Blog

December 2015

• Long Term Psychodynamic Psychotherapy for Treatment Resistant Depression

  Fonagy, P., Rost, F., Carlyle, J., McPherson, S.,… Taylor, D. (2015). Pragmatic randomized controlled trial of long-term psychoanalytic psychotherapy for treatment-resistant depression: The Tavistock adult depression study (TADS). World Psychiatry, 14, 312-321.

  Usually I do not write about individual studies, mainly because meta-analyses and systematic reviews are much more reliable. But occasionally a unique study is published that is important enough to report. This is a rare trial that focuses on “treatment-resistant” depression defined as long-standing depression that has not responded to at least two previous evidence-based interventions. Depression is known to have a relapsing chronic course for about 12% to 20% of patients. And not responding to treatment is highly predictive of non-response to future treatment for depression. Fonagy and colleagues argued that in order to be effective, treatments for chronic and resistant depression need to be longer and more complex than current time-limited evidence-based approaches. Further, they argued that follow ups should be of longer duration. The authors tested a manualized long term psychoanalytic psychotherapy (LTPP). The treatment involved 60 sessions over 18 months provided by 22 trained therapists. In this trial, the “control” condition was treatment as usual (TAU) as defined by the National Institute for Clinical Excellence in the United Kingdom. TAU was made up of short term evidence-based interventions like antidepressant medications or CBT provided by licensed trained professionals. LTPP plus TAU was compared to TAU alone for 129 patients randomly assigned to one of the conditions. At pre-treatment, the majority of patients scored in the severe range on the Beck Depression Inventory (BDI) or the Hamilton Depression Rating Scale (HDRS). The average patient had 4 previous unsuccessful treatments for depression. No differences were found between LTPP and TAU at post treatment, but differences began to emerge after 24 months. Complete remission was infrequent in both conditions after 42 months (14.9% LTPP vs 4.4% TAU). However, partial remission at 42 months was significantly more likely in LTPP (30.0%) than TAU (4.4%). Patients were significantly more likely not to meet DSM-IV criteria for depression at 42 months in LTPP (44%) than in TAU (10%). The differences between conditions in mean BDI and HDRS scores were significant and medium sized indicating greater improvement with LTPP.

  Practice Implications

  This is the first study of its kind to test a manualized LTPP for treatment resistant depression. Patients in LTPP were more likely to maintain gains whereas those receiving evidence-based TAU were more likely to relapse. Although this is only one study and should be interpreted cautiously, it does suggest that chronic treatment-resistant depression is more likely to respond to longer and more complex treatment, and that outcomes of such treatment tend to be maintained in the longer term.