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.

BACKGROUND: Adding short-term psychodynamic psychotherapy (STPP) to antidepressants increases treatment efficacy, but it is unclear which patients benefit specifically. This study examined efficacy moderators of combined treatment (STPP + antidepressants) v. antidepressants for adults with depression. METHODS: For this systematic review and meta-analysis (PROSPERO registration number: CRD42017056029), we searched PubMed, PsycINFO, Embase.com, and the Cochrane Library from inception to 1 January 2022. We included randomized clinical trials comparing combined treatment (antidepressants + individual outpatient STPP) v. antidepressants in the acute-phase treatment of depression in adults. Individual participant data were requested and analyzed combinedly using mixed-effects models (adding Cochrane risk of bias items as covariates) and an exploratory machine learning technique. The primary outcome was post-treatment depression symptom level. RESULTS: Data were obtained for all seven trials identified (100%, n = 482, combined: n = 238, antidepressants: n = 244). Adding STPP to antidepressants was more efficacious for patients with high rather than low baseline depression levels [B = -0.49, 95% confidence interval (CI) -0.61 to -0.37, p < 0.0001] and for patients 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) and than 1-2 years (B = -0.86, 95% CI -1.66 to -0.06, p = 0.04). Heterogeneity was low. Effects were replicated in analyses controlling for risk of bias. CONCLUSIONS: To our knowledge, this is the first study that examines moderators across trials assessing the addition of STPP to antidepressants. These findings need validation but suggest that depression severity and episode duration are factors to consider when adding STPP to antidepressants and might contribute to personalizing treatment selection for depression.

The efficacy of adding short-term psychodynamic psychotherapy to antidepressants in the treatment of depression: A systematic review and meta-analysis of individual participant data.

PURPOSE: We examined the efficacy of adding short-term psychodynamic psychotherapy (STPP) to antidepressants in the treatment of depression by means of a systematic review and meta-analysis of individual participant data, which is currently considered the most reliable method for evidence synthesis. RESULTS: A thorough systematic literature search resulted in 7 studies comparing combined treatment of antidepressants and STPP versus antidepressant mono-therapy (n = 3) or versus antidepressants and brief supportive psychotherapy (n = 4). Individual participant data were obtained for all these studies and totaled 482 participants. Across the total sample of studies, combined treatment of antidepressants and STPP was found significantly more efficacious in terms of depressive symptom levels at both post-treatment (Cohen's d = 0.26, SE = 0.10, p = .01) and follow-up (d = 0.50, SE = 0.10, p < .001). This effect was most apparent at follow-up and in studies examining STPP's specific treatment efficacy. Effects were still apparent in analyses that controlled for risk of bias and STPP quality in the primary studies. CONCLUSIONS: These findings support the evidence-base of adding STPP to antidepressants in the treatment of depression. However, further studies are needed, particularly assessing outcome measures other than depression and cost-effectiveness, as well as examining the relative merits of STPP versus other psychotherapies as added to antidepressants.

Evaluation of an outpatient intervention for women with severe depression and a history of childhood trauma.

OBJECTIVE: The study examined the effectiveness of a three-month structured outpatient intervention developed for women with severe depression and childhood trauma that used brief psychodynamic psychotherapy by comparing it to standard treatment recommended in clinical guidelines issued by the Chilean Ministry of Health. METHODS: Eighty-seven women who sought treatment from a public health service in Curicó, Chile, and who had severe depression and a history of childhood traumatic experiences were randomly assigned to receive either the intervention (N=44) or standard treatment (N=43). The participants were assessed at baseline and at three months (completion of the intervention) and six months with use of the Hamilton Depression Scale (Ham-D); Lambert's Outcome Questionnaire (OQ-45.2), which rates psychiatric symptoms, interpersonal relationships, and social role functioning; and the Post-traumatic Stress Treatment Outcome scale (PTO 8), which assesses symptoms of posttraumatic stress disorder. An intent-to-treat design was used with multiple analyses of variance. RESULTS: At three months significant differences were found in favor of the intervention group in Ham-D scores (p<.001) and OQ-45.2 scores (p<.05). At six months a significantly greater proportion of the intervention group had indicators of remission as measured by the OQ-45.2 (39% versus 14%, p<.05) and by the Ham-D (22% versus 5%, p<.05). Scores on the PTO 8 indicated significant improvements in posttraumatic stress disorder symptoms at six months, although there were no significant differences between the groups. CONCLUSIONS: An outpatient intervention that screened for and focused on childhood traumas and that helped patients understand current psychosocial difficulties as a repetition of past traumas was effective in reducing psychiatric symptoms and improving interpersonal relationships and social role functioning among women with severe depression and a history of childhood trauma.