Sofia Hall - Bulgarian Red Cross

Primun non nocere - Side effects in psychological treatments

Per Carlbring, Michael Linden, Steve Hollon, Alexander Rozental Speaker

Track: Adult mental health

Chair/Discussant: Per Carlbring, Stockholm University

Convenor: Johanna Boettcher, Freie Universität Berlin


  • Michael Linden, Charité Berlin, Germany

  • Johanna Boettcher, Freie Universitaet Berlin, Germany

  • Alexander Rozental, Karolinska Institutet, Stockholm, Sweden

  • Steve Hollon, Vanderbilt University, Nashville, USA

Psychological treatments help patients overcome mental health problems. Thousands of studies document the positive effects of psychotherapeutic interventions. The potential of these same interventions to cause harm, on the other hand, has scarcely been subject to scientific investigation. The nature and frequency of side effects of psychological treatments are largely unknown. The present symposium aims at shedding light on some important questions concerning negative effects: How should side effects be defined? What are typical side effects? How frequent are side effects in different treatment formats? And how can side effects be effectively measured?

In the first presentation, Michael Linden will speak about side effects in group therapy and will report data from two different group therapy formats. Johanna Boettcher will focus on side effects of individual therapy for depression. She will present data from a large trial of Internet-based therapy and will summarize a qualitative analysis of the patients’ experience of negative effects. Steve Hollon will talk specifically about one particular side effect, the deterioration of targeted symptoms. He will report results of an individual patient data meta-analysis and compare rates of deterioration in cognitive-behaviour therapy and pharmacotherapy. Finally, Alexander Rozental will present a new questionnaire for the assessment of negative effects and will demonstrate its psychometric properties in a Rasch analysis.

Presentation 1: Negative effects of group psychotherapy

M. Linden1, B. Muschalla1

1 Charité Berlin, Germany

Group psychotherapy is a widely used mode of treatment with similar therapeutic effects than individual psychotherapy. The encounter with other patients can be therapeutically helpful, but also detrimental, as co-patients can make negative comments, start confrontational discussions, give wrong advice, or be a burden to others by inappropriate behavior.

Sixty two patients from a somatic rehabilitation hospital were randomized to cognitive behavioral group therapy or an unspecific group encounter and filled in the Unwanted Events in Group Therapy Scale (UE-G scale).

In the cognitive behavior therapy group 41.9% of the patients reported at least one severe burdensome effect, and 28.9% in the recreational group. Problems were an increase of anxiety and perception of work-problems, crowding in the room, the encounter with other patients, the content of discussions, worries in regard to confidentiality, and demoralization after observing the problems of others.

Group psychotherapy regularly has frequent and severe side effects. There are burdens, which are characteristic for all types of group therapy and others, which are specific for the type of intervention. Therapists should be aware of this and patients should be carefully selected.

Presentation 2: Experiencing negative effects in an online treatment for depression

Johanna Boettcher1, Friederike Fenski1, Pavle Zagorskac1, Alexander Rozental2

1 Freie Universitaet Berlin, Germany

2 Karolinska Institutet, Stockholm, Sweden

Background: Numerous randomized controlled trials show the efficacy of Internet-based interventions (IBI) in the treatment of depression. Only very few studies also focus on investigating potential negative effects. The current study examined side effects of an IBI for depression, making use of quantitative as well as qualitative measures.

Method: N=814 patients with mild to moderate depressive symptoms took part in a 8-week IBI. At the end of treatment, patients completed closed and open-format questions regarding potential side effects. Open questions were subjected to a qualitative content analysis. Quantitative analyses examined consequences and predictors of side effects.

Results: 8.6% of the patients experienced side effects. These included the development of new symptoms, struggling with increased insight, problems with the online format, problems in carrying out treatment tasks, and perceived lack of support. The only significant predictor of side effects was a poor quality of the therapeutic relationship.

Conclusion: A small but significant proportion of patients in IBI for depression experiences side effects, some of them specific to the online format. Patients should be informed about potential side effects prior to the start of treatment and should be encouraged to address these with their online therapist.

Presentation 3: Measuring adverse and unwanted events in psychotherapy

Rozental, A.1,2, Kottorp, A., Forsström, D., Månsson, K., Boettcher, J., Andersson, G., Furmark, T., & Carlbring, P.

1 Department of Clinical Neuroscience, Karolinska Institutet;

2 Institute of Child Health, University College London.


Background: Psychotherapy offers many benefits, but research also indicate that negative effects sometimes occur. The Negative Effects Questionnaire (NEQ) was therefore developed to help researchers and clinicians determine the occurrence and characteristics of such incidents.

Method: The NEQ was evaluated in two studies, using data from both clinical trials and a survey distributed among individuals in the general population (Ns 653 and 564).

Results: The results from an exploratory factor analysis suggest that six factors could be relevant to retain: symptoms, quality, dependency, stigma, hopelessness, and failure, with poor treatment quality and therapeutic relationship having the highest self-rated negative effects. Further, the results from a Rasch analysis, a modern test theory application, suggest that the self-report measure exhibits fairness in testing across sociodemographics and that it is suitable for monitoring items with regard to their frequencies or levels of impact. Overall, 18.8% of the patients experienced more stress, 12.6% reported the resurfacing of unpleasant memories, and 12.2% were more anxious during treatment, implying that adverse and unwanted events are not uncommon in psychotherapy and may have to be monitored.

Conclusion: The NEQ could be a useful self-report measure to investigate negative effects in both research and clinical practice.

Presentation 4: Divergent Outcomes in Cognitive-Behavioral Therapy and Pharmacotherapy for Adult Depression

Hollon, S.1, Vittengl, J.R., Jarrett, R.B., Weitz, E., Cuijpers, P.

1 Vanderbilt University, USA

Objective: Although the average depressed patient benefits moderately from cognitive-behavioral therapy (CBT) or pharmacotherapy, some experience divergent outcomes. The authors tested frequencies, predictors, and moderators of negative and unusually positive outcomes.

Method: Sixteen RCTs comparing CBT and pharmacotherapy for unipolar depression in 1,700 patients provided individual pre- and post-treatment scores on the Hamilton Depression Rating Scale (HAM-D) and/or Beck Depression Inventory (BDI). The authors examined demographic and clinical predictors and treatment moderators of any deterioration, reliable deterioration, extreme nonresponse, superior improvement, and superior response using multilevel models.

Results: About 5%-7% of patients showed any deterioration, 1% reliable deterioration, 4%-5% extreme nonresponse, 6%-10% superior improvement, and 4%-5% superior response. Superior improvement on the HAM-D only (OR=1.67) and attrition (OR=1.67) were more frequent in pharmacotherapy than in CBT. Patients with deterioration or superior response had lower pretreatment symptom levels, whereas patients with extreme nonresponse or superior improvement had higher levels.

Conclusions: Deterioration and extreme nonresponse and, similarly, superior improvement and superior response, both occur infrequently in randomized clinical trials comparing CBT and pharmacotherapy for depression. Pretreatment symptom levels help forecast negative and unusually positive outcomes but do not guide selection of CBT versus pharmacotherapy. Pharmacotherapy may produce clinician-rated superior improvement and attrition more frequently than does CBT.