Psychodynamic Psychotherapy in the Treatment of Mood Disorders

Michael Bond

Disclosures

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

In This Article

Conclusion

Any review of empirical studies of psychotherapy with mood disorders must take into account the many issues discussed by Westen et al.[10] when examining assumptions and findings, and reporting in controlled clinical trials. Efficacy studies focusing on homogeneous samples may use exclusion criteria that prevent many average patients with multiple problems from participating.[11] For example, a study by Zimmerman et al.[12] showed that only 14% of the depressed patients from his department's practice would have been eligible to participate in an antidepressant efficacy trial. Naturalistic, effectiveness studies are no panacea either, however, since they do not ensure therapist adherence to a particular type of therapy, they cannot prove causation and leave open too many naturalistic influences. Longer-term studies have the advantage of following the ups and downs of a chronic or recurrent illness like depression and effectiveness studies examine real-life situations of patients with co-morbidities who receive more than one type of therapy.

Our review included efficacy and effectiveness studies. No study met the criteria of a randomized clinical control trial using a longer-term dynamic psychotherapy aimed specifically at a sample of depressed patients. One study showed improvement with a 16-session dynamic psychotherapy with or without concomitant pharmacotherapy. The majority of the studies reviewed revealed useful information pointing in the direction that psychodynamic psychotherapy was associated with improvement in depressive symptoms and some studies showed concurrent improvements in character or defensive measures. Although any given study has flaws which limit conclusions, the overall weight of evidence points to psychodynamic psychotherapy being helpful in the treatment of depression but no more so than other psychotherapies. For more severe depressions, psychotherapy combined with pharmacotherapy seems to be indicated. Taken from another perspective, patients who are already taking medication when embarking on long-term psychodynamic psychotherapy improve more slowly. The same applies to having a personality disorder. Thus, being on medication or having a personality disorder appear to be markers of relative treatment resistance.

Work still remains to be done on identifying if there are clinical features which would shed light on who would benefit from what type of psychotherapy. Also, it would be useful to see more randomized clinical trials comparing both shorter and longer dynamic and cognitive therapies. Finally, although many papers quote the important economic costs and burden of illness from depression, there are no studies demonstrating the cost savings of treating depression with dynamic therapy, short or long term. A long-term psychotherapeutic treatment may help prevent relapse and allow someone to keep working. So studies addressing these questions would be relevant.

References

Papers of particular interest, published within the annual period of review, have been highlighted as:

* of special interest
** of outstanding interest

Additional references related to this topic can also be found in the Current World Literature section in this issue (p. 103).

  1. Greenson RR. The technique and practice of psychoanalysis. New York: International Universities Press; 1967.

  2. Anderson EM, Lambert MJ. Short-term dynamically oriented psychotherapy: a review and meta-analysis. Clin Psychol Rev 1995; 15:503-514.

  3. Ablon JS, Jones EE. Validity of controlled clinical trials of psychotherapy: findings from the NIMH Treatment of Depression Collaborative Research Program. Am J Psychiatry 2002; 169:775-783.

  4. de Jonghe F, Hendricksen M, van Aalst G, et al. Psychotherapy alone and combined with pharmacotherapy in the treatment of depression. Br J Psychiatry 2004; 185:37-45.
    * This study compared short psychodynamic supportive psychotherapy with combined therapy in depressed outpatients. Both groups improved at 24 weeks but more patients agreed to psychotherapy alone (99%) than combined therapy, that is medications and psychotherapy (84%).

  5. Leichsenring F, Rabung S, Leibing E. The efficacy of short-term psychodynamic psychotherapy in specific psychiatric disorders: a meta-analysis. Arch Gen Psychiatry 2004; 61:1208-1216.
    * This metaanalysis had rigorous standards for inclusion but only two of the 17 studies examined depression and its response to short-term dynamic psychotherapy.

  6. Bond M, Perry JC. Long-term changes in defense styles with psychodynamic psychotherapy for depressive, anxiety, and personality disorders. Am J Psychiatry 2004; 161:1665-1671.
    * This study had the advantage of a long-term follow-up in a real life sample complete with co-morbidity and showed improvements in defense styles and symptoms. It was a naturalistic, not a randomized control trial.

  7. Bond M, Perry JC. Psychotropic medication use, personality disorder and improvement in long-term dynamic psychotherapy. J Nerv Ment Dis (in press).

  8. Wilczek A, Barber JP, Gustavsson JP, et al. Change after long-term psychoanalytic psychotherapy. J Am Psychoanal Assoc 2004; 52:1163-1184.
    * This study showed an improvement in depressive symptoms and in character features with analytic therapy. The naturalistic design, however, limits the conclusion.

  9. Puschner B, Kraft S, Bauer S. Interpersonal problems and outcome in outpatient psychotherapy: findings from a longitudinal study in Germany. J Pers Assess 2004; 83:223-234.

  10. Westen D, Novotny CM, Thompson-Brenner H. The empirical status of empirically supported psychotherapies: assumptions, findings, and reporting in controlled, clinical trials. Psychol Bull 2004; 130:631-663.

  11. Westen D, Morrison K. A multi-dimensional meta-analysis of treatments for depression, panic and generalized anxiety disorder: an empirical examination of the status of empirically supported therapies. J Consult Clin Psychol 2001; 69:875-899.

  12. Zimmerman M, Mattia J, Pasternak M. Are subjects in pharmacological treatment trials of depression representative of patients in routine clinical practice? Am J Psychiatry 2002; 159:469-473.

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