Efficacy and moderators of short-term psychodynamic psychotherapy for depression: A systematic review and meta-analysis of individual participant data.

BACKGROUND: Short-term psychodynamic psychotherapy (STPP) is frequently used to treat depression, but it is unclear which patients might benefit specifically. Individual participant data (IPD) meta-analyses can provide more precise effect estimates than conventional meta-analyses and identify patient-level moderators. This IPD meta-analysis examined the efficacy and moderators of STPP for depression compared to control conditions. METHODS: PubMed, PsycInfo, Embase, and Cochrane Library were searched September 1st, 2022, to identify randomized trials comparing STPP to control conditions for adults with depression. IPD were requested and analyzed using mixed-effects models. RESULTS: IPD were obtained from 11 of the 13 (84.6%) studies identified (n = 771/837, 92.1%; mean age = 40.8, SD = 13.3; 79.3% female). STPP resulted in significantly lower depressive symptom levels than control conditions at post-treatment (d = -0.62, 95%CI [-0.76, -0.47], p < .001). At post-treatment, STPP was more efficacious for participants with longer rather than shorter current depressive episode durations. CONCLUSIONS: These results support the evidence base of STPP for depression and indicate episode duration as an effect modifier. This moderator finding, however, is observational and requires prospective validation in future large-scale trials.

The anger-depression mechanism in dynamic therapy: Experiencing previously avoided anger positively predicts reduction in depression via working alliance and insight.

A central tenet of psychodynamic theory of depression is the role of avoided anger. However empirical research has not yet addressed the question of for which patients and via what pathways experiencing anger in sessions can help. The therapeutic alliance and acquisition of patient insight are important change processes in dynamic therapy and may mediate the anger-depression association. This study was embedded into a randomized trial testing the efficacy of Intensive Short-Term Dynamic Psychotherapy (ISTDP) for treatment resistant depression. In-session patient affect experiencing (AE) was coded for every available session (475/481) by blinded observers in 27 patients randomized to ISTDP. Dynamic Structural Equation Modeling was used to examine within-person associations between variation in depression scores session-by-session and both patient ratings (alliance) and observer ratings (AE and insight) of the treatment process. Alliance and insight were independent mediators of the effect of anger on next-session depression. However, the relative importance of these two indirect effects of anger on depression was conditional on pretreatment patient personality pathology (PP). In patients with higher PP, in-session anger was negatively related to depressive symptoms next session, with this effect operating through higher alliance. In patients with low PP, in-session anger was negatively related to depressive symptoms next session, with this effect operating through enhanced patient insight. These findings highlight an anger-depression mechanism of change in dynamic therapy. Depending upon patient personality, either an "insight pathway" or a "relational pathway" may promote the effectiveness of facilitating arousal and expression of patients' in-session feelings. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Alliance rupture-repair processes in intensive short-term dynamic psychotherapy: Working with resistance.

Intensive short-term dynamic psychotherapy (ISTDP) was developed to manage treatment impasses preventing the experiencing of feelings related to childhood attachment interruptions, such as parental loss. According to ISTDP theory, certain categories of patients will exhibit habitual patterns of responding within the treatment relationship (called defenses) to certain anxiety-provoking thoughts and feelings. Such defensive behaviors interrupt awareness of one's own feelings, self-directed compassion and engagement in close human attachments, including the bond with the therapist. Rupture-repair sequences in ISTDP are primarily considered in the context of a patient's defenses and the responses a therapist has to these defenses. By understanding and clarifying these defenses, this risk of subsequent misalliance, that is negative shifts or ruptures in the alliance, are minimized. In this paper we summarize ISTDP theory and technique through the use of clinical vignettes to illustrate defense management as a rupture-repair equivalent in ISTDP.

Efficacy and cost-effectiveness of intensive short-term dynamic psychotherapy for treatment resistant depression: 18-Month follow-up of the Halifax depression trial.

BACKGROUND: Depressed patients with chronic and complex health issues commonly relapse; therefore, examining longer-term outcomes is an important consideration. For treatment resistant depression (TRD), the post-treatment efficacy of time-limited Intensive Short-Term Dynamic Psychotherapy (ISTDP) has been demonstrated but longer-term outcomes and cost-effectiveness are unclear. METHOD: In this superiority trial, 60 patients referred to Community Mental Health Teams (CMHT) were randomised to 2 groups (ISTDP=30 and CMHT=30). The primary outcome was Hamilton Depression Rating scale (HAM-D) scores at 18 months. Secondary outcomes included Patient Health Questionnaire (PHQ-9) depression scores and dichotomous measure remission. A health economic evaluation examined mental health costs with quality-adjusted life years (QALYs). RESULTS: Statistically significant treatment differences in depression previously found at 6 months favouring ISTDP were maintained at 18-month follow-up. Group differences in depression were in the moderate to large range on both the observer rated (Cohen's d = .64) and self-report measures (Cohen's d = .70). At 18 months follow-up the remission rate in ISTDP patients was 40.0%, and 23.4% had discontinued antidepressants. Health economic analysis suggests that ISTDP was more cost-effective than CMHT at 18 months. Probabilistic analysis suggests that there is a 64.5% probability of ISTDP being cost-effective at a willingness to pay for a QALY of $25,000 compared to CMHT at 18 months. LIMITATIONS: Replication of these findings is necessary in larger samples and future cost analyses should also consider indirect costs. CONCLUSIONS: ISTDP demonstrates long-term efficacy and cost-effectiveness in TRD.

Clinical- and cost-effectiveness of intensive short-term dynamic psychotherapy for chronic pain in a tertiary psychotherapy service.

OBJECTIVE: The objective of this study is to assess the clinical- and cost-effectiveness of intensive short-term dynamic psychotherapy (ISTDP) for patients with chronic pain. METHOD: A sample of 228 pain patients was drawn from a larger naturalistic study of ISTDP. They received an average of 6.1 sessions delivered by 31 therapists. Psychiatric symptoms and interpersonal problems were assessed at three time points. Healthcare data from baseline year and three years following treatment came from independent governmental databases. RESULTS: Multilevel models indicated significant reductions in symptoms and interpersonal problems during treatment, including a moderate to large pre-post effect size (d = 0.76) for somatization. Further, the sample had successive reductions in yearly healthcare costs, reaching the normal population mean two years post-treatment. CONCLUSION: Within the limitations of the uncontrolled design, our study suggests that ISTDP may be both clinically effective and cost-effective for patients with chronic pain.

The role of emotion in psychotherapeutic change for medically unexplained symptoms.

OBJECTIVES: Evidence of the contribution of emotional processes to the emergence, maintenance, and experience of medically unexplained symptoms (MUS) suggests that clinical approaches which target these processes could be beneficial. In this study, qualitative methods were used to examine patients' perspectives and subjective experiences of emotional processes in the context of a psychotherapy assessment and treatment service for MUS provided in a hospital emergency department (ED). METHODS: Seven semi-structured interviews were conducted with ED patients presenting with MUS who received a course of intensive short-term dynamic psychotherapy treatment. RESULTS: Interpretative phenomenological analysis was employed with three superordinate themes emerging: Barriers to examining emotional processes; reflections on the therapeutic process; psychological change; and improved well-being. Obstacles to clinical engagement in treatment for MUS were described in relation to patients' and therapists' ability to identify, address, and utilize emotion processes. Specific elements of this work were identified as integral components of the psychotherapy change process for MUS. CONCLUSIONS: Directly observing the physical effects of emotional experiencing in MUS provides sensory evidence that can enable patients to make mind-body connections. Psycho-emotional processes warrant further study to explore the applicability to other conceptual models for assessing and treating MUS. Clinical and methodological significance: In this article, we highlight that Medically Unexplained Symptoms (MUS) are a priority area for both physical and mental health care services. We present findings relevant to the effectiveness of a novel psychotherapy innovation within a hospital emergency department (ED). The use of interpretative phenomenological analysis to study the experiences of ED clients with MUS offers an established qualitative method for exploring the processes underlying therapeutic change. The results provide new insights around obstacles to engagement alongside potential solutions when addressing the psychological needs of clients with MUS. Although emotion processes have been described as a potentially important change process for MUS and in psychotherapy more generally, little empirical research has studied these two areas collectively.

Which patients benefit specifically from short-term psychodynamic psychotherapy (STPP) for depression? Study protocol of a systematic review and meta-analysis of individual participant data.

INTRODUCTION: Short-term psychodynamic psychotherapy (STPP) is an empirically supported treatment that is often used to treat depression. However, it is largely unclear if certain subgroups of depressed patients can benefit specifically from this treatment method. We describe the protocol for a systematic review and meta-analysis of individual participant data (IPD) aimed at identifying predictors and moderators of STPP for depression efficacy. METHOD AND ANALYSIS: We will conduct a systematic literature search in multiple bibliographic databases (PubMed, PsycINFO, Embase.com, Web of Science and Cochrane's Central Register of Controlled Trials), 'grey literature' databases (GLIN and UMI ProQuest) and a prospective trial register (http://www.controlled-trials.com). We will include studies reporting (a) outcomes on standardised measures of (b) depressed (c) adult patients (d) receiving STPP. We will next invite the authors of these studies to share the participant-level data of their trials and combine these data to conduct IPD meta-analyses. The primary outcome for this study is post-treatment efficacy as assessed by a continuous depression measure. Potential predictors and moderators include all sociodemographic variables, clinical variables and psychological patient characteristics that are measured before the start of treatment and are assessed consistently across studies. One-stage IPD meta-analyses will be conducted using mixed-effects models. ETHICS AND DISSEMINATION: Institutional review board approval is not required for this study. We intend to submit reports of the outcomes of this study for publication to international peer-reviewed journals in the fields of psychiatry or clinical psychology. We also intend to present the outcomes at international scientific conferences aimed at psychotherapy researchers and clinicians. The findings of this study can have important clinical implications, as they can inform expectations of STPP efficacy for individual patients, and help to make an informed choice concerning the best treatment option for a given patient. PROSPERO REGISTRATION NUMBER: CRD42017056029.

Intensive Short-Term Dynamic Psychotherapy for generalized anxiety disorder: A pilot effectiveness and process-outcome study.

The objective of this study was to evaluate the clinical- and cost-effectiveness of Intensive Short-Term Dynamic Psychotherapy (ISTDP) for generalized anxiety disorder (GAD). We further aimed to examine if a key clinical process within the ISTDP framework, termed the level of mobilization of unprocessed complex emotions (MUCE), was related to outcome. The sample consisted of 215 adult patients (60.9% female) with GAD and comorbid conditions treated in a tertiary mental health outpatient setting. The patients were provided an average of 8.3 sessions of ISTDP delivered by 38 therapists. The level of MUCE in treatment was assessed from videotaped sessions by a rater blind to treatment outcome. Year-by-year healthcare costs were derived independently from government databases. Multilevel growth models indicated significant decreases in psychiatric symptoms and interpersonal problems during treatment. These gains were corroborated by reductions in healthcare costs that continued for 4 years post-treatment reaching normal population means. Further, we found that the in-treatment level of MUCE was associated with larger treatment effects, underlining the significance of emotional experiencing and processing in the treatment of GAD. We conclude that ISTDP appears to reduce symptoms and costs associated with GAD and that the ISTDP framework may be useful for understanding key therapeutic processes in this challenging clinical population. Controlled studies of ISTDP for GAD are warranted.

Is affect experiencing therapeutic in major depressive disorder? Examining associations between affect experiencing and changes to the alliance and outcome in intensive short-term dynamic psychotherapy.

Affect experiencing (AE), defined as the facilitation of client in-session bodily arousal and visceral experiencing of affect, is a distinct theoretical process presumed to contribute to therapeutic improvement. This study examined the role of AE in the treatment of major depressive disorder by exploring its association to client distress and therapeutic alliance on a session-by-session basis. A case series design was used to conduct an intensive analysis of the treatment process of 4 clients who received time-limited intensive short-term dynamic psychotherapy, 2 of whom were considered "recovered" and 2 who showed "no change" based upon posttreatment outcomes. Consistent with our hypothesis, we found that cross-correlations between AE and client distress discriminated between "recovered" and "no change" clients. In "recovered" clients, there was evidence that higher in-session peak affect experience was associated with reduced distress 7 days later. The results did not provide consistent evidence for a reverse effect, showing that lower distress during the preceding week predicted higher AE in that session. Finally, there was evidence that AE is an in-session activity that can promote the strengthening of the therapeutic alliance. These collective findings suggest that AE is an important treatment process that contributes to alliance formation and psychotherapeutic improvement. Clinical implications include further evidence that psychodynamic therapists can utilize AE as an active change ingredient for depression. (PsycINFO Database Record

A randomised controlled trial of Intensive Short-Term Dynamic Psychotherapy for treatment resistant depression: the Halifax Depression Study.

BACKGROUND: While short-term psychodynamic psychotherapies have been shown effective for major depression, it is unclear if this could be a treatment of choice for depressed patients, many of whom have chronic and complex health issues, who have not sufficiently responded to treatment. METHOD: This superiority trial used a single blind randomised parallel group design to test the efficacy of time-limited Intensive Short-Term Dynamic Psychotherapy (ISTDP) for treatment resistant depression (TRD). Patients referred to secondary care community mental health teams (CMHT) who met DSM-IV criteria for major depressive episode, had received antidepressant treatment ≥6 weeks, and had Hamilton Depression Rating Scale (HAM-D) scores of ≥16 were recruited. The effects of 20 sessions of ISTDP were judged through comparison against secondary care CMHT treatment as usual (TAU). The primary outcome was HAM-D scores at 6 months. Secondary outcomes included the Patient Health Questionnaire (PHQ-9) self-report measures for depression and dichotomous measures of both remission (defined as HAM-D score ≤7) and partial remission (defined as HAM-D score ≤12). RESULTS: Sixty patients were randomised to 2 groups (ISTDP=30 and TAU=30), with data collected at baseline, 3, and 6 months. Multi-level linear regression modelling showed that change over time on both depression scales was significantly greater in the ISTDP group in comparison to TAU. Statistically significant between-group treatment differences, in the moderate to large range, favouring ISTDP, were observed on both the observer rated (Cohen's d=0.75) and self-report measures (Cohen's d=0.85) of depression. Relative to TAU, patients in the ISTDP group were significantly more likely after 6 months to achieve complete remission (36.0% vs. 3.7%) and partial remission (48.0% vs. 18.5%). LIMITATIONS: It is unclear if the results are generalizable to other providers, geographical locations and cultures. CONCLUSIONS: Time-limited ISTDP appears an effective treatment option for TRD, showing large advantages over routine treatment delivered by secondary care services.

A pilot study of reduction in healthcare costs following the application of intensive short-term dynamic psychotherapy for psychogenic nonepileptic seizures.

PURPOSE: The purpose of this study was to examine preliminary evidence of intensive short-term dynamic psychotherapy (ISTDP) as a treatment option for psychogenic nonepileptic seizures (PNES) in terms of impact on healthcare costs, emotional wellbeing, and somatic symptoms. METHOD: Drawn from a sample of patients treated in a tertiary psychiatric service over a nine-year period, this naturalistic pilot study compared within-group changes from pretreatment with each year up to three years posttreatment, in physician visits, physician costs, hospital admissions, and overall hospital costs. RESULTS: Twenty-eight patients with PNES received ISTDP with average treatment duration of 3.6 sessions. Healthcare costs significantly reduced in follow-up compared with those in baseline, with patient costs falling below the healthy population means, and reductions in healthcare costs compared with those in baseline by 88% in year one, 90% in year two, and 81% in year three. This was accompanied by significant reductions in symptoms and interpersonal problems. CONCLUSION: These preliminary findings indicate the potential for short-term and long-term healthcare savings and improvements in emotional wellbeing, for patients with PNES from the application of ISTDP. Further research evaluating the impact of ISTDP on seizure reduction and comparing this approach with control conditions is warranted.

Effects of Intensive Short-Term Dynamic Psychotherapy on Depressive Symptoms and Executive Functioning in Major Depression.

This study examined the efficacy of intensive short-term dynamic psychotherapy (ISTDP) on depressive symptoms and executive functioning in patients with major depression. We examined pretest, posttest, and follow-up depression scores as well as pretest-posttest executive functioning scores between 16 participants receiving ISTDP and 16 allocated to wait-list control. Participants in each group were matched according to age, sex, and educational level. Mixed-models analyses demonstrated significant interaction effects of group and time on depression scores when the group ISTDP was compared with the wait-list control group; participants receiving ISTDP had significantly reduced depression severity both after treatment and at follow-up. Next, a series of hierarchical regression models demonstrated modest improvements on most tests of executive functioning in participants receiving ISTDP. Depressed patients receiving ISTDP show a sustained reduction in depression severity after treatment and after 12-month follow-up and improvements in executive functioning after treatment compared with a wait-list control.

Long-term healthcare cost reduction with Intensive Short-term Dynamic Psychotherapy in a tertiary psychiatric service.

OBJECTIVE: To evaluate whether a mixed population of patients treated with Intensive Short-term Dynamic Psychotherapy (ISTDP) would exhibit reduced healthcare costs in long-term follow-up. METHODS: A quasi-experimental design was employed in which data on pre- and post-treatment healthcare cost were compared for all ISTDP cases treated in a tertiary care service over a nine year period. Observed cost changes were compared with those of a control group of patients referred but never treated. Physician and hospital costs were compared to treatment cost estimates and normal population cost figures. RESULTS: 1082 patients were included; 890 treated cases for a broad range of somatic and psychiatric disorders and 192 controls. The treatment averaged 7.3 sessions and measures of symptoms and interpersonal problems significantly improved. The average cost reduction per treated case was $12,628 over 3 follow-up years: this compared favorably with the estimated treatment cost of $708 per patient. Significant differences were seen between groups for follow-up hospital costs. CONCLUSIONS: ISTDP in this setting appears to facilitate reductions in healthcare costs, supporting the notion that brief dynamic psychotherapy provided in a tertiary setting can be beneficial to health care systems overall. CLINICALTRIALS. GOV IDENTIFIER NUMBER: NCT01924715.

Davanloo's Intensive Short-Term Dynamic Psychotherapy in a tertiary psychotherapy service: overall effectiveness and association between unlocking the unconscious and outcome.

Background. Intensive Short-Term Dynamic Psychotherapy (ISTDP), as developed by Habib Davanloo, is an intensive emotion-focused psychodynamic therapy with an explicit focus on handling resistance in treatment. A core assumption in ISTDP is that psychotherapeutic effects are dependent on in-session emotional processing in the form of rise in complex transference feelings that occurs when treatment resistance is challenged. Recent research indicates that an unlocking of the unconscious, a powerful emotional breakthrough achieved at a high rise in complex transference feelings, can potentially enhance ISTDP's effectiveness. While ISTDP has a growing evidence base, most of the research conducted has used small samples and has tested therapy delivered by expert therapists. The aims of this study were to evaluate the overall effectiveness of ISTDP when delivered in a tertiary psychotherapy service, and to investigate if having an unlocking of the unconscious during therapy predicted enhanced treatment effectiveness. Methods. A total of 412 patients were included in the analyses. The average length of treatment was 10.2 sessions (SD 13.3). Multilevel growth curve modeling was used to evaluate treatment effectiveness and the association between unlocking the unconscious and outcome. A number of control predictors including type of treatment resistance were selected and included in the analyses. Outcome measures were the Brief Symptom Inventory (BSI) and the Inventory of Interpersonal Problems (IIP). About half of the patients in the study were treated by therapists in training and the other half by more experienced therapists. Results. Growth curve analyses using the full intention-to-treat sample revealed significant within-group effects of ISTDP on both the BSI and the IIP. Effect sizes were large (>0.80). Unlocking the unconscious during therapy was associated with significantly larger treatment outcome. The relationship was further moderated by type of treatment resistance. Conclusion. This study adds to the empirical base of Davanloo's ISTDP with confirmed treatment effectiveness in a large-scale patient sample when ISTDP was delivered by therapists with a range of experience. Furthermore, emotional mobilization in the form of unlocking the unconscious was confirmed as a process factor enhancing the effectiveness of ISTDP.

Short-term psychodynamic psychotherapies for common mental disorders.

BACKGROUND: Since the mid-1970s, short-term psychodynamic psychotherapies (STPP) for a broad range of psychological and somatic disorders have been developed and studied. Early published meta-analyses of STPP, using different methods and samples, have yielded conflicting results, although some meta-analyses have consistently supported an empirical basis for STPP. This is an update of a review that was last updated in 2006. OBJECTIVES: To evaluate the efficacy of STPP for adults with common mental disorders compared with wait-list controls, treatments as usual and minimal contact controls in randomised controlled trials (RCTs). To specify the differential effects of STPP for people with different disorders (e.g. depressive disorders, anxiety disorders, somatoform disorders, mixed disorders and personality disorder) and treatment characteristics (e.g. manualised versus non-manualised therapies). SEARCH METHODS: The Cochrane Depression, Anxiety and Neurosis Group's Specialised Register (CCDANCTR) was searched to February 2014, this register includes relevant randomised controlled trials from The Cochrane Library (all years), EMBASE (1974-), MEDLINE (1950-) and PsycINFO (1967-). We also conducted searches on CENTRAL, MEDLINE, EMBASE, CINAHL, PsycINFO, DARE and Biological Abstracts (all years to July 2012) and all relevant studies (identified to 2012) were fully incorporated in this review update. We checked references from papers retrieved. We contacted a large group of psychodynamic researchers in an attempt to find new studies. SELECTION CRITERIA: We included all RCTs of adults with common mental disorders, in which a brief psychodynamic therapy lasting 40 or fewer hours in total was provided in individual format. DATA COLLECTION AND ANALYSIS: Eight review authors working in pairs evaluated studies. We selected studies only if pairs of review authors agreed that the studies met inclusion criteria. We consulted a third review author if two review authors could not reach consensus. Two review authors collected data and entered it into Review Manager software. Two review authors assessed and scored risk of bias. We assessed publication bias using a funnel plot. Two review authors conducted and reviewed subgroup analyses. MAIN RESULTS: We included 33 studies of STPP involving 2173 randomised participants with common mental disorders. Studies were of diverse conditions in which problems with emotional regulation were purported to play a causative role albeit through a range of symptom presentations. These studies evaluated STPP for this review's primary outcomes (general, somatic, anxiety and depressive symptom reduction), as well as interpersonal problems and social adjustment. Except for somatic measures in the short-term, all outcome categories suggested significantly greater improvement in the treatment versus the control groups in the short-term and medium-term. Effect sizes increased in long-term follow-up, but some of these effects did not reach statistical significance. A relatively small number of studies (N < 20) contributed data for the outcome categories. There was also significant heterogeneity between studies in most categories, possibly due to observed differences between manualised versus non-manualised treatments, short versus longer treatments, studies with observer-rated versus self report outcomes, and studies employing different treatment models. AUTHORS' CONCLUSIONS: There has been further study of STPP and it continues to show promise, with modest to large gains for a wide variety of people. However, given the limited data, loss of significance in some measures at long-term follow-up and heterogeneity between studies, these findings should be interpreted with caution. Furthermore, variability in treatment delivery and treatment quality may limit the reliability of estimates of effect for STPP. Larger studies of higher quality and with specific diagnoses are warranted.

Key clinical processes in intensive short-term dynamic psychotherapy.

Davanloo's Intensive Short-term Dynamic Psychotherapy (ISTDP), while derived from traditional psychoanalytic theory, is a modified brief treatment with growing empirical support for its effectiveness with clients with psychoneurotic disorders and character pathology. This model describes key empirically derived processes that can bring ready access to unprocessed unconscious emotions that otherwise perpetuate widespread symptom and behavioral disorders. Herein we describe the metapsychological underpinnings, clinical application, and evidence for central interventions used in ISTDP through the use of a case example.

Effectiveness and cost effectiveness of Davanloo's intensive short-term dynamic psychotherapy: does unlocking the unconscious make a difference?

More than 20 years ago Habib Davanloo coined the term unlocking of the unconscious to describe how the psychodynamic concept of the human unconscious can become accessible using the technique of Intensive Short-Term Dynamic Psychotherapy (ISTDP). According to Davanloo, the possibility that unconscious material will be revealed is greatly increased when therapeutic efforts promote dominance of the unconscious therapeutic alliance over unconscious resistance. When these ingredients are present there is a psychic shift that allows unacceptable painful feelings to come to the surface. Toward adding further empirical support for the concept, in this article we compare outcomes between patients who experienced one or more major unlocking of the unconscious (N = 57) to those who did not experience major unlocking (N = 32) during ISTDP treatment. Significant and widespread differences were seen between these two groups, those with major unlocking had greater symptom reduction, interpersonal gains, and cost reduction for treatment. The relevance of this to clinical practice and healthcare utilization will be discussed.