Abstract
Despite growing awareness of occasional adverse effects of psychological treatments, only a few instruments cover side effects and other unwanted effects of psychotherapy. For the present study, the Positive and Negative Effects of Psychotherapy Scale (PANEPS) was evaluated in a population of individuals with depression who had completed at least one course of face-to-face psychotherapy. A total of 135 individuals with a current or previous depressive episode as verified by a diagnostic interview filled out the online version of the PANEPS, which is designed to capture both positive and adverse events. Factor analysis yielded four dimensions: positive effects, side effects, malpractice, and unethical conduct. Internal consistency of the individual subscales was satisfactory to excellent (Cronbach’s α: 0.72 and 0.92). Positive effects were reported by virtually all patients (95.6%). At the same time, approximately half of the sample noted at least one adverse event (52.6%). Among these, side effects (38.5%) and malpractice (26.7%) were significantly more prevalent than unethical conduct (8.1%). As expected, positive effects were negatively correlated with adverse events. Our results challenge the common clinical assumption that some degree of destabilization is necessary for symptom improvement. The survey was conducted anonymously, and the sample underwent diagnostic verification. The results indicate a need for improved treatment guidelines and mechanisms to monitor treatment.
Similar content being viewed by others
References
Cuijpers P, Sijbrandij M, Koole SL et al (2013) The efficacy of psychotherapy and pharmacotherapy in treating depressive and anxiety disorders: a meta-analysis of direct comparisons. World Psychiatry 12:137–148. https://doi.org/10.1002/wps.20038
Skapinakis P, Caldwell D, Hollingworth W et al (2016) A systematic review of the clinical effectiveness and cost-effectiveness of pharmacological and psychological interventions for the management of obsessive–compulsive disorder in children/adolescents and adults. Health Technol Assess 20:1–392. https://doi.org/10.3310/hta20430
Cuijpers P, van Straten A, Schuurmans J et al (2010) Psychotherapy for chronic major depression and dysthymia: a meta-analysis. Clin Psychol Rev 30:51–62. https://doi.org/10.1016/j.cpr.2009.09.003
Kliem S, Kröger C, Kosfelder J (2010) Dialectical behavior therapy for borderline personality disorder: a meta-analysis using mixed-effects modeling. J Consult Clin Psychol 78:936–951. https://doi.org/10.1037/a0021015
Hofmann SG, Asnaani A, Vonk IJJ et al (2012) The efficacy of cognitive behavioral therapy: a review of meta-analyses. Cognitive Ther Res 36:427–440. https://doi.org/10.1007/s10608-012-9476-1
Mehl S, Werner D, Lincoln TM (2015) Does cognitive behavior therapy for psychosis (CBTp) show a sustainable effect on delusions? A meta-analysis. Front Psychol 6:1450. https://doi.org/10.3389/fpsyg.2015.01450
McMahon K, Herr NR, Zerubavel N et al (2016) Psychotherapeutic treatment of bipolar depression. Psychiatr Clin N Am 39:35–56. https://doi.org/10.1016/j.psc.2015.09.005
Karyotaki E, Smit Y, de Beurs DP et al (2016) The long-term efficacy of acute-phase psychotherapy for depression: a meta-analysis of randomized trials. Depression Anxiety 33:370–383. https://doi.org/10.1002/da.22491
Nieuwsma JA, Trivedi RB, McDuffie J et al (2012) Brief psychotherapy for depression: a systematic review and meta-analysis. Int J Psychiatry Med 43:129–151. https://doi.org/10.2190/PM.43.2.c
Boutron I, Moher D, Altman DG et al (2008) Extending the CONSORT statement to randomized trials of nonpharmacologic treatment: explanation and elaboration. Ann Intern Med 148:295–309. https://doi.org/10.7326/0003-4819-148-4-200802190-00008
Leichsenring F, Abbass A, Hilsenroth MJ et al (2017) Biases in research: risk factors for non-replicability in psychotherapy and pharmacotherapy research. Psychol Med 47:1000–1011. https://doi.org/10.1017/S003329171600324X
Barlow DH (2010) Negative effects from psychological treatments: a perspective. Am Psychol 65:13–20. https://doi.org/10.1037/a0015643
Berk M, Parker G (2009) The elephant on the couch: side-effects of psychotherapy. Aust N Z J Psychiatry 43:787–794. https://doi.org/10.1080/00048670903107559
Linden M, Schermuly-Haupt ML (2014) Definition, assessment and rate of psychotherapy side effects. World Psychiatry 13:306–309. https://doi.org/10.1002/wps.20153
Linden M (2013) How to define, find and classify side effects in psychotherapy: from unwanted events to adverse treatment reactions. Clin Psychol Psychother 20:286–296. https://doi.org/10.1002/cpp.1765
Ladwig I, Rief W, Nestoriuc Y (2014) Welche Risiken und Nebenwirkungen hat Psychotherapie? – Entwicklung des Inventars zur Erfassung Negativer Effekte von Psychotherapie (INEP). Verhaltenstherapie. https://doi.org/10.1159/000367928
Moritz S, Fieker M, Hottenrott B et al (2015) No pain, no gain? Adverse effects of psychotherapy in obsessive-compulsive disorder and its relationship to treatment gains. J Obsess Compuls Relat Disord 5:61–66. https://doi.org/10.1016/j.jocrd.2015.02.002
Rief W, Barsky AJ, Glombiewski JA et al (2011) Assessing general side effects in clinical trials: reference data from the general population. Pharmacoepidemiol Drug Saf 20:405–415. https://doi.org/10.1002/pds.2067
Nestoriuc Y, Rief W (2012) Nebenwirkungen von Verhaltenstherapie. In: Linden M, Strauß B (eds) Risiken und Nebenwirkungen von Psychotherapie. MWV Medizinisch Wissenschaftliche Verlagsgesellschaft, Berlin, pp 59–74
Olatunji BO, Deacon BJ, Abramovitz JS (2009) The crulest cure? Ethical issues in the implementation of exposure based treatments. Cognit Behav Pract 16:172–180
Foa EB, Zoellner LA, Feeny NC et al (2002) Does imaginal exposure exacerbate PTSD symptoms? J Consult Clin Psychol 70:1022–1028. https://doi.org/10.1037/0022-006X.70.4.1022
Pope GG (1990) Abuse of psychotherapy: psychotherapist-patient intimacy. Psychother Psychosom 53:191–198. https://doi.org/10.1159/000288366
Borruso MT (1991) Sexual abuse by psychotherapists: the call for a uniform criminal statute. Am J Law Med 17:289–311
Crawford MJ, Thana L, Farquharson L et al (2016) Patient experience of negative effects of psychological treatment: results of a national survey. Br J Psychiatry 208:260–265. https://doi.org/10.1192/bjp.bp.114.162628
Planès S, Villier C, Mallaret M (2016) The nocebo effect of drugs. Pharmacol Res Perspect. https://doi.org/10.1002/prp2.208
Wells RE, Kaptchuk TJ (2012) To tell the truth, the whole truth, may do patients harm: the problem of the nocebo effect for informed consent. Am J Bioeth 12:22–29. https://doi.org/10.1080/15265161.2011.652798
Swift JK, Derthick AO (2013) Increasing hope by addressing clients’ outcome expectations. Psychotherapy 50:284–287. https://doi.org/10.1037/a0031941
Gumz A, Kästner D, Geyer M et al (2010) Instability and discontinuous change in the experience of therapeutic interaction: an extended single-case study of psychodynamic therapy processes. Psychother Res J Soc Psychother Res 20:398–412. https://doi.org/10.1080/10503300903551021
Klein JP, Berger T, Schröder J et al (2013) The EVIDENT-trial: protocol and rationale of a multicenter randomized controlled trial testing the effectiveness of an online-based psychological intervention. BMC Psychiatry 13:239. https://doi.org/10.1186/1471-244X-13-239
Klein JP, Berger T, Schröder J et al (2016) Effects of a psychological internet intervention in the treatment of mild to moderate depressive symptoms: results of the evident study, a randomized controlled trial. Psychother Psychosom 85:218–228. https://doi.org/10.1159/000445355
Lecrubier Y, Sheehan DV, Weiller E et al (1997) The mini international neuropsychiatric interview (MINI). A short diagnostic structured interview: reliability and validity according to the CIDI. Eur Psychiatry 12:224–231. https://doi.org/10.1016/S0924-9338(97)83296-8
Hamilton M (1960) A rating scale for depression. J Neurol Neurosurg Psychiatry 23:56–62. https://doi.org/10.1136/jnnp.23.1.56
Kroenke K, Spitzer RL, Williams JBW (2001) The PHQ-9. J Gen Intern Med 16:605–613. https://doi.org/10.1046/j.1525-1497.2001.016009606.x
Gilbody S, Richards D, Brealey S, Hewitt C (2007) Screening for depression in medical settings with the Patient Health Questionnaire (PHQ): a diagnostic meta-analysis. J Gen Intern Med 22:1596–1602. https://doi.org/10.1007/s11606-007-0333-y
Albert PR (2015) Why is depression more prevalent in women? J Psychiatry Neurosci 40:219–221. https://doi.org/10.1503/jpn.150205
Nübling R, Schmidt J, Munz D (2010) Psychologische Psychotherapeuten in Baden-Württemberg – Prognose der Versorgung. Psychotherap J 9:46–52
Rheker J, Beisel S, Kräling S, Rief W (2017) Rate and predictors of negative effects of psychotherapy in psychiatric and psychosomatic inpatients. Psychiatry Res 254:143–150. https://doi.org/10.1016/j.psychres.2017.04.042
Hatfield D, McCullough L, Frantz SHB, Krieger K (2010) Do we know when our clients get worse? An investigation of therapists’ ability to detect negative client change. Clin Psychol Psychother 17:25–32. https://doi.org/10.1002/cpp.656
Moritz S, Berna F, Jaeger S et al (2017) The customer is always right? Subjective target symptoms and treatment preferences in patients with psychosis. Eur Archiv Psychiatry Clin Neurosci 267:335–339. https://doi.org/10.1007/s00406-016-0694-5
Author information
Authors and Affiliations
Corresponding author
Ethics declarations
Conflict of Interest
None.
Appendix
Appendix
See Table 4.
Rights and permissions
About this article
Cite this article
Moritz, S., Nestoriuc, Y., Rief, W. et al. It can’t hurt, right? Adverse effects of psychotherapy in patients with depression. Eur Arch Psychiatry Clin Neurosci 269, 577–586 (2019). https://doi.org/10.1007/s00406-018-0931-1
Received:
Accepted:
Published:
Issue Date:
DOI: https://doi.org/10.1007/s00406-018-0931-1