Henricus L. Van

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.

The efficacy of cognitive-behavioral therapy and psychodynamic therapy in the outpatient treatment of major depression: a randomized clinical trial.

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 Cohens 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.

Predicting the Outcome of Antidepressants and Psychotherapy for Depression: A Qualitative, Systematic Review

&NA; As treatment outcome in depression varies widely, it is important to understand better the predictive value of particular patient characteristics. However, qualitative systematic reviews of the association between easily identifiable patient characteristics and outcome for commonly used treatment options have been unavailable. This article provides an overview of the consistency of findings on the association between sociodemographic factors and depression characteristics, on the one hand, and outcomes of pharmacotherapy, cognitive‐behavioral therapy, and interpersonal/psychodynamic psychotherapy for major depression, on the other. There were no findings indicating that gender was associated with treatment outcome in the case of tricyclic antidepressants. There are some indications that younger patients respond worse to tricyclics, whereas especially women appeared to have better outcomes with modern antidepressants (selective serotonin/norepinephrine reuptake inhibitors). Marital status may be related to better outcome in the case of antidepressants and cognitive‐behavioral therapy. Longer duration of depression was identified as a negative predictor, most consistently in psychotherapy. In none of the treatment modalities was recurrence a negative predictor. The relation between severity of depression and outcome appeared to be complex, precluding any straightforward inferences.

Managing the patient with co-morbid depression and an anxiety disorder

Depression and anxiety disorders frequently co-occur. This type of co-morbidity is associated with higher severity, suicidality, chronicity and treatment resistance. However, available treatment guidelines mainly focus on treatment for singular disorders. The current paper describes diagnostic and treatment issues relevant for adequately addressing patients with depression and an anxiety disorder, using information from both guidelines and a search of recent literature.Apart from differential diagnosis, the diagnostic evaluation should include a thorough assessment of the symptoms of both disorders, preferably by using a structured clinical interview, and an assessment of depression severity in terms of suicidality, psychotic symptoms and impairment. Treatment should first address the primary disorder in terms of severity and risk. As a rule, severe depression should be treated before the anxiety disorder, using antidepressant medication or combined treatment (plus psychotherapy). In less severe pathology, the primary focus may be determined by examining the temporal pattern and the subjective burden of each disorder as experienced by the patient.Treatment is often sequential. Treatment of the primary disorder may or may not relieve the co-morbid disorder as well. If the primary disorder is an anxiety disorder, co-morbid depression generally implies earlier use of an antidepressant. Co-morbid mild depression may also react favourably to psychotherapeutic treatment of the anxiety disorder. Recent literature on concurrent treatment of both depression and anxiety shows that modern antidepressants such as sertraline, paroxetine, fluoxetine, venlafaxine, nefazodone and bupropion have demonstrated efficacy in relieving both depressive and anxiety symptoms compared with placebo. Head-to-head comparisons, although relatively scarce, tend to show superiority over tricyclic antidepressants. Venlafaxine was found to be more effective than fluoxetine in some studies. However, these results should be interpreted with caution because studies vary considerably in terms of patient selection, assessment of anxiety and primary outcome measures. Only one randomized controlled trial compared atypical antipsychotics with placebo. Psychotherapy was generally shown to have a beneficial effect on the co-morbid conditions, and available evidence appears to favour combined treatment. The results should be interpreted with caution because the number of studies on this issue was relatively small, with considerable clinical and methodological heterogeneity.

Cognitive Behavioral Therapy versus Short Psychodynamic Supportive Psychotherapy in the outpatient treatment of depression: a randomized controlled trial

BackgroundPrevious research has shown that Short Psychodynamic Supportive Psychotherapy (SPSP) is an effective alternative to pharmacotherapy and combined treatment (SPSP and pharmacotherapy) in the treatment of depressed outpatients. The question remains, however, how Short Psychodynamic Supportive Psychotherapy compares with other established psychotherapy methods. The present study compares Short Psychodynamic Supportive Psychotherapy to the evidence-based Cognitive Behavioral Therapy in terms of acceptability, feasibility, and efficacy in the outpatient treatment of depression. Moreover, this study aims to identify clinical predictors that can distinguish patients who may benefit from either of these treatments in particular. This article outlines the study protocol. The results of the study, which is being currently carried out, will be presented as soon as they are available.Methods/DesignAdult outpatients with a main diagnosis of major depressive disorder or depressive disorder not otherwise specified according to DSM-IV criteria and mild to severe depressive symptoms (Hamilton Depression Rating Scale score ≥ 14) are randomly allocated to Short Psychodynamic Supportive Psychotherapy or Cognitive Behavioral Therapy. Both treatments are individual psychotherapies consisting of 16 sessions within 22 weeks. Assessments take place at baseline (week 0), during the treatment period (week 5 and 10) and at treatment termination (week 22). In addition, a follow-up assessment takes place one year after treatment start (week 52). Primary outcome measures are the number of patients refusing treatment (acceptability); the number of patients terminating treatment prematurely (feasibility); and the severity of depressive symptoms (efficacy) according to an independent rater, the clinician and the patient. Secondary outcome measures include general psychopathology, general psychotherapy outcome, pain, health-related quality of life, and cost-effectiveness. Clinical predictors of treatment outcome include demographic variables, psychiatric symptoms, cognitive and psychological patient characteristics and the quality of the therapeutic relationship.DiscussionThis study evaluates Short Psychodynamic Supportive Psychotherapy as a treatment for depressed outpatients by comparing it to the established evidence-based treatment Cognitive Behavioral Therapy. Specific strengths of this study include its strong external validity and the clinical relevance of its research aims. Limitations of the study are discussed.Trial registrationCurrent Controlled Trails ISRCTN31263312

Patient preference compared with random allocation in short-term psychodynamic supportive psychotherapy with indicated addition of pharmacotherapy for depression.

Abstract Depressed patients randomized to psychotherapy were compared with those who had been chosen for psychotherapy in a treatment algorithm, including addition of an antidepressant in case of early nonresponse. There were no differences between randomized and by-preference patients at baseline in adherence and outcome. About half of the early nonresponders refused the additional medication. However, no clear effect of medication addition on ultimate outcome could be demonstrated. In total, 37% of the patients achieved remission. The study suggested that randomization of patients does not induce a great influence on outcome. It might be warranted to continue an initially ineffective psychotherapy for depression, because a considerable number of patients do have a pattern of delayed response.

Identifying Patients at Risk of Complete Nonresponse in the Outpatient Treatment of Depression

Background: Although complete nonresponse in depression treatment is considered to be a major problem in clinical practice, research in this area is very limited. The objective of this preliminary study was to determine the frequency and predictors of complete nonresponse in different treatments for depression. Methods: Post hocanalysis of the pooled data of 3 consecutive randomized controlled trials of outpatient depression treatment was conducted. The subjects were 313 patients with major depressive disorder and 17-item Hamilton Rating Scale for Depression (HAM-D-17) scores between 14 and 25 who were treated for 6 months with either pharmacotherapy, short-term psychodynamic supportive psychotherapy or combined therapy. Complete nonresponse was defined as a <25% response according to the HAM-D-17. Sociodemographic factors, depression features and adherence were investigated as predictors in a multivariate stepwise logistic regression analysis. Results: Overall, nonresponse occurred in 34% of the patients. In pharmacotherapy this was 46%, in psychotherapy 39% and in combined therapy 28%. The severity of somatic symptoms was associated with nonresponse in both combined therapy and psychotherapy. No predictive factors were found in the case of pharmacotherapy. In psychotherapy, nonresponse was related to age above 40 years, chronic depression and nonadherence by the patient. In the case of combined therapy, younger age, previous use of an antidepressant and having a previous depressive episode were associated with nonresponse. Conclusion: Easily measurable patient characteristics may help to identify patients at risk of complete nonresponse to treatment. It is suggested that predictors may differ across treatment modalities. However, head-to-head comparisons are required before it can be recommended to take this into account when selecting the most appropriate treatment for individual depressed patients.

Predictive Value of Object Relations for Therapeutic Alliance and Outcome in Psychotherapy for Depression : An Exploratory Study

The concept of object relations has been shown to be relevant for the process and outcome of psychodynamic psychotherapies. However, little is known about its relevance for the psychotherapeutic treatment of depression. In this study, we explored the predictive value of object relational functioning (ORF) for the therapeutic alliance and outcome of short-term psychodynamic supportive psychotherapy in patients with mild to moderately severe depression. The ORF of 81 patients was rated by using the Developmental Profile. The overall maturity of ORF measured at baseline was higher in patients who showed a better treatment response. In multiple regression analysis, the adaptive level of individuation appeared to be specifically predictive of outcome. Patients with a recurrent depression showed less mature levels of ORF, lower adaptive levels and a higher score on the symbiotic level. No association was found between ORF and therapeutic alliance during treatment. In contrast to the single measure of alliance early in therapy, the growth of the alliance was related to outcome. The study indicated the relevance of ORF for depression and established that it is distinctive from the actual therapeutic alliance.

Victimisation in adults with severe mental illness: prevalence and risk factors.

BACKGROUND Patients with a severe mental illness (SMI) are more likely to experience victimisation than the general population. AIMS To examine the prevalence of victimisation in people with SMI, and the relationship between symptoms, treatment facility and indices of substance use/misuse and perpetration, in comparison with the general population. METHOD Victimisation was assessed among both randomly selected patients with SMI (n = 216) and the general population (n = 10 865). RESULTS Compared with the general population, a high prevalence of violent victimisation was found among the SMI group (22.7% v. 8.5%). Compared with out-patients and patients in a sheltered housing facility, in-patients were most often victimised (violent crimes: 35.3%; property crimes: 47.1%). Risk factors among the SMI group for violent victimisation included young age and disorganisation, and risk factors for property crimes included being an in-patient, disorganisation and cannabis use. The SMI group were most often assaulted by someone they knew. CONCLUSIONS Caregivers should be aware that patients with SMI are at risk of violent victimisation. Interventions need to be developed to reduce this vulnerability.

What Is the Best Sequential Treatment Strategy in the Treatment of Depression? Adding Pharmacotherapy to Psychotherapy or Vice Versa?

Background: Insufficient response to monotreatment for depression is a common phenomenon in clinical practice. Even so, evidence indicating how to proceed in such cases is sparse. Methods: This study looks at the second phase of a sequential treatment algorithm, in which 103 outpatients with moderately severe depression were initially randomized to either short-term supportive psychodynamic therapy (PDT) or antidepressants. Patients who reported less than 30% symptom improvement after 8 weeks were offered combined treatment. Outcome measures were the Hamilton Depression Rating Scale (HAM-D), the Clinical Global Impression of Severity and Improvement, the SCL-90 depression subscale and the EuroQOL questionnaire. Results: Despite being nonresponsive, about 40% of patients preferred to continue with monotherapy. At treatment termination, patients initially randomized to PDT had improved more than those initially receiving antidepressants, as indicated by the HAM-D and the EuroQOL, independently of whether the addition was accepted or not. Conclusions: Starting with psychotherapy may be preferable in mildly and moderately depressed outpatients. For patients who receive either PDT or antidepressants, combined therapy after early nonresponse seems to be helpful. Nevertheless, this sequential strategy is not always preferred by patients.