Elsevier

Clinical Psychology Review

Volume 42, December 2015, Pages 1-15
Clinical Psychology Review

The efficacy of short-term psychodynamic psychotherapy for depression: A meta-analysis update

https://doi.org/10.1016/j.cpr.2015.07.004Get rights and content

Highlights

  • Short-term psychodynamic psychotherapy (STPP) is a treatment for depression.

  • STPP results in symptom reduction and function improvement during treatment.

  • These gains are either maintained or further improved at follow-up.

  • STPP is efficacious when compared to control conditions.

  • Individual STPP does not differ from other psychotherapies on depression outcomes.

Abstract

Objectives

The efficacy of short-term psychodynamic psychotherapy (STPP) for depression is debated. Recently, a number of large-scale and high-quality studies have been conducted. We examined the efficacy of STPP by updating our 2010 meta-analysis.

Results

After a thorough literature search, 54 studies (33 randomized clinical trials) totaling 3946 subjects were included. STPP was significantly more effective than control conditions at post-treatment on depression, general psychopathology and quality of life measures (d = 0.49 to 0.69). STPP pre-treatment to post-treatment changes (d = 0.57 to 1.18) indicated significant improvements on all outcome measures, which either significantly improved further (d = 0.20 to 1.04) or were maintained from post-treatment to follow-up. No significant differences were found between individual STPP and other psychotherapies at post-treatment (d =  0.14) and follow-up (d =  0.06) in analyses that were adequately powered to detect a clinically relevant difference. STPP was significantly more efficacious than other psychotherapies on anxiety measures at both post-treatment (d = 0.35) and follow-up (d = 0.76).

Conclusion

We found clear indications that STPP is effective in the treatment of depression in adults. Although more high-quality studies are needed, particularly to assess the efficacy of STPP compared to control conditions at follow-up and to antidepressants, these findings add to the evidence-base of STPP for depression.

Introduction

Affecting more than 150 million people worldwide (World Health Organization, 2003), depression is a highly prevalent and disabling disorder associated with major personal and societal costs (Kessler, 2012). Major depression is the fourth leading cause of disease burden worldwide and it is expected to rank first in high-income countries by the year 2030 (Mathers & Loncar, 2006). Given the tremendous disease burden, there is a high need for effective and efficient treatments for depression. Antidepressant medications and different psychological therapies constitute the predominant treatments for depressive disorders (Marcus & Olfson, 2010). Short-term psychodynamic psychotherapy (STPP) is one of the oldest psychological treatments for depression and has been used to treat this condition for decades.

STPP refers to a family of treatments that share the common feature of being rooted in psychoanalytical theories, such as drive psychology, ego psychology, object relations psychology and attachment theory. Psychodynamic approaches to the treatment of depression focus on the patient's internal world, emphasizing “how (unconscious) motivational factors lead the patient to (mis)perceive and (mis)interpret external reality and experiences and to create, unwillingly, problems that maintain depressive symptoms, particularly in interpersonal relationships” (Luyten & Blatt, 2012; p. 113). Psychodynamic approaches to the treatment of depression are more person- than disorder-centered. In changing attitudes and feelings in the present, they emphasize the importance of a developmental perspective as well as the role of insight into the past (Luyten & Blatt, 2012).

Although STPP is a time-honored treatment for depression, its efficacy in this regard has not been studied as extensively as the efficacy of other psychotherapies, such as cognitive behavioral therapy (e.g., Cuijpers et al., 2008a, Thase, 2013). This is reflected in treatment guidelines, which typically have not considered STPP a first-choice treatment for depression (e.g., American Psychiatric Association, 2010, National Institute for Health and Clinical Excellence, 2009). Relatedly, Connolly-Gibbons, Crits-Christoph, and Hearon (2008) argued that STPP for depression does not meet the criteria for empirically supported psychological treatments formulated by Chambless and Hollon (1998), due to different STPP types studied and the methodological quality of studies.

In 2010, we conducted a meta-analysis in order to summarize the available literature examining the efficacy of STPP for depression (Driessen et al., 2010). This meta-analysis included 23 studies totaling 1365 subjects. STPP was found to be significantly more effective than control conditions at post-treatment (d = 0.69). STPP pre-treatment to post-treatment effect size (d = 1.34) indicated a significant symptom improvement that was maintained until 1-year follow-up. Comparing (group and individual) STPP to other psychotherapies, a small but significant effect size (d =  0.30) was found, indicating the superiority of other treatments over STPP immediately post-treatment, but no significant differences were found at follow-up. Studies examining individual STPP (d = 1.48) found larger pre- to post-treatment effect sizes than studies examining group STPP (d = 0.83), and no significant differences were found between individual STPP and other individual psychotherapies at post-treatment and follow-up (Abbass & Driessen, 2010). These findings indicated that STPP is effective in the treatment of depression in adults and added to the evidence-base of STPP for depression (Driessen et al., 2010). However, these results must be interpreted with caution, bearing in mind the limitations of the body of literature that was reviewed. First, the quality of the included studies was highly variable. Only 13 of the 23 included studies were randomized clinical trials and various studies lacked quality standards or had a small sample. Secondly, this meta-analysis used depression level as the sole outcome measure. Reliable effect sizes could not be computed for other outcome measures due to the diverse use of these measures in the primary studies, but examining the efficacy of STPP on additional outcome measures (e.g., interpersonal functioning, personality functioning, general psychopathology, and quality of life) would be desirable as these are also important aspects of patient functioning (Driessen et al., 2010).

Since the publication of the abovementioned meta-analysis, a number of relative large-scale and high-quality studies have been conducted (e.g., Barber et al., 2012, Driessen et al., 2013). Adding these studies to the meta-analysis described above would augment the patient sample size, increase the precision of the effect size estimates and possibly change the pattern of results. Moreover, the increased number of studies would facilitate both the power of moderator analyses and the examination of outcome measures other than depression. Since the publication of the abovementioned meta-analysis, other reviews concerning STPP have been published too, most notably by Abbass et al. (2014) and Barber, Muran, McCarthy, and Keefe (2013). Abbass et al. (2014) have updated their Cochrane Review of STPP for common mental disorders, including five studies focusing on depression specifically, but their review is restricted to comparisons of STPP with control conditions. Barber and colleagues' meta-analysis compared STPP to control and active treatment conditions. Yet in this last meta-analysis depression was used as the sole outcome measure and some of the more recent large studies (e.g., Beutel et al., 2014, Driessen et al., 2013) were not included (Barber et al., 2013).

We therefore decided to update the abovementioned meta-analysis (Driessen et al., 2010). We aimed to 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 conditions and alternative treatments at post-treatment and follow-up. We also performed moderator analyses to examine the association between effect size on the one hand and participant, intervention, and study quality characteristics on the other hand. The present review adds to the available body of evidence by not focusing on a specific comparison of STPP with another condition only, but aiming to examine all aspects of STPP efficacy on multiple outcome measures.

Section snippets

Protocol registration

The protocol for this meta-analysis update was registered in the PROSPERO International prospective register of systematic reviews before the screening of search results against the eligibility criteria started (CRD42014005894; Driessen et al., 2014).

Search strategy

We used an extensive search strategy including six different search methods in order to retrieve as many relevant studies as possible. The searches were performed in March 2014. First, we searched the electronic databases PubMed, PsychINFO, //Embase.com

Inclusion of studies

As shown in Fig. 1, the literature search resulted in 4454 records, of which the majority (4234) was excluded in the first screening phase. A total of 220 titles were reviewed in full-text. Of these, 30 primary studies were included. Three studies were later excluded because the paper did not provide the information necessary to confirm that the therapy met the criteria for STPP and we were unable to reach the investigators for additional information (Klasik et al., 2012, Quilty et al., 2008,

Findings

In the last years, there has been a vast increase in the number of studies that examined the efficacy of STPP for depression. While 30 of such studies were retrieved for our previous meta-analysis, which covered the literature up to 2007, 24 additional studies meeting the same inclusion criteria were published in the last 7 years. With regard to total number of study participants, the sample almost tripled (from 1365 to 3946) as a result of this. The field has also benefitted from the recent

Conclusion

In recent years, there has been a major increase in the number of studies examining the efficacy of STPP for depression. The findings of this meta-analysis are supportive of the efficacy of STPP for depression. This study indicates that STPP is more efficacious than control conditions at post-treatment on depression, general psychopathology and quality of life outcome measures. Significant STPP pre-treatment to post-treatment improvements were apparent for all outcome measures. These gains

Role of the funding sources

No funding was received for this work.

Contributors

ED wrote the study protocol. IJ and ED updated the search strategy. IJ conducted the searches. ED and LMH screened the search records and full-text papers against the inclusion criteria. AAA, JPB, JJMD and HLV checked the full-text papers to confirm that the therapy used met the criteria for STPP and rated the STPP types. ED and LMH extracted effect size data and study characteristics. PC advised on data-extraction disagreements and data-analysis. ED conducted the analyses and wrote the

Conflicts of interest statement

The authors declare that they have no conflicts of interest.

Acknowledgments

The authors wish to thank all investigators that have provided unpublished data and additional information regarding their studies upon our request.

References2 (45)

  • J.P. Barber et al.

    Short-term dynamic psychotherapy versus pharmacotherapy for major depressive disorder: A randomized, placebo-controlled trial

    Journal of Clinical Psychiatry

    (2012)
  • J.P. Barber et al.

    Research on psychodynamic therapies

  • M.D. Blagys et al.

    Distinctive features of short-term psychodynamic interpersonal psychotherapy: A review of the comparative psychotherapy literature

    Clinical Psychology: Science and Practice

    (2000)
  • M. Borenstein et al.

    Introduction to meta-analysis

    (2009)
  • D.L. Chambless et al.

    Defining empirically supported psychotherapies

    Journal of Consulting and Clinical Psychology

    (1998)
  • M.B. Connolly-Gibbons et al.

    The empirical status of psychodynamic therapies

    Annual Review of Clinical Psychology

    (2008)
  • P. Cuijpers et al.

    What is the threshold for a clinically relevant effect? The case of major depressive disorders

    Depression & Anxiety

    (2014)
  • P. Cuijpers et al.

    Psychotherapy for depression in adults: A meta-analysis of comparative outcome studies

    Journal of Consulting and Clinical Psychology

    (2008)
  • P. Cuijpers et al.

    Psychological treatment of depression: A meta-analytic database of randomized studies

    BMC Psychiatry

    (2008)
  • H. Davanloo

    Short-term dynamic psychotherapy

    (1980)
  • E. Driessen et al.

    The efficacy of short-term psychodynamic psychotherapy for depression: A meta-analysis update

    (2014)
  • E. Driessen et al.

    The efficacy of cognitive–behavioral therapy and psychodynamic therapy in the outpatient treatment of major depression: A randomized clinical trial

    American Journal of Psychiatry

    (2013)
  • Cited by (148)

    View all citing articles on Scopus
    2

    References of the studies included in the meta-analysis are listed in Appendix A.

    View full text