Therapeutic Alliance in Antidepressant Treatment: Cause or Effect of Symptomatic Levels?

Abstract

Background: Previous studies have shown that in psychotherapy alliance is a predictor of symptomatic change, even while accounting for the temporal precedence between alliance and symptoms. However, the extent to which alliance predicts outcomes in psychopharmacology is yet to be fully investigated considering the fact that alliance can be the result, rather than the cause, of symptomatic change. The current prospective study examined whether the alliance predicts outcomes in psychopharmacology, while controlling for previous symptomatic change throughout the course of treatment. Methods: Data from a psychopharmacological randomized controlled trial for the treatment of adult major depression (n = 42), including the patients' rating of the alliance with the physicians, were analyzed. Multilevel models controlling for autoregressive lag of the dependent variable were used in all analyses to examine the effect of alliance on outcome. Results: The effect of alliance on outcome, while controlling for prior symptomatic levels, was significant and restricted to the middle phase of treatment (week 4, p = 0.005), when most of the reductions in symptoms were observed. Exploratory analyses of the differences between placebo and medication conditions suggest that the differences between the patients in their average alliance levels predicted a greater reduction in symptoms in the placebo compared to the medication conditions (p = 0.008). The main limitation is the small cohort size. Conclusions: The findings suggest an effect of alliance on outcome in psychopharmacology, which is not merely the result of previous symptomatic levels. This effect may be more robust in conditions that do not include active treatment (placebo), possibly serving as a compensatory effect.

Current Psychosomatic Practice

“…These findings shed new light on classic psychosomatic studies exploring patient-doctor interactions [149,150]. Expectations, preferences, motivation, and quality of patient-doctor interactions are examples of variables that may affect treatment outcomes [151,152,153]. In a pioneer study [154], a small amount of individual attention and education (about what to expect during the postsurgical period) by the anesthetist resulted in a significantly lower requirement of postsurgery analgesia and a shorter hospital stay compared to a control group submitted to usual postsurgical care.…”

New analytic strategies help answer the controversial question of whether alliance is therapeutic in itself

“…In total, we retained 19 RCTs in our meta-analysis [1][2][3][4][5][6][7][8][9][10][11][12][13][14][15][16][17][18][19] , totaling 181 patients with bipolar disorder (type I, N540; type II, N520; unspecified, N5121). The RCTs employed different stimulation targets: the left dorsolateral prefrontal cortex (DLPFC) [1][2][3][4][5][6][9][10][11]13,16,17 , the right DLPFC 8,14,15,18 , or bilateral DLPFC 7,12,17,19 .…”

“…The RCTs employed different stimulation targets: the left dorsolateral prefrontal cortex (DLPFC) [1][2][3][4][5][6][9][10][11]13,16,17 , the right DLPFC 8,14,15,18 , or bilateral DLPFC 7,12,17,19 . The majority of studies delivered high-frequency stimulation (HFS) 1,[3][4][5][6][9][10][11][12][13]16,18 , while some delivered low-frequency stimulation (LFS) 3,8,9,15,18 , sequential LFS and HFS 7,17,19 , or theta burst stimulation (TBS) 2,14,17 .…”

“…Recent studies used statistical methods such as autoregressive cross-lagged modeling to examine whether alliance levels precede symptomatic levels, session by session over the entire course of treatment. The findings show that alliance indeed precedes symptom reduction over the course of treatment in both psychotherapy [5][6][7] and psychopharmacotherapy 8 , suggesting that it is a true predictor of outcome.…”

Clinical Pharmacopsychology: Conceptual Foundations and Emerging Tasks

“…Each therapeutic act may be seen as a result of multiple ingredients that may be specific or nonspecific: expectations, preferences, motivation, illness behavior, and patient-doctor interactions are examples of variables that may affect treatment outcome [68,69,70]. Such variables may be the object of study of clinical pharmacopsychology.…”