Allan Abbass

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

OBJECTIVES The efficacy of short-term psychodynamic psychotherapy (STPP) for depression is debated. Recently, a number of large-scale and high-quality studies have been conducted. We examined the efficacy of STPP by updating our 2010 meta-analysis. RESULTS After a thorough literature search, 54 studies (33 randomized clinical trials) totaling 3946 subjects were included. STPP was significantly more effective than control conditions at post-treatment on depression, general psychopathology and quality of life measures (d=0.49 to 0.69). STPP pre-treatment to post-treatment changes (d=0.57 to 1.18) indicated significant improvements on all outcome measures, which either significantly improved further (d=0.20 to 1.04) or were maintained from post-treatment to follow-up. No significant differences were found between individual STPP and other psychotherapies at post-treatment (d=-0.14) and follow-up (d=-0.06) in analyses that were adequately powered to detect a clinically relevant difference. STPP was significantly more efficacious than other psychotherapies on anxiety measures at both post-treatment (d=0.35) and follow-up (d=0.76). CONCLUSION We found clear indications that STPP is effective in the treatment of depression in adults. Although more high-quality studies are needed, particularly to assess the efficacy of STPP compared to control conditions at follow-up and to antidepressants, these findings add to the evidence-base of STPP for depression.

Short-Term Psychodynamic Psychotherapy for Somatic Disorders: Systematic Review and Meta-Analysis of Clinical Trials

Background: Somatic symptom disorders are common, disabling and costly. Individually provided short-term psychodynamic psychotherapies (STPP) have shown promising results. However, the effectiveness of STPP for somatic symptom disorders has not been reviewed. Methods: We undertook a systematic review of randomized controlled trials and controlled before and after studies. The outcomes included psychological symptoms, physical symptoms, social-occupational function, healthcare utilization and treatment continuation. Results: A total of 23 studies met the inclusion criteria and covered a broad range of somatic disorders. Thirteen were RCTs and 10 were case series with pre-post outcome assessment. Of the included studies, 21/23 (91.3%), 11/12 (91.6%), 16/19 (76.2%) and 7/9 (77.8%) reported significant or possible effects on physical symptoms, psychological symptoms, social-occupational function and healthcare utilization respectively. Meta-analysis was possible for 14 studies and revealed significant effects on physical symptoms, psychiatric symptoms and social adjustment which were maintained in long-term follow-up. Random-effect modeling attenuated some of these relationships. There was a 54% greater treatment retention in the STPP group versus controls. Conclusion: STPP may be effective for a range of medical and physical conditions underscoring the role of patients’ emotional adjustment in overall health. Future research should include high-quality randomized and clinical effectiveness studies with attention to healthcare use and costs.

Emotional Influences in Patient Safety

Objective: The way that health care providers feel, both within themselves and toward their patients, may influence their clinical performance and impact patient safety, yet this aspect of provider behavior has received relatively little attention. How providers feel, their emotional or affective state, may exert a significant, unintended influence on their patients, and may compromise safety. Methods: We examined a broad literature across multiple disciplines to review the interrelationships between emotion, decision making, and behavior, and to assess their potential impact on patient safety. Findings: There is abundant evidence that the emotional state of the health care provider may be influenced by factors including characteristics of the patient, ambient conditions in the health care setting, diurnal, circadian, infradian, and seasonal variables, as well as endogenous disorders of the individual provider. These influences may lead to affective biases in decision making, resulting in errors and adverse events. Clinical reasoning and judgment may be particularly susceptible to emotional influence, especially those processes that rely on intuitive judgments. Conclusions: There are many ways that the emotional state of the health care provider can influence patient care. To reduce emotional errors, the level of awareness of these factors should be raised. Emotional skills training should be incorporated into the education of health care professionals. Specifically, clinical teaching should promote more openness and discussion about the providers feelings toward patients. Strategies should be developed to help providers identify and de-bias themselves against emotional influences that may impact care, particularly in the emotionally evocative patient. Psychiatric conditions within the provider, which may compromise patient safety, need to be promptly detected, diagnosed, and managed.

Intensive Short-Term Dynamic Psychotherapy: A Systematic Review and Meta-analysis of Outcome Research

&NA; Habib Davanloo has spent his career developing and teaching methods to accelerate dynamic psychotherapy, including his technique of intensive short‐term dynamic psychotherapy (ISTDP). Over the past 20 years, outcome studies using this treatment have been conducted and published. We performed a systematic review of the literature to obtain studies presenting ISTDP outcome data. We found 21 studies (10 controlled, and 11 uncontrolled) reporting the effects of ISTDP in patients with mood, anxiety, personality, and somatic disorders. Using the random‐effects model, we performed meta‐analyses including 13 of these studies and found pre‐ to post‐treatment effect sizes (Cohens d) ranging from 0.84 (interpersonal problems) to 1.51 (depression). Post‐treatment to follow‐up effect sizes suggested that these gains were maintained at follow‐up. Based on post‐treatment effect sizes, ISTDP was significantly more efficacious than control conditions (d = 1.18; general psychopathology measures). Study quality was highly variable, and there was significant heterogeneity in some analyses. Eight studies using various measures suggested ISTDP was cost‐effective. Within limitations of study methodologies, this evidence supports the application of ISTDP across a broad range of populations. Further rigorous and targeted research into this method is warranted.

Web-Conference Supervision for Advanced Psychotherapy Training: A Practical Guide

The advent of readily accessible, inexpensive Web-conferencing applications has opened the door for distance psychotherapy supervision, using video recordings of treated clients. Although relatively new, this method of supervision is advantageous given the ease of use and low cost of various Internet applications. This method allows periodic supervision from point to point around the world, with no travel costs and no long gaps between direct training contacts. Web-conferencing permits face-to-face training so that the learner and supervisor can read each others emotional responses while reviewing case material. It allows group learning from direct supervision to complement local peer-to-peer learning methods. In this article, we describe the relevant literature on this type of learning method, the practical points in its utilization, its limitations, and its benefits.

Psychodynamic Psychotherapy for Children and Adolescents: A Meta-Analysis of Short-Term Psychodynamic Models

OBJECTIVE Psychodynamically based brief psychotherapy is frequently used in clinical practice for a range of common mental disorders in children and adolescents. To our knowledge, there have been no meta-analyses to evaluate the effectiveness of these therapies. METHOD After a broad search, we meta-analyzed controlled outcome studies of short-term psychodynamic psychotherapies (STPP, 40 or fewer sessions). We also performed sensitivity analyses and evaluated the risk of bias in this body of studies. RESULTS We found 11 studies with a total of 655 patients covering a broad range of conditions including depression, anxiety disorders, anorexia nervosa, and borderline personality disorder. STPP did not separate from what were mostly robust treatment comparators, but there were some subgroup differences. Robust (g = 1.07, 95% CI = 0.80-1.34) within group effect sizes were observed suggesting the treatment may be effective. These effects increased in follow up compared to post treatment (overall, g = 0.24, 95% CI = 0.00-0.48), suggesting a tendency toward increased gains. Heterogeneity was high across most analyses, suggesting that these data need be interpreted with caution. CONCLUSION This review suggests that STPP may be effective in children and adolescents across a range of common mental disorders.

A Meta-Analysis of Psychodynamic Psychotherapy Outcomes: Evaluating the Effects of Research-Specific Procedures

The aim of this research was to examine the extent to which the use of research-specific procedures in psychodynamic psychotherapy impacts upon treatment effectiveness and which variables moderate this potential relationship. Effects of audio/video recording of sessions, use of treatment manuals, and checks of treatment fidelity were examined. A meta-analysis was conducted on randomized controlled trials of psychodynamic psychotherapy. Forty-six independent treatment samples totaling 1615 patients were included. The magnitude of change between pretreatment and posttreatment aggregated across all studies (45 treatment samples) for overall outcome was large (d = 1.01), and further improvement was observed between posttreatment and an average 12.8-month follow-up (d = 0.18). Subgroup analyses comparing studies that used research-specific procedures and those that did not revealed that for posttreatment data no differences in treatment effects were found. However, the use of treatment manuals and fidelity checks were significantly associated with improvement between the end of treatment and follow-up assessment. Within the limitations of analyses, this data offered preliminary evidence that use of research-specific procedures does not contribute in a negative manner to posttreatment outcomes in psychodynamic psychotherapy, and their use contributes to positive differences that emerge with time. These findings, although observational in nature, make a case for reconsidering how dimensions of clinical utility and experimental control may be integrated in psychodynamic psychotherapy to enable further elucidation of principles that evidently work.

Psychodynamic therapy meets evidence-based medicine: a systematic review using updated criteria

Psychodynamic therapy (PDT) is an umbrella concept for treatments that operate on an interpretive-supportive continuum and is frequently used in clinical practice. The use of any form of psychotherapy should be supported by sufficient evidence. Efficacy research has been neglected in PDT for a long time. In this review, we describe methodological requirements for proofs of efficacy and summarise the evidence for use of PDT to treat mental health disorders. After specifying the requirements for superiority, non-inferiority, and equivalence trials, we did a systematic search using the following criteria: randomised controlled trial of PDT; use of treatment manuals or manual-like guidelines; use of reliable and valid measures for diagnosis and outcome; adults treated for specific mental problems. We identified 64 randomised controlled trials that provide evidence for the efficacy of PDT in common mental health disorders. Studies sufficiently powered to test for equivalence to established treatments did not find substantial differences in efficacy. These results were corroborated by several meta-analyses that suggest PDT is as efficacious as treatments established in efficacy. More randomised controlled trials are needed for some mental health disorders such as obsessive-compulsive disorder and post-traumatic stress disorder. Furthermore, more adequately powered equivalence trials are needed.

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

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.

Effectiveness of psychotherapy for severe somatoform disorder: meta-analysis

BACKGROUND Patients with severe somatoform disorder (in secondary and tertiary care) typically experience functional impairment associated with physical symptoms and mental distress. Although psychotherapy is the preferred treatment, its effectiveness remains to be demonstrated. AIMS To examine the effectiveness of psychotherapy for severe somatoform disorder in secondary and tertiary care compared with treatment as usual (TAU) but not waiting-list conditions. METHOD Main inclusion criteria were presence of a somatoform disorder according to established diagnostic criteria and receiving psychotherapy for somatoform disorder in secondary and tertiary care. Both randomised and non-randomised trials were included. The evaluated outcome domains were physical symptoms, psychological symptoms (depression, anxiety, anger, general symptoms) and functional impairment (health, life satisfaction, interpersonal problems, maladaptive cognitions and behaviour). RESULTS Ten randomised and six non-randomised trials were included, comprising 890 patients receiving psychotherapy and 548 patients receiving TAU. Psychotherapy was more effective than TAU for physical symptoms (d = 0.80 v. d = 0.31, P<0.05) and functional impairment (d = 0.45 v. d = 0.15, P<0.01), but not for psychological symptoms (d = 0.75 v. d = 0.51, P = 0.21). These effects were maintained at follow-up. CONCLUSIONS Overall findings suggest that psychotherapy is effective in severe somatoform disorder. Future randomised controlled studies should examine specific interventions and mechanisms of change.