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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.

Practice Implications

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.

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.

Practice Implications

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.

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.

Practice Implications

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.

Keefe, J. R., McMain, S. F., McCarthy, K. S., Zilcha-Mano, S., Dinger, U., Sahin, Z., Graham, K., & Barber, J. P. (2019, December 5). A meta-analysis of psychodynamic treatments for borderline and Cluster C personality disorders. Personality Disorders: Theory, Research, and Treatment. Advance online publication.

Personality disorders are common mental conditions affecting between 6.1% and 9.1% of the population. Having a comorbid personality disorder predicts a number of negative outcomes from psychotherapy including lower remission rates, greater resistance to therapy, and greater relapse after therapy. Psychodynamic therapies are one of two classes of therapy that have been repeatedly tested in clinical trials for personality disorders (the other being cognitive-behavioral therapies). Psychodynamic therapies aim to help patients improve their personality functioning, including attachment, mentalization, and maturity of defense mechanisms. Dynamic therapies for personality disorders include transference-focused therapy, affect-phobia therapy, mentalization based treatment, and good psychiatric management. In this meta-analysis, Keefe and colleagues systematically assessed whether psychodynamic therapy was as effective as other active treatments and more effective than no treatment. They also evaluated the quality of the studies. They found 16 randomized controlled studies of over 1100 patients that directly compared psychodynamic therapy to another therapy or to a control condition. Outcomes included personality disorder symptoms, suicidality, general symptoms, and drop-out rates. Overall, psychodynamic therapy was as effective as other therapies when it came to all of these outcomes, and the drop-out rates were equivalent. Psychodynamic therapy was more effective than no treatment for personality disorder symptoms (g = 0.63; 95% CI [0.87, 0.41], SE = 0.08, p = .002), suicidality (g = 0.67; 95% CI [1.13, 0.20], SE = 0.15, p = .020), and general symptoms (g = 0.38;95% CI [0.68, 0.08], SE = 0.13, p = .019). Average study quality was high, suggesting that one could be confident in the overall findings of this meta analysis.

Practice Implications

For all outcomes, psychodynamic therapies were as effective as other active treatments and more effective than no-treatment controls for borderline personality disorder and for mixed Cluster C disorders (dependent, avoidant, and obsessive-compulsive personality disorders). The authors concluded that psychodynamic therapies are effective in treating personality disorders like borderline personality disorder and those with Cluster C personality disorders.

Lilliengren, P., Johansson, R., Lindqvist, K., Mechler, J., & Andersson, G. (2016). Efficacy of experiential dynamic therapy for psychiatric conditions: A meta-analysis of randomized controlled trials. Psychotherapy, 53(1), 90-104.

There is growing research support for the efficacy of short-term psychodynamic psychotherapies to treat common mental health problems. A subtype of short-term psychodynamic psychotherapies is called experiential-dynamic therapy (EDT), which goes by a number of different names such as Fosha’s accelerated experiential-dynamic psychotherapy, and McCullough’s affect phobia therapy. A fundamental assumption of EDT is that conditions like depression, anxiety and personality disorders are by-products of an individual’s attempts to regulate strong emotions associated with adverse experiences in attachment relationships during childhood. When the attachment system and associated affects are re-awakened in current relationships, the individual may engage in maladaptive coping that leads to difficulties in relationships. While EDTs may focus on helping patients to understand how their attachment difficulties lead to inhibitory affects and maladaptive defenses, the treatment favors interventions that facilitate direct experience of underlying emotions in the here and now of the therapy. In this meta-analysis, Lilliengren and colleagues reviewed 28 studies with 1,782 adult patients who had a mood, anxiety, personality, or mixed disorder. Compared to inactive controls, EDT showed a moderate and significant effect at post-treatment (range: d = .39 to .65) and at follow-up assessments (range: d = .26 to .62), with largest effects for depression and anxiety. When researchers compared EDT to cognitive-behavioral therapy (CBT) in five studies, there were no significant effects at post-treatment (d = .02, 95% CI: -.24, .28) or follow-up (d = .07, 95% CI: -.22, .36). The average quality of EDT studies was good. In fact, studies with larger samples, that used blind randomization and assessments, and appropriate statistical tests showed larger effects for EDT. Drop-out rates for EDT (16.3%) were similar to other treatments.

Practice Implications

Experiential-dynamic therapy (EDT), which is a variant of short-term psychodynamic psychotherapy, was more effective than no-treatment and just as effective as evidence-based treatments like CBT. The findings are similar to those reported in many comparative outcome studies in which any bona-fide psychotherapy is effective for many disorders. The average quality of the EDT studies was quite good, suggesting that the findings were reliable and valid, and perhaps underestimating the true effects of EDT.

Author email: peter.lilliengren@psychology.su.se

Grenon, R., Carlucci, S., Brugnera, A., Schwartze, D., … Tasca, G. A. (2018). Psychotherapy for eating disorders: A meta-analysis of direct comparisons, Psychotherapy Research, DOI: 10.1080/10503307.2018.1489162

Eating disorders can cause a great deal of physical and mental impairment because of the severity of the symptoms and because of comorbid conditions like depression, anxiety, substance use, and others. Anorexia nervosa (AN) occurs in about 0.5% of the population, bulimia nervosa (BN) occurs in about 1.5% of the population, and binge-eating disorder (BED) occurs in about 3.5% of the population. Treatment guidelines include both cognitive behavioral therapy (CBT) and interpersonal psychotherapy (IPT) as front line interventions for BN and BED. However, results from previous meta analyses of psychological treatments for eating disorders were confounded by not focusing exclusively on randomized controlled trials, mixing studies of adult and adolescent samples, combining an array of outcomes rather than separately reporting primary (eating disorder symptoms) and secondary (interpersonal problems, depression) outcomes, and not distinguishing between bona fide psychotherapies (like CBT, IPT, psychodynamic therapy, and others) from non-bona fide treatments (like self help, behavioral weight loss supportive counseling). Grenon and colleagues conducted a meta analysis of psychotherapies for eating disorders to examine if: psychotherapy is effective compared to a wait list, if bona fide psychotherapy and non-bona fide treatment differ in outcomes, and if one type of psychotherapy (i.e., CBT) was more effective than other bona fide psychotherapies (like IPT, behavior therapy, psychodynamic therapy, dialectical behavior therapy). Their meta analysis included 35 randomized controlled trials of direct comparisons. Psychotherapy was significantly more effective than a wait-list control at post treatment, so that 53.89% of patients were abstinent of symptoms after psychotherapy compared to only 8.92% who were abstinent in the wait-list group. Bona fide psychotherapies (51% abstinent) were significantly more effective than non-bona fide treatments (40% abstinent) at post treatment, and dropout in bona fide psychotherapies (17.5%) was significantly lower than in non-bona fide treatment (29.1%). Further, the difference between CBT and other bona fide psychotherapies was not significant.

Practice Implications

Psychotherapy for eating disorders are effective for patients with BN or BED. There were too few studies of those with AN to come to any conclusions about their treatment. Patients with BN or BED are best treated with a bona fide psychotherapy that involves face to face psychological therapy like CBT, IPT, psychodynamic therapy, dialectical behavior therapy, or behavior therapy. Non-bona fide treatments like self help, behavioral weight loss, and supportive counseling should only be used as an adjunct to bona fide psychotherapy for eating disorders.