Evidence Based Treatments are Superior to Treatment as Usual for the treatment of Depression and Anxiety: Really?

By:  Christopher Christian, PhD

It has become conventional wisdom that evidence-based treatments (EBTs) are the treatment of choice for conditions in which they have proven to be superior when compared to treatment as usual (TAU).
That certainly should be how you answer any question regarding evidence-based treatment in your psychology licensing exam.  However, a recently published study (2011) in the journal *Clinical Psychology*, entitled *“Evidence-based treatments for depression and anxiety versus treatment-as-usual: A meta-analysis of direct comparisons”* by Wampold, Budge, Laska, Del Re, Baardseth, Fluckiger, Minami, and Gunn, throws into question this conventional wisdom.
The authors conclude that once the quality of TAUs is assessed and
controlled for, they have similar outcomes to EBT.  Their meta-analysis of 14 studies showed that many design operations in studies comparing TAU and EBT favor EBT (e.g., a greater dose of therapy for EBT patients or supervision of EBT therapists only). From the article we learn that often when we talk about comparisons between EBT and treatment as usual, what is being compared is the introduction of an EBT to a setting where no form of psychotherapy was being provided in any way that assured quality of care!  When you consider the quality of the TAU and adjust for things like the amount of supervision, the number of sessions, the type of supervision, you can make a more adequate comparison to EBT.  In their meta-analysis, the authors also made sure to exclude from the research any studies that imposed limitations on how the TAU therapy was conducted, when such limitations were meant to circumscribe the treatment to techniques that did not overlap with techniques in the EBT. After all, in usual care, therapists are flexible in their techniques.  The researchers conclude and convincingly show that the quality of the comparisons between EBT and TAU are not sufficient to make claims about whether EBT is more beneficial than TAU for the treatment of anxiety and depression. In fact, they found that in most of the studies included in the meta-analysis, it was possible that a patient in the TAU condition received little or *no* treatment, whereas a patient in the EBT condition received approximately 12 sessions by a therapist who received special training and received supervision during the course of therapy.  So, what can be stated with some degree of certainty is that implementing EBTs into routine care that does not involve any form of psychotherapy would improve the quality of care. I guess that's encouraging.