Research roundup: Is the standard treatment protocol always best?

According to APA’s October 2022 Stress in America^TM survey, 27% of adults reported being so stressed that they cannot function, and mental health demands have significantly increased. At the same time, according to the 2022 covid-19 Practitioner Impact Survey, 60% of psychologists reported having no openings for patients. New research is emerging on the acceptability and feasibility of modifying the timing of psychotherapy sessions (i.e., reducing the frequency, length, or number of sessions) and the relationship to clinically meaningful change, which could increase flexibility in how care is provided and potentially improve access to necessary mental health treatment.

In this installment of “Research Roundup,” we explore the latest research on the length and frequency of therapy sessions needed to improve symptoms of mental health disorders. The first study examines whether there are differences in treatment outcomes in individuals with borderline personality disorder who received a shorter course of treatment. The second study looks at whether outcomes in individuals with PTSD who received reduced prolonged exposure therapy sessions were equivalent to individuals who received the standard, longer treatment sessions. The final study examines individual differences between shorter and longer sessions for individuals with depression.

Note: In addition to reviewing the research summaries, psychologists are encouraged to further explore the literature to determine what may be useful to them in practice, particularly as it relates to patients’ values, culture, and preferences.

McMain, S. F., Chapman, A. L., Kuo, J. R., Dixon-Gordon, K. L., Guimond, T. H., Labrish, C., Isaranuwatchai, W., & Streiner, D. L. (2022). The effectiveness of 6 versus 12 months of dialectical behavior therapy for borderline personality disorder: A noninferiority randomized clinical trialopens in new window. Psychotherapy and Psychosomatics. Advance online publication.

The length of a course of dialectical behavior therapy (DBT) for the treatment of borderline personality disorder (BPD) could be a year or more depending on the patient’s situation, which poses a significant barrier to accessing treatment due to potential long waitlists. The study authors were interested in examining whether there was a reduction in self-harm in individuals who received DBT for only six months (26 weekly individual therapy sessions) versus 12 months (52 weekly individual therapy sessions).

A multisite randomized trial was conducted in Canada where 240 adults ages 18 to 60 years old with suicidality and BPD were randomly assigned to receive either six or 12 months of DBT. DBT consists of weekly individual and group therapy sessions where individuals learn a variety of cognitive-behavioral and acceptance-based skills, with 24/7 telephone consultation as needed. The researchers’ primary outcome was the number of suicidal or nonsuicidal self-injurious behaviors while their secondary outcomes consisted of depression, anger expression, skills uptake, BPD symptoms, and general psychopathology. Outcomes were assessed at baseline and then every three months until the 24th month.

Individuals in both groups showed a reduction in suicidal or nonsuicidal self-injurious behaviors and, most notably, individuals who were assigned to the 6-month group started showing improvement earlier (i.e., at 6-month assessment) than their 12-month counterparts. Individuals in both groups also showed improvement in other mental health outcomes. While the study did not explain why individuals in the 6-month group started showing improvement earlier than individuals in the 12-month group, it demonstrated that a reduction in the number of DBT sessions was as safe and effective as traditional DBT for the treatment of BPD. This could increase access to necessary services by increasing the number of patients clinicians can successfully treat over time.

Foa, E. B., Bredemeier, K., Acierno, R., Rosenfield, D., Muzzy, W., Tuerk, P. W., Zandberg, L. J., Hart, S., Young-McCaughan, S., Peterson, A. L., & McLean, C. P. (2022). The efficacy of 90-min versus 60-min sessions of prolonged exposure for PTSD: A randomized controlled trial in active-duty military personnelopens in new window. Journal of Consulting and Clinical Psychology, 90(6), 503–512.

APA’s (2017) Clinical practice guideline for the treatment of posttraumatic stress disorder (PTSD) in adults strongly recommends prolonged exposure therapy for the treatment of PTSD, and the traditional length of prolonged exposure consists of weekly one and a half hour sessions. The lengthy treatment sessions could create long waitlists for accessing the evidence-based treatment for individuals with PTSD. The researchers therefore explored whether there were similarities in treatment benefits if the sessions were reduced to one hour.

The researchers predicted that of the 160 active-duty military personnel who were randomized to receive either the 60-minute or 90-minute sessions, those assigned to the reduced sessions would improve at the same rate as individuals who received the traditional 90-minute sessions. In addition to assessing the individual’s PTSD severity rating through both clinician and self-report at baseline, posttreatment, 3- and 6-months posttreatment, the researchers also assessed whether any adverse events occurred during the trial.

There were no significant differences in the safety and effectiveness of shortened prolonged exposure therapy versus the traditional 90-minute sessions, as individuals assigned to receive only 60-minute sessions reported significant improvements in PTSD severity and there were no serious adverse events that occurred during the trial. Since improvements in PTSD severity remained at 6-month follow-up in both groups, it may be worth tailoring this evidence-based treatment to meet the increasing demand for mental health services. However, given that most study participants were active-duty military men, more research is needed on the effectiveness, acceptability, and feasibility in reduced prolonged exposure sessions in populations outside the military setting.

Bruijniks, S. J. E., van Bronswijk, S. C., DeRubeis, R. J., Delgadillo, J., Cuijpers, P., & Huibers, M. J. H. (2022). Individual differences in response to once versus twice weekly sessions of CBT and IPT for depressionopens in new window. Journal of Consulting and Clinical Psychology, 90(1), 5–17.

Two of the recommended treatments for adults with depression in APA’s (2019) Clinical practice guideline for the treatment of depression across three age cohorts are cognitive-behavioral therapy (CBT) and interpersonal psychotherapy (IPT). As with most psychotherapy, these treatments are typically delivered once weekly, however, recent research has demonstrated that individuals with depression showed improvement when attending either CBT or IPT therapy sessions twice a week versus only once a week (Bruijniks et al., 2020). In this study, the researchers wanted to explore whether session frequency could be individualized based on characteristics ranging from demographic to working memory performance, and whether the individualized session frequency would improve depressive symptoms.

The study authors analyzed baseline demographic and perceived physical and mental well-being data from a previous trial, in which 200 adults with depression were randomly assigned to receive either CBT or IPT twice a week or once a week (Bruijniks et al., 2020), to see if the demographic data could be used to individualize session frequency to improve outcomes. The analyses revealed that individuals identified as male benefited the most from receiving twice-weekly CBT versus once a week, although differences were not found in individuals who received either once or twice-weekly IPT sessions. Interestingly, researchers also found that individuals who reported at baseline that their perceived general health was low fared better in less frequent CBT sessions, whereas individuals who rated their general health as high preferred and fared better in more frequent CBT sessions.

The overall study illustrates the potential benefits of tailoring session length and frequency based on individual characteristics, and by considering the individuals’ preferences, values, context, and situation, the therapy sessions could be optimized which could improve care.

Now more than ever there is a need for evidence-based mental health services as we continue to experience the aftereffects of the covid-19 pandemic as well as other current events that may induce stress or exacerbate existing mental health concerns. While treatments such as DBT or prolonged exposure typically have very structured patterns of delivery and other psychotherapy is provided in weekly 45-minute sessions, these studies suggest that tailoring the standard delivery of mental health care to meet individual needs or accommodate clinician resources can still result in expected treatment gains. Increased flexibility in the timing and delivery of treatment could result in more individuals being seen without sacrificing expected treatment benefits. More research is needed on the applicability and feasibility of shortened therapy interventions in a variety of settings with different populations and problems to better understand how to deliver services most flexibly and efficiently to a larger portion of the population.