Empirically supported methods of short-term psychodynamic therapy in depression – Towards an evidence-based unified protocol

Abstract

Context

There is evidence that psychotherapy is helpful in depressive disorders, with no significant differences between psychotherapies. For psychodynamic therapy (PDT) various models prove to be efficacious. Thus, the evidence for PDT is “scattered” between different forms of PDT, also implying problems in training of psychotherapy and in transferring research to clinical practice. A unified protocol based on empirically-supported methods of PDT in depression may contribute to solve these problems

Methods

Systematic search for randomized controlled trials fulfilling the following criteria: (a) individual psychodynamic therapy (PDT) of depressive disorders, (b) treatment manuals or manual-like guidelines, (c) PDT proved to be efficacious compared to control conditions, (d) reliable measures for diagnosis and outcome, and (f) adult patients.

Findings

Fourteen RCTs fulfilled the inclusion criteria. By a systematic review of the applied methods of PDT seven treatment components were identified. A high consistency between components was found. The components were conceptualized in the form of seven interrelated treatment modules.

Conclusions

A unified psychodynamic protocol for depression may enhance the empirical status of PDT, facilitate both the training in psychotherapy and the transfer of research to clinical practice and may have an impact on the health care system.

Introduction

There is evidence from a large number of randomized controlled trials (RCTs) that psychotherapy is effective in depressive disorders (Barth et al., 2013). Psychotherapy was found to be as efficacious as pharmacotherapy in the short-term but superior in the long-term especially with regard to relapse prevention (Cuijpers et al., 2013e, Dobson et al., 2008, Forand et al., 2013, Hollon et al., 2005, Imel et al., 2008, Spielmans et al., 2011, Vittengl et al., 2007). In dysthymia, however, a small but significant advantage of pharmacotherapy was found (Cuijpers et al., 2013e, Imel et al., 2008). Whereas the combination of psychotherapy and pharmacotherapy was reported to be superior to monotherapies by small to medium effect sizes in the short-term (Cuijpers et al., 2009a, Cuijpers et al., 2009b, Cuijpers et al., 2009b, Hollon and Beck, 2013), no superiority was found with regard to long-term effects (Cuijpers et al., 2009b, Cuijpers et al., 2009b, Forand et al., 2013). With rates of relapse between 40% and 85%, the risk of relapse after pharmacotherapy is relatively high (Hughes and Cohen, 2009). Maintenance pharmacotherapy has shown moderate efficacy in preventing relapse (Forand et al., 2013, Geddes et al., 2003).

With regard to the different forms of psychotherapy, several meta-analyses found no significant differences in efficacy in depressive disorders including cognitive-behavioural therapy (CBT), psychodynamic therapy (PDT), interpersonal therapy and supportive therapy (Abbass and Driessen, 2010, Barth et al., 2013, Cuijpers et al., 2013a, Driessen et al., 2010, Leichsenring, 2001). These results were corroborated by a recent large-scale RCT finding PDT and CBT to be equally effective in the treatment of depression (Driessen et al., 2013). From these results, Thase (2013, p. 954) concluded: “On the basis of these findings, there is no reason to believe that psychodynamic psychotherapy is a less effective treatment of major depressive disorder than CBT.”

However, in spite of the evidence for psychotherapy in depression, we cannot be satisfied with the current state for the following reasons. (1) The effects of psychotherapy in depression appear to be overestimated (Cuijpers et al., 2010); (2) with post-therapy rates for remission between 30% and 40% and for response between 40% and 60% a substantial proportion of patients do not benefit sufficiently from the available treatments (Blackburn and Moore, 1997, DeRubeis et al., 2005, Dimidjian et al., 2006, Elkin et al., 1989, Keller et al., 2000, Rush et al., 2006, Shea et al., 1992). A recent meta-analysis found rates for remission and response of 43% and 54% respectively, again with no significant differences between the various methods of psychotherapy (Cuijpers et al., 2014). (3) Furthermore, results for long-term outcome are often disappointing and the likelihood of relapse is relatively high (Emmelkamp, 2013). There is evidence which suggests that about 50% of the patients who recovered by the end of treatment suffered a relapse two years later. Maintenance treatments have only shown moderate efficacy with regard to relapse prevention, especially in long-term follow-ups of up to two years, not only for pharmacotherapy, but also for psychotherapy (Blackburn and Moore, 1997, Fava et al., 2004, Forand et al., 2013, Hollon et al., 2005, Vittengl et al., 2007). Thus, there is a need to further improve the efficacy of psychotherapy in depression (Thase, 2013). As PDT is frequently used in clinical practice (Cook et al., 2010, Norcross et al., 2002), this applies to psychotherapy in general and to PDT in particular.

As another problem, evidence for PDT in depression comes from RCTs in which different concepts and methods of PDT were applied. Thus, the evidence for PDT is “scattered” between the different forms of PDT, not only for depressive disorders, but for other mental disorders as well (Leichsenring and Klein, 2014). It was for this very reason that PDT was judged as only “possibly efficacious” by Chambless and Hollon (1998). To be judged as “efficacious” at least two RCTs are required in which the same treatment was effectively applied in the same mental disorder (Chambless and Hollon, 1998). Furthermore, the existence of different methods of PDT (for any mental disorder) implies a problem for training in psychotherapy: should candidates in psychotherapy learn to apply all empirically supported methods of PDT in depression? Should the training focus on only a limited number of these approaches and if so, on which of the approaches? Furthermore, a clinician is confronted with a similar problem if he or she sees a patient suffering from a depressive disorder. In addition, it is not clear how “different” the various approaches really are.

During the last ten years, unified, transdiagnostic and modular treatments have emerged (Barlow et al., 2004, Wilamowska et al., 2010). Unified protocols aim at integrating the most effective disorder-specific treatment components targeting the core processes underlying the respective disorder. Barlow et al. (2004), for example, have developed a unified cognitive-behavioural protocol for “emotional disorders”, including both depressive and anxiety disorders. For the psychodynamic treatment of depressive disorders, however, a unified protocol has not yet been developed.

Unified protocols for the psychodynamic treatment of mental disorders would have several advantages, that is (1) using unified protocols in efficacy studies will enhance the status of evidence of PDT by aggregating the evidence; (2) unified protocols will facilitate both training in PDT and transfer of research to clinical practice; (3) thus, they can be expected to have a significant impact on the health care system. Furthermore integrating the most effective treatment principles of empirically supported treatments, unified protocols can be hypothesized to further enhance the efficacy of PDT. Further RCTs to test the unified protocol are desirable.

For these reasons we made the effort to develop a unified protocol for the psychodynamic treatment of depressive disorders. For this purpose the available RCTs of PDT in depression were reviewed and the treatment components included in the efficacious approaches were identified and integrated within a unified protocol.