The efficacy of short-term psychodynamic psychotherapy for depression: A meta-analysis
Introduction
Since the second half of the 20th century, different types of short-term psychodynamic psychotherapy (STPP) have been developed by Malan (1963), Mann (1973), Sifneos (1979), Davanloo (1980), Strupp and Binder (1984), Pollack and Horner (1985), and de Jonghe (1994). They share the common feature of being rooted in psychoanalytical theories such as drive psychology, ego psychology, object relations psychology, attachment theory and self psychology. These psychoanalytic perspectives consider the underlying personality structure to play an important role in the development and maintenance of symptom disorders such as depression. Hence, STPP focuses on interpersonal relationships and unconscious feelings, desires, strivings and thoughts in order to treat symptom disorders.
STPP is by definition short in duration. The number and frequency of the sessions are typically agreed upon by the therapist and the patient before treatment starts, and usually a focus is defined that guides the therapy content. This focus is often on building awareness of the unconscious affect, cognition and behavior that produce symptom and relationship problems. The primary goal of STPP is symptom reduction; in this aspect STPP does not differ from other short-term psychotherapies, such as Cognitive Behavioral Therapy (CBT) or Supportive Therapy (ST). The secondary goal consists of personality change, albeit limited due to the time frame of the therapy. This personality change can be understood in terms of decreasing a person's vulnerability and increasing his or her long-term resiliency.
With regard to the interventions used, various STPP types can be placed on a continuum between a purely ‘expressive’ and a purely ‘supportive’ pole (Luborksy, 1984). The more expressive therapies define the therapeutic relationship by its transference aspects, rely heavily on interpreting conflicts concerning sexuality and aggression in the therapist–patient relationship and/or defenses that the patient uses, emphasize insight as being curative, and consider personality restructuring to be paramount. The more supportive therapies define the therapeutic relationship by its interpersonal aspects, rely heavily on a strong, conscious therapeutic alliance, consider growth through the relationship as curative, and consider personality building to be paramount. It must be emphasized, however, that this distinction is a continuum and not a dichotomy. Most STPPs include both expressive and supportive interventions. However, the relative weight they place on either one of the poles merits the division into supportive and expressive therapy modes.
A number of authors have found STPP efficacious in the treatment of psychiatric disorders in general, consistently reporting the superiority of STPP over control conditions (Svartberg and Stiles, 1991, Crits-Christoph, 1992, Anderson and Lambert, 1995, Leichsenring et al., 2004, Abbass et al., 2006). With regard to the comparison of STPP to other psychotherapy approaches for psychiatric disorders in general, however, these meta-analyses reached different conclusions; some finding STPP inferior to alternative psychotherapies (Svartberg & Stiles, 1991), while others reported equal efficacy (Crits-Christoph, 1992, Anderson and Lambert, 1995, Leichsenring et al., 2004). These meta-analyses included a small number (n = 2–6) of studies regarding STPP for depression (see Table 1). With exception of Svartberg and Stiles, who found alternative psychotherapies superior to STPP in their subgroup of six studies regarding depressed populations, these meta-analyses do not report on the efficacy of STPP for depression, due to the limited number of included studies regarding this population specifically.
Whereas the meta-analyses discussed so far reviewed the efficacy of STPP in general psychiatric disorders, two other fairly recent meta-analyses did focus specifically on the psychodynamic treatment of depression (Leichsenring, 2001, Churchill et al., 2001). Leichsenring (2001) included six studies comparing STPP with CBT and found that both psychotherapies were equally effective in the treatment of depression, a result the author suggested should be regarded as preliminary, due to the small number of included studies. Churchill et al. (2001) compared STPP to CBT and to ST and found that patients receiving CBT were more likely to recover than those receiving STPP, but found no differences in post-treatment symptoms, symptom reduction or drop-out. Due to a lack of data, no conclusions could be drawn regarding the efficacy of STPP versus ST. Both meta-analyses did not include a comparison of STPP with control groups. Thus, so far two meta-analyses have addressed the efficacy of STPP for depression specifically, focusing on specific comparisons only and reporting contradictory results. Moreover, these two meta-analyses do not compare STPP to control conditions. Therefore, it remains largely unclear whether STPP is an effective treatment for depression.
Furthermore, research on factors moderating the effectiveness of STPP in depression is scarce. In a meta-analysis, differences in the efficacy between groups of studies with certain characteristics can be assessed by means of subgroup analyses. These analyses provide the basis to determine for what type of patients and under which conditions the treatment is effective. They also provide the opportunity to compare the efficacy of supportive and expressive STPP modes. To our knowledge, no previous meta-analysis has conducted subgroup analyses in order to identify STPP treatment moderators for depression.
The purpose of the present study is twofold. First, we examine the efficacy of STPP for depression by means of computing STPP pre- to post-treatment and post-treatment to follow-up effect sizes, and by means of comparing STPP with control groups and alternative treatments at post-treatment and follow-up. Second, we perform subgroup analyses to assess differences in the STPP efficacy between study, participant and intervention characteristics, such as study type (randomized controlled trial, non-random controlled study or open study), target group (adults or older adults), or treatment format (individual or group therapy).
The present study adds to the available body of evidence by including 13 studies regarding the efficacy of STPP for depression, which were published after the meta-analyses of Leichsenring (2001) and Churchill et al. (2001). In addition, it does not focus on a comparison of STPP with a specific other psychotherapy method only, but aims to compare the efficacy of STPP with all other treatments as well as with control conditions. Furthermore, this study is the first which conducts subgroup analyses in order to identify STPP treatment moderators for depression.
Section snippets
Search strategy
We retrieved as many studies as possible by means of an extensive search strategy using six different search methods. First, we searched the electronic databases PubMed, PsychINFO, Embase.com, Web of Science and Cochrane's Central Register of Controlled Trials (CENTRAL). Search terms included a wide range of synonyms for psychodynamic (e.g., psychoanalytic, analytic, dynamic, interpersonal–psychodynamic, interpretive, insight-oriented, STPP), therapy (e.g., psychotherapy, counseling), and
Inclusion of studies
The literature search resulted in 5073 citations and 43 reviews including potentially relevant references. The majority of these citations and references were excluded in the first screening phase. A total of 218 titles were requested in full-text and screened by two raters independently in the second screening phase. The most important reason for exclusion in this phase was a heterogeneous research population that did not include depressed patients exclusively (n = 59). In the case of a
Discussion
In this study we found clear indications that STPP is effective in the treatment of depression in adults. The pre- to post-treatment effect sizes were consistently large, indicating a significant reduction of depressive symptoms after STPP. These reductions were maintained at 3-month, 6-month and 1 year follow-up. Moreover, in STPP conditions post-treatment depression levels were significantly lower than in waiting list or care as usual conditions. These results are in line with earlier reviews
Acknowledgements
The authors wish to thank P. Crits-Christoph, G. H. Franke, H. H. Jensen, H. Karlsson, M. Lotz, and A. Werbart for providing additional information or data regarding their studies. Our thanks are also due to I. Jansma for her help in designing the search strategies and Y. Boom, S. I. Lentjes, S. M. Wagemans, and D. Westra, for their help in the screening process.
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