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Letter to the editor
The efficacy of short-term psychodynamic
psychotherapy for depression: a summary
of recent findings
DOI: 10.1111/j.1600-0447.2009.01526.x
To the editor:
We commend Malhi et al. (1) and this journal for publishing
excellent clinical practice recommendations for depression. We
write to highlight new findings supporting Short-Term Psy-
chodynamic Psychotherapy (STPP) for depression which, using
the authorsÕcriteria requiring a systematic review of random-
ized controlled trials (1), may result in increasing the level of
evidence for this treatment.
We recently published a meta-analysis of group and
individual STPP for depression (2), including 23 studies
totaling 1365 patients. We found STPP resulted in large
symptom reductions (d=1.34), that were maintained until
1-year follow-up. STPP was found superior to controls
(d= 0.69), but somewhat less efficacious than other psycho-
therapies at post-treatment (d=)0.30). However, we found
no significant differences at 3- and 12-month follow-up
(d=)0.05; d=)0.29). Individual STPP (d= 1.43) was
more effective than group STPP (d= 0.83), and as effective
as other individual psychotherapies at post-treatment
(d=)0.19), 3- and 12-month follow-up (d=)0.05 and
)0.31; all non-significant). These findings add to the evidence-
base of STPP for depression and may result in an increase to
the highest level of evidence according to the criteria used by
Malhi et al. (1).
Furthermore, STPP has been found effective at reducing
symptoms in treatment resistant depression (3) and personal-
ity-disordered depressed patients (4). A recent review (5) found
STPP producing robust and persistent symptom-reducing
effects for personality-disordered patients (d= 0.97). These
findings render STPP a treatment of choice for these depressed
populations that are frequently non-responsive to initial
depression treatment.
A. Abbass,E. Driessen,
Department of Clinical Psychology,
VU University Amsterdam, Amsterdam,
the Netherlands
1. Malhi GS, Adams D, Porter R et al. Clinical practice rec-
ommendations for depression. Acta Psychiatr Scand
2. Driessen E, Cuijpers P, De Maat SCM, Abbass AA, De Jonghe
F, Dekker JJM. The efficacy of short-term psychodynamic
psychotherapy for depression: a meta-analysis. Clin Psychol
Rev 2010;30:25–36.
3. Abbass A. Intensive short-term dynamic psychotherapy in
treatment resistant depression: a pilot study. Depress Anx-
iety 2006;23:449–552.
4. Hardy GE, Barkham M, Shapiro DA, Stiles WB, Rees A,
Reynolds S. Impact of cluster C personality disorders on
outcomes of contrasting brief psychotherapies for depres-
sion. J Consult Clin Psychol 1995;63:997–1004.
5. Messer S, Abbass A. Evidence-based psychodynamic therapy
with personality disorders. In: MAGNAVITA J, ed. Evi-
dence-Based Treatment of Personality Dysfunction: Princi-
ples, Methods and Processes. Washington, DC: American
Psychological Association Press (in press).
DOI: 10.1111/j.1600-0447.2009.01527.x
We welcome the brief correspondence by Abbass and Driessen
(1) that provides a summary of recent research findings in
relation to the efficacy of Short-Term Psychodynamic Psycho-
therapy (STPP) for the treatment of depression. The findings
from the cited meta-analysis (2) endorse our position that
psychological strategies should be given greater consideration
(3). Whether in the context of combination treatment, where
short-term therapy supplements effective medication or is
delivered alone, the benefits of such therapy are implicated in
the longer-term, especially when the acute phase of depression is
targeted (4, 5).
The comparative efficacy of STPP to other psychotherapies
including cognitive behaviour therapy, cognitive therapy,
behaviour therapy, supportive therapy, non-directive counsel-
ing, and art therapy (2, 6, 7) is interesting and reflects clinical
experience with respect to the treatment of depression in that
Ôdoing something is generally better than doing nothingÕ, and as
regards doing something, Ômost interventions when compared
over a short period of time are broadly equal in terms of
effectivenessÕ(8). That is not to say there aren’t genuine
differences between different interventions, but that identifying
specificity or partitioning effect often proves difficult. This is
particularly so in randomized controlled trials, which are
usually powered to demonstrate a difference from placebo but
non-inferiority to an active comparator. Interestingly, this
applies to all therapeutic modalities and includes comparisons
conducted within the ever-expanding pharmacotherapeutic
With respect to the comment from Abbass and Driessen
(1), it is further interesting to note that individual therapy
Acta Psychiatr Scand 2010: 121: 398–399
All rights reserved
2010 John Wiley & Sons A/S
appears to be more effective than that delivered in a group
setting. This suggests that perhaps the therapeutic relationship
which is presumably more readily achieved in a setting with
exclusive interaction, is perhaps key. Overall these recent
findings could elevate the status of STPP to first-line
administration in particular for acute short-term manage-
ment of major depression. However, generalization to more
difficult populations in particular, where there has been
partial or no response to initial treatments, is more conten-
tious and further research is still perhaps needed before a
definitive conclusion can be made.
G. S. Malhi,C. M. Coulston
CADE Clinic, Discipline of Psychiatry,
Sydney Medical School,
University of Sydney, Australia
1. Abbass A, Driessen E. The efficacy of short-term psycho-
dynamic psychotherapy (STPP) for depression: a sum-
mary of recent findings. Acta Psychiatr Scand 2010 (this
2. Driessen E, Cuijpers P, De Maat SCM, Abbass AA, De Jonghe
F, Dekker JJM. The efficacy of short-term psychodynamic
psychotherapy for depression: A meta-analysis. Clin
Psychol Rev (in press).
3. Malhi GS, Adams D, Porter R et al. Clinical practice
recommendations for depression. Acta Psychiatr Scand
4. Rosso G, Crespi C, Martini B, Maina G. Combining brief
dynamic therapy with antidepressants in major depressive
disorder. Clin Neuropsychiatry 2009;6:56–62.
5. Dekker JJM, Koelen JA, Van HL et al. Speed of action: the
relative efficacy of short psychodynamic supportive
psychotherapy and pharmacotherapy in the first 8 weeks of
a treatment algorithm for depression. J Affect Disord
6. Leichsenring F, Salzer S, Jaeger U et al. Short-term
psychodynamic psychotherapy and cognitive-behavioral
therapy in generalized anxiety disorder: a randomized,
controlled trial. Am J Psychiatry 2009;166:875–881.
7. Leichsenring F, Leibing E. Psychodynamic psychotherapy: A
systematic review of techniques, indication and empirical
evidence. Psychol Psychother 2007;80:217–228.
8. Malhi GS, Adams D. Are guidelines in need of CPR? The
development of clinical practice recommendations (CPR).
Acta Psychiatr Scand 2009;119:5–7.
Letter to the editor
Introduction: The aim of this study is to evaluate the clinical efficacy of short-term psychodynamic psychotherapy (STPP) in comparison with treatment as usual (TAU) in treatment of patients suffering from anxiety and depressive disorders. Methods: Sixty patients were recruited from the Psychotherapy Service, University of Milan, Department of Psychiatry, at Milan's IRCCS Foundation Ca' Granda, Ospedale Maggiore Policlinico with the diagnosis of depressive or anxiety disorders according to DSM-IV-TR criteria. These subjects were randomly assigned in a 1:1 ratio to an intervention group (STPP) or control group (TAU) for 12 months (T1). Each patient was clinically evaluated at the moment of recruitment (T0) and after 12 months using a battery composed of these scales: Clinical Global Impression Scale (CGI), Symptom Checklist-90-Revised (SCL-90-R), Inventory of Interpersonal Problems (IIP). Results: Statistical analysis highlighted significant improvements (p<0.05) for the group treated with STPP in every clinical scale. Instead control group revealed significant changes (p<0.05) only for SCL-90 scale scores. We noticed a clinical improvement in both groups without particular differences, but the IIP scores went through a significant higher enhancement only in STPP group. Conclusions: Our results suggest that STPP is so effective as TAU in treatment of anxiety and depressive disorders. Moreover STPP leads to a better recover of relational functioning.
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Brief dynamic therapy (BDT) is a time-limited, focused psychodynamic intervention that derives its principles from the psychoanalytic theory. The efficacy of BDT in the treatment of major depressive disorder (MDD) is still a matter of debate. The purpose of this review is to analyse the results of the studies that have considered the treatment of MDD with the combination of BDT and antidepressant pharmacotherapy. The present paper reviews the most recent studies on the combination treatment of major depressive disorder with BDT. Some findings suggest that supplemental BDT in the acute treatment of patients with major depressive disorder who are receiving effective medication has some significant advantages in comparison with monotherapies (drug or psychotherapy alone). Some recent data also suggest the superiority of brief dynamic therapy over a non-specific supportive psychotherapy. According to some recent investigations, the efficacy of BDT added to medication in the acute treatment of major depressive disorder especially suggests a long-term advantage in recurrences prevention. This could depend on the fact that the primary objective of BDT, which is to enhance the patient's insight into repetitive conflicts (intrapsychic and interpersonal) and trauma, is a specific therapeutic factor: it underlies and sustains the patient's problems not only during the treatment sessions. Long-term efficacy trials in a time-limited treatment represent the most demanding challenge for the authors who sustain BDT. Moreover, future randomized controlled trials to compare BDT with other forms of specific psychotherapy (cognitive-behavioural therapy and interpersonal psychotherapy) in terms of efficacy and cost-effectiveness are needed.
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Somatic symptom disorders are common, disabling and costly. Individually provided short-term psychodynamic psychotherapies (STPP) have shown promising results. However, the effectiveness of STPP for somatic symptom disorders has not been reviewed. We undertook a systematic review of randomized controlled trials and controlled before and after studies. The outcomes included psychological symptoms, physical symptoms, social-occupational function, healthcare utilization and treatment continuation. A total of 23 studies met the inclusion criteria and covered a broad range of somatic disorders. Thirteen were RCTs and 10 were case series with pre-post outcome assessment. Of the included studies, 21/23 (91.3%), 11/12 (91.6%), 16/19 (76.2%) and 7/9 (77.8%) reported significant or possible effects on physical symptoms, psychological symptoms, social-occupational function and healthcare utilization respectively. Meta-analysis was possible for 14 studies and revealed significant effects on physical symptoms, psychiatric symptoms and social adjustment which were maintained in long-term follow-up. Random-effect modeling attenuated some of these relationships. There was a 54% greater treatment retention in the STPP group versus controls. STPP may be effective for a range of medical and physical conditions underscoring the role of patients' emotional adjustment in overall health. Future research should include high-quality randomized and clinical effectiveness studies with attention to healthcare use and costs.
The research evidence for Short-Term Psychodynamic Psychotherapy (STPP) in the treatment of personality disorders (PD) was examined through consideration of studies utilizing randomized controlled designs. An extensive literature search revealed eight published Randomized Controlled Trials (RCT) of moderate study quality. A critical review of this literature is offered to provide an evidence-based guidance for clinicians and implications for treatments are discussed. Preliminary conclusions suggest STPP may be considered an efficacious empirically-supported treatment option for a range of PDs, producing significant and medium to long-term improvements for a large percentage of patients. Further research is recommended to allow comparisons with alternative evidence-based approaches.
To determine whether supportive-expressive psychotherapy (SET), a form of dynamic psychotherapy, and pharmacotherapy + clinical management (MED) for major depressive disorder (MDD) are more effective than pill-placebo + clinical management (PBO). This National Institute of Mental Health (NIMH)-sponsored randomized controlled trial was conducted (from November 2001 through June 2007) at the University of Pennsylvania Medical School. The sample included 156 patients diagnosed with MDD (DSM-IV) and having a 17-item Hamilton Rating Scale for Depression (HRSD(17)) score ≥ 14 for at least 2 consecutive weeks. This was an underserved sample in which 41% were male, 52% were self-designated minorities, and 76% had an annual income under $30,000. Treatment lasted 16 weeks. Medication patients not responsive by week 8 (maximum dose 200 mg/d of sertraline) were switched to venlafaxine (maximum dose 375 mg/d). Nonresponsive placebo patients at week 8 were switched to a different placebo. Patients' depression improved over the 16 weeks (P < .0001), with no between-group differences (P = .95), even among severely (HRSD(17) score ≥ 20) depressed patients (P = .45). Response rates did not differ between groups (P = .73). Gender and minority status moderated outcome (P = .014), with psychotherapy more efficacious for minority men than MED (P = .027, Cohen d = 1.02) and PBO (P = .019, d = 1.09). PBO was more efficacious for white men than MED (P = .03, d = 0.62) and SET (P = .003, d = 1.07). For white women, MED (P = .005, d = 0.77) and SET (P = .033, d = 0.71) were more efficacious than placebo. No differences among treatments were found for minority women. This trial of urban MDD patients failed to confirm that either active treatment was better than placebo. Minority status and gender had significant and differential effects on outcome that warrant replication in future studies. Identifier: NCT00043550.
The presence of comorbid personality disorder (PD) is one of the factors that can make the treatment of depression unsuccessful. Short-term Psychodynamic Psychotherapy (STPP) has been shown efficacious in the treatment of personality and depressive disorders (DD). However, the efficacy of STPP for comorbid DD and PD has not been systematically evaluated. In this study, data from patients meeting criteria for both DD and PD participating from randomized controlled trials of STPP was collected, systematically reviewed, and meta-analyzed where possible. Eight studies were included, 6 with major depression and 2 with minor depressive disorders. Pre- to post- treatment effects sizes were large (d = 1.00-1.27), suggesting symptom improvement during STPP, and these gains were maintained in follow-ups averaging over 1.5 years. For major depression, no differences were found comparing STPP to other psychotherapies, and STPP was found superior to a wait-list condition in one study. STPP may have had an advantage over other therapy controls in treating minor depression as noted in ratings of general psychopathology. Patients with Cluster A/B and C PD were responsive to STPP, with the majority of all studied patients showing clinically significant change on self-report measures. Within the limits of this study, these findings suggest that STPP warrants consideration as a first line treatment for combined personality disorder and depression. Future research directions are proposed.
It remains largely unclear, firstly whether short-term psychodynamic psychotherapy (STPP) is an effective treatment for depression, and secondly, which study, participant, or intervention characteristics may moderate treatment effects. The purpose of this study is to assess the efficacy of STPP for depression and to identify treatment moderators. After a thorough literature search, 23 studies totaling 1365 subjects were included. STPP was found to be significantly more effective than control conditions at post-treatment (d=0.69). STPP pre-treatment to post-treatment changes in depression level were large (d=1.34), and these changes were maintained until 1-year follow-up. Compared to other psychotherapies, a small but significant effect size (d=-0.30) was found, indicating the superiority of other treatments immediately post-treatment, but no significant differences were found at 3-month (d=-0.05) and 12-month (d=-0.29) follow-up. Studies employing STPP in groups (d=0.83) found significantly lower pre-treatment to post-treatment effect sizes than studies using an individual format (d=1.48). Supportive and expressive STPP modes were found to be equally efficacious (d=1.36 and d=1.30, respectively). We found clear indications that STPP is effective in the treatment of depression in adults. Although more high-quality RCTs are necessary to assess the efficacy of the STPP variants, the current findings add to the evidence-base of STPP for depression.
While several studies have shown that cognitive-behavioral therapy (CBT) is an efficacious treatment for generalized anxiety disorder, few studies have addressed the outcome of short-term psychodynamic psychotherapy, even though this treatment is widely used. The aim of this study was to compare short-term psychodynamic psychotherapy and CBT with regard to treatment outcome in generalized anxiety disorder. Patients with generalized anxiety disorder according to DSM-IV were randomly assigned to receive either CBT (N=29) or short-term psychodynamic psychotherapy (N=28). Treatments were carried out according to treatment manuals and included up to 30 weekly sessions. The primary outcome measure was the Hamilton Anxiety Rating Scale, which was applied by trained raters blind to the treatment conditions. Assessments were carried out at the completion of treatment and 6 months afterward. Both CBT and short-term psychodynamic psychotherapy yielded significant, large, and stable improvements with regard to symptoms of anxiety and depression. No significant differences in outcome were found between treatments in regard to the primary outcome measure. These results were corroborated by two self-report measures of anxiety. In measures of trait anxiety, worry, and depression, however, CBT was found to be superior. The results suggest that CBT and short-term psychodynamic psychotherapy are beneficial for patients with generalized anxiety disorder. In future research, large-scale multicenter studies should examine more subtle differences between treatments, including differences in the patients who benefit most from each form of therapy.
To provide clinically relevant evidence-based recommendations for the management of depression in adults that are informative, easy to assimilate and facilitate clinical decision making. A comprehensive literature review of over 500 articles was undertaken using electronic database search engines (e.g. MEDLINE, PsychINFO and Cochrane reviews). In addition articles, book chapters and other literature known to the authors were reviewed. The findings were then formulated into a set of recommendations that were developed by a multidisciplinary team of clinicians who routinely deal with mood disorders. The recommendations then underwent consultative review by a broader advisory panel that included experts in the field, clinical staff and patient representatives. The clinical practice recommendations for depression (Depression CPR) summarize evidence-based treatments and provide a synopsis of recommendations relating to each phase of the illness. They are designed for clinical use and have therefore been presented succinctly in an innovative and engaging manner that is clear and informative. These up-to-date recommendations provide an evidence-based framework that incorporates clinical wisdom and consideration of individual factors in the management of depression. Further, the novel style and practical approach should promote uptake and implementation.