Short-Term Dynamic Psychotherapy Versus Pharmacotherapy for Major Depressive Disorder: A Randomized, Placebo-Controlled Trial

Center for Psychotherapy Research, Department of Psychiatry, University of Pennsylvania School of Medicine, Philadelphia, USA.
The Journal of Clinical Psychiatry (Impact Factor: 5.5). 11/2011; 73(1):66-73. DOI: 10.4088/JCP.11m06831
Source: PubMed


To determine whether supportive-expressive psychotherapy (SET), a form of dynamic psychotherapy, and pharmacotherapy + clinical management (MED) for major depressive disorder (MDD) are more effective than pill-placebo + clinical management (PBO).
This National Institute of Mental Health (NIMH)-sponsored randomized controlled trial was conducted (from November 2001 through June 2007) at the University of Pennsylvania Medical School. The sample included 156 patients diagnosed with MDD (DSM-IV) and having a 17-item Hamilton Rating Scale for Depression (HRSD(17)) score ≥ 14 for at least 2 consecutive weeks. This was an underserved sample in which 41% were male, 52% were self-designated minorities, and 76% had an annual income under $30,000. Treatment lasted 16 weeks. Medication patients not responsive by week 8 (maximum dose 200 mg/d of sertraline) were switched to venlafaxine (maximum dose 375 mg/d). Nonresponsive placebo patients at week 8 were switched to a different placebo.
Patients' depression improved over the 16 weeks (P < .0001), with no between-group differences (P = .95), even among severely (HRSD(17) score ≥ 20) depressed patients (P = .45). Response rates did not differ between groups (P = .73). Gender and minority status moderated outcome (P = .014), with psychotherapy more efficacious for minority men than MED (P = .027, Cohen d = 1.02) and PBO (P = .019, d = 1.09). PBO was more efficacious for white men than MED (P = .03, d = 0.62) and SET (P = .003, d = 1.07). For white women, MED (P = .005, d = 0.77) and SET (P = .033, d = 0.71) were more efficacious than placebo. No differences among treatments were found for minority women.
This trial of urban MDD patients failed to confirm that either active treatment was better than placebo. Minority status and gender had significant and differential effects on outcome that warrant replication in future studies. Identifier: NCT00043550.

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    • "Barber and colleagues recently summarized the results of the few studies relating patient characteristics to outcome of dynamic therapies[2]. Only fragments of the bigger picture of how to predict the later course of therapy could be derived; e.g., outcome was better for minority males and white females in supportive expressive therapy for depression[7], and panic patients with Cluster C personality disorders achieved more improvement by Panic focused Psychodynamic Psychotherapy (PFPP) than patients without personality disorders[8]. For social anxiety disorder, one of the most frequentand debilitating anxiety disorders[9], no study so far has addressed patient characteristics as predictors of psychodynamic psychotherapy. "
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    ABSTRACT: Objectives: Little is known about patient characteristics as predictors for outcome in manualized short term psychodynamic psychotherapy (PDT). No study has addressed which patient variables predict outcome of PDT for social anxiety disorder. Research design and methods: In the largest multicenter trial on psychotherapy of social anxiety (SA) to date comparing cognitive therapy, PDT and wait list condition N = 230 patients were assigned to receive PDT, of which N = 166 completed treatment. Treatment outcome was assessed based on diverse parameters such as endstate functioning, remission, response, and drop-out. The relationship between patient characteristics (demographic variables, mental co-morbidity, personality, interpersonal problems) and outcome was analysed using logistic and linear regressions. Results: Pre-treatment SA predicted up to 39 percent of variance of outcome. Only few additional baseline characteristics predicted better treatment outcome (namely, lower comorbidity and interpersonal problems) with a limited proportion of incremental variance (5.5 to 10 percent), while, e.g., shame, self-esteem or harm avoidance did not. Conclusions: We argue that the central importance of pre-treatment symptom severity for predicting outcomes should advocate alternative treatment strategies (e.g. longer treatments, combination of psychotherapy and medication) in those who are most disturbed. Given the relatively small amount of variance explained by the other patient characteristics, process variables and patient-therapist interaction should additionally be taken into account in future research. Trial registration:
    Full-text · Article · Jan 2016 · PLoS ONE
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    • "fer - ences in outcomes for minority and gender in predicting differ - ences between treatments . SET was more efficacious for minority men than MED and PBO . PBO was more efficacious for white men than MED and SET . For white women , MED and SET were more efficacious than placebo . No differences between treatments were found for minority women ( Barber et al . , 2012 ) . Therefore , we redid all the analyses controlling for minority status , gender , and the interaction between them . The findings of these analyses re - mained similar to those reported above ( Table 3 in the Supple - mental Material ) ."
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    ABSTRACT: Background The goal of the study was to examine two central theory-driven mechanisms of change, causal attributions and relational representations, to account for symptomatic improvement in psychodynamic treatment and supportive clinical management, combined with either pharmacotherapy or placebo, in a randomized control trial (RCT) for depression. Method We used data from an RCT for depression, which reported non-significant differences in outcome among patients (N=149) who received supportive-expressive psychotherapy (SET), clinical management combined with pharmacotherapy (CM+MED), or clinical management with placebo pill (CM+PBO) (Barber et al., 2012). Mechanism and outcome measures were administered at intake, mid-treatment, end of treatment, and at a 4-month follow-up. Results Improvements in causal attributions and in relational representations were found across treatments. Changes in causal attributions did not predict subsequent symptomatic level when controlling for prior symptomatic level. In contrast, decrease in negative relational representations predicted subsequent symptom reduction across all treatments, and increase in positive relational representations predicted subsequent symptom reduction only in SET. Limitations The study is limited by its moderate sample size. Additional studies are needed to examine the same questions using additional treatment orientations, such as cognitive treatments. Conclusions Findings demonstrate that changes in negative relational representations may act as a common mechanism of change and precede symptom reduction across psychodynamic therapy and supportive case management combined with either pharmacotherapy or placebo, whereas an increase in positive relational representation may be a mechanism of change specific to psychodynamic therapy.
    Full-text · Article · Dec 2015 · Journal of Affective Disorders
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    • "Antidepressant medications, while being used at an all-time high (National Center for Health Statistics, 2014), have not demonstrated a consistent advantage over placebo pills (Kirsch et al. 2008), and only half of psychotherapy patients recover after their first course of treatment (e.g. Barber et al. 2012; Carter et al. 2013). "
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    ABSTRACT: Background: Depression is a complex public health problem with considerable variation in treatment response. The systemic complexity of depression, or the feedback processes among diverse drivers of the disorder, contribute to the persistence of depression. This paper extends prior attempts to understand the complex causal feedback mechanisms that underlie depression by presenting the first broad boundary causal loop diagram of depression dynamics. Method: We applied qualitative system dynamics methods to map the broad feedback mechanisms of depression. We used a structured approach to identify candidate causal mechanisms of depression in the literature. We assessed the strength of empirical support for each mechanism and prioritized those with support from validation studies. Through an iterative process, we synthesized the empirical literature and created a conceptual model of major depressive disorder. Results: The literature review and synthesis resulted in the development of the first causal loop diagram of reinforcing feedback processes of depression. It proposes candidate drivers of illness, or inertial factors, and their temporal functioning, as well as the interactions among drivers of depression. The final causal loop diagram defines 13 key reinforcing feedback loops that involve nine candidate drivers of depression. Conclusions: Future research is needed to expand upon this initial model of depression dynamics. Quantitative extensions may result in a better understanding of the systemic syndrome of depression and contribute to personalized methods of evaluation, prevention and intervention.
    Full-text · Article · Dec 2015 · Psychological Medicine
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