Optimizing psychotherapy dosage for comorbid depression and personality disorders (PsyDos): a pragmatic randomized factorial trial using schema therapy and short-term psychodynamic psychotherapy.

BACKGROUND: Patients with comorbid depression and personality disorders suffer from a heavy disease burden while tailored treatment options are limited, accounting for a high psychological and economic burden. Little is known about the effect of treatment dosage and type of psychotherapy for this specific co-morbid patient population, in terms of treatment-effect and cost-effectiveness. This study aims to compare treatment outcome of 25 versus 50 individual therapy sessions in a year. We expect the 50-session condition to be more effective in treating depression and maintaining the effect. Secondary objectives will be addressed in order to find therapy-specific and non-specific mechanisms of change. METHODS: In a mono-center pragmatic randomized controlled trial with a 2 × 2 factorial design, 200 patients with a depressive disorder and personality disorder(s) will be included. Patients will be recruited from a Dutch mental health care institute for personality disorders. They will be randomized over therapy dosage (25 vs 50 sessions in a year) and type of therapy (schema therapy vs short-term psychodynamic supportive psychotherapy). The primary clinical outcome measure will be depression severity and remission. Changes in personality functioning and quality of life will be investigated as secondary outcomes. A priori postulated effect moderators and mediators will be collected as well. All patients are assessed at baseline and at 1, 2, 3, 6, 9-12 months (end of therapy) and at follow up (6 and 12 months after end of treatment). Alongside the trial, an economic evaluation will be conducted. Costs will be collected from a societal perspective. DISCUSSION: This trial will be the first to compare two psychotherapy dosages in patients with both depression and personality disorders. Insight in the effect of treatment dosage for this patient group will contribute to both higher treatment effectiveness and lower costs. In addition, this study will contribute to the limited evidence base on treating patients with both depression and personality disorders. Understanding the processes that account for the therapeutic changes could help to gain insight in what works for whom. TRIAL REGISTRATION: This trial has been registered on July 20th 2016, Netherlands Trial Register, part of the Dutch Cochrane Centre ( NTR5941 ).

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.

Short psychodynamic supportive psychotherapy, antidepressants, and their combination in the treatment of major depression: a mega-analysis based on three randomized clinical trials.

The efficacy of Short Psychodynamic Supportive Psychotherapy (SPSP) has not yet been compared with pharmacotherapy. A mega-analysis based on three original Randomized Clinical Trials (RCTs) was performed. Patients with (mild to moderate) major depressive disorder were randomized in (24 weeks) SPSP (n = 97), pharmacotherapy (n = 45), or their combination (n = 171). Efficacy was assessed by the Hamilton Depression Rating Scale (HDRS), Clinical Global Impression of Severity and of Improvement (CGI-S), the Symptom Checklist (SCL; depression subscale) and the Quality of Life Depression Scale (QLDS). Pearson chi(2) calculations were used to compare success rates. Analyses of covariance (ANCOVAs) were used to test inter-group differences. Success rates indicated that independent observers (HDRS) found no differences in symptom reduction between SPSP and pharmacotherapy (P = 0.214), but therapists (CGI-S, P = 0.026), and patients (SCL, P = 0.036) favored SPSP. Combined therapy was found superior to pharmacotherapy by all three (patients (P = 0.000), therapists (P = 0.024), independent observers (P = 0.024)). Independent observers (P = 0.062) and therapists (P = 0.430) found no differences between combined therapy and SPSP, but patients (P = 0.016) found combined therapy to be superior. As far as quality of life is concerned, success rates indicated that patients (QLDS) found no differences between SPSP and pharmacotherapy (P = 0.073) or between SPSP and combined therapy (P = 0.217). However, they found combined therapy superior to pharmacotherapy (P = 0.015). The results of the mega-analysis suggest that combined therapy is more efficacious than pharmacotherapy. SPSP and pharmacotherapy seem equally efficacious, except for some indications that patients and therapists favor SPSP for symptom reduction. Combined therapy and SPSP also seem equally efficacious, except that patients think that the first is better in symptom reduction.

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.

Costs and benefits of long-term psychoanalytic therapy: changes in health care use and work impairment.

OBJECTIVE: systematic review regarding the effectiveness of long-term psychoanalytic therapy (LPT) on health care use and work impairment in adult outpatients. METHOD: a systematic search for studies published between 1970 and 2005. Calculation of the weighted mean changes between pretreatment and treatment termination, and between pretreatment and follow-up. The findings are translated into financial terms, and the costs of treatment are balanced against the financial gains. RESULTS: seven studies (n = 861) met all the inclusion and none of the exclusion criteria. The mean cost of LPT per patient was 20,900 Euro. During the year preceding treatment termination and the year preceding mean follow-up (2.9 years), the average reduction was 85% and 59%, respectively, in the number of hospital days; 54% and 56%, respectively, in the number of medical consultations; 70% and 19%, respectively, in the number of medication users, and 61% and 67% in days of sick leave. Health care use and sick-leave costs fell by an average of 5,584 Euro , or 66%, between the year preceding the start of psychotherapy and the year preceding treatment termination. At mean follow-up (2.9 years) these costs reductions were still apparent, as the reduction was 5,372 Euro, or 64%, in the year preceding follow-up. The break-even point for benefits and treatment costs was approximately three years after treatment termination. The reduction in work impairment appears to be the main factor (65% to 75%) in these positive results. CONCLUSIONS: our data suggest that LPT substantially reduces health care use and sick leave. The benefits seem to endure for years after termination and reach the point of counterbalancing the costs of treatment approximately three years after treatment termination.

Relative efficacy of psychotherapy and combined therapy in the treatment of depression: a meta-analysis.

BACKGROUND: Reviews of the relative efficacy of psychotherapy and combined therapy (psychotherapy with pharmacotherapy) for depression have yielded contradicting conclusions. This may be explained by the clinical heterogeneity of the studies reviewed. AIMS: To conduct a meta-analysis with an acceptable level of homogeneity in order to investigate the relative efficacy of psychotherapy and combined therapy in the acute treatment of depression. METHOD: A systematic search was performed for RCTs published between 1980 and 2005 comparing psychotherapy and combined therapy in adult psychiatric outpatients with non-psychotic unipolar major depressive disorder. The studies were classified according to the chronicity and severity of the depression. Data were pooled by means of meta-analysis and statistical tests were conducted to measure heterogeneity. RESULTS: The meta-analysis included seven studies looking at a total of 903 patients. None of the heterogeneity tests established significance. This indicates a lack of evidence for the heterogeneity of the results. The dropout rates did not differ significantly between the two treatment modalities (25% in combined therapy and 24% in psychotherapy, p=0.77). At treatment termination, the intention-to-treat remission rate for combined therapy (46%) was better than for psychotherapy (34%) (p=0.0007); Relative Risk 1.32 (95% CI: 1.12-1.56), Odds Ratio 1.59 (95% CI: 1.22-2.09). In moderate depression, the difference between the remission rate for combined therapy and psychotherapy was statistically significant (47% compared to 34% respectively, p=0.001). This was not the case in mild major depression (42% compared to 37% respectively, p=0.29). The difference was also statistically significant in chronic major depression (48% compared to 32%, p<0.001), but not in non-chronic major depression (43% compared to 37%, p=0.22). On a more specific level, no differences were found in the remission rates for the treatment modalities in mild or moderate non-chronic depression. Combined therapy led to significantly better results than psychotherapy in moderate chronic depression only (48% compared to 32%, p<0.001). CONCLUSIONS: In the acute treatment of adult psychiatric outpatients with major depressive disorder, patient compliance with combined therapy matches compliance with psychotherapy alone. Combined therapy is more efficacious than psychotherapy alone. However, these results depend on severity and chronicity. Combined therapy outperformed psychotherapy in moderate chronic depression only. No differences were found in mild and moderate non-chronic depression. No data were found for mild chronic depression and for severe depression.

Efficacy of pharmacotherapy in depressed patients with and without personality disorders: a systematic review and meta-analysis.

BACKGROUND: During the past decades personality pathology was considered to have a negative influence on the outcome of pharmacotherapy of depressive disorders. Recently, there has been a shift towards a less negative opinion. Still, the evidence in the literature remains inconclusive. This may be explained by methodological differences between published studies. OBJECTIVE: To present a meta-analysis of the results of Randomised Controlled Trials with pharmacotherapy in the treatment of depression with comorbid personality disorders. METHOD: Systematic literature search for RCTs in adult ambulatory patients with major depressive disorder and comorbid PDs; pooling of data and meta-analysis according to strict methodological criteria. RESULTS: The difference in remission rates between the groups with and without personality disorders in high quality studies was 3%; this difference was neither statistically significant nor clinically relevant. LIMITATIONS: Due to the specific and sensitive methods of the search only six studies could be included in the meta-analysis. Due to lack of data, analyses of drop-out rates could not be made. CONCLUSION: When only data from high quality RCTs are included, comorbidity of personality disorder and major depression does not have a negative effect on the treatment outcome of pharmacotherapy for major depression.

The current state of the empirical evidence for psychoanalysis: a meta-analytic approach.

LEARNING OBJECTIVES: After participating in this educational activity, the reader should be better able to evaluate the empirical evidence for pre/post changes in psychoanalysis patients with complex mental disorders, and assess the limitations of the meta-analysis. BACKGROUND: The effectiveness of psychoanalysis is still a controversial issue, despite increasing research efforts. OBJECTIVE: To investigate the empirical evidence for psychoanalysis by means of a systematic review of the literature and a meta-analysis of the research data. METHOD: A systematic literature search was undertaken to find studies regarding the effectiveness of psychoanalysis, published between 1970 and 2011. A meta-analysis was performed. RESULTS: Fourteen studies (total n = 603) were included in the meta-analysis. All but one were pre/post cohort studies. At treatment termination, the mean pre/post effect size across all outcome measures was 1.27 (95% confidence interval [CI], 1.03-1.50; p < .01). The mean pre/post effect size for symptom improvement was 1.52 (95% CI, 1.20-1.84; p < .01), and for improvement in personality characteristics 1.08 (95% CI, 0.89-1.26; p < .01). At follow-up the mean pre/follow-up effect size was 1.46 across all outcome measures (95% CI, 1.08-1.83; p < .01), 1.65 for symptom change (95% CI, 1.24-2.06; p < .01), and 1.31 for personality change (95% CI, 1.00-1.62; p < .01). CONCLUSIONS: A limited number of mainly pre/post studies, presenting mostly completers analyses, provide empirical evidence for pre/post changes in psychoanalysis patients with complex mental disorders, but the lack of comparisons with control treatments is a serious limitation in interpreting the results. Further controlled studies are urgently needed.

Designs for studying the effectiveness of long-term psychoanalytic treatments: balancing level of evidence and acceptability to patients.

Long-Term Psychoanalytic Treatments (LTPT) include both long-term psychoanalytic psychotherapy (LTPP) and psychoanalysis (PsAn). Current opinion seems to be that there is some evidence for the effectiveness of LTPP, but none for that of PsAn. This may be due in part to researchers not balancing the level of evidence of randomized controlled studies (RCTs), cohort studies, and pre-post studies with patients' acceptance of these various research designs used in studying the effectiveness of LTPT. After a review of the merits of eight possible control conditions for LTPT in RCTs and cohort studies, and a consideration of the limitations and merits of pre-post studies, it was found that RCTs pair high levels of evidence with limited degrees of patient acceptance, especially where PsAn is concerned. Cohort studies appear to provide at most a moderate level of evidence. Their acceptability is hardly better than that of RCTs, as it depends on the acceptability of control conditions similar to those of RCTs. The acceptability of pre-post studies is much better, but they can provide, at most, a moderate level of evidence. Apart from randomization, they can meet all methodological criteria for high-quality research (often they do not, but there are ways to correct this). In summary, in the long-term treatment of complex mental disorders with LTPT, RCTs often pair a high level of evidence with limited patient acceptance of the method. Compared to RCTs, cohort studies show a lower level of evidence without much gain in acceptability. Pre-post studies pair the highest level of acceptability with the lowest level of evidence of the three designs. Limited acceptability is not to be confused with no acceptability, nor moderate level of evidence with none.

The efficacy of short-term psychodynamic psychotherapy for depression: a meta-analysis.

OBJECTIVES: It remains largely unclear, firstly whether short-term psychodynamic psychotherapy (STPP) is an effective treatment for depression, and secondly, which study, participant, or intervention characteristics may moderate treatment effects. The purpose of this study is to assess the efficacy of STPP for depression and to identify treatment moderators. RESULTS: After a thorough literature search, 23 studies totaling 1365 subjects were included. STPP was found to be significantly more effective than control conditions at post-treatment (d=0.69). STPP pre-treatment to post-treatment changes in depression level were large (d=1.34), and these changes were maintained until 1-year follow-up. Compared to other psychotherapies, a small but significant effect size (d=-0.30) was found, indicating the superiority of other treatments immediately post-treatment, but no significant differences were found at 3-month (d=-0.05) and 12-month (d=-0.29) follow-up. Studies employing STPP in groups (d=0.83) found significantly lower pre-treatment to post-treatment effect sizes than studies using an individual format (d=1.48). Supportive and expressive STPP modes were found to be equally efficacious (d=1.36 and d=1.30, respectively). CONCLUSION: We found clear indications that STPP is effective in the treatment of depression in adults. Although more high-quality RCTs are necessary to assess the efficacy of the STPP variants, the current findings add to the evidence-base of STPP for depression.

The effectiveness of long-term psychoanalytic therapy: a systematic review of empirical studies.

BACKGROUND: There is a gap in the research literature on the effectiveness of long-term psychoanalytic therapies (LPT). AIM: To present a systematic review of studies dealing with LPT effectiveness and published from 1970 onward. METHODS: A systematic literature search for studies dealing with the effectiveness of individual LPT in ambulatory, adult patients. Data about the overall effectiveness of LPT, its impact on symptom reduction, and its effect on personality changes were pooled both at treatment termination and at follow-up, using effect sizes (ESs) and success rates. RESULTS: We found 27 studies (n = 5063). Psychotherapy yielded large mean ESs (0.78 at termination; 0.94 at follow-up) and high mean overall success rates (64% at termination; 55% at follow-up) in moderate/mixed pathology. The mean ES was larger for symptom reduction (1.03) than for personality change (0.54). In severe pathology, the results were similar. Psychoanalysis achieved large mean ESs (0.87 at termination; 1.18 at follow-up) and high mean overall success rates (71% at termination; 54% at follow-up) in moderate pathology. The mean ES for symptom reduction was larger (1.38) than for personality change (0.76). CONCLUSION: Our data suggest that LPT is effective treatment for a large range of pathologies, with moderate to large effects.