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Connolly Gibbons, M.B., Gallop, R., Thompson, D., Luther, D., Crits-Christoph, K., Jacobs, J., Yin, S., & Crits-Christoph, P. (2016). Comparative effectiveness of cognitive therapy and dynamic psychotherapy for major depressive disorder in a community mental health setting: A randomized clinical noninferiority trial. JAMA Psychiatry. doi:10.1001/jamapsychiatry.2016.1720.

Dynamic psychotherapy is widely practiced in the community, but there remain very few trials assessing its effectiveness. Dynamic therapy targets individuals’ problematic relationship conflicts. Cognitive therapy on the other hand has been established as effective for major depression in a number of controlled trials. This study by Connolly Gibbons and colleagues was designed to test if dynamic therapy was equivalent (not inferior) to cognitive therapy in treating major depressive disorder in a community setting. There are two important and novel aspects to this research. First, the study takes place with community-based therapists in a community mental health setting. This means that the usual critique that randomized controlled trials do not speak to what therapists do with real patients in everyday practice is addressed in this study. Second, the sample size is large enough and the study is sufficiently powered so that one can make conclusions about non-inferiority (statistics geeks will know that making a hypothesis of non-inferiority, equivalence, or no difference requires enough power and a large enough sample size – something that is quite rare in psychotherapy trials). Twenty therapists who worked in a community mental health center were trained by experts in dynamic therapy or cognitive therapy. The therapists treated 237 adults with major depressive disorder with 16 sessions of dynamic or cognitive therapy. Therapists were followed the treatment manuals and they were judged by independent raters as competent in delivering the treatment. Patients on average got significantly better regarding depressive symptoms (d = .55 to .65), and there were no significant differences in the rate of improvement between dynamic and cognitive therapy patients (d = .11). There were also no differences between treatments on several measures of quality of life. A noteworthy finding was that about 80% of patients continued to have some depressive symptoms by the end of treatment even though they improved.

Practice Implications

This study adds to research indicating that short-term dynamic psychotherapy is as effective as short term cognitive therapy for treating major depression. The study also indicates that the treatments under intensive supervision and training can be provided effectively by community therapists in real world settings. That 80% of patients continued to have some depressive symptoms suggests that the short term nature of the therapies may not have represented a large enough dose of treatment for most patients.

Driessen, E., Van, H.L., Don, F.J., Peen, J., Kool, S. ....Dekker, J.J. (2013). The 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.

Psychotherapy is one of the most widely used treatments for major depression. Unfortunately there is no commercial entity like the pharmaceutical industry to support research and development of psychotherapy. As a result, researchers have limited ability to conduct larger-scale studies of comparative treatment effectiveness, of which there are only a handful. Although psychodynamic therapy (PDT) has been used to treat depressed patients for decades, randomized controlled trials of its efficacy are relatively infrequent. A concurrent problem with outcome research in psychotherapy is that sample sizes tend to be too small to actually test if two treatments are equivalent in what is called an “equivalency trial”. Without large samples, all one can conclude is that two treatments are “not significantly different” (a statistical note: an equivalency trial is planned from the outset to have a large enough sample to test the hypothesis that, with 95% certainty, the effect of one treatment falls within a narrow, predetermined margin of the effect of another treatment). The study by Driessen and colleagues was conducted in several sites in Amsterdam, in which 341 patients seeking outpatient psychotherapy for depression in psychiatric clinics were randomized to PDT or cognitive behavioural therapy (CBT). This is largest trial ever of PDT. Participants received 16 weeks of therapy and then were followed up for 1 year. About 40% of patients started with severe depression. Therapists were 93 experienced and well trained therapists who provided one of the two treatments. The main outcome was remission from depression, defined by achieving a low score on a validated observer rating scale. Post treatment remission rates were 21% for CBT and 24% for PDT, indicating that the treatments were equivalent.

Practice Implications

Cognitive-behavioral therapy (CBT) and short-term PDT provided similar outcomes for patients with a major depressive episode, but remission rates at the end of treatment were low for both treatments. Lower remission rates were likely due to the greater level of severity for these patients compared to those seen in primary care settings. The results highlight that even the best available psychological (and pharmacological) treatments yield modest outcomes for more severely depressed patients. Nevertheless, this rare equivalency trial found that both CBT and PDT were equivalent in terms of outcomes for these patients.

Author email: e.driessen@vu.nl

Ulvenes, P. G., Berggraf, L., Hoffart, A., Stiles, T. C., Svartberg, M., McCullough, L., & Wampold, B. E. (2012). Different processes for different therapies: Therapist actions, therapeutic bond, and outcome. Psychotherapy, 49(3), 291-302.

One of the few truisms of psychotherapy is that the therapeutic alliance is important to treatment outcomes. But does the alliance work similarly in Cognitive Behavioral Therapy (CBT) and in Psychodynamic Therapy (PDT)? Therapeutic alliance is defined by three elements: the bond between client and therapist, agreement on tasks, and agreement on goals. Compared to PDT therapists, CBT therapists tend to focus more on cognitions and focus less on emotions, and so the bond may be less important in CBT than agreement on tasks and goals. Will the bond between client and therapist be differentially affected by the differing focus on emotions between CBT and PDT? A study by Ulvenes and colleagues (2012) looked at this question. This study is a follow up study of a randomized controlled trial comparing CBT to PDT for the treatment of cluster C personality traits (i.e. individuals who have trouble in experiencing and expressing emotions, and in developing close relationships). Fifty clients were randomized to either CBT or PDT, therapy was short term, and therapists were experienced and competent in delivering their therapy. In the previous study the authors reported that CBT and PDT were both equally effective in treating clients with cluster C personality disorder. In the current study, the authors found that therapist avoidance of affect was associated with developing a greater bond with patients in both CBT and PDT. That is, Cluster C patients liked their therapists better if the therapists avoided talking about the clients’ feelings. However, focusing on affect in PDT was also associated with positive outcome. In other words, therapists who avoided talking about emotions in PDT helped the patient like the therapist better, but this was counterproductive for good outcome. PDT therapists had to manage to create a bond despite their focus on affect in order to achieve good outcomes. On the other hand, focusing on affect in CBT was associated with poorer outcome. That is, therapists who avoided affect in CBT, which is consistent with the treatment model, had clients who experienced both a better bond and better outcomes. Therapeutic alliance is important for all therapies, but may operate quite differently depending on how much the therapy focuses on affect (PDT) or on cognitions (CBT).

Practice Implications

PDT therapists working with cluster C patients have to negotiate a complex task of maintaining a bond despite the treatment model’s focus on emotions in order to achieve good outcomes. CBT therapists will do well to be consistent with the treatment model and focus primarily on cognitions to help with the bond and promote good outcomes. CBT therapists in particular may need to develop a strong bond before agreeing on tasks and goals, which are also keys to a therapeutic alliance.

Author email: pal.ulvenes@modum-bad.no