Psychodynamic Psychotherapy in the Treatment of Mood Disorders

Michael Bond

Disclosures

Curr Opin Psychiatry. 2006;19(1):40-43. 

In This Article

Recent Findings

We can divide the recent research into shorter-term and longer-term therapy studies.

Empirical Studies of Shorter-Term Dynamic Psychotherapy for Depression

A study by de Jonghe et al.[4*] compared short psychodynamic supportive psychotherapy (SPSP) (n = 106) with combined therapy (SPSP plus antidepressant medications) (n = 85) in ambulatory patients with mild or moderate major depressive disorder diagnosed using Diagnostic and Statistical Manual of Medical Disorders, fourth edition (DSM-IV) criteria. Efficacy was assessed using the Hamilton Rating Scale for Depression, 17-item version (HRSD-17), the Clinical Global Impression of Severity and Improvement (CGI), and the depression subscale of the Symptom Checklist-90 (SCL-D). Patients whose HRSD-17 score was lower than 12 or higher than 24 were excluded. The therapy consisted of 16 sessions within a 6-month period. There were adherence checks for the psychotherapists. Pharmacotherapy followed a reasonable protocol.

From the original 208 participants, one refused randomization to psychotherapy and 16 refused combined therapy. Using Kaplan-Meier survival analysis, the mean time to remission on the HRSD was 138 days in the psychotherapy group and 129 days in the combined therapy group (not a significant difference). In the observed cases sample, statistically significant inter-group differences at week 24 (the combined therapy group improved more quickly) are shown by the HRSD (P < 0.046) and SCL-D (P < 0.001), but in the intent-to-treat sample no difference was found at any point by any assessment method (once Bonferroni adjusted). Both groups showed improvement at 24 weeks with success rates of 73% for psychotherapy and 81% for combined therapy, using CGI as an indicator.

An interesting finding was that more patients (99%) agreed to psychotherapy rather than combined therapy (84%). This was a sample of patients with mild to moderately severe depression, however (75% less than 2 years' duration). It is possible that the acceptance rate for combined therapy would be higher for more severely depressed patients because of patients' perceived need for medication and doctors' increased motivation for prescribing it. For this sample, however, the authors concluded that adding psychotherapy to pharmacotherapy improved the feasibility of longer-term adherence. This points to the need for longer-term studies examining the treatment of depression, which is often a chronic or recurrent illness.

Leichsenring et al.[5*] performed a metaanalysis of studies of short-term psychodynamic psychotherapy (STPP), examining 17 studies which fulfilled their inclusion criteria. They found that STPP yielded significant and large pretreatment-posttreatment effect sizes for target problems (1.39), general psychiatric symptoms (0.90) and functioning (0.80). The effect sizes of STPP significantly exceeded those of waiting list controls and treatments as usual. No differences were found between STPP and other forms of psychotherapy. Only two of the studies, however, looked at depression specifically.

Longer-Term Studies

Bond and Perry,[6*] in a naturalistic study, followed participants in a long-term project of psychodynamic psychotherapy for depressive, anxiety and personality disorders. Thirty-nine of 53 patients had depression and 40 had personality disorders, reflecting a high degree of co-morbidity. Looking at both dynamic and symptomatic changes, they found that those with high initial scores on the maladaptive and self-sacrificing defense styles improved in the direction of more adaptive defensive functioning. For the symptom measures, there was significant change in global assessment of functioning, depression and distress. Changes in defensive functioning added substantially to the prediction of variance in these three measures, reinforcing the notion that the changes that occurred were not just symptomatic but involved psychodynamic changes. Since psychodynamic therapy specifically addresses defense mechanisms, it is interesting to note that they changed and that change in this measure predicted better functioning, less depression and less distress. Since patients' defense styles generally improve as they recover from depression, however, no causality can be inferred. One can only note that patients who were depressed initially improved over time and with psychotherapy and this improvement was sustained as follow-up evaluations were performed.

One must consider the possibility that patients who have recurrent or chronic depression, as well as personality disorders, as did those in this sample, benefit more from a longer-term psychotherapy. (In this study, a minimum of 3 years was offered at onset.) More specifically, patients with borderline personality disorder, who are very abandonment sensitive, might need an offer of long-term therapy to engage in a psychodynamic treatment and STPP could be contra-indicated.

In a follow-up report of the same project, Bond and Perry[7] found that, although long-term dynamic psychotherapy was associated with improvement in symptoms and functioning, personality disorder pathology was associated with less improvement in depression and functioning and being on medication at intake was associated with less improvement in depression.

Wilczek et al.[8*] invited 55 individuals selected for long-term psychoanalytic psychotherapy (average 3 years) to participate in a naturalistic study. Thirty-six of these individuals completed the therapy (three of which ended their therapy in less than 12 months and were excluded). Ten of the 13 'nontherapy' individuals agreed to participate in a follow-up interview 3 years after the initial interview.

Although the main goal of this group seemed to be character assessment using the Karolinska Psychodynamic Profile (KAPP), which is interviewer rated and the self-report Karolinska Scales of Personality, they did find that there was a significant change in depressive symptoms (t = 6.13, P < 0.001, effect size = 1.23) in the therapy group, as well as significant changes in the anxiety and obsessive-compulsive scales of the Comprehensive Psychopathological Rating Scale for Affective Syndromes. The nontherapy group (n = 10) did not show significant changes in diagnoses, global assessment of functioning (GAF) scores or symptoms. Of the 22 patients in the therapy group who met criteria for an axis I or II diagnosis at intake, only five patients met criteria after therapy. GAF scores improved significantly following therapy, from a mean of 68.75 to 75.22 (t = -4.46, P < 0.001, effect size = -0.87).

In the therapy group, eight KAPP subscales showed character improvement. Overall, greater change was found in the therapy group than in the nontherapy group on all measures.

One advantage of this study is that patients can have confidence that experienced therapists have adhered to the long-term psychodynamic psychotherapy model and that the outcome assessments were 6 months following termination of 3 years of treatment. The disadvantages include the small size of the nontherapy sample, the nonrandom naturalistic design and the potential for bias favouring psychoanalytic psychotherapy. Although this was not specifically a study of depression, it does add weight to the literature indicating that long-term psychodynamic psychotherapy helps reduce depressive symptoms and is associated with 'dynamic' changes like increased frustration tolerance.

In a German study[9] the authors were primarily interested in whether interpersonal problems influenced the trajectory of change in symptom distress over 2 years in participants undergoing three types of psychotherapy (psychodynamic, cognitive-behavioral or analytic). Only 47% of the sample of 622 had affective disorders.

Of the participants with available data (n = 464), 53% were classified as reliably improved, 43.3% as unchanged and 3.7% as reliably deteriorated. There was no breakdown for improvement in affective disorders specifically. Participants in psychodynamic psychotherapy who showed 'low affiliation' as an interpersonal trait improved more than those showing 'high affiliation'.

Since this study was not designed to examine change in depression specifically, it does not shed much light on the efficacy of psychodynamic psychotherapy for affective disorders. It does lead one to question the folk wisdom that 'highly affiliative' patients are the best candidates for psychodynamic therapy.

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