Article

A randomised controlled trial of Intensive Short-Term Dynamic Psychotherapy for treatment resistant depression: the Halifax Depression Study

March 2017
Journal of Affective Disorders 214(Suppl 1)

DOI:10.1016/j.jad.2017.02.035

Authors:

Joel M Town

Dalhousie University

Allan Abbass

Dalhousie University

Chris Stride

The University of Sheffield

Denise Bernier

Dalhousie University

Background While short-term psychodynamic psychotherapies have been shown effective for major depression, it is unclear if this could be a treatment of choice for depressed patients who have not sufficiently responded to existing treatments and commonly have chronic and complex health issues. Method This superiority trial used a single blind randomised parallel group design to test the effectiveness of time-limited Intensive Short-Term Dynamic Psychotherapy (ISTDP) for treatment resistant depression (TRD). Patients referred to secondary care community mental health teams (CMHT) who met DSM-IV criteria for major depressive episode, had received antidepressant treatment 6 weeks, and had Hamilton Depression Rating Scale (HAM-D) scores of  16 were recruited. The effects of 20 sessions of ISTDP were judged through comparison against secondary care CMHT treatment as usual (TAU). The primary outcome was HAM-D scores at 6 months. Secondary outcomes included dichotomous measures of both remission (defined as HAM-D score  7) and partial remission (defined as HAM-D score  12). Results Sixty patients were randomised to 2 groups (ISTDP=30 and TAU=30), with data collected at baseline, 3, and 6 months. Multi-level linear regression modelling showed that change over time on both depression scales was significantly greater in the ISTDP group in comparison to TAU. Statistically significant between-group treatment differences, in the moderate to large range, favouring ISTDP, were observed on both the observer rated (Cohen’s d = 0.75) and self-report measures (Cohen’s d = 0.85) of depression. Relative to TAU, patients in the ISTDP group were significantly more likely after 6 months to achieve complete remission (36.0% vs. 3.7%) and partial remission (48.0% vs. 18.5%). Limitations It is unclear if the results are generalizable to other providers, geographical locations and cultures. Conclusions Time-limited ISTDP appears an effective treatment option for TRD, showing large advantages over routine treatment delivered by secondary care services.

The anger-depression mechanism in dynamic therapy: Experiencing previously avoided anger positively predicts reduction in depression via working alliance and insight

Article

Full-text available

Jul 2021
J COUNS PSYCHOL

Objective: A central tenet of psychodynamic theory of depression is the role of avoided anger. However empirical research has not yet addressed the question of for which patients and via hat pathways experiencing anger in sessions can help. The therapeutic alliance and acquisition of patient insight are important change processes in dynamic therapy and may mediate the anger-depression association. Methods: This study was embedded into a randomised trial testing the efficacy of Intensive Short-Term Dynamic Psychotherapy (ISTDP) for treatment resistant depression. In-session patient affect experiencing (AE) was coded for every available session (475/481) by blinded observers in 27 patients randomized to ISTDP. Dynamic Structural Equation Modelling was used to examine within-person associations between variation in depression scores session-by-session and both patient ratings (alliance) and observer ratings (AE and insight) of the treatment process. Results: Alliance and insight were independent mediators of the effect of anger on next-session depression. However, the relative importance of these two indirect effects of anger on depression was conditional on pre-treatment patient personality pathology (PP). In patients with higher PP, in-session anger was negatively related to depressive symptoms next-session, with this effect operating through higher alliance. In patients with low PP, in-session anger was negatively related to depressive symptoms next-session, with this effect operating through enhanced patient insight. Discussion: These findings highlight an anger-depression mechanism of change in dynamic therapy. Depending upon patient personality, either an ‘insight pathway’ or a ‘relational pathway’ may promote the effectiveness of facilitating arousal and expression of patients’ in-session feelings.

Epistemological flaws in NICE review methodology and its impact on recommendations for psychodynamic psychotherapies for complex and persistent depression

Chapter

Jun 2020

The Social and Interpersonal Origins of Depression Today

Book

Mar 2020

Originally published as a special issue of Psychoanalytic Psychotherapy, this collection was timed to coincide with the publication of the new NICE guideline for the treatment of depression, which will shape the context of NHS talking therapy services for the next decade. In 2005, Professor Lord Layard demonstrated for the first time that mental health should matter to the UK Treasury. Layard showed that the cost of untreated depression was huge due to welfare spending on invalidity benefits, and that this was a social problem rising across the OECD, but more so in the UK. NICE had already published a clinical guideline recommending several talking therapies that were cost-effective. Why could no one still get them? In 2007, under New Labour, the world's first universal free-at-the-point-of-need service was launched to remedy this: IAPT Improving Access to Psychological Therapies. Thus began a race against depression, predicted by the World Health Organisation to become the leading cause of disability worldwide by 2020. But on the eve of NICE’s new guideline for depression, due in 2021, it is now clear that across large parts of the UK we are set to lose this race. Badly. Why? What went wrong? Clarke, Cundy and Yakeley have brought together a group of researchers and experts in this collection who address some of the fundamental flaws in the policy design for IAPT. By drawing attention to neglected social and interpersonal origins of depression, pointing us towards more effective approaches, and seeking to pinpoint some of the gaps in thinking during IAPT's first decade, this book offers alternative answers to what still remains Britain’s biggest social problem.

Relationships, Emotions, and Defenses Among Patients with Substance Use Disorders, Assessed with Karolinska Psychodynamic Profile: Possibilities to use Intensive Short-Term Dynamic Psychotherapy in Substance Abuse Treatment

Article

Full-text available

Nov 2018

Substance use disorders (SUDs) are connected to emotional and relational difficulties. Intensive Short-Term Dynamic Psychotherapy (ISTDP) aims at supporting emotion regulation and relational capacity through confronting the patient’s defenses. The authors assessed relational capacity, emotion regulation, and defenses in nine patients with severe SUD and a history of childhood maltreatment, using the semistructured method Karolinska Psychodynamic Profile. All participants had difficulties in handling interpersonal dependence and separations. Functioning in other areas varied. ISTDP could be useful in substance abuse treatment. Thorough assessment before starting ISTDP is however recommended so that treatment is planned according to the patients’ level of functioning.

Feelings as a therapy compass- Towards a cross-school treatment heuristic (Part 3): Affect-focused Transtheoretical Experiential Model of Change (ATEM)- Illustration of methods of emotion regulation and emotion transformation on the basis of contrasting procedures (ACT -EFT -ISTDP)

Preprint

Full-text available

Mar 2023

The original German version can be found in a separate RG research item. Summary I feel (Damasio), I think (Descartes), therefore I am. Across therapy schools, there is agreement that working on maladaptive thoughts and feelings is critical to facilitating sustainable therapeutic change for a more resilient self in the world. In two previous steps we have elaborated that emotional processing problems are at the core of mental disorders. We have presented a compass for differentiating levels of feelings and how these can more easily guide through therapy. Now we will illustrate this compass in more detail using interventions from three different psychotherapeutic approaches as examples. In the first part (Meissner et al., 2023a) we presented the tension between basic emotion theories and the often interchangeably used feeling terms in order to derive a unified terminology that is practicable for the field of psychotherapy. The feeling compass presented there can simplistically navigate three essential emotional processing levels (affects, predictive emotion schemas, conscious narratives) and helps integrate "mind and body" on the way to more adaptive emotions and self-regulation. In a second part, we then developed implications for therapeutic work, focusing on the question of when "top-down" work on feelings with emotion regulation interventions or "bottom-up" working through feelings with emotion evocation interventions is more appropriate. We now derive a cross-school treatment heuristic ("Affect-focused Transtheoretical Experiential Model of Change", ATEM). In doing so, we bring together evidence-based psychotherapeutic and neuroscience-based process models. Using three innovative therapeutic approaches ISTDP (Intensive Short-Term Dynamic Psychotherapy), EFT (Emotion Focused Therapy) and ACT (Acceptance and Commitment Therapy), each with roots in the three well known approaches of psychoanalysis, humanistic therapy and behavioral therapy. We will illustrate and contrast how a feeling compass can navigate through processing levels in the treatment of disorder-related maladaptive (emotion) schemas. Thus, our integrative heuristic for working with differentiated types of feelings on the axes of "structure" (neurobiological processing level) and "time course of a therapy session" (processing phases) can orient therapeutic work in three steps each. This model can also represent an entire course of treatment, because with a clear therapy focus, each session is a condensed version of the pursuit of an overarching therapy goal that, at best, remains focused on the central emotion processing problem and aims at adaptive affect regulation.

Gefühle als Therapiekompass - Auf dem Weg zu einer schulenübergreifenden Behandlungsheuristik (Teil 3): Allgemeiner Therapiekompass emotionsfokussierter Methoden (ATEM) - Illustration von Methoden der Emotionsregulation und Emotionstransformation anhand kontrastierender Verfahren (ACT -EFT -ISTDP)

Preprint

Full-text available

Nov 2022

Zusammenfassung: Ich fühle (Damasio), ich denke (Descartes), also bin ich. Therapieschulen-übergreifend besteht Einigkeit darüber, dass die Arbeit an ungesunden Gedanken und Gefühlszuständen von entscheidender Bedeutung ist, um nachhaltige therapeutische Veränderungen zu ermöglichen für ein resilienteres Selbst in der Welt. Der zentrale Stellenwert von emotionalen Verarbeitungsproblemen als Kern von psychischen Störungen und wie ein Gefühlskompass für die Psychotherapie als richtungsweisend verstanden werden kann, wurde in zwei vorangegangenen Schritten herausgearbeitet, um nun am Beispiel von Interventionen aus drei unterschiedlichen psychotherapeutischen Ansätzen illustriert zu werden. Im ersten Teil (Meißner et al., 2022a) haben wir das Spannungsfeld grundlegender Emotionstheorien und die oft austauschbar verwendeten Gefühlsbegriffe vorgestellt, um eine einheitliche Terminologie abzuleiten, die für die psychotherapeutische Praxis praktikabel ist. Der dort vorgestellte Gefühlskompass kann vereinfachend auf drei wesentlichen emotionalen Verarbeitungsebenen navigieren (Affekte, Emotionsschemata, Narrative) und hilft, "Verstand und Herz" zu integrieren auf dem Weg zu einer resilienteren Emotions-und Selbstregulation. In einem zweiten Teil haben wir dann Implikationen für die therapeutische Arbeit entwickelt; hierbei lag der Fokus auf der Frage, wann eher eine "top-down"-Arbeit mit Interventionen zur Emotionsregulation oder eher "bottom-up"-Arbeit mit Interventionen zur Emotionsevokation indiziert ist. Wir leiten nun eine schulenübergreifende Behandlungsheuristik ab ("Allgemeiner Therapiekompass emotionsfokussierter Methoden", ATEM). Wir führen dabei evidenzbasierte psychotherapeutische und neurowissenschaftlich fundierte Prozessmodelle zusammen. Anhand dreier innovativer Therapieansätze ISTDP (Intensive Short Term Dynamic Psychotherapy), EFT (Emotionsfokussierte Therapie) und ACT (Acceptance and Commitment Therapy) mit jeweiligen Wurzeln in den drei "großen Schulen" Psychoanalyse, Humanistische Therapie und Verhaltenstherapie, soll illustriert und kontrastiert werden, wie ein Gefühlskompass durch emotionale Verarbeitungsebenen navigieren kann bei der Behandlung störungsbezogener maladaptiver (Emotions-) Schemata. Damit kann unsere integrative Heuristik zur Arbeit mit Emotionen auf den Achsen "Struktur" (neurobiologische Emotionsprozessierungsebene) und "Zeitverlauf einer Therapiesitzung" (Emotionsprozessierungsphasen) in jeweils drei Schritten die therapeutische Arbeit orientieren. Dieses Modell kann auch einen gesamten Behandlungsverlauf repräsentieren, denn jede Sitzung ist bei einem klaren Therapiefokus eine kondensierte Variante der Verfolgung eines übergeordneten Therapiezieles, das bestenfalls am zentralen Emotionsverarbeitungsproblem orientiert bleibt.

Psicanálise Funciona? Avaliando a Prova Cabal de Christian Dunker

Preprint

Full-text available

Mar 2022

Discussões sobre a cientificidade e eficácia da psicanálise têm se popularizado, impulsionadas em parte pelo movimento da Psicologia Baseada em Evidências. Há casos em que determinados estudos são citados para atestar a eficácia de terapias psicanalíticas ou psicodinâmicas, mas pouco é discutido sobre sua qualidade metodológica, característica crucial para a justificação das intervenções. Neste artigo realizamos uma avaliação da qualidade metodológica de 17 artigos denominados como “provas cabais a favor da eficácia da psicanálise” pelo psicanalista Christian Dunker. Conduzimos avaliações pareadas e independentes sobre um estudo quase-experimento com o instrumento ROBINS-I, três ensaios clínicos randomizados com o instrumento RoB 2 e duas revisões sistemáticas, além de seis metanálises, com o instrumentos AMSTAR 2. Também discutimos a pertinência de um relato de experiências e quatro revisões narrativas. Além disso, esclarecemos confusões comuns sobre as diferenças entre avaliar a cientificidade de uma teoria e avaliar a eficácia de uma terapia, bem como as diferenças entre terapias psicanalíticas e psicodinâmicas. Ao final, os resultados mostraram que todos os estudos listados por Dunker ou obtinham a pior classificação possível para o respectivo delineamento, ou não eram de delineamentos adequados para responder sobre eficácia psicoterápica, o que impede que sejam tratados como boas provas a favor de terapias psicodinâmicas ou psicanalíticas.

Comparing outcomes in chronic depression following inpatient psychotherapy for patients continuing versus discontinuing antidepressant medication

Article

Full-text available

Feb 2021
CLIN PSYCHOL PSYCHOT

Research indicates combination of psychotherapy and antidepressant medication (ADM) provide cumulative effects and thus outperforms monotherapy in treating chronic depression. In this quasi‐experimental study, we explored symptom change for patients with chronic depression treated with ADM when presenting for a 12‐week psychotherapeutic inpatient treatment program. We compared outcomes through treatment and follow‐up of patients who continued medication with those who discontinued. We also tested possible moderator effects of initial depression severity on change between the groups. Based on prior research, we hypothesized that combination treatment would yield better results (i.e., more reduction in depression). Patients (N=112) were referred from general practitioners or local secondary health care. Outcome was measured by Beck Depression Inventory‐II (BDI‐II) and comparisons were carried out using multi‐level modelling. While 35 patients discontinued ADM during treatment, 77 continued. Both continuers and discontinuers had a significant treatment effect that was maintained at one‐year follow up. There was no difference in outcome between continuers and discontinuers of ADM. Patients with severe depression had significantly more symptom improvement than patients with moderate depression, but depression severity did not affect outcomes across continuers and discontinuers of ADM differently. The results could indicate that patients had developed resistance and/or tolerance to the prophylactic effects of medication and that ADM did not contribute to the reduction of depressive symptoms. The findings may also indicate psychotherapy alone in some instances can be a viable alternative to continued combined treatment. Clinicians should carefully assess benefits of patients´ ongoing use of antidepressant medication when entering psychotherapy.

Psychodynamic Therapy in Canada in the Era of Evidence-based Practice

Article

Oct 2020
Psychoanal Psychother

In this article, Canadian psychotherapy researchers and teachers review the state of psychodynamic therapy (PDT) in Canada. We review the ways in which PDT has been implemented, developed and researched within the public and private sector, and how psychoanalytic and psychodynamic practitioners regionally have responded to the challenges of evidence-based practice and the emphasis on empirically supported treatments (EST) as it is defined today. We note that neglect and misrepresentation of the scientific evidence behind PDT has resulted in its marginalization. There is also a dearth of evidence collected to measure the effectiveness of implementing EST. Based on its empirical standing, we propose a model of care that incorporates PDT as an effective, evidence-based model for first line treatment, and also as an alternative for those patients who do not respond to other treatments or who express a preference for PDT or insight-oriented therapy.

Short term psychodynamic psychotherapy (STPP) for clients with complex and enduring difficulties within NHS mental health services: a case series

Article

Aug 2020

Purpose: Short Term Psychodynamic Psychotherapy (STPP) has been demon- 10 strated as an effective treatment for several mental health difficulties. However, its implementation in secondary mental health services in the National Health Service (NHS) is scarce. The aim of this study was to bridge the gap between controlled trials and practice-based evidence, by exploring an initial estimate of the therapeutic effects of this intervention as well as its 15 safety in a secondary care NHS community mental health setting. Method: The study followed a quantitative case series design. Eight clients with com- plex, enduring mental health difficulties, supported by a community secondary mental health service received a course of STPP. They completed outcome measures at the start, at the end and eight-weeks following completion of 20 therapy. Results: All participants but one completed the therapy and atten- dance rates were high (>75%). No adverse effects were reported. All partici- pants but two reported improvement in the CORE-OM, BSI and the PHQ-9 and these were maintained at follow-up. Conclusions: The results suggested that STPP was a safe and acceptable intervention, that may have contributed to 25 clinical and reliable improvement for 4 participants, non-reliable improvement for 2 and non-reliable deterioration for one participant who finished the treatment.

Efficacy of intensive short-term dynamic psychotherapy in mood disorders: A critical review

Article

May 2020
J AFFECT DISORDERS

Background Intensive Short-Term Dynamic Psychotherapy (ISTDP) is an intervention introduced by Davanloo in order to treat affective and somatic symptoms, and personality disorders. It is a brief intervention aimed to reach awareness of painful or forbidden emotions and consequently to override symptoms and self-destructive tendencies. In this review we examine the efficacy of ISTDP on symptoms of patients with Major Depressive Disorder (MDD) and Bipolar Disorder (BD). Methods A thorough search of articles in Pubmed, PsycINFO, Isi Web of Knowledge was carried out in order to obtain available studies of ISTDP for BD and MDD. We included all studies conducted on patients with a diagnosis of MDD or BD and who received ISTDP. Results Eight studies were included. These were two randomized controlled trials and six observational studies. Overall the results of the included manuscripts suggest a positive effect of ISTDP on depressive symptoms for patients affected by mood disorders. Furthermore, they suggest ISTDP maybe cost-effective through reducing doctor visits and hospitalizations in follow-up. Limitations Most studies had small samples and consisted of non-randomized trials. Conclusions These are preliminary positive results on the effectiveness of this approach for the treatment of depressive symptoms. They have to be confirmed by studies with larger sample sizes and by comparing this technique with other psychological treatments such as cognitive-behavioural therapy.

Dynamic Psychotherapy: The Therapeutic Process in the Treatment of Obsessive-Compulsive Disorder

Article

Full-text available

Dec 2019

Dynamic Psychotherapy (DP) was developed to overcome the limitations of traditional psychoanalysis, responding to a broader demand of patients who seek help to cope with specific problems in the short term, such as Obsessive-Compulsive Disorder (OCD). OCD is a chronic disabling mental disorder that leads to substantial distress, functional disability and severe occupational and social impairments. Recognizing the literature gap in this field, and the improvements reported by dynamic therapists who have dealt with patients suffering from OCD, a study on the treatment of these patients was conducted in order to discuss the effects of this technique. The method involved a narrative literature review and the analysis of two clinical cases to discuss therapeutic processes, which include the specificities of OCD patients and the mechanisms adopted in the treatment through DP. The therapist's active stance seemed to be essential to encourage the patient to face feared situations and identify the core conflict. Both patients who were treated through DP presented similarities, such as high anxiety, feelings of guilt and inhibition of aggressive and sexual impulses. Through emotional exploration, confrontation of defensive functioning and interpretative interventions of inner conflicts, patients had reached awareness of their hidden feelings and experiences, and their symptoms and feelings of guilt decreased. They also showed significant improvements in their interpersonal relationships. Although both treatments do not fit into short-term therapies, this technique has led to long-term results, providing evidence that DP may produce favorable outcomes in the treatment of OCD.

Therapists' views on the challenges and helpful factors in long-term psychoanalytic therapy for treatment-resistant depression

Conference Paper

Oct 2018

Guy Maissis

Background: The Tavistock Adult Depression Study (TADS) demonstrated that long- term psychoanalytic therapy is more effective for Treatment-Resistant Depression (TRD) than treatment as usual, reporting that 30% of the patients reached partial remission. Aim: The aim of this study was to explore the experiences of the therapists, who provided TADS’ psychoanalytic therapies, and in particular, their views on the challenges and helpful factors to the therapeutic process and its outcome. Methods: Thematic analysis was used to analyse 23 Private Theories Interviews, which were conducted with therapists who treated patients that experienced partial remission after completing the 18-month treatment. Partial remission was defined as a Hamilton Depression Rating Scale score < 12. Secondary exploratory analysis compared the emerging themes between two groups of patients based on their outcome at the end of a 42-month follow-up: patients who sustained their remission (n = 11) and patients who did not (n = 12). Results: The analysis identified two main themes as helpful: ‘a containing and meaningful therapeutic relationship’ and ‘an effective psychoanalytic intervention’. Challenges were attributed to the effects of patients’ pathology on their views of the therapy and on their therapists. Only ‘insight gain’ was found to be identified differently depending on patients’ sustainment of remission. Conclusion: Establishing the therapeutic relationship through effective containment of patients over time was highlighted as a priority, as it enabled therapists to address patients’ pathology more directly. A multitude of pathological mechanisms and techniques were used, supporting the view of TRD as a broad category of depression. The effects of patients’ pathology interfered with the therapeutic efforts, and were mitigated by use of supervision and the support of others’ involved in the patients’ care. Further research is needed to understand the mechanisms of establishing patients’ sense of safety within the therapy and the effects of therapeutic changes on long-term outcome.

Which patients benefit from adding short-term psychodynamic psychotherapy to antidepressants in the treatment of depression? A systematic review and meta-analysis of individual participant data

Article

Full-text available

Nov 2022

Background Adding short-term psychodynamic psychotherapy (STPP) to antidepressants increases treatment efficacy, but it is unclear which patients benefit specifically. This study examined efficacy moderators of combined treatment (STPP + antidepressants) v. antidepressants for adults with depression. Methods For this systematic review and meta-analysis (PROSPERO registration number: CRD42017056029), we searched PubMed, PsycINFO, Embase.com, and the Cochrane Library from inception to 1 January 2022. We included randomized clinical trials comparing combined treatment (antidepressants + individual outpatient STPP) v. antidepressants in the acute-phase treatment of depression in adults. Individual participant data were requested and analyzed combinedly using mixed-effects models (adding Cochrane risk of bias items as covariates) and an exploratory machine learning technique. The primary outcome was post-treatment depression symptom level. Results Data were obtained for all seven trials identified (100%, n = 482, combined: n = 238, antidepressants: n = 244). Adding STPP to antidepressants was more efficacious for patients with high rather than low baseline depression levels [ B = −0.49, 95% confidence interval (CI) −0.61 to −0.37, p < 0.0001] and for patients with a depressive episode duration of >2 years rather than <1 year ( B = −0.68, 95% CI −1.31 to −0.05, p = 0.03) and than 1–2 years ( B = −0.86, 95% CI −1.66 to −0.06, p = 0.04). Heterogeneity was low. Effects were replicated in analyses controlling for risk of bias. Conclusions To our knowledge, this is the first study that examines moderators across trials assessing the addition of STPP to antidepressants. These findings need validation but suggest that depression severity and episode duration are factors to consider when adding STPP to antidepressants and might contribute to personalizing treatment selection for depression.

Intensive short-term dynamic psychotherapy (ISTDP) offers unique procedures for acceptance of emotion and may contribute to the process-based therapy movement

Article

Full-text available

Jul 2022

A variety of contemporary cognitive behavioral therapy (CBT) frameworks have collectively converged on acceptance of emotion as a therapeutic process central to producing positive outcomes. However, evidence shows that not all patients respond to these treatments, such as those with more severe and complicated symptomatology and more entrenched emotion avoidance tendencies. Intensive short-term dynamic psychotherapy (ISTDP) is a specific, highly active, emotion-focused model of therapy grounded in empirical research that was designed to treat complex patients with entrenched emotion avoidance behaviors. This paper presents the clinical techniques of ISTDP to illustrate its methods of facilitating acceptance of emotion, which is likely unfamiliar to many CBT therapists. Leaders of the field in CBT have recently made calls for psychotherapy, including CBT, to move toward a focus on process-based therapy (PBT), which seeks to highlight and investigate promising change processes and their related change procedures, no matter their original therapeutic framework. In introducing ISTDP techniques to CBT and PBT researchers and therapists, we seek to stimulate awareness, curiosity, and further collaboration in the study and use of these techniques in the hopes that ISTDP may contribute to the PBT movement.

Emotional clarity and tolerance of emotional distress as mechanisms of change in short-term psychodynamic psychotherapy for chronic depression

Article

Apr 2022

Objective: The aim of this naturalistic process study was to investigate the relationship between emotional clarity and tolerance of emotional distress and depressive symptoms over the course of short-term psychodynamic psychotherapy for chronically depressed patients. Method: Weekly self-reports of emotional clarity, tolerance of emotional distress, and depressive symptoms (PHQ-9) were provided by 252 patients with chronic depression who were admitted to a 13-week inpatient treatment program. Latent curve modeling with structured residuals (LCM-SR) was applied to investigate the between- and within-person effects of week-to-week change in emotional clarity and tolerance of emotional distress as predictors of subsequent depression. The relationship between emotional clarity and tolerance of emotional distress was also investigated. Results: At the within-person level, higher level of emotional clarity and tolerance of emotional distress predicted subsequent lower level of depression. A reciprocal relationship was found for tolerance of emotional distress (lower level of depression predicted subsequent level of tolerance emotional distress) but not for emotional clarity. No within-person effect between emotional clarity and tolerance of emotional distress was found. Discussion: The results indicate that emotional clarity and tolerance of emotional distress may be mechanisms of change in short-term psychodynamic psychotherapy for chronic depression. The results are consistent with previous findings of the importance of emotional clarity and tolerance of emotional distress in psychotherapy. This study demonstrated the utility of LCM-SR as a method to identity mechanisms of change in psychotherapy. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Psychodynamic Psychotherapy

Chapter

May 2022

The phrase “psychodynamic therapy” refers to the family of treatment approaches based on the early work of Sigmund Freud. It is one of the major forms of contemporary psychotherapy practice and has undergone a great deal of theoretical and technical modification over the past 120 years. Its main techniques have been catalogued and many forms of psychodynamic therapy have been manualized. There is mounting evidence not only in favor of its efficacy, but also in terms of theory-based mechanisms of change and the research generativity of its concepts (e.g., attachment theory).

Psychodynamic Psychotherapy

Chapter

Jan 2021

The phrase “psychodynamic therapy” refers to the family of treatment approaches based on the early work of Sigmund Freud. It is one of the major forms of contemporary psychotherapy practice and has undergone a great deal of theoretical and technical modification over the past 120 years. Its main techniques have been cataloged and many forms of psychodynamic therapy have been manualized. There is mounting evidence not only in favor of its efficacy, but also in terms of theory-based mechanisms of change and the research generativity of its concepts (e.g., attachment theory).

Malestar depresivo en jóvenes universitarios:impacto de un modelo de psicoterapia breve focalizada con orientación psicoanalítica.

Article

Full-text available

Apr 2021

El estudio tiene como objetivo evaluar los efectos de una psicoterapia breve focal psicoanalíticamente orientada en una muestra de 38 jóvenes universitarios con sintomatología depresiva leve o moderada y malestar emocional general de una Facultad de la UNAM. Se utilizó un diseño cuasiexperimental pretest-postest y seguimientos.

How effective is augmentation with psychotherapy as a next-step option for treatment-resistant depression?

Article

Sep 2020

Daniel Silman

Determining the optimum next-step treatment for the numerous patients with depression who do not adequately respond to an initial trial of medication remains a source of uncertainty in clinical practice. Although a number of psychological treatments are known to be effective for depression, their relative merits in the treatment-resistant group have not been ascertained. The Cochrane Collaboration has recently published a meta-analysis of the evidence available for the use of various psychotherapies as an adjunct to antidepressants compared with antidepressants alone in treatment-resistant depression. This article provides a commentary and appraisal of the clinical utility of these findings.

Efficacy of brief dynamic interpersonal therapy in patients with major depressive disorder: a prospective, multicenter randomized controlled trial protocol

Article

Full-text available

Jul 2020
TRIALS

Background: In China, psychodynamic psychotherapies are widely used as a treatment for depression. However, very few efficacy studies of psychodynamic therapies have been conducted with the Chinese population. This paper describes a study protocol of a multicenter randomized controlled trial of dynamic interpersonal psychotherapy (DIT), a brief manualized depression-focused intervention, in Chinese adults with major depressive disorder (MDD). Methods: Recruitment is planned in five hospitals. Two hundred forty patients with MDD will be randomly allocated on a 1:1:1 basis to either medication plus DIT, medication plus an active control psychotherapy, or medication alone. Patients will be assessed at baseline and at weeks 2, 4, 8, 12, and 16 during the acute treatment phase and 1, 3, 6, and 12 months posttreatment. The primary outcome is change from baseline in the 17-item Hamilton Depression Rating Scale, administered by independent raters who are blind to treatment allocation. The Hamilton Anxiety Rating Scale, Patient Health Questionnaire-9, Generalized Anxiety Disorder 7-item scale, response, remission and relapse rates, self-assessment of overall efficacy and satisfaction of patients, and side effect profiles are secondary measures. Discussion: This will be the first multicentered RCT in China to assess the efficacy of a brief psychodynamic intervention for MDD. The study has the potential to inform clinical treatment guidelines for the treatment of depression in China. Trial registration: ChiCTR, ChiCTR1800016970 . Registered on July 5, 2018.

Efficacy of brief dynamic interpersonal therapy in patients with major depressive disorder: a prospective, multicenter randomized controlled trial protocol

Preprint

Full-text available

Feb 2020

Background: In China, psychodynamic psychotherapies are widely used as a treatment for depression. However, very few efficacy studies of psychodynamic therapies have been conducted with the Chinese population. This paper describes a study protocol of a multicenter randomized controlled trial of Dynamic Interpersonal Psychotherapy (DIT), a brief manualized depression-focused intervention, in Chinese adults with major depressive disorder (MDD). Methods: Recruitmemt is planned in five hospitals. 240 patients with MDD will be randomly allocated on a 1:1:1 basis to either medication plus DIT, medication plus an active control psychotherapy, or medication alone. Patients will be assessed at baseline and at weeks 2, 4, 8, 12, 16 during the acute treatment phase, and 1, 3, 6 and 12 months posttreatment. The primary outcome is change from baseline in the 17-item Hamilton Depression Rating Scale, administered by independent raters who are blind to treatment allocation. The Hamilton Anxiety Rating Scale, Patient Health Questionnaire-9, Generalized Anxiety Disorder 7-item scale, response, remission and relapse rates, self-assessment of overall efficacy and satisfaction of patients, and side effect profiles are secondary measures. Discussion: This will be the first multicentered RCT in China to assess the efficacy of a brief psychodynamic intervention for MDD. The study has the potential to inform clinical treatment guidelines for the treatment of depression in China. Trial registration: ChiCTR，ChiCTR1800016970， Registered on July 5th 2018. Retrospectively registered, http://www.chictr.org.cn/showprojen.aspx?proj=28786.

Emotion-focused and video-technology considerations in the COVID-19 crisis

Article

Jun 2020

The coronavirus or COVID-19 crisis has forced counsellors and therapists around the globe to use online videoconference programs to provide psychotherapy treatment, teaching, and supervision. Some varieties of psychotherapy have historically used video technology for these purposes. Intensive short-term dynamic psychotherapy (ISTDP), one such method, is built on activating intrapsychic crises that lead to emotional experiencing and change. In the current context, external or extrapsychic crises can also be a launchpad for personal growth. The treatment method relies on detailed examination of verbal and nonverbal cues as markers of unconscious avoidance processes and unconscious emotional experiences. Adopting video technology and online treatment presents some unique challenges and benefits. At the same time, the current COVID-19 crisis results in common treatment themes that therapists will encounter. In this review, we will examine common crisis response patterns, some client characteristics based on attachment trauma, and common themes emerging due to this crisis and the related social changes it brings. We will also review some technical issues and tips for those now pressed into using video technology, often for the first time.

Improving Depression Outcome by Patient-Centered Medical Management

Article

Apr 2020

(Reprinted with permission from The American Journal of Psychiatry 2018; 175:1187-1198).

Efficacy of brief dynamic interpersonal therapy in patients with major depressive disorder: a prospective, multicenter randomized controlled trial protocol

Preprint

Full-text available

Feb 2020

Background : Dynamic Interpersonal Psychotherapy (DIT) is a brief manualized depression-focused intervention. This paper describes a study protocol of a multi-site, three-arm randomized controlled trial comparing medication plus DIT to medication alone and medication plus an active control psychotherapy in the treatment of major depressive disorder (MDD). Methods : 240 patients with MDD will be randomly allocated on a 1:1:1 basis to the treatment conditions, with 80 patients in each group. Patients will be assessed pre-and post-intervention and at 6- and 12-months follow-up with the 17-item Hamilton Depression Scale (HAMD-17) and Hamilton Anxiety Scale (HAMA-14) administered by blind evaluators, and the Patient Health Questionnaire (PHQ-9), Generalized Anxiety Disorder-7-item scale(GAD-7), side effect reaction scale (TESS), and The Self-Assessment Scale of the Overall Efficacy and Satisfaction of Patients (SASE). The primary outcome is change from baseline in HAMD-17 scores. Secondary outcomes include rates of response, remission and relapse, change from baseline in self-report depression and measures of anxious symptomatology, and subjective satisfaction of patients. Discussion: This will be the first multicentered RCT in China to assess the potential efficacy of psychotherapy for MDD. The study has the potential to inform clinical treatment guidelines for the treatment of MDD in China. Trial registration : ChiCTR，ChiCTR1800016970， Registered on July 5 th 2018 - Retrospectively registered, http://www.chictr.org.cn/showprojen.aspx?proj=28786 . Key words : Depression; Dynamic Interpersonal Therapy; Multicenter randomized controlled trial

The assessment of resistance to antidepressant treatment: Rationale for the Antidepressant Treatment History Form: Short Form (ATHF-SF)

Article

Full-text available

Jun 2019

There is considerable diversity in how treatment-resistant depression (TRD) is defined. However, every definition incorporates the concept that patients with TRD have not benefited sufficiently from one or more adequate trials of antidepressant treatment. This review examines the issues fundamental to the systematic evaluation of antidepressant treatment adequacy and resistance. These issues include the domains of interventions deemed effective in treatment of major depressive episodes (e.g., pharmacotherapy, brain stimulation, and psychotherapy), the subgroups of patients for whom distinct adequacy criteria are needed (e.g., bipolar vs. unipolar depression, psychotic vs. nonpsychotic depression), whether trials should be rated dichotomously as adequate or inadequate or on a potency continuum, whether combination and augmentation strategies require specific consideration, and the criteria used to evaluate the adequacy of treatment delivery (e.g., dose, duration), trial adherence, and clinical outcome. This review also presents the Antidepressant Treatment History Form: Short-Form (ATHF-SF), a completely revised version of an earlier instrument, and details how these fundamental issues were addressed in the ATHF-SF.

Treating treatment non-responders: A meta-analysis of randomized controlled psychotherapy trials

Article

Dec 2019
CLIN PSYCHOL REV

Background: Non-responsiveness to treatment occurs in approximately one third of patients. Randomized clinical trials of psychotherapy options for these patients are scarce and systematic knowledge about whether psychotherapy is a viable option is lacking. Objectives: This meta-analysis aimed to 1) determine the amount of evidence available for treatment non-response using psychotherapy relative to pharmacological procedures; 2) systematically review randomized controlled psychotherapy trials (RCTs) used to treat non-responders; and 3) examine whether some psychotherapies are more efficacious than others. Data sources: Online databases were systematically examined and references of relevant systematic reviews were hand-searched. Study eligibility criteria: RCTs that administered a psychotherapy new to non-responders were considered. All Mood and Anxiety Disorders were considered. No limitations were made with respect to type of treatment. Review method: A meta-analytic review of the psychotherapy RCTs for treatment non-responders. Results: Results showed that psychotherapy was successful in treating treatment non-responders with a medium to large effect size. Between-group comparisons did not reveal significant differences in treatment effects for any of the assessed disorder or treatment types. Effects were maintained at follow-up. Conclusions: Psychotherapy is a viable treatment option for treatment non-responders. More attention to this group of patients is needed and more research with better quality studies is warranted. Recommendations are discussed.

Healthcare cost reduction and psychiatric symptom improvement in posttraumatic stress disorder patients treated with intensive short-term dynamic psychotherapy

Article

Sep 2019

Introduction Posttraumatic stress disorder (PTSD) is associated with significant psychiatric morbidity and high healthcare costs. Objective The aim of this pilot study was to evaluate changes in healthcare costs and general psychiatric symptom severity in patients with PTSD following intensive short-term dynamic psychotherapy (ISTDP). Method Healthcare services cost and utilization data were compiled at intake, prior to starting ISTDP and then assessed annually for three years thereafter. Two validated self-report scales, the Brief Symptom Inventory and the Inventory of Interpersonal Problems, were administered at intake and termination. Results Results showed significant reductions in physician costs and physician visits at one-year post-treatment, with these persisting over the three-year follow-up period. There were also large but statistically non-significant reductions in hospital costs. At termination, self-reported psychiatric symptoms and interpersonal problems were reduced. Conclusion These preliminary findings suggest that ISTDP may lead to healthcare cost reductions and general psychiatric symptom improvement in patients with PTSD, with healthcare utilization benefits maintained at long-term follow up. Future research directions were discussed.

Pilot study: An inpatient drug rehabilitation program based on intensive short-term dynamic psychotherapy

Article

Full-text available

Aug 2019
J ADDICT DIS

Addiction programs are plagued with high dropout and relapse rates. A large proportion of patients suffering from addiction also suffer from personality disorders. Aim: A 30-day inpatient program based on intensive short-term dynamic psychotherapy was developed to address features of personality disorders such as anxiety regulation, emotion recognition, and handling of fear responses and projective processes. The hypothesis was that addressing comorbid symptoms of personality disorder might improve recovery from drug addiction. We used a pilot randomized controlled trial design with six-month follow-up of both cases and controls. Rates of remission, relapse and drop out were recorded at each time point. N-1 chi-squared (v 2) tests were conducted to examine the statistical significance of differences in outcomes in patients receiving the experimental treatment and controls. A control group of 20 patients and an experimental group of 42 patients were treated. Dropout: control group 40%; experimental group 23.8%. Sobriety at six months: control group 17.6%, experimental group 48.8%. Future study is warranted to examine intensive short-term dynamic psychotherapy's long-term effects, study moderators of effects, and study its efficacy using a randomized controlled design.

Personality and Outcome in Individuals With Treatment-Resistant Depression-Exploring Differential Treatment Effects in the Tavistock Adult Depression Study (TADS)

Article

Full-text available

Apr 2019
J CONSULT CLIN PSYCH

Objective: Although research over the past decades has investigated the impact of the personality dimensions of dependency and self-criticism on treatment outcome, little is known of how these personality features influence responsiveness to treatment in patients with severe, chronic forms of depression. Method: The present study uses data from the Tavistock Adult Depression Study, a randomized controlled trial investigating the effectiveness of long-term psychoanalytic psychotherapy (LTPP) compared with treatment as usual (TAU) for individuals diagnosed with treatment-resistant depression. Patients were rated with the Anaclitic-Introjective Depression Assessment Q-sort, which distinguishes between two more maladaptive (Submissive and Dismissive) and two less maladaptive (Needy and Self-Critical) subdimensions of dependent or anaclitic and self-critical or introjective depression. Multilevel modeling was used to compare individuals' growth curves of depression severity as measured by the Hamilton Rating Scale for Depression over the 18-month treatment period and 2-year follow-up. Rates of clinically significant change were also determined. Results: As expected, depressed patients with more maladaptive dependent and self-critical features did not benefit from LTPP or TAU. Patients with less maladaptive self-critical features benefited from both LTPP and TAU, while those with less maladaptive dependent features showed considerable gains from LTPP but not from TAU, with medium to large effect sizes. Conclusions: Findings of this study are consistent with existing research suggesting the need to modify and tailor treatments in accordance with individuals' pretreatment personality features. Given the time and cost-intensive nature of longer-term treatment, this may be particularly important in patients with treatment-resistant depression. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Psykodynaamisen psykoterapian vaikuttavuus

Article

Mar 2019

• Vaikuttavuudesta on kohtalaisesti näyttöä masennus-, ahdistuneisuus-, syömis-, somatisaatio- ja persoonallisuushäiriöiden hoidossa. • Etenkin uusimpien korkeatasoisten tutkimusten perusteella vaikuttavuus on pääosin samaa tasoa kuin muilla psykoterapioilla. • Pitkä terapia voi olla tarpeen, kun potilaalla on pitkäaikaisia ja monimuotoisia ongelmia.

Sustained Reduction in Health Care Service Usage after Adjunctive Treatment of Intensive Short-Term Dynamic Psychotherapy in Patients with Bipolar Disorder

Article

Mar 2019

The aim of this study was to evaluate changes in long-term health care costs and symptom severity after adjunctive intensive short-term dynamic psychotherapy (ISTDP) individually tailored and administered to patients with bipolar disorder undergoing standard psychiatric care. Eleven therapists with different levels of expertise delivered an average of 4.6 one-hour sessions of ISTDP to 29 patients with bipolar disorders. Health care service costs were compiled for a one-year period prior to the start of ISTDP along with four one-year periods after termination. Two validated self-report scales, the Brief Symptom Inventory and the Inventory of Interpersonal Problems, were administered at intake and termination of ISTDP. Hospital cost reductions were significant for the one-year post-treatment period relative to baseline year, and all cost reductions were sustained for the follow-up period of four post-treatment years. Self-reported psychiatric symptoms and interpersonal problems were significantly reduced. These preliminary findings suggest that this brief adjunctive psychotherapy may be beneficial and cost-effective in select patients with bipolar disorders, and that gains may be sustained in long-term follow-up. Future research directions are discussed.

A Psychodynamic Approach to Treatment Resistance: Risk Factors, Biology, and Management

Chapter

Full-text available

Jan 2019

Despite the growth of neurobiologic research in psychiatry, the fundamental clinical problems of psychiatry remain unresolved. “Treatment resistance” has become an increasingly recognized problem. Meanwhile, financial and academic support for psychodynamic concepts has decreased, with a troubling bias against psychodynamic ideas. Nevertheless, psychodynamic concepts and psychodynamic therapy (PDT) offer opportunities for novel, effective approaches to treatment resistance. Conceptual errors in mainstream psychiatry include ignoring the meaning of psychiatric symptoms, assuming that patients are best described by single diagnoses, assuming that mental illness is always caused by a specific biological pathology that can be addressed by a biological treatment, neglecting the effects of the psychosocial context on treatment, and failing to attend to the treatment alliance. This chapter reviews literature describing psychodynamic approaches to treatment resistance and demonstrating the relevance of psychodynamic concepts and the effectiveness of psychodynamic therapies.

Improving Depression Outcome by Patient-Centered Medical Management

Article

Sep 2018
AM J PSYCHIAT

Specific challenges that profoundly affect the outcome of treatment for depression include 1) patient engagement and retention in care and optimization of treatment adherence, 2) optimization of symptom and side effect control by medication adjustments using measurement-based care procedures, 3) restoration of daily functioning and quality of life, and 4) prevention or at least mitigation of symptomatic relapse or recurrence. According to data from the Sequenced Treatment Alternatives to Relieve Depression study, some 10%-15% of patients will not return for treatment after an initial thorough evaluation visit; an additional 20%-35% will not complete the first acute-phase treatment step, and another 20%-50% will not complete 6 months of continuation treatment. Among patients who stay in treatment, over 50% exhibit poor adherence. Thus, most patients do not overcome the first two challenges. There are no systematic, widely agreed-upon psychosocial approaches to any of these four major challenges. The authors propose "patient-centered medical management" to address each of the four challenges, using psychoeducational, behavioral, cognitive, interpersonal, and dynamic models and methods. A renewed emphasis on the development and testing of systematic approaches to overcoming these common clinical challenges could enhance the chances of patient recovery and care system cost efficiencies. [AJP AT 175: Remembering Our Past As We Envision Our Future July 1933: Psychotherapeutics at Stockbridge Horace K. Richardson: "Frequently, in the simpler situations, very few interviews are required in order that he [the patient] discover for himself what part of the adaptive machinery is at fault, and for him to develop a technique of handling the maladjustment on a more satisfactory level in the future."(Am J Psychiatry 1933; 90:45-56 )].

Efficacy and moderators of short-term psychodynamic psychotherapy for depression: A systematic review and meta-analysis of individual participant data

Article

Mar 2023
CLIN PSYCHOL REV

Background: Short-term psychodynamic psychotherapy (STPP) is frequently used to treat depression, but it is unclear which patients might benefit specifically. Individual participant data (IPD) meta-analyses can provide more precise effect estimates than conventional meta-analyses and identify patient-level moderators. This IPD meta-analysis examined the efficacy and moderators of STPP for depression compared to control conditions. Methods: PubMed, PsycInfo, Embase, and Cochrane Library were searched September 1st, 2022, to identify randomized trials comparing STPP to control conditions for adults with depression. IPD were requested and analyzed using mixed-effects models. Results: IPD were obtained from 11 of the 13 (84.6%) studies identified (n = 771/837, 92.1%; mean age = 40.8, SD = 13.3; 79.3% female). STPP resulted in significantly lower depressive symptom levels than control conditions at post-treatment (d = -0.62, 95%CI [-0.76, -0.47], p < .001). At post-treatment, STPP was more efficacious for participants with longer rather than shorter current depressive episode durations. Conclusions: These results support the evidence base of STPP for depression and indicate episode duration as an effect modifier. This moderator finding, however, is observational and requires prospective validation in future large-scale trials.

Applications of Psychodynamic Psychotherapy to Specific Disorders

Chapter

Mar 2023

Effectiveness of Intensive Short- Term Dynamic Psychotherapy on Alexithymia in Rheumatoid Arthritis Patients

Article

Mar 2021

Aim and Background: Rheumatoid arthritis is associated with an increased risk of various types of psychological afflictions. Indication of these disorders is added to the erosive factors of chronic disease and has many negative effects on the level of adaptation and mental and social health of these people. This study aimed to evaluate the effectiveness of intensive short-term dynamic psychotherapy (ISTDP) on reducing alexithymia in rheumatoid patients. Methods and Materials: The present research was a quasi-experimental study with pre-test, post-test design as well as control group. In order to select the sample, first of all, based on the criteria of the American Rheumatology Association and the inclusion and exclusion criteria, 40 male and female patients were purposefully selected from specialized rheumatology clinics in Kerman. This selection was made by rheumatologists. The members of the sample group were randomly divided into two 20-memeber groups of experimental and control. For the experimental group, 15 one-and-a-half-hour sessions of intensive short-term dynamic psychotherapy were held. Data were collected through Toronto Alexithymia Scale (TAS). Research data were analyzed using Analysis of covariance. Findings: The findings showed that intensive short-term dynamic psychotherapy is effective in reducing the rate of alexithymia in rheumatoid patients (p

Changes in psychoanalytic therapy in Europe over three decades. Then and now

Article

Dec 2022
Psychoanal Psychother

Brian Martindale

In 1988, the APP hosted a conference on psychoanalytic psychotherapy (PP) in the public sector in other European countries. This taught us that Britain had much to learn from other countries as well as much to share. The APP realised the need for a European Federation of PP in the public sector (EFPP) to represent and facilitate the field. The APP therefore joined with representatives from the Association of Child Psychotherapy and the Institute of Group Analysis and in 1991 formally created such an organisation by linking with similar representatives from European Union countries. This article takes an overview of PP in European countries, comparing the situation now in 2022 with the time of the founding of the EFPP in 1991. Despite significant setbacks in some countries, the indications are that PP has made very significant process in most countries in terms of the number of training organisations and practitioners in all four EFPP sections. The impact on public mental health provision is impressive in some countries but remains limited if not very limited in many. The article reviews some of the factors that have led to progress and setbacks, pinpointing ‘lessons’ and warning signs.

Implementing routine outcome monitoring in a psychodynamic training clinic: it’s complicated

Article

Aug 2022

The use of routine outcome monitoring (ROM) has been shown to improve treatment outcomes, reduce symptom deterioration and treatment dropout, and is especially relevant for training clinics. However, the use of ROM in a psychodynamic training clinic has remained relatively unexplored. We aimed to instigate an open dialogue about the use and usefulness of ROM within the context of contemporary psychodynamic clinical practice. As a graduate trainee and professor in a psychodynamic training program, we reflect on the seemingly irreconcilable differences between psychoanalytic thinking and ROM, the anxiety around being evaluated as a trainee, whom ROM is for, the pragmatic challenges when trying new tools and technology (especially when not chosen yourself), and the limitations of standardized self-report measures, such as the OQ. Overall, these complexities suggest that although ROM is likely worthwhile for patients, therapists, supervisors, and researchers, it will only come to its fruition if we integrate it into the tri-legged stool of evidence-based practice . We will need to engage in a genuine discussion about the use of ROM and consider the possibility that ROM might even improve our psychodynamic practices. Integrating ROM into psychodynamic didactic courses and supervision in graduate training could be a good starting point.

Community mental health interventions for people with major depressive disorder: A scoping review

Article

Jun 2022

People with major depressive disorder continue to be marred by chronically pernicious yet preventable outcomes in the biopsychosocial aspects. With the reallocation of healthcare resources towards the fight against the coronavirus 2019 pandemic, much emphasis has been placed on existing community mental health interventions to ameliorate the disruption of mental health services. Moreover, the recent propulsion of community mental health services by the World Health Organization Mental Health Action Plan 2013–2030 ignited the need to bolster existing community interventions by providing comprehensive, responsive and integrated mental healthcare. The enhanced emphasis on mental healthcare in the community and the heightened demands of people with major depressive disorder underscores the need to explore the current state of community mental health interventions. This scoping review examined 51 primary studies published from year 2010 to 2020 using Arskey & O′Malley's five‐stage framework and provided an overview of the impact of existing community mental health interventions for people with major depressive disorder. Findings using thematic analysis have recommended the adoption of person‐centred community mental healthcare via the biopsychosocial approach for people with major depressive disorder. Enablers of community mental health interventions were driven by culturally appropriate care and augmented by technology‐driven modalities. Challenges and gaps of community mental health interventions include the perpetuation of stigma and misconception, complex demands of persons with major depressive disorder and lack of holistic and long‐term outcomes. Given the impact of major depressive disorder on the various biopsychosocial aspects, it is envisioned that our insights into the enablers and barriers of community mental health interventions will guide prospective interdisciplinary and nurse‐led interventions in holistically improving the care of persons with major depressive disorder in the community settings.

The 2020 Royal Australian and New Zealand College of Psychiatrists clinical practice guidelines for mood disorders

Article

Full-text available

Jan 2021

Objectives To provide advice and guidance regarding the management of mood disorders, derived from scientific evidence and supplemented by expert clinical consensus to formulate s that maximise clinical utility. Methods Articles and information sourced from search engines including PubMed, EMBASE, MEDLINE, PsycINFO and Google Scholar were supplemented by literature known to the mood disorders committee (e.g. books, book chapters and government reports) and from published depression and bipolar disorder guidelines. Relevant information was appraised and discussed in detail by members of the mood disorders committee, with a view to formulating and developing consensus-based recommendations and clinical guidance. The guidelines were subjected to rigorous consultation and external review involving: expert and clinical advisors, key stakeholders, professional bodies and specialist groups with interest in mood disorders. Results The Royal Australian and New Zealand College of Psychiatrists mood disorders clinical practice guidelines 2020 (MDcpg ²⁰²⁰ ) provide up-to-date guidance regarding the management of mood disorders that is informed by evidence and clinical experience. The guideline is intended for clinical use by psychiatrists, psychologists, primary care physicians and others with an interest in mental health care. Conclusion The MDcpg ²⁰²⁰ builds on the previous 2015 guidelines and maintains its joint focus on both depressive and bipolar disorders. It provides up-to-date recommendations and guidance within an evidence-based framework, supplemented by expert clinical consensus. Mood disorders committee Gin S Malhi (Chair), Erica Bell, Darryl Bassett, Philip Boyce, Richard Bryant, Philip Hazell, Malcolm Hopwood, Bill Lyndon, Roger Mulder, Richard Porter, Ajeet B Singh and Greg Murray.

L’évaluation et l’efficacité des psychothérapies psychanalytiques et de la psychanalyse

Article

Oct 2020
EVOL PSYCHIATR

Thomas Rabeyron

Résumé Objectif Cet article propose une revue de littérature concernant l’évaluation et l’efficacité des psychothérapies psychanalytiques et de la psychanalyse (PPP). Méthode Après avoir proposé une vue d’ensemble de l’évaluation des psychothérapies, nous reprenons les travaux portant sur l’évaluation empirique et quantitative des PPP avant de nous centrer sur leur évaluation qualitative et processuelle. Résultats Les résultats des études menées en ce domaine démontrent que les psychothérapies sont efficaces aussi bien sur le court terme que le long terme. Leur efficacité est le plus souvent indépendante de l’obédience théorique du clinicien. En revanche, les facteurs communs comme l’alliance thérapeutique ou les particularités du thérapeute sont des éléments prévalents de même que la durée et la fréquence des psychothérapies. Concernant plus précisément l’évaluation des PPP, celles-ci sont démontrées empiriquement comme étant efficaces pour la plupart des troubles psychiatriques. Plusieurs caractéristiques des PPP sont en outre corrélées de manière significative avec l’efficacité thérapeutique. Discussion L’évaluation qualitative et processuelle des PPP apparaît complémentaire à ce premier niveau d’évaluation empirique qui présente plusieurs limites (biais d’allégeance, indistinction des processus, pratiques de recherches questionnables, etc.) mises notamment en évidence par la crise de la reproductibilité. La méthodologie des Essais Contrôlés Randomisés propose une évaluation de surface à laquelle doivent être associées des approches fondées davantage sur la pratique clinique. L’approche du groupe de Boston, l’analyse des processus psychothérapiques par le Psychotherapy Q-Sort (PQS) ainsi que la modélisation du processus de symbolisation par l’École de Lyon sont trois paradigmes de recherche qualitatifs particulièrement riches de ce point de vue. Conclusion Les PPP sont efficaces pour la plupart des troubles psychiatriques sur le court terme, en fin de thérapie et plusieurs années après celle-ci. Elles engendrent des transformations durables sur le plan des symptômes et de la personnalité. Elles apparaissent souvent plus efficaces que la pharmacothérapie et conduisent à des économies substantielles quand elles sont mises en œuvre dans des services de soin auprès de patients souffrant de pathologies variées.

Comparison of the Effectiveness of Schema Therapy and Integrated Schema Oriented Therapy on Components of Impulsivity in People with Borderline Personality Characteristic

Article

Full-text available

Jan 2020

Introduction: Impulsivity is one of the problems which Individuals with borderline personality characteristics suffered from them. According to this point, the aim of this study was to the comparison of the effectiveness of schema therapy and integrated schema oriented therapy on impulsivity and their components among individuals with borderline personality characteristics. Methods: The research method was semi-experimental, and the research design was three groups with two stages of pre-test and post-test. The 45 persons were selected from 70 persons with borderline personality characteristics in Isfahan in winter leading to the summer of 2018, based on criteria of entry and exit and then randomly assigned in two experimental groups and a control group (each group with 15 people). Barratt's impulsivity scale was used to measure the dependent variable in the pretest and post-test. The group of integrated schema oriented therapy and schema therapy received 15 sessions of treatment, and the control group did not receive any treatment. The data were analyzed by multivariate analysis of covariance and Bonferroni post hoc test using SPSS 21 software. Results: The results showed that there is a significant difference between the integrated schema oriented therapy and schema therapy and control groups in impulsivity, cognitive impulsivity and motor impulsivity in post-test after controlling for pretest (P < 0.001), but there is not a significant difference between integrated schema oriented therapy and schema therapy with the control group in non-planning subscale (P > 0.05). Also, there is not a considerable difference between built-in schema oriented therapy and schema therapy in impulsivity and their components (P > 0.05). Conclusions: Based on the findings of this study (schema therapy, and integrated schema) oriented therapy can be effective treatments for reducing impulsivity in individuals with borderline personality characteristics. It is recommended that these two treatments be used for people with borderline personality traits in therapeutic centers.

Development and Validation of the Mentalising Profile Q-Sort (MQS)

Conference Paper

Jan 2020

Wilson Adolfo Gallego-Hoyos

The last couple of decades have seen a significant increase in the fields of research and clinical practice inspired by the theory of mentalising. Mentalisation, the capacity to understand one’s own and others’ behaviour in terms of mental states, is considered to be a “defining human social and psychological achievement” (Fonagy & Allison, 2014). The dialogue between mentalising theory and other fields such as developmental psychopathology or the neurosciences has added complexity and nuance to the understanding of this mental capacity. However, there is a gap in the research literature concerning the assessment of mentalising during therapeutic sessions. This assessment has often been done at the beginning and end of the treatment, missing session-to-session variations and the possibility to inquire about a mentalising style and its outcome in psychotherapy. This thesis describes the development and preliminary validation of the Mentalising Profile Q-set (MQS), an observer-rated measure that aims to bridge the gap between scientific research and clinical observations by describing the mentalising process of patients undergoing psychotherapy in a jargon-free language. The MQS focuses on the patient and provides a picture of the mentalising process in relation to its four polarities and pre-mentalising modes of experience. The data used in this research was derived from the Randomised Evaluation Study of Dynamic Interpersonal Therapy (REDIT) and the Tavistock Adult Depression Study (TADS), two trials that worked with depressed patients, although with differences in clinical characteristics. The preliminary results suggest that the MQS is an instrument that can differentiate groups of individual mentalising profiles and their likely effect on therapeutic outcomes, as assessed by the HRSD-17, at the beginning of treatment. The MQS contributes to the extant literature on assessment instruments and, at the same time, expands on the role of the capacity to mentalise in the therapeutic outcome.

Wirksamkeits- und Prozessforschung in der IS-TDP

Chapter

Jan 2020

In diesem Kapitel wird zunächst eine Übersicht über verschiedene Wirksamkeitsnachweise für die Intensive Psychodynamische Kurzzeittherapie nach Davanloo (IS-TDP) gegeben. Im Anschluss werden die aktuellen Forschungsaktivitäten der Deutschen Gesellschaft für IS-TDP beschrieben.

Barriers to complete recovery of major depression: Cross-sectional, multi-centre study on clinical practice. RECORD study

Article

Jul 2019

Introduction To identify barriers to complete recovery in patients suffering from major depressive disorder. Methods A total of 461 psychiatrists participated in a cross-sectional, non-randomised, qualitative and multi-centre study based on a survey. The study questionnaire included 42 items related to management, prevalence, patient profile, impact of residual symptoms, barriers to full recovery, and strategies to increase complete recovery. Results Complete recovery was defined by 86% of participants as complete remission of symptoms plus functional recovery. A total of 83.4% of participants considered that sick leave usually lasted more than 4 months. Seventy-five percent stated that residual symptoms were the main reason for prolongation of sick leave, and 62% that between 26% and 50% of patients complained of residual symptoms. Poor compliance with treatment was the most important barrier to complete recovery, followed by a lack of patient cooperation, late beginning of treatment, partial response to antidepressants, and low doses of antidepressant medication. In the case of partial response, 71.8% of participants chose to increase the dose of current treatment, and in the case of lack of response, 72.7% would switch to another antidepressant, and 22.8% would use the combination of two antidepressants, in which case 85.2% would choose agents with complementary mechanisms of action. Forty-nine percent of participants would recommend standard cognitive-behavioural psychotherapy for patients without complete response. Conclusions Some 50% of patients did not achieve complete remission, frequently related to persistence of residual symptoms. Achievement of complete recovery should be an essential objective.

Treatment Resistance in Psychiatry Risk Factors, Biology, and Management: Risk Factors, Biology, and Management

Book

Jan 2019

Yong-Ku Kim

This book reviews all the important aspects of treatment-resistant psychiatric disorders, covering issues such as definitions, clinical aspects, neurobiological correlates, treatment options, and predictors of treatment response. The book is divided into three sections, the first of which examines the most recent thinking on treatment resistance in psychiatry, including definition and epidemiology, paradigm shift in the study of the subjects, individual susceptibility and resilience, abnormal structural or functional connectivity, and insights from animal models. The second section then discusses treatment resistance in each of the major psychiatric disorders, with particular focus on the responsible clinical and biological factors and the available management strategies. Finally, more detailed information is presented on diverse pharmacological and non-pharmacological therapeutic interventions. The book, written by leading experts from across the world, will be of value to all who seek a better understanding of the clinical-neurobiological underpinnings and the development of management for treatment resistance in psychiatric disorders.

Barreras para la recuperación completa en la depresión mayor: estudio transversal multicéntrico en la práctica clínica. Estudio RECORD

Article

Nov 2018

Resumen Introducción El objetivo de este estudio fue identificar las barreras para lograr una recuperación completa en pacientes con depresión mayor. Métodos Un total de 461 psiquiatras participaron en un estudio cualitativo, no randomizado, transversal y multicéntrico basado en una encuesta. El cuestionario incluía 42 ítems relacionados con el tratamiento, prevalencia, perfil del paciente, impacto de los síntomas residuales, barreras y estrategias para aumentar la recuperación completa. Resultados Un 86% de participantes definieron recuperación completa como la remisión completa de síntomas más recuperación funcional. Un 83,4% consideraron que las bajas laborales se suelen prolongar más de 4 meses. Un 75% que los síntomas residuales eran el principal motivo de esta prolongación de las bajas, y un 62% que un 26-50% de pacientes tenían síntomas residuales. La falta de adherencia al tratamiento fue la barrera más importante para la recuperación completa, seguida de falta de colaboración del paciente, inicio tardío del tratamiento, respuesta parcial y bajas dosis de antidepresivos. En caso de respuesta parcial, el 71,8% de los participantes aumentaría la dosis del tratamiento actual, y en caso de falta de respuesta, el 72,7% cambiaría a otro antidepresivo. Un 22,8% usaría la combinación de dos antidepresivos, en cuyo caso el 85,2% elegiría fármacos con mecanismos de acción complementarios. Un 49% recomendaría la psicoterapia cognitivo-conductual en pacientes sin respuesta completa. Conclusiones En un 50% de los pacientes no se logra la recuperación completa, con frecuencia por la presencia de síntomas residuales. Lograr la recuperación completa debe ser un objetivo imprescindible.

Psychological therapies for treatment-resistant depression in adults

Article

May 2018

Background: Antidepressants are a first-line treatment for adults with moderate to severe major depression. However, many people prescribed antidepressants for depression don't respond fully to such medication, and little evidence is available to inform the most appropriate 'next step' treatment for such patients, who may be referred to as having treatment-resistant depression (TRD). National Institute for Health and Care Excellence (NICE) guidance suggests that the 'next step' for those who do not respond to antidepressants may include a change in the dose or type of antidepressant medication, the addition of another medication, or the start of psychotherapy. Different types of psychotherapies may be used for TRD; evidence on these treatments is available but has not been collated to date.Along with the sister review of pharmacological therapies for TRD, this review summarises available evidence for the effectiveness of psychotherapies for adults (18 to 74 years) with TRD with the goal of establishing the best 'next step' for this group. Objectives: To assess the effectiveness of psychotherapies for adults with TRD. Search methods: We searched the Cochrane Common Mental Disorders Controlled Trials Register (until May 2016), along with CENTRAL, MEDLINE, Embase, and PsycINFO via OVID (until 16 May 2017). We also searched the World Health Organization (WHO) trials portal (ICTRP) and ClinicalTrials.gov to identify unpublished and ongoing studies. There were no date or language restrictions. Selection criteria: We included randomised controlled trials (RCTs) with participants aged 18 to 74 years diagnosed with unipolar depression that had not responded to minimum four weeks of antidepressant treatment at a recommended dose. We excluded studies of drug intolerance. Acceptable diagnoses of unipolar depression were based onthe Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR) or earlier versions, International Classification of Diseases (ICD)-10, Feighner criteria, or Research Diagnostic Criteria. We included the following comparisons.1. Any psychological therapy versus antidepressant treatment alone, or another psychological therapy.2. Any psychological therapy given in addition to antidepressant medication versus antidepressant treatment alone, or a psychological therapy alone.Primary outcomes required were change in depressive symptoms and number of dropouts from study or treatment (as a measure of acceptability). Data collection and analysis: We extracted data, assessed risk of bias in duplicate, and resolved disagreements through discussion or consultation with a third person. We conducted random-effects meta-analyses when appropriate. We summarised continuous outcomes using mean differences (MDs) or standardised mean differences (SMDs), and dichotomous outcomes using risk ratios (RRs). Main results: We included six trials (n = 698; most participants were women approximately 40 years of age). All studies evaluated psychotherapy plus usual care (with antidepressants) versus usual care (with antidepressants). Three studies addressed the addition of cognitive-behavioural therapy (CBT) to usual care (n = 522), and one each evaluated intensive short-term dynamic psychotherapy (ISTDP) (n = 60), interpersonal therapy (IPT) (n = 34), or group dialectical behavioural therapy (DBT) (n = 19) as the intervention. Most studies were small (except one trial of CBT was large), and all studies were at high risk of detection bias for the main outcome of self-reported depressive symptoms.A random-effects meta-analysis of five trials (n = 575) showed that psychotherapy given in addition to usual care (vs usual care alone) produced improvement in self-reported depressive symptoms (MD -4.07 points, 95% confidence interval (CI) -7.07 to -1.07 on the Beck Depression Inventory (BDI) scale) over the short term (up to six months). Effects were similar when data from all six studies were combined for self-reported depressive symptoms (SMD -0.40, 95% CI -0.65 to -0.14; n = 635). The quality of this evidence was moderate. Similar moderate-quality evidence of benefit was seen on the Patient Health Questionnaire-9 Scale (PHQ-9) from two studies (MD -4.66, 95% CI 8.72 to -0.59; n = 482) and on the Hamilton Depression Rating Scale (HAMD) from four studies (MD -3.28, 95% CI -5.71 to -0.85; n = 193).High-quality evidence shows no differential dropout (a measure of acceptability) between intervention and comparator groups over the short term (RR 0.85, 95% CI 0.58 to 1.24; six studies; n = 698).Moderate-quality evidence for remission from six studies (RR 1.92, 95% CI 1.46 to 2.52; n = 635) and low-quality evidence for response from four studies (RR 1.80, 95% CI 1.2 to 2.7; n = 556) indicate that psychotherapy was beneficial as an adjunct to usual care over the short term.With the addition of CBT, low-quality evidence suggests lower depression scores on the BDI scale over the medium term (12 months) (RR -3.40, 95% CI -7.21 to 0.40; two studies; n = 475) and over the long term (46 months) (RR -1.90, 95% CI -3.22 to -0.58; one study; n = 248). Moderate-quality evidence for adjunctive CBT suggests no difference in acceptability (dropout) over the medium term (RR 0.98, 95% CI 0.66 to 1.47; two studies; n = 549) and lower dropout over long term (RR 0.80, 95% CI 0.66 to 0.97; one study; n = 248).Two studies reported serious adverse events (one suicide, two hospitalisations, and two exacerbations of depression) in 4.2% of the total sample, which occurred only in the usual care group (no events in the intervention group).An economic analysis (conducted as part of an included study) from the UK healthcare perspective (National Health Service (NHS)) revealed that adjunctive CBT was cost-effective over nearly four years. Authors' conclusions: Moderate-quality evidence shows that psychotherapy added to usual care (with antidepressants) is beneficial for depressive symptoms and for response and remission rates over the short term for patients with TRD. Medium- and long-term effects seem similarly beneficial, although most evidence was derived from a single large trial. Psychotherapy added to usual care seems as acceptable as usual care alone.Further evidence is needed on the effectiveness of different types of psychotherapies for patients with TRD. No evidence currently shows whether switching to a psychotherapy is more beneficial for this patient group than continuing an antidepressant medication regimen. Addressing this evidence gap is an important goal for researchers.

Epistemological flaws in NICE review methodology and its impact on recommendations for psychodynamic psychotherapies for complex and persistent depression

Article

Full-text available

Apr 2018
Psychoanal Psychother

The UK draft NICE guideline on depression in adults was sent out for stakeholder consultation between July and September 2017. The final guideline publication date currently remains ‘to be confirmed’. This paper sets out key concerns with the methodology employed in the guideline and its impact on recommendations for psychodynamic psychotherapies for complex and persistent depression. The draft largely ignored the subjective experiences and voices of service users, carers and members of the public, using out of date limited evidence of service user and carer experiences. The guideline fails to incorporate what limited qualitative evidence it reviewed into any treatment recommendations. The Guideline Committee created its own method for categorising depression by longevity, severity and complexity. This has resulted in erroneous and unhelpful classifications of research studies under groupings which do not match clinical and service user experiences or US and European approaches, rendering analyses and conclusions unreliable. We also outline instances of incorrect classification of psychodynamic treatments (such as inclusion of non bona fide treatments or exclusion of relevant bona fide treatment studies) which enables the omission of a recommendation for psychodynamic psychotherapy for complex and persistent depression. Depression is often a long-term condition or can become so if immediate care is inadequate; yet the draft recommendations are all made on the basis of short-term outcome data (with often less than eight weeks between baseline and outcome). NICE guidelines for long-term physical conditions would treat this evidence as inadequate. Finally, the draft guideline used the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) system of assessing methodological quality in such a way as to produce a systematic bias in favour of drug trials, selectively omitting trial data with long-term follow-up points and those which used non-symptom outcomes. Herein, we consider the increasingly evident limitations of the paradigm NICE works within for ensuring patient choice and equity of access to a wide range of therapies. Ok it is Romeo green which means I can archive the accepted version in an open access university respository. So I've pdfed it and uploaded it. Accepted full text: https://ris.essex.ac.uk/viewobject.html?cid=1&id=111725

Comparative Effectiveness of Cognitive Therapy and Dynamic Psychotherapy for Major Depressive Disorder in a Community Mental Health Setting: A Randomized Clinical Noninferiority Trial

Article

Full-text available

Aug 2016

Importance: Dynamic psychotherapy (DT) is widely practiced in the community, but few trials have established its effectiveness for specific mental health disorders relative to control conditions or other evidence-based psychotherapies. Objective: To determine whether DT is not inferior to cognitive therapy (CT) in the treatment of major depressive disorder (MDD) in a community mental health setting. Design, setting, and participants: From October 28, 2010, to July 2, 2014, outpatients with MDD were randomized to treatment delivered by trained therapists. Twenty therapists employed at a community mental health center in Pennsylvania were trained by experts in CT or DT. A total of 237 adult outpatients with MDD seeking services at this site were randomized to 16 sessions of DT or CT delivered across 5 months. Final assessment was completed on December 9, 2014, and data were analyzed from December 10, 2014, to January 14, 2016. Interventions: Short-term DT or CT. Main outcomes and measures: Expert blind evaluations with the 17-item Hamilton Rating Scale for Depression. Results: Among the 237 patients (59 men [24.9%]; 178 women [75.1%]; mean [SD] age, 36.2 [12.1] years) treated by 20 therapists (19 women and 1 man; mean [SD] age, 40.0 [14.6] years), 118 were randomized to DT and 119 to CT. A mean (SD) difference between treatments was found in the change on the Hamilton Rating Scale for Depression of 0.86 (7.73) scale points (95% CI, -0.70 to 2.42; Cohen d, 0.11), indicating that DT was statistically not inferior to CT. A statistically significant main effect was found for time (F1,198 = 75.92; P = .001). No statistically significant differences were found between treatments on patient ratings of treatment credibility. Dynamic psychotherapy and CT were discriminated from each other on competence in supportive techniques (t120 = 2.48; P = .02), competence in expressive techniques (t120 = 4.78; P = .001), adherence to CT techniques (t115 = -7.07; P = .001), and competence in CT (t115 = -7.07; P = .001). Conclusions and relevance: This study suggests that DT is not inferior to CT on change in depression for the treatment of MDD in a community mental health setting. The 95% CI suggests that the effects of DT are equivalent to those of CT. Trial registration: clinicaltrials.gov Identifier: NCT01207271.

Characterization of Treatment Resistant Depression Episodes in a Cohort of Patients from a US Commercial Claims Database

Article

Full-text available

Oct 2013
PLOS ONE

Treatment Resistant Depression (TRD) is a significant and burdensome health concern. To characterize, compare and understand the difference between TRD and non-TRD patients and episodes in respect of their episode duration, treatment patterns and healthcare resource utilization. Patients between 18 and 64 years with a new diagnosis of major depressive disorder (MDD) and without a previous or comorbid diagnosis of schizophrenia or bipolar disease were included from PharMetrics Integrated Database, a claims database of commercial insurers in the US. Episodes of these patients in which there were at least two distinct failed regimens involving antidepressants and antipsychotics were classified as TRD. 82,742 MDD patients were included in the analysis; of these patients, 125,172 episodes were identified (47,654 of these were drug-treated episodes). Comparison between TRD and non-TRD episodes in terms of their duration, number and duration of lines of treatment, comorbidities, and medical resource utilization. Of the treated episodes, 6.6% (N = 3,134) met the criteria for TRD. The median time to an episode becoming TRD was approximately one year. The mean duration of a TRD episode was 1,004 days (vs. 452 days for a non-TRD episode). More than 75% of TRD episodes had at least four lines of therapy; half of the treatment regimens included a combination of drugs. Average hospitalization costs were higher for TRD than non-TRD episodes: $6,464 vs. $1,734, as were all other health care utilization costs. While this study was limited to relatively young and commercially covered patients, used a rigorous definition of TRD and did not analyze for cause or consequence, the results highlight high unmet medical need and burden of TRD on patients and health care resources.

The Efficacy of Cognitive-Behavioral Therapy and Psychodynamic Therapy in the Outpatient Treatment of Major Depression: A Randomized Clinical Trial

Article

Full-text available

Sep 2013
AM J PSYCHIAT

Objective: The efficacy of psychodynamic therapies for depression remains open to debate because of a paucity of high-quality studies. The authors compared the efficacy of psychodynamic therapy with that of cognitive-behavioral therapy (CBT), hypothesizing nonsignificant differences and the noninferiority of psychodynamic therapy relative to CBT. Method: A total of 341 adults who met DSM-IV criteria for a major depressive episode and had Hamilton Depression Rating Scale (HAM-D) scores ≥14 were randomly assigned to 16 sessions of individual manualized CBT or short-term psychodynamic supportive therapy. Severely depressed patients (HAM-D score >24) also received antidepressant medication according to protocol. The primary outcome measure was posttreatment remission rate (HAM-D score ≤7). Secondary outcome measures included mean posttreatment HAM-D score and patient-rated depression score and 1-year follow-up outcomes. Data were analyzed with generalized estimating equations and mixed-model analyses using intent-to-treat samples. Noninferiority margins were prespecified as an odds ratio of 0.49 for remission rates and a Cohen's d value of 0.30 for continuous outcome measures. Results: No statistically significant treatment differences were found for any of the outcome measures. The average posttreatment remission rate was 22.7%. Noninferiority was shown for posttreatment HAM-D and patient-rated depression scores but could not be demonstrated for posttreatment remission rates or any of the follow-up measures. Conclusions: The findings extend the evidence base of psychodynamic therapy for depression but also indicate that time-limited treatment is insufficient for a substantial number of patients encountered in psychiatric outpatient clinics.

Measuring Psychodynamic-Interpersonal and Cognitive-Behavioral Techniques: Development of the Comparative Psychotherapy Process Scale.

Article

Full-text available

Sep 2005
PSYCHOTHERAPY

Many instruments have been developed to assess techniques and interventions in a variety of psychotherapies. However, existing scales are limited by several factors such as relatively weak psychometric properties, applicability to only a single form of treatment or manual, and extensive time required for completion. The authors report on the development of a new measure, the Comparative Psychotherapy Process Scale (CPPS). The CPPS is designed to assess the distinctive features of psychodynamic-interpersonal and cognitive- behavioral treatments. Data are presented on the psychometric properties, reliability, and validity of the CPPS. The findings suggest that the scale possesses excellent interrater reliability and internal consistency as well as promising validity. Clinical utility, potential limitations, and future research of the CPPS are discussed. (PsycINFO Database Record (c) 2012 APA, all rights reserved)

Examination of the Utility of Psychotherapy for Patients with Treatment Resistant Depression: A Systematic Review

Article

Full-text available

Dec 2010
J GEN INTERN MED

To examine the utility of psychotherapy in managing treatment resistant depression. PubMed, PsycInfo, Embase, Cochrane Registry of Controlled Clinical Trials, article bibliographies. Eligible articles had to be in English and include English-speaking adult outpatients from general medical or mental health clinics. Studies had to be randomized clinical trials (RCT) involving at least one of the following psychotherapy modalities: cognitive therapy, interpersonal therapy, or behavior therapy. Patients were considered treatment resistant if they reported partial or no remission following treatment with an adequate antidepressant dose for ≥ 6 weeks. Exclusion criteria included receiving psychotherapy at the time of recruitment, and/or comorbid psychiatric conditions unlikely to be treated outside of specialized mental health care (e.g., severe substance abuse). Due to heterogeneity in study designs, a summary estimate of effect was not calculated. Studies were critically analyzed and a qualitative synthesis was conducted. Of 941 original titles, 13 articles evaluating 7 unique treatment comparisons were included. Psychotherapy was examined as an augmentation to antidepressants in five studies and as substitution treatment in two studies. A total of 592 patients were evaluated (Mean age ~40 y; Females = 50-85%; Caucasians ≥ 75%). The STAR*D trial used an equipoise stratified randomization design; the remaining studies were RCTs. Compared to active management, two good quality trials showed similar benefit from augmenting antidepressants with psychotherapy; one fair quality and one poor quality trial showed benefit from psychotherapy augmentation; and one good and one poor trial found similar benefit from substituting psychotherapy for antidepressants. One fair quality trial showed lithium augmentation to be more beneficial than psychotherapy. Review demonstrates the utility of psychotherapy in managing treatment resistant depression. However, evidence is sparse and results are mixed. Given that quality trials are lacking, rigorous clinical trials are recommended to guide practice. In the interim, primary care providers should consider psychotherapy when treating patients with treatment resistant depression.

Relief of Chronic or Resistant Depression (Re-ChORD): A pragmatic, randomized, open-treatment trial of an integrative program intervention for chronic depression

Article

Full-text available

Nov 2009

Chronic depression is a particularly disabling mood disorder and treatment outcomes are poor with either psychotherapy or pharmacotherapy alone. There is growing evidence that an integrative treatment approach may be optimal. A novel multi-modal, multi-disciplinary treatment program, Re-ChORD, was developed at the University of British Columbia and evaluated in this pilot study. Re-ChORD consisted of guidelines-based medication management, and group-based interpersonal psychotherapy and occupational therapy. A randomized, parallel-groups, open-treatment trial was conducted comparing Re-ChORD to treatment as usual (TAU). Inclusion criteria were current depression (17-item Ham-D > or = 15) and a diagnosis of a chronic depressive disorder. The primary outcome variable was clinical remission (17-item Ham-D < or = 7) at 4 month assessment. A total of 64 patients were randomised to Re-ChORD (N=34) and TAU (N=30). Under both intention to treat (ITT) and completer analyses, the remission rate was significantly higher in the Re-ChORD than TAU groups. Treatment effect size for remission was of medium magnitude (22.2% and 29.6% over TAU under ITT and completer analyses). We did not collect sufficient follow-up data to investigate maintenance of gains. Re-ChORD shares elements with other combined treatments, and the present positive findings cannot be interpreted as being specific to the Re-ChORD program. Consistent with growing evidence that integrative treatments are necessary for chronic depressive disorders, Re-ChORD was demonstrated in this pilot study to produce significantly greater rates of remission than treatment as usual. A larger-scale trial is warranted.

Cognitive Behavioral Analysis System of Psychotherapy and Brief Supportive Psychotherapy for Augmentation of Antidepressant Nonresponse in Chronic Depression: The REVAMP Trial

Article

Full-text available

Nov 2009

Previous studies have found that few chronically depressed patients remit with antidepressant medications alone. To determine the role of adjunctive psychotherapy in the treatment of chronically depressed patients with less than complete response to an initial medication trial. This trial compared 12 weeks of (1) continued pharmacotherapy and augmentation with cognitive behavioral analysis system of psychotherapy (CBASP), (2) continued pharmacotherapy and augmentation with brief supportive psychotherapy (BSP), and (3) continued optimized pharmacotherapy (MEDS) alone. We hypothesized that adding CBASP would produce higher rates of response and remission than adding BSP or continuing MEDS alone. Eight academic sites. Chronically depressed patients with a current DSM-IV-defined major depressive episode and persistent depressive symptoms for more than 2 years. Phase 1 consisted of open-label, algorithm-guided treatment for 12 weeks based on a history of antidepressant response. Patients not achieving remission received next-step pharmacotherapy options with or without adjunctive psychotherapy (phase 2). Individuals undergoing psychotherapy were randomized to receive either CBASP or BSP stratified by phase 1 response, ie, as nonresponders (NRs) or partial responders (PRs). Proportions of remitters, PRs, and NRs and change on Hamilton Scale for Depression (HAM-D) scores. In all, 808 participants entered phase 1, of which 491 were classified as NRs or PRs and entered phase 2 (200 received CBASP and MEDS, 195 received BSP and MEDS, and 96 received MEDS only). Mean HAM-D scores dropped from 25.9 to 17.7 in NRs and from 15.2 to 9.9 in PRs. No statistically significant differences emerged among the 3 treatment groups in the proportions of phase 2 remission (15.0%), partial response (22.5%), and nonresponse (62.5%) or in changes on HAM-D scores. Although 37.5% of the participants experienced partial response or remitted in phase 2, neither form of adjunctive psychotherapy significantly improved outcomes over that of a flexible, individualized pharmacotherapy regimen alone. A longitudinal assessment of later-emerging benefits is ongoing.

Intensive Short-Term Dynamic Psychotherapy of treatment-resistant depression: a pilot study

Article

Full-text available

Jan 2006

Allan Abbass

This pilot study examined the effectiveness of Intensive Short-term Dynamic Psychotherapy (ISTDP) in treatment-resistant depression (TRD). Ten patients with TRD were provided a course of ISTDP. Clinician and patient symptom and interpersonal measures were completed every 4 weeks, at termination, and in follow-up. Medication, disability, and hospital costs were compared before and after treatment. After an average of 13.6 sessions of therapy, all mean measures reached the normal range, with effect sizes ranging from 0.87 to 3.3. Gains were maintained in follow-up assessments. Treatment costs were offset by cost reductions elsewhere in the system. This open study suggests that ISTDP may be effective with this challenging patient group. A randomized, controlled trial and qualitative research are warranted to evaluate this treatment further and to examine its possible therapeutic elements.

Acute and Longer-Term Outcomes in Depressed Outpatients Requiring One or Several Treatment Steps: A STAR*D Report

Article

Full-text available

Nov 2006

This report describes the participants and compares the acute and longer-term treatment outcomes associated with each of four successive steps in the Sequenced Treatment Alternatives to Relieve Depression (STAR*D) trial. A broadly representative adult outpatient sample with nonpsychotic major depressive disorder received one (N=3,671) to four (N=123) successive acute treatment steps. Those not achieving remission with or unable to tolerate a treatment step were encouraged to move to the next step. Those with an acceptable benefit, preferably symptom remission, from any particular step could enter a 12-month naturalistic follow-up phase. A score of <or=5 on the Quick Inventory of Depressive Symptomatology-Self-Report (QIDS-SR(16)) (equivalent to <or=7 on the 17-item Hamilton Rating Scale for Depression [HRSD(17)]) defined remission; a QIDS-SR(16) total score of >or=11 (HRSD(17)>or=14) defined relapse. The QIDS-SR(16) remission rates were 36.8%, 30.6%, 13.7%, and 13.0% for the first, second, third, and fourth acute treatment steps, respectively. The overall cumulative remission rate was 67%. Overall, those who required more treatment steps had higher relapse rates during the naturalistic follow-up phase. In addition, lower relapse rates were found among participants who were in remission at follow-up entry than for those who were not after the first three treatment steps. When more treatment steps are required, lower acute remission rates (especially in the third and fourth treatment steps) and higher relapse rates during the follow-up phase are to be expected. Studies to identify the best multistep treatment sequences for individual patients and the development of more broadly effective treatments are needed.

Intensive short-term dynamic psychotherapy

Article

Jan 2005

H. Davanloo

Systematic Review of Clinical Practice Guidelines for Failed Antidepressant Treatment Response in Major Depressive Disorder, Dysthymia, and Subthreshold Depression in Adults

Article

Aug 2016
CAN J PSYCHIAT

Objective: This systematic review critically evaluated clinical practice guidelines (CPGs) for treating adults with major depressive disorder, dysthymia, or subthreshold or minor depression for recommendations following inadequate response to first-line treatment with selective serotonin reuptake inhibitors (SSRIs). Method: Searches for CPGs (January 2004 to November 2014) in English included 7 bibliographic databases and grey literature sources using CPG and depression as the keywords. Two raters selected CPGs on depression with a national scope. Data extraction included definitions of adequate response and recommended treatment options. Two raters assessed quality using the Appraisal of Guidelines for Research and Evaluation II (AGREE II) instrument. Results: From 46,908 citations, 3167 were screened at full text. From these 21 CPG were applicable to adults in primary care and outpatient settings. Five CPGs consider patients with dysthymia or subthreshold or minor depression. None provides recommendations for those who do not respond to first-line SSRI treatment. For adults with MDD, most CPGs do not define an "inadequate response" or provide specific suggestions regarding how to choose alternative medications when switching to an alternative antidepressant. There is variability between CPGs in recommending combination strategies. AGREE II ratings for stakeholder involvement in CPG development, editorial independence, and rigor of development are domains in which depression guidelines are often less robust. Conclusions: About half of patients with depression require second-line treatment to achieve remission. Consistency and clarity in guidelines for second-line treatment of depression are therefore important for clinicians but lacking in most current guidelines. This may reflect a paucity of primary studies upon which to base conclusions.

The Global Burden of Disease: A Comprehensive Assessment of Mortality and Disability from Diseases, Injuries, and Risk Factors in 1990 and Projected to 2020

Book

Jan 1996

Interpersonal psychotherapy as add-on for treatment-resistant depression: A pragmatic randomized controlled trial

Article

Jan 2016

Background: Treatment-resistant depression (TRD) is an extremely prevalent clinical condition. Although Interpersonal Psychotherapy (IPT) is an established treatment for uncomplicated depression, its effectiveness has never before been studied in patients with TRD in real-world settings. We investigate IPT as an adjunct strategy to treatment as usual (TAU) for TRD patients in a pragmatic, randomized, controlled trial. Methods: A total of 40 adult patients with TRD (satisfying the criteria for major depressive disorder despite adequate antidepressant treatment) were recruited from a tertiary care facility for this pragmatic trial and blinded to the evaluator. Patients were randomized to one of two treatment conditions: (1) TAU - pharmacotherapy freely chosen by the clinician (n=23) and (2) TAU+IPT (n=17). Assessments were performed at weeks 8, 12, 19 and 24. Changes in the estimated means of the Hamilton Depression Rating Scale score were the primary outcome measure. Secondary outcomes included patient-rated scales and quality of life scales. We used a linear mixed model to compare changes over time between the two groups. Results: Both treatments lead to improvements in depressive symptoms from baseline to week 24 with no significant between group differences in either primary: TAU (mean difference: 4.57; CI95%: 0.59-8.55; d=0.73) vs. IPT+TAU (mean difference: 5.86, CI95%: 1.50-10.22; d=0.93) or secondary outcomes. Limitations: Our relatively small sample limits our ability to detect differences between treatments. Conclusions: Both treatments lead to equal improvements in depressive symptoms. We found no evidence to support adding IPT to pharmacotherapy in patients with TRD. Trial registration: ClinicalTrials.gov-NCT01896349.

The PHQ-9: A New Depression Diagnostic and Severity Measure the nine-item Patient Health Questionnaire depression scale is a dual-purpose instrument that can establish provisional depressive disorder diagnoses as well as grade depression severity

Article

Jan 2002

CONSORT 2010 Explanation and Elaboration: Updated guidelines for reporting parallel group randomised trial

Article

Jan 2010
PLOS MED

Borderline Personality Disorder, Atypical Depression, and Cyclothymia: Diagnostic Distinctions Crossing Mood and Personality Disorders Borders

Article

Jan 2015

Atypical depression, cyclothymia, and borderline personality disorder are three diagnostic terms used to describe the clinical presentations of patients with both chronic affective instability and interpersonal sensitivity. The historical development of these diagnostic concepts represents separate streams of effort in defining features of patients prone to develop complex configurations of psychiatric comorbidities and poor treatment response. While a small empirical literature has studied the relationship between these disorders, the boundaries between them remain unclear. The evidence-based treatment for atypical depression and cylcothymia promotes the use of medications like MAOIs (monoamine oxidase inhibitors) and lithium, with significant side effect burdens and lethality in overdose. Psychotherapeutic approaches are established as the primary treatment modality for BPD, but are inadequately tested for atypical depression and cyclothymia. In clinical presentations where all three diagnoses are possible, a combined approach utilizing psychotherapy to stabilize interpersonal sensitivities and affective instability with adjunctive mood stabilizing agents may optimize the long-term outcomes for this chronic and functionally challenged group of patients.

The great psychotherapy debate: The evidence for what makes psychotherapy work: Second edition

Book

Jan 2015

The second edition of The Great Psychotherapy Debate has been updated and revised to expand the presentation of the Contextual Model, which is derived from a scientific understanding of how humans heal in a social context and explains findings from a vast array of psychotherapies studies. This model provides a compelling alternative to traditional research on psychotherapy, which tends to focus on identifying the most effective treatment for particular disorders through emphasizing the specific ingredients of treatment. The new edition also includes a history of healing practices, medicine, and psychotherapy, an examination of therapist effects, and a thorough review of the research on common factors such as the alliance, expectations, and empathy.

The efficacy of short-term psychodynamic psychotherapy for depression: A meta-analysis update

Article

Dec 2015
CLIN PSYCHOL REV

Pragmatic randomized controlled trial of long-term psychoanalytic psychotherapy for treatment-resistant depression: The Tavistock Adult Depression Study (TADS)

Article

Sep 2015

This pragmatic randomized controlled trial tested the effectiveness of long-term psychoanalytic psychotherapy (LTPP) as an adjunct to treatment-as-usual according to UK national guidelines (TAU), compared to TAU alone, in patients with long-standing major depression who had failed at least two different treatments and were considered to have treatment-resistant depression. Patients (N=129) were recruited from primary care and randomly allocated to the two treatment conditions. They were assessed at 6-monthly intervals during the 18 months of treatment and at 24, 30 and 42 months during follow-up. The primary outcome measure was the 17-item version of the Hamilton Depression Rating Scale (HDRS-17), with complete remission defined as a HDRS-17 score ≤8, and partial remission defined as a HDRS-17 score ≤12. Secondary outcome measures included self-reported depression as assessed by the Beck Depression Inventory - II, social functioning as evaluated by the Global Assessment of Functioning, subjective wellbeing as rated by the Clinical Outcomes in Routine Evaluation - Outcome Measure, and satisfaction with general activities as assessed by the Quality of Life Enjoyment and Satisfaction Questionnaire. Complete remission was infrequent in both groups at the end of treatment (9.4% in the LTPP group vs. 6.5% in the control group) as well as at 42-month follow-up (14.9% vs. 4.4%). Partial remission was not significantly more likely in the LTPP than in the control group at the end of treatment (32.1% vs. 23.9%, p=0.37), but significant differences emerged during follow-up (24 months: 38.8% vs. 19.2%, p=0.03; 30 months: 34.7% vs. 12.2%, p=0.008; 42 months: 30.0% vs. 4.4%, p=0.001). Both observer-based and self-reported depression scores showed steeper declines in the LTPP group, alongside greater improvements on measures of social adjustment. These data suggest that LTPP can be useful in improving the long-term outcome of treatment-resistant depression. End-of-treatment evaluations or short follow-ups may miss the emergence of delayed therapeutic benefit.

The researcher's own therapy allegiances: A “wild card” in comparisons of treatment efficacy

Article

Feb 1999

Lester Luborsky

This report examines a possible distortion in the results of comparative treatment studies due to the association of the researcher's therapy allegiances with outcomes of those treatments. In eight past reviews a trend appeared for significant associations between the researcher's allegiance and outcomes of treatments compared. In this review of 29 studies of treatment comparisons, a similar trend appeared. Allegiance ratings were based not only on the usual reprint method, but also on two new methods: ratings by colleagues who knew the researcher well, and self-ratings by the researchers themselves. The two new allegiance methods intercorrelated only moderately, but each allegiance measure correlated significantly with outcomes of the treatments compared, and when combined, the three measures explained 69% of the variance in outcomes. Such an association can distort comparative treatment results. This report concludes with how the researcher's allegiance may become associated with treatment outcomes and how studies should deal with these associations. (PsycINFO Database Record (c) 2008 APA, all rights reserved)

Applied Longitudinal Data Analysis: Modeling Change and Event Occurrence

Book

Jan 2003

Change is constant in everyday life. Infants crawl and then walk, children learn to read and write, teenagers mature in myriad ways, and the elderly become frail and forgetful. Beyond these natural processes and events, external forces and interventions instigate and disrupt change: test scores may rise after a coaching course, drug abusers may remain abstinent after residential treatment. By charting changes over time and investigating whether and when events occur, researchers reveal the temporal rhythms of our lives. This book is concerned with behavioral, social, and biomedical sciences. It offers a presentation of two of today's most popular statistical methods: multilevel models for individual change and hazard/survival models for event occurrence (in both discrete- and continuous-time). Using data sets from published studies, the book takes you step by step through complete analyses, from simple exploratory displays that reveal underlying patterns through sophisticated specifications of complex statistical models.

The PHQ-9: A New Depression Diagnostic and Severity Measure

Article

Sep 2002
PSYCHIAT ANN

The nine-item Patient Health Questionnaire depression scale is a dual-purpose instrument that can establish provisional depressive disorder diagnoses as well as grade depression severity.

Cognitive behavioural therapy as an adjunct to pharmacotherapy for primary care based patients with treatment resistant depression: Results of the CoBalT randomised controlled trial

Article

Dec 2012
LANCET

Background: Only a third of patients with depression respond fully to antidepressant medication but little evidence exists regarding the best next-step treatment for those whose symptoms are treatment resistant. The CoBalT trial aimed to examine the effectiveness of cognitive behavioural therapy (CBT) as an adjunct to usual care (including pharmacotherapy) for primary care patients with treatment resistant depression compared with usual care alone. Methods: This two parallel-group multicentre randomised controlled trial recruited 469 patients aged 18-75 years with treatment resistant depression (on antidepressants for ≥6 weeks, Beck depression inventory [BDI] score ≥14 and international classification of diseases [ICD]-10 criteria for depression) from 73 UK general practices. Participants were randomised, with a computer generated code (stratified by centre and minimised according to baseline BDI score, whether the general practice had a counsellor, previous treatment with antidepressants, and duration of present episode of depression) to one of two groups: usual care or CBT in addition to usual care, and were followed up for 12 months. Because of the nature of the intervention it was not possible to mask participants, general practitioners, CBT therapists, or researchers to the treatment allocation. Analyses were by intention to treat. The primary outcome was response, defined as at least 50% reduction in depressive symptoms (BDI score) at 6 months compared with baseline. This trial is registered, ISRCTN38231611. Findings: Between Nov 4, 2008, and Sept 30, 2010, we assigned 235 patients to usual care, and 234 to CBT plus usual care. 422 participants (90%) were followed up at 6 months and 396 (84%) at 12 months, finishing on Oct 31, 2011. 95 participants (46%) in the intervention group met criteria for response at 6 months compared with 46 (22%) in the usual care group (odds ratio 3·26, 95% CI 2·10-5·06, p<0·001). Interpretation: Before this study, no evidence from large-scale randomised controlled trials was available for the effectiveness of augmentation of antidepressant medication with CBT as a next-step for patients whose depression has not responded to pharmacotherapy. Our study has provided robust evidence that CBT as an adjunct to usual care that includes antidepressants is an effective treatment, reducing depressive symptoms in this population. Funding: National Institute for Health Research Health Technology Assessment.

User's guide for the structured clinical interview for DSM-IV Axis II personality disorders (SCID-II)

Article

Jan 1990

The Structured Clinical Interview for DSM-III-R [Diagnostic and Statistical Manual, Revised] (SCID) is a semistructured interview for making the major Axis I and Axis II diagnoses. It is administered by a clinician or trained mental health professional who is familiar with the DSM-III-R classification and diagnostic criteria (1). The subjects may be either psychiatric or general medical patients or individuals who do not identify themselves as patients, such as subjects in a community survey of mental illness or family members of psychiatric patients. The language and diagnostic coverage make the SCID most appropriate for use with adults (age 18 or over), but with slight modification, it may be used with adolescents. (PsycINFO Database Record (c) 2012 APA, all rights reserved)

The Researcher's Own Therapy Allegiances: A “Wild Card” in Comparisons of Treatment Efficacy

Article

Mar 1999
CLIN PSYCHOL-SCI PR

This report examines a possible distortion in the results of comparative treatment studies due to the association of the researcher's treatment allegiances with outcomes of those treatments. In eight past reviews a trend appeared for significant associations between the researcher's allegiance and outcomes of treatments compared. In a new review of 29 studies of treatment comparisons, a similar trend appeared. Allegiance ratings were based not only on the usual reprint method, but also on two new methods: ratings by colleagues who knew the researcher well, and self-ratings by the researchers themselves. The two new allegiance methods Interco related only moderately, but each allegiance measure correlated significantly with outcomes of the treatments compared, and when combined, the three measures explained 69% of the variance in outcomes Such an association can distort comparative treatment results. Our report concludes with how the researcher's allegiance may become associated with treatment outcomes and how studies should deal with these associations.

The Efficacy of Short-Term Psychodynamic Psychotherapy for Depressive Disorders with Comorbid Personality Disorder

Article

Mar 2011
PSYCHIATRY

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.

The efficacy of short-term psychodynamic psychotherapy for depression: A meta-analysis

Article

Sep 2009

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.

Canadian Network for Mood and Anxiety Treatments (CANMAT) Clinical guidelines for the management of major depressive disorder in adults. III. Pharmacotherapy

Article

Sep 2009

In 2001, the Canadian Psychiatric Association and the Canadian Network for Mood and Anxiety Treatments (CANMAT) partnered to produce evidence-based clinical guidelines for the treatment of depressive disorders. A revision of these guidelines was undertaken by CANMAT in 2008-2009 to reflect advances in the field. The CANMAT guidelines are based on a question-answer format to enhance accessibility to clinicians. An evidence-based format was used with updated systematic reviews of the literature and recommendations were graded according to Level of Evidence using pre-defined criteria. Lines of Treatment were identified based on criteria that included Levels of Evidence and expert clinical support. This section on "Pharmacotherapy" is one of 5 guideline articles. Despite emerging data on efficacy and tolerability differences amongst newer antidepressants, variability in patient response precludes identification of specific first choice medications for all patients. All second-generation antidepressants have Level 1 evidence to support efficacy and tolerability and most are considered first-line treatments for MDD. First-generation tricyclic and monoamine oxidase inhibitor antidepressants are not the focus of these guidelines but generally are considered second- or third-line treatments. For inadequate or incomplete response, there is Level 1 evidence for switching strategies and for add-on strategies including lithium and atypical antipsychotics. Most of the evidence is based on trials for registration and may not reflect real-world effectiveness. Second-generation antidepressants are safe, effective and well tolerated treatments for MDD in adults. Evidence-based switching and add-on strategies can be used to optimize response in MDD that is inadequately responsive to monotherapy.

Canadian Network for Mood and Anxiety Treatments (CANMAT) Clinical guidelines for the management of major depressive disorder in adults

Article

Sep 2009

In 2001, the Canadian Psychiatric Association and the Canadian Network for Mood and Anxiety Treatments (CANMAT) partnered to produce evidence-based clinical guidelines for the treatment of depressive disorders. A revision of these guidelines was undertaken by CANMAT in 2008-2009 to reflect advances in the field. There is widespread interest in complementary and alternative medicine (CAM) therapies in the treatment of major depressive disorder (MDD). The CANMAT guidelines are based on a question-answer format to enhance accessibility to clinicians. An evidence-based format was used with updated systematic reviews of the literature and recommendations were graded according to Level of Evidence using pre-defined criteria. Lines of Treatment were identified based on criteria that included evidence and expert clinical support. This section on "Complementary and Alternative Medicine Treatments" is one of 5 guideline articles. There is Level 1 evidence to support light therapy in seasonal MDD and St. John's wort in mild to moderate MDD. There is also some evidence for the use of exercise, yoga and sleep deprivation, as well as for omega-3 fatty acids and SAM-e . Support for other natural health products and therapies is still limited. The evidence base remains limited and studies often have methodological problems, including small samples, variability in dose, short duration of treatment, unknown quality of the agent and limited long-term data. Safety data are also sparse with little information about drug interactions. Some CAM treatments have evidence of benefit in MDD. However, problems with standardization and safety concerns may limit their applicability in clinical practice.

Clinical practice recommendations for depression

Article

Jun 2009

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.

When should psychotherapy be the treatment of choice for major depressive disorder?

Article

Dec 2009
Curr Psychiatr Rep

John C Markowitz

Clinicians should think carefully before deciding on the initial treatment for a patient with major depressive disorder. The author argues that this does not happen often enough, and that psychotherapy may be overlooked too often as a first treatment option. Based on the research literature and the American Psychiatric Association Practice Guidelines, this article reviews potential cautions and relative indications for initiating treatment with evidence-based psychotherapies for major depressive disorder. Potential indications include 1) patient preference; 2) symptom severity; 3) relative contraindications to pharmacotherapy; 4) prior treatment history; 5) nature of symptoms; 6) psychosocial context, including a life crisis or complicated bereavement; 7) control and credit; and 8) new and enduring skills.

A randomised controlled trial of Intensive Short-Term Dynamic Psychotherapy for treatment resistant depression: the Halifax Depression Study

Abstract

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