviour therapy and usual general practitioner care in the management of depression as well as mixed anxiety and depression in primary care. Health Technology Assessment, 4 (19). [Well-designed study with two embedded RCTs and one preference trial; 62% of clients met criteria for depression, but Beck Depression Inventory was used a primary outcome measure and mean pre-therapy scores were at levels typical of clinically depressed samples. Results for Person-Centred therapy were comparable to CBT.] (1+)
Stiles, W.B., Barkham, M., Mellor-Clark, J., Connell, J. (2007). An Addendum to "Effectiveness of Cognitive-Behavioural, Person-Centred, and Psychodynamic Therapies in UK Primary Care Routine Practice: Replication in a Larger Sample." Unpublished manuscript, Miami University, Ohio, USA. [Subsample analysis of larger published study (Stiles et al., 2007): Well-controlled naturalistic study in NHS primary care with large sample of clients identified as depressed by therapists; identical pretherapy scores with no difference in posttherapy outcomes among Person-centred, CBT and Psychodynamic.] (2++)
Stiles, W.B., Barkham, M., Mellor-Clark, J., Connell, J. (2007). Effectiveness of cognitive-Behavioural, person-centred, and psychodynamic therapies as practiced in UK primary care routine practice: replication in a larger sample. Psychological Medicine. Published online 10 September 2007. doi:10.1017/S0033291707001511.


3. Process-Experiential/Emotion-Focused Therapy (PE-EFT) for Depression:

Process-Experiential therapy (also known as Emotion-Focused Therapy) is an integrative form of Person-Centred therapy that incorporates other humanistic therapy techniques such as Gestalt Two Chair exercises into a treatment targetted for depression. There are three well-designed RCTs testing this approach, using medium-sized samples and conducted by two different research teams, comparing PE-EFT to other therapies in the treatment of Major Depressive Disorder. One of these studies found that PE-EFT had significantly better outcomes (including very low relapse rates) when compared to Person-Centred therapy. The other study found equivalent, and on some measures better, results than CBT. (1+ or 1 ++)
(Grade of recommendation: A)

References:
Goldman, R. N., Greenberg, L. S., & Angus, L. (2006). The effects of adding emotion-focused interventions to the client-centered relationship conditions in the treatment of depressions. Psychotherapy Research, 16, 537-549. [Replication of Greenberg & Watson, 1998: Well-designed RCT with clinically depressed clients and medium-sized sample, comparing PE-EFT to Person-Centred therapy; outcomes were strongly and significantly better for PE-EFT.]
Greenberg, L.S., & Watson, J. (1998). Experiential therapy of depression: Differential effects of client-centered relationship conditions and process experiential interventions. Psychotherapy Research, 8, 210-224. [Well-designed RCT with clinically depressed clients and medium-sized sample, comparing PE-EFT to Person-Centred therapy; outcomes were slightly but not significantly better for PE-EFT.]
Watson, J.C., Gordon, L.B., Stermac, L., Kalogerakos, F., Steckley, P. (2003). Comparing the effectiveness of process-experiential with cognitive-behavioral psychotherapy in the treatment of depression. Journal of Consulting and Clinical Psychology, 71, 773-781. [Balanced researcher allegiance RCT comparing PE-EFT to CBT in clinically depressed sample; outcomes for PE-EFT were generally at least as good as CBT and on some measures were better.]

4. Person-Centred Therapy for Perinatal Depression:

Perinatal depression is currently excluded from the draft guideline; however, the current SIGN guideline for Postnatal depression and puerperal psychosis states, “Postnatal depression should be managed in the same way as depression at any other time, but with the additional considerations regarding the use of antidepressants when breast feeding and in pregnancy.” In other words, the major difference between the treatment of postpartum depression and depression more generally is that antidepressant medication should be used more cautiously. There are four reasonably well-designed RCTs for perinatal depression with medium to large sample sizes that show superiority to treatment as usual (3 studies) or no difference in comparison to CBT (2 studies) or short-term Psychodynamic therapy (1 study). We are proposing this important population be included in this guideline, on the basis of these studies; in addition, we suggest that this body of research is relevant to the effectiveness of Person-centred therapy with depression more generally. (Level of evidence: 1+ or 1++) (Grade of recommendation: specific to Perinatal depression: A; extrapolated to depression generally: B)

References:
Cooper, P. J., Murray, L., Wilson, A., & Romaniuk, H. (2003). Controlled trial of the short- and long-term effect of psychological treatment of post-partum depression. British Journal of Psychiatry,182, 412-419 . [Well-designed RCT; Person-centred comparable outcome to CBT and Psychodynamic]
Holden, J.M., Sagovsky, R., & Cox, J.L. (1989). Counselling in a general practice
setting: Controlled study of health visitor intervention in treatment of postnatal depression. British Medical Journal, 298, 223-226. [Medium-sized RCT: Clients in Person-centred therapy had better outcomes than control clients]
Morrell CJ, Warner R, Slade P, Paley G, Dixon S, Walters SJ, Brugha T, Barkham M, Parry G, Nicholl J. (In Press). Clinical effectiveness of health visitor training in psychological interventions for postnatal women – a pragmatic cluster-randomised trial in primary care. British Medical Journal. [RCT; Person-centred similar outcome to CBT, better than treatment as usual]
Wickberg, B., & Hwang, C. P. (1996). Counselling of postnatal depression: A controlled study on a population based Swedish sample. Journal of Affective Disorders, 39, 209-216. [RCT; Person-centred much better than treatment as usual]