Recovery from chronic depression and structural change: 5-year outcomes after psychoanalytic and cognitive-behavioural long-term treatments (LAC depression study).

OBJECTIVE: Psychotherapy of chronic depression has remained a challenge due to limited prognosis and high rates of recurrence. We present 5-year outcome data from a multicentre trial comparing psychoanalytic (PAT) and cognitive-behavioural (CBT) long-term treatments with randomized and preferred allocations analysing symptom (N = 227) and structural change (N = 134) trajectories. METHOD: Self- and blinded expert ratings of depression symptoms were performed at yearly intervals using the Beck Depression Inventory-II (BDI-II) and Quick Inventory of Depressive Symptoms (QIDS-C). Blinded expert ratings of Operationalized Psychodynamic Diagnosis (OPD) and the Heidelberg Restructuring Scale (HRS) at baseline, 1, 3, and 5 years assessed structural change in a subsample. RESULTS: Lasting and comparable symptom changes were achieved by PAT and CBT. However, compared to CBT, PAT was more successful in restructuring, a major goal of long-term psychodynamic treatments with high frequency and duration. LIMITATIONS: Due to practical reasons, the time criterion for chronic depression of an acute phase had to be defined for over 1 year in the present study, which does not correspond to the DSM-5 criterion of 2 years. Therapy duration and session frequency were not incorporated into the statistical models. CONCLUSION: Long-term psychotherapy helps patients with a yearlong history of depression and often multiple unsuccessful treatment attempts to achieve lasting symptom changes. Future follow-up will clarify whether restructuring promotes further sustainable improvements.

Outcome of Psychoanalytic and Cognitive-Behavioural Long-Term Therapy with Chronically Depressed Patients: A Controlled Trial with Preferential and Randomized Allocation.

OBJECTIVE: For chronic depression, the effectiveness of brief psychotherapy has been limited. This study is the first comparing the effectiveness of long-term cognitive-behavioural therapy (CBT) and long-term psychoanalytic therapy (PAT) of chronically depressed patients and the effects of preferential or randomized allocation. METHODS: A total of 252 adults met the inclusion criteria (aged 21-60 years, major depression, dysthymia, double depression for at least 24 months, Quick Inventory of Depressive Symptoms [QIDS] >9, Beck Depression Inventory II [BDI] >17, informed consent, not meeting exclusion criteria). Main outcome measures were depression self-rating (BDI) and rating (clinician-rated QIDS [QIDS-C]) by independent, treatment-blinded clinicians. Full remission rates (BDI ≤12, QIDS-C ≤5) were calculated. An independent center for data management and biostatistics analyzed the treatment effects and differences using linear mixed models (multilevel models and hierarchical models). RESULTS: The average BDI declined from 32.1 points by 12.1 points over the first year and 17.2 points over 3 years. BDI overall mean effect sizes increased from d = 1.17 after 1 year to d = 1.83 after 3 years. BDI remission rates increased from 34% after 1 year to 45% after 3 years. QIDS-C overall effect sizes increased from d = 1.56 to d = 2.08, and remission rates rose from 39% after 1 year to 61% after 3 years. We found no significant differences between PAT and CBT or between preferential and randomized allocation. CONCLUSIONS: Psychoanalytic as well as cognitive-behavioural long-term treatments lead to significant and sustained improvements of depressive symptoms of chronically depressed patients exceeding effect sizes of other international outcome studies.

FIRST STEPS - a randomized controlled trial on the evaluation of the implementation and effectiveness of two early prevention programs for promoting the social integration and a healthy development of children with an immigrant background from 0-3.

BACKGROUND: The social integration of children with an immigrant background has become one of the most urgent social responsibilities in Germany. They are more likely to live in high-risk environments and are disadvantaged with respect to health related variables as well as educationally. Quite a number of projects supporting their integration into the German society exist although many are hardly scientifically evaluated. Most of them focus on the acquisition of German language and therefore address older children (and adults). However, international experts agree that social integration is not only a matter of language but also of earlier developmental processes of children in their first months of life connected to adequate early parenting. METHODS/DESIGN: The model project FIRST STEPS focuses on earliest prevention for children with an immigrant background, supporting their parents in the critical phase of migration and early parenthood. In a prospective randomized comparison group design the effectiveness of a psychoanalytically oriented early prevention program (intervention A) is compared to the outcomes of groups offered by paraprofessionals with an immigrant background (intervention B). Intervention A is a professional offer supporting immigrant families based on developmental psychological and on knowledge on early parenting. 180 families are randomly assigned to intervention A or B. They are supported during the first 3 years of the children's lives. Social and family stressors, the quality of the parent-child-interaction, child attachment security, the affective, cognitive and social-emotional development of the children and the social integration of the families are assessed during and after the intervention. DISCUSSION: The project aims at evaluating the implementation as well as the short- and long-term effectiveness of psychoanalytically oriented intervention A compared to the outcomes of intervention B. It is expected that professionally supported early parenting (intervention A) improves the social-emotional, cognitive and language development of immigrant children as well as the social integration of their families to a greater extent than in the comparison groups. In case the model project proves to be effective, a rollout across Germany is possible. Due to the "difficult-to-reach" immigrant families challenges in recruitment, uptake and retention of participants are anticipated. TRIAL REGISTRATION: DRKS-ID: DRKS00004632, trial registration date: 05.02.2013.

Evaluation of two prevention programs 'Early Steps' and 'Faustlos' in daycare centers with children at risk: the study protocol of a cluster randomized controlled trial.

BACKGROUND: While early programs to prevent aggression and violence are widely used, only a few controlled trials of effectiveness of psychoanalytically based prevention programs for preschoolers have been evaluated. This study compares 'Faustlos' (a violence prevention program) and 'Early Steps' (a psychoanalytically based, whole daycare center intervention to prevent violence) in daycare centers in socioeconomically deprived neighborhoods. METHODS/DESIGN: Preschoolers in 14 daycare centers in Frankfurt, Germany, participate in a cluster randomized controlled trial (CRCT). The daycare centers were randomly chosen from a representative baseline survey of all Frankfurt's daycare centers carried out in 2003 (n = 5,300) with the following stratifying factors: children's aggressiveness, hyperactivity, anxiety and socioeconomic status. Additionally, the geographic identification of socioeconomically deprived neighborhoods regarding low-income children was taken from the Frankfurt Municipality Statistics. Children's attachment classification and children's aggressiveness, hyperactivity, anxiety and social competence are measured as outcome criteria before and after 2 years of intervention. The programs in the study aim to reach a high-risk population. Therefore, the combination of a random sampling of daycare centers out of a representative baseline survey in all daycare centers in Frankfurt and the application of official data on the local distribution of low-income children are unique features offered by the EVA study design. Data on preschooler's attachment representations are collected in socioeconomically deprived neighborhoods for the first time. TRIAL REGISTRATION DRKS-ID: DRKS00003500.

Psychoanalytic and cognitive-behavior therapy of chronic depression: study protocol for a randomized controlled trial.

BACKGROUND: Despite limited effectiveness of short-term psychotherapy for chronic depression, there is a lack of trials of long-term psychotherapy. Our study is the first to determine the effectiveness of controlled long-term psychodynamic and cognitive-behavioral (CBT) treatments and to assess the effects of preferential vs. randomized assessment. METHODS/DESIGN: Patients are assigned to treatment according to their preference or randomized (if they have no clear preference). Up to 80 sessions of psychodynamic or psychoanalytically oriented treatments (PAT) or up to 60 sessions of CBT are offered during the first year in the study. After the first year, PAT can be continued according to the 'naturalistic' usual method of treating such patients within the system of German health care (normally from 240 up to 300 sessions over two to three years). CBT therapists may extend their treatment up to 80 sessions, but focus mainly maintenance and relapse prevention. We plan to recruit a total of 240 patients (60 per arm). A total of 11 assessments are conducted throughout treatment and up to three years after initiation of treatment. The primary outcome measures are the Quick Inventory of Depressive Symptoms (QIDS, independent clinician rating) and the Beck Depression Inventory (BDI) after the first year. DISCUSSION: We combine a naturalistic approach with randomized controlled trials(RCTs)to investigate how effectively chronic depression can be treated on an outpatient basis by the two forms of treatment reimbursed in the German healthcare system and we will determine the effects of treatment preference vs. randomization. TRIAL REGISTRATION: http://www.controlled-trials.com/ISRCTN91956346.

How to study the 'quality of psychoanalytic treatments' and their long-term effects on patients' well-being: a representative, multi-perspective follow-up study.

How can we study the 'quality of psychoanalytic treatments'? The authors attempt to answer this question by discussing a naturalistic, multi-perspective and representative follow-up study of psychoanalyses and long-term psychoanalytic psychotherapies. We studied a representative sample (n = 401) of all the patients who had terminated their psychoanalytic treatments with members of the German Psychoanalytical Association (DPV) between 1990 and 1993. Between 70 and 80 per cent of the patients achieved (average 6.5 years after the end of treatment) good and stable psychic changes according to the evaluations of the patients themselves, their analysts, independent psychoanalytic and non-psychoanalytic experts, and questionnaires commonly applied in psychotherapy research. The evaluation of mental health costs showed a cost reduction through fewer days of sick leave during the seven years following the end of long-term psychoanalytic treatments. The results achieved using non-psychoanalytical instruments are complemented by the richness of the idiosyncratic findings, gained by the psychoanalytic research instruments.