The Psychotherapy Practice Research Network (PPRNet) blog began in 2013 in response to psychotherapy clinicians, researchers, and educators who expressed interest in receiving regular information about current practice-oriented psychotherapy research. It offers a monthly summary of two or three published psychotherapy research articles. Each summary is authored by Dr. Tasca and highlights practice implications of selected articles. Past blogs are available in the archives. This content is only available in English.
…I blog about transtheoretical principles of change, microaggressions and outcomes, interpretations and outcomes.
Type of Research
- ALL Topics (clear)
- Alliance and Therapeutic Relationship
- Anxiety Disorders
- Attendance, Attrition, and Drop-Out
- Client Factors
- Client Preferences
- Cognitive Therapy (CT) and Cognitive-Behavioural Therapy (CBT)
- Combination Therapy
- Common Factors
- Depression and Depressive Symptoms
- Efficacy of Treatments
- Feedback and Progress Monitoring
- Group Psychotherapy
- Illness and Medical Comorbidities
- Interpersonal Psychotherapy (IPT)
- Long-term Outcomes
- Neuroscience and Brain
- Outcomes and Deterioration
- Personality Disorders
- Placebo Effect
- Practice-Based Research and Practice Research Networks
- Psychodynamic Therapy (PDT)
- Resistance and Reactance
- Self-Reflection and Awareness
- Suicide and Crisis Intervention
- Therapist Factors
- Transference and Countertransference
- Trauma and/or PTSD
- Treatment Length and Frequency
Short-term Psychodynamic Psychotherapy for Depression
Wienicke, F.J., Beutel, M.E., Zwerenz, R. et al. (2023). Efficacy and moderators of short-term psychodynamic psychotherapy for depression: A systematic review and meta-analysis of individual participant data, Clinical Psychology Review.
Depression affects 264 million adults worldwide making it one of the most prevalent mental health conditions. Depression affects quality of life, health care costs, and mortality making it a leading cause of disability in the world. Previous meta-analyses have looked at psychological treatments for depression and found CBT, short term psychodynamic psychotherapy (STPP), interpersonal psychotherapy (IPT), and others are effective in reducing depressive symptoms among adult patients. STPP, for example, works by focusing on the underlying personality factors of the patient (defense mechanisms, emotion regulation, interpersonal style, self-concept, attachment) that may lead to depressive experiences. There are very few studies that look specifically at what patient characteristics are associated with better outcomes for a specific type of psychotherapy. The challenge with such patient level analyses is that most researchers report aggregated individual patient data at the study level thus possibly obscuring important variability among patients. In this meta-analysis, Wienicke and colleagues identified 13 studies of STPP compared to a control group. The authors were able to get 11 of the study authors to provide individual patient data of 771 participants. This allowed Wienicke and colleagues to do a meta-analysis of individual patient data. At post-treatment, STPP was significantly more efficacious than control conditions on measures of depression (d = -0.62, 95%CI [-0.76, - 0.47], p <.001), anxiety (d = -0.29, 95%CI [-0.45, -0.12], p <.001), general psychopathology (d = -0.38, 95%CI [-0.59, -0.17], p <.001), and quality of life (d = 0.44, 95%CI [0.23, 0.64], p <.001). At follow-up, STPP was again superior to control conditions on depression outcomes (d = -0.21, 95%CI [-0.38, -0.05], p = .011), but not more efficacious on other outcomes. When the authors looked at individual patient characteristics related to outcomes, they found that length of the current depressive episode was found to moderate post-treatment depression levels, such that STPP was more efficacious for participants reporting longer rather than shorter episode durations (d = -0.006, 95%CI [-0.01, -0.001], p = .002).
Like what was reported in previous meta-analyses, STPP was efficacious to reduce depressive symptoms in the shorter and longer term. Patients with a longer duration or chronicity of depressive symptoms experienced the most benefit from STPP. It is likely that individuals with longer episode durations have depressive symptoms that are more influenced by their underlying personality vulnerabilities resulting in more complex working alliances and transference feelings with therapists. Training in psychodynamic principles of treatment may allow therapists to identify and work with these therapeutic relational aspects if necessary.
Capacity to Mentalize Predicted Outcomes in Inpatient Therapy for Resistant Depression
Halstensen, K., Gjestad, R., Luyten, P., Wampold, B., Granqvist, P., Stålsett, G., & Johnson, S. U. (2021). Depression and mentalizing: A psychodynamic therapy process study. Journal of Counseling Psychology, 68(6), 705–718.
Mentalizing, or reflective functioning, refers to someone’s capacity to view themselves and others in terms of mental states (i.e., behaviors are interpreted in terms of feelings, wishes, desires, values, and goals). This capacity underlies skills like empathy, emotion regulation, and interpersonal functioning. Diminished mentalizing can aggravate depressed mood through negative biases in one’s perceptions of others and relationships and might prevent the reflection needed to regulate emotions. Individuals with mentalizing deficits might hypo mentalize so that they are very uncertain about the thoughts, feelings, or attitudes that underlie their own and others’ behaviors. Such individuals may experience apathy associated with depression. Others might hyper mentalize, that is they are too certain about what goes on in the minds of others, which means they may misinterpret or misunderstand the intentions and behaviors of others. Such individuals can experience chronic emptiness due to the lack of genuine connection with others. In this study, Halstensen and colleagues assessed if mentalizing predicted outcomes in 57 patients with treatment resistant depression who received inpatient therapy in Norway. This was a naturalistic study of intensive psychodynamic inpatient therapy. The average chronicity of depression was 11.7 years, all patients received previous unsuccessful psychological or medical treatment, and most had a comorbid diagnosis (e.g., panic disorder, social anxiety disorder). Measurements of mentalizing and depression were taken pre-treatment, during therapy, and up to one year post treatment. Depressive symptoms improved from pre-treatment to one year follow-up with a large effect (d = 1.47; α mean = −.09 per week, p = .001). The capacity to mentalize did not improve on average during that period, although there was a lot of individual variability in mentalizing scores. Interestingly, there was an increase in depressive symptoms at the outset of treatment that then declined significantly by post-treatment. Higher pre-treatment levels of mentalizing were associated with better depressive symptom outcomes (b = −16.80, p = .043), and those patients who improved their mentalizing capacity experienced stronger improvements in depressive symptoms.
Although all patients were severely and chronically depressed, their capacities to mentalize varied significantly (some had higher and others lower levels). Patients in this study who had a high initial level of mentalizing capacity profited most from the intensive therapy. They seemed to be able to engage in the emotional work associated with the initial phase of intensive inpatient treatment for depression. On the other hand, patients in this study who had low levels mentalizing skills were likely to be non-responsive to intensive treatment. Patients with limited mentalizing capacity may require more support and more work to help them develop the reflective capacities necessary to understand their own and others’ behaviors in terms mental states.
Adding Short-Term Psychodynamic Psychotherapy to Antidepressants
Driessen, E., Fokkema, M., Dekker, J.J.M., Peen, J., Van, H.L…. Cuijpers, P. (2022). Which patients benefit from adding short-term psychodynamic psychotherapy to antidepressants in the treatment of depression? A systematic review and meta-analysis of individual participant data. Psychological Medicine.
Short-term psychodynamic psychotherapy (STPP) and anti-depressant medications are both considered empirically supported treatments for depression. And there have been several trials demonstrating the efficacy of long-term psychoanalytic psychotherapy for treatment-resistant depression. Despite this research, it remains unclear which patient might benefit from anti-depressant medication alone and which patient might benefit from adding STPP to the antidepressants. The best use of scarce resources makes this an important question. There are challenges to doing a meta-analysis of patient characteristics that predict different outcomes in antidepressants alone versus antidepressants plus STPP. A key challenge is that common meta-analyses use study-level data (an overall summary of the effect size found in a study), and so statistical power often is limited by the small number of studies. The unique aspect of this study by Driessen and colleagues is that they conducted a meta-analysis of patient-level data. That is, they got individual patient data from the authors of the seven studies that specifically tested the effects of antidepressants alone vs antidepressants plus STPP. So instead of being limited by seven summary effect size statistics, the authors had a sample of 482 patient effect sizes to work with. The effect of adding STPP to antidepressants was larger for participants with high rather than low baseline depression scores [B = −0.49, 95% CI: −0.61 to −0.37, p < 0.0001], for participants with ⩽8 rather than more years of education (B = −0.66, 95% CI −1.05 to −0.27, p < 0.0009), and for participants with a depressive episode duration of >2 years rather than <1 year (B = −0.68, 95% CI −1.31 to −0.05, p = 0.03) or less than 1–2 years (B = −0.86, 95% CI −1.66 to −0.06, p = 0.04). At follow-up, higher baseline depression scores and longer depressive episode duration were still associated with better outcomes for those receiving a combination of antidepressants plus STPP.
The results of this patient-level meta-analysis suggests that adding short-term psychodynamic psychotherapy to antidepressant medication might be particularly efficacious for patients with higher initial levels of depression and/or with longer duration of depressive symptoms. It is possible that the addition of a psychological treatment like STPP may tackle some of the underlying psychological vulnerabilities whose treatment is necessary for those who have more persistent and severe depressive symptoms.
The Evidence for Psychodynamic Therapy
Barber, J., Muran, J.C., McCarthy, K., Keefe, J.R., & Zilchamano, S. (2021). Research on dynamic therapies. In Barkham, W. Lutz, and L.G. Castonguay (Eds.) Bergin and Garfield’s Handbook of Psychotherapy and Behavior Change (7th ed.). Wiley. Chapter 12.
One of the persistent myths about psychotherapy is that among treatments that are meant to be effective, some treatments are more effective than others. There are complex historical reasons for such claims, but one therapy that has been most negatively affected by this narrative in psychodynamic therapy. Once a prominent treatment model up to the 1970s, psychodynamic therapy has fallen out of favor among some researchers and is sometimes disparaged as having no evidence base to support its efficacy. In this part of the chapter, Barber and colleagues review the research on the efficacy for psychodynamic therapy for a variety disorders. At the time of writing the chapter, the authors identified 245 randomized controlled trials of psychodynamic therapy. Randomized controlled trials are considered by some as representing the highest quality evidence for interventions. In a number of meta analyses, psychodynamic therapies have demonstrated efficacy compared to control groups in the treatment of mood, anxiety, personality, and somatic disorders, with effects lasting into posttreatment follow-up. In the treatment of suicidality and self-harm, psychodynamic therapies are more effective than control treatments, such as treatment as usual, routine psychiatric care, enhanced usual care, placebo, or any other comparison, including with a different psychological therapy. Long-term psychodynamic therapies for complex or chronic disorders (e.g., borderline personality disorder; treatment-resistant depression) outperformed active and inactive controls. A meta-analysis assessing statistical equivalence in trials comparing psychodynamic therapies to other gold-standard treatments found no evidence that other treatments were more effective. In treatment of unipolar mood disorders, adding short-term psychodynamic therapy to psychopharmacology improved depression symptoms over medications alone (g = 0.26 at termination; g = 0.50 at follow-up).
Some who practice psychodynamic therapy may feel that the research has been stacked against this treatment modality. And while the narrative is certainly one sided, the evidence is not. Psychodynamic therapy has a robust evidence base for a variety of disorders for which it was tested. Meta analyses consistently demonstrate psychodynamic therapy is as effective as other so called gold standard treatments and provides added value to the treatment of depression over and above medications alone.
Psychological Treatments for Panic Disorder
Papola, D., Ostuzzi, G., Tedeschi, F., Gastaldon, C., Purgato, M., Del Giovane, C., . . . Barbui, C. (2021). Comparative efficacy and acceptability of psychotherapies for panic disorder with or without agoraphobia: Systematic review and network meta-analysis of randomised controlled trials. The British Journal of Psychiatry, 1-13. doi:10.1192/bjp.2021.148
Panic disorder affects between 1.1% and 3.7% of the population, and panic symptoms can occur in about 10% of patients in primary care. Panic disorder is characterized by recurrent and unexpected panic attacks including heart palpitations, sweating, and trembling. Often, the fear of panic attacks results in avoidance of places or situations that might cause another panic attack. Sometimes, panic attack co-occurs with agoraphobia, or anxiety related to being in certain places or situations. Panic disorder can be debilitating and can also co-occur with depression or substance use disorders. In this network meta-analysis, Papola and colleagues systematically reviewed 136 randomized controlled trials of psychological therapies for panic disorder that included over 7,300 patients. The therapies included CBT, psychodynamic therapy, behavior therapy, EMDR and others that were compared to each other and treatment as usual (which often included minimal intervention). The most effective treatments compared to treatment as usual were CBT (SMD = -0.67, 95%CI: -0.95 to -0.39) and short term psychodynamic therapy (SMD = -0.61, 95%CI: -1.15 to -0.07). All other psychotherapies (EMDR, IPT, behavior therapy, third wave CBT, cognitive therapy, psychoeducation) were not more effective than treatment as usual. The authors also evaluated acceptability of the treatment to patients, which they defined as the dropout rates from the therapies that were offered. Behavior therapy and cognitive therapy were less accepted by patients than short term psychodynamic therapy and CBT.
The results of this large network meta-analysis indicates that CBT and short-term dynamic therapy are efficacious treatments for panic disorder. The authors suggest that these treatments should be considered as first line interventions. These findings confirm a growing trend indicating the efficacy of psychodynamic therapies for panic and as well as for other common mental disorders.
Psychotherapies for Depression
Cuijpers, P., Quero, S., Noma, H., Ciharova, M., Miguel, C., Karyotaki, E., Cipriani, A., Cristea, I.A., Furukawa, T.O. (2021). Psychotherapies for depression: A network meta-analysis covering efficacy, acceptability and long-term outcomes of all main treatment types. World Psychiatry, 20, 283-293.
Depressive disorders are common, and they have an important negative impact on quality of life and on mortality. For that reason, the treatment of depression is critical. The most commonly tested psychotherapy is CBT but others like interpersonal psychotherapy (IPT), psychodynamic therapy (PDT), and behavioral activation (BA) have also been tested. In this network meta analysis, Cuijpers and colleagues simultaneously test the effects of different psychotherapies for depression. Network meta-analysis, fundamentally, works by the transitivity assumption: if treatment A = treatment B, and treatment B = treatment C, then treatment A = treatment C even if Treatments A and C were never tested against each other in the same study. This procedure is not without controversy: what if the studies of treatment A vs B are all higher quality (thus resulting in lower effects) than studies of treatments B vs C? Is it fair to equate the studies by comparing treatments A and C when we know study quality impacts effect sizes? Nevertheless, network meta-analyses are used by some to aggregate many studies and to estimate relative outcomes across treatment types. Cuijpers included 331 studies (representing over 34,000 patients) in their network meta-analysis. CBT was tested in over 63% of trials, but other therapies (PDT, IPT, BA) were tested as well. All psychotherapies were more efficacious than care-as-usual and wait list controls with almost no significant differences between therapies for treating depression, except non-directive therapy was less efficacious than other therapies. (Non-directive therapy was often treated as a placebo control condition in studies, and so it may have been delivered in a way that limited its efficacy). CBT, IPT, PDT and BA all were more efficacious than care as usual at 12 months follow up.
Overall, this network meta-analysis of psychotherapies for depression echoes the findings of many meta-analyses that preceded it. All psychotherapies that were examined, except for non-directive therapy, were equally efficacious for treating depression. When initiating therapy, it may be more important for therapists to be responsive to patient characteristics than to focus on which brand of therapy to deliver. For example, patients with internalizing coping styles may do better with insight oriented therapies, those with high levels of resistance/reactance may require a therapist that is less directive, and patients from marginalized race and ethnic communities may do better with a therapist who is multiculturally competent.