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Psychoanalytic Journal of the American

http://apa.sagepub.com/content/62/1/116The online version of this article can be found at:

 DOI: 10.1177/0003065114525237

2014 62: 116J Am Psychoanal AssocSonya Martin

randomized clinical trialpsychodynamic therapy in the outpatient treatment of major depression: A Journal Watch review of The efficacy of cognitive-behavioral therapy and

  

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e. DrieSSen, H.l. Van, F.J. Don, J. Peen, S. Kool, D. WeStra, M. HenDriKSen, r.a. ScHoeVerS, P. cuiJPerS, J.W. tWiSK, & J.J. DeKKer (2013). Th e efficacy of cognitive-behavioral therapy and psychodynamic therapy in the outpatient treatment of major depression: A randomized clinical trial. American Journal of Psychiatry 170:1041–1050.

DOI: 10.1177/0003065114525237

Psychoanalysts have long celebrated the ameliorative effects of talk therapy on individual patients. Early practitioners of psychoanalysis relied primarily on case studies to demonstrate their treatment’s efficacy: that Bertha Pappenheim regained her motor and sensory functions to become a prominent social worker and activist, for example, or that Herbert Graf conquered his fear of horses to produce world-class operas. Subsequent skeptics have challenged the purported benefits of psycho-analysis by suggesting that other interventions—or possibly no interven-tion at all—might have yielded similar outcomes. Meanwhile, advocates of newer treatment modalities such as cognitive-behavioral therapy (CBT) have relied increasingly on quantitative measures to illustrate their success. Now, in an article published in the American Journal of Psy-chiatry, Driessen and colleagues have reported a randomized controlled trial demonstrating that time-limited psychodynamic therapy is at least as effective as CBT.

Driessen et al. measured the benefit of sixteen sessions of individual manualized CBT or short-term psychodynamic supportive therapy for 341 Dutch adults, randomly assigned to a treatment condition, who met DSM-IV criteria for a major depressive episode and had Hamilton Depression Rating Scale (HAM-D) scores ≥ 14. The primary outcome measure was post-treatment remission rate (HAM-D score ≤ 7). Second-ary outcome measures included HAM-D and depressive self-report (IDS-SR) scores at the end of treatment and one year post-treatment. HAM-D assessors were not blind to treatment condition but displayed no signifi-cant biases on sensitivity analysis of their treatment expectations. Severely depressed individuals (HAM-D score > 24) were also given pharmaco-logical treatment with extended-release venlafaxine at daily doses of 75 to 225 mg, followed by citalopram or nortryptilline for adverse effects or non-response, at rates that did not differ significantly between treatment groups.

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Each psychotherapy consisted of sixteen sessions within twenty-two weeks by a psychiatrist or psychologist with a master’s degree or greater who had completed a training course of three days in psychodynamics or 100 hours in CBT, and had conducted one or more therapy cases under intensive supervision. Therapists followed published treatment manuals and participated in biweekly supervisions, chaired by a study supervisor, with review of audiotaped materials to ensure fidelity to the manuals. CBT was based on Beck’s principles of behavioral activation and cognitive restructuring according to a session-by-session protocol with homework assignments. Psychodynamic supportive psychotherapy con-sisted of “an open patient-therapist dialogue” using supportive and insight-oriented techniques to address “the emotional background of the depressive symptoms” by focusing on “current relationships, internalized past relationships and intrapersonal patterns.”

Driessen and colleagues achieved a remission rate of 24.3% (N = 27/111) for CBT patients and 21.3% (26/122) for psychodynamic therapy patients for a combined post-treatment remission rate of 22.7% overall. Response rates, defined as a reduction in HAM-D scores ≥ 50%, were 38.7% (N = 43/111) for CBT and 36.9% (45/122) for psychody-namic therapy. In severely depressed individuals receiving additional pharmacotherapy, post-treatment remission rates for CBT and psychody-namic therapy were 20.9% (N = 9/43) and 7.7% (3/39), respectively, but response rates for this subgroup were not provided. Notably, the investi-gators detected no significant differences between groups or subgroups for remission, response, or any other outcome measure. Moreover, they demonstrated that dynamic therapy was “non-inferior” to CBT in terms of post-treatment HAM-D and ISD-SR scores, but they were unable to do so for post-treatment remission rates.

This study suggests that a sixteen-session course of weekly psycho-dynamic psychotherapy confers roughly equivalent benefit to a sixteen-session course of weekly CBT. Yet the relatively low success rates—22.7% for remission and 37.7% for response overall, even when combined with pharmacotherapy (in severe cases)—highlight the limita-tions of these time-limited, once-weekly therapies for the majority of depressed individuals. We ought to embrace these results as a testament to the comparable efficacy of short-term dynamic therapy to CBT, while also pursuing higher-intensity therapeutic interventions, such as those investigated by Huber et al. (2013) to achieve more robust and enduring relief for our patients.

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REFERENCE

huBeR, d., henRich, G., claRkin, J., & kluG, G. (2013). Psychoanalytic versus psychodynamic therapy for depression: A three-year follow-up study. Psychiatry 76:132–149.

Sonya Martin

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D. HuBer, J. ZiMMerMan, G. HenricH, & G. KluG (2013). Compari-son of cognitive-behavioral therapy with psychoanalytic and psychodynamic therapy for depressed patients: A three-year follow-up study. Psychosomatic Medicine & Psychotherapy 58: 299–316.

DOI: 10.1177/0003065114525238

It is widely acknowledged that whatever misgivings some may have about empirical research, data that support the effectiveness of psycho-analysis can only help our field in this era of evidence-based therapeutics. This is especially so if the study design has the methodological rigor to ensure acceptance of the results beyond the borders of psychoanalysis and if the study compares psychoanalysis to the currently popular briefer- term psychotherapies. However, conducting studies of long-term treat-ments is a complex venture in myriad ways. Perhaps the biggest chal-lenge is to develop a study design that strikes the right balance between clinical relevance and rigorous methodology. It is not surprising that the number of meaningful outcome studies of psychoanalysis is painfully small, and so when such a study is completed the results should be widely known and discussed among psychoanalysts.

Recently Dorothea Huber and colleagues published the results of a three-year follow–up of the Munich Psychotherapy Study. This study included patients with chronic unipolar depression and randomized them to treatment in one of three conditions: cognitive-behavioral therapy (CBT), 40–60 sessions at a frequency of one session a week; psycho dynamic therapy (PD), 50–80 sessions also at a frequency of one session a week; or psychoanalysis (PSA), 160–240 sessions at a frequency of two to three sessions a week with the patient lying on the couch (a lesser frequency and shorter duration than is common for psychoanalytic treatments conducted in the United States). According to the authors, the study “is designed to

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