Psychodynamic Psychotherapies: Efficacy

Evidence for Acute-Phase Efficacy
No controlled efficacy studies exist for extended dynamic therapy or psychoanalysis of depression. Brief dynamic therapy, on the other hand, has been studied in 10 randomized controlled trials. Of these studies, 6 of the early investigations were subjected to meta-analysis, but significant methodological and design problems prevented any far-reaching conclusions regarding efficacy (Depression Guideline Panel 1993). Five of the 6 studies examined brief dynamic therapy in a group format, even though individual therapy is much more widely practiced. No study compared a pill placebo with brief dynamic therapy. Another major difficulty in generalizing from these data is that the investigations were usually conducted by researchers who were not professionally trained in brief dynamic psychotherapy and were merely using it as a control group for comparison with other forms of therapy.

Nevertheless, the overall evidence does point in the direction of a reduction of depressive symptoms with brief dynamic therapy. In the six studies subjected to meta-analysis, the overall efficacy of brief dynamic therapy was 34.8%, an efficacy that was somewhat less impressive than that of other therapies (Depression Guideline Panel 1993). The meta-analysis did not show any differences in efficacy between medication and brief dynamic therapy. In the studies that involved a waiting-list control (Thompson et al. 1987) and a nonspecific treatment control, brief dynamic therapy was significantly more effective than a waiting list but no different in efficacy than nonspecific treatment.

Two randomized controlled studies have shown brief psychodynamic therapy to be equivalent in efficacy to cognitive-behavioral therapy. As noted earlier, Gallagher-Thompson and Steffen (1994) found no overall differences after 20 sessions of each treatment for depressed caregivers. In the second Sheffield Psychotherapy Project (Shapiro et al. 1994, 1995) in the United Kingdom, similar findings were noted. One hundred twenty depressed patients were assigned to either 8 or 16 sessions of psychodynamic-interpersonal therapy or cognitive-behavioral therapy. Both treatments were found to be equally effective and to exert their effects with equal rapidity. Patients who had only mild or moderate depression had the same outcome whether they were treated with 8 or 16 weeks of therapy. However, in the severely depressed patients, significantly superior outcomes were noted when 16 weeks of therapy were provided, regardless of whether the treatment was psychodynamic-interpersonal or cognitive-behavioral. At 1-year follow-up, no overall differences were found in outcome or maintenance of gains between the two types of therapy. Longer periods of therapy did appear to be associated with better long-term outcomes, particularly in the case of psychodynamic-interpersonal therapy.

There is also evidence that brief psychodynamic-interpersonal therapy may be quite cost-effective. In a study of 110 nonpsychotic patients who were unresponsive to routine specialist mental health treatment over a 6-month period (Guthrie et al. 1999), 75.5% were found to have a depressive illness. All patients were randomized to 8 weekly sessions of psychodynamic-interpersonal psychotherapy or a control group of usual care from their psychiatrist. Those in therapy had significantly greater improvement in social functioning and psychological distress at 6-month follow-up than control subjects. They also showed significant reductions in health care utilization in the 6 months after treatment compared with control subjects. The additional cost of the therapy was made up by the reductions in health care expenditures within 6 months.

Although efficacy studies are not available for extended dynamic therapy, there have been multiple case reports (Arieti 1977; Cohen et al. 1954) that many clinicians have found useful. Further research is needed to assess the specific effects of this approach. Notable among these case reports is Arieti’s (1977) report of 12 severely depressed patients whom he treated with intensive psychotherapy. All patients were treated at a frequency of two or more sessions per week for 18 months or more. Arieti followed up all 12 patients at intervals of at least 3 years posttermination and determined that 7 of the patients had achieved full recovery without relapse, 4 had made substantial improvements, and 1 showed no improvement. Arieti concluded from his clinical experience that intensive dynamic psychotherapy can be highly effective treatment for persons with severe depression. He noted that when somatic treatments fail or are refused, psychotherapy becomes a necessity. The psychodynamic understanding Arieti derived from his work is discussed later in this chapter.

Evidence for Continuation- and Maintenance-Phase Efficacy
Studies of the prophylactic effects following acute-phase brief dynamic psychotherapy are too problematic from a methodological standpoint to allow for any definitive conclusions (Depression Guideline Panel 1993). No studies on the continuation effects of acute-phase dynamic therapy have been reported. Published reports on the efficacy of maintenance brief dynamic therapy are not sufficiently rigorous to determine whether the modality is useful in the maintenance-phase treatment for depression.