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.

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.

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.

Clinical use of the Hamilton Depression Rating Scale: is increased efficiency possible? A post hoc comparison of Hamilton Depression Rating Scale, Maier and Bech subscales, Clinical Global Impression, and Symptom Checklist-90 scores.

BACKGROUND: The 17-item Hamilton Depression Rating Scale (HDRS) is used as a semi-gold standard in research. In treatment guidelines, the HDRS measurements serve to determine response and remission and guide clinical decision making for nonresponders. However, its use in clinical practice is limited, possibly because the HDRS is time consuming. In addition, the multidimensional HDRS is criticized for not measuring a unidimensional aspect as depression severity. The Maier and the Bech, two 6-item severity subscales extracted from the HDRS, are relatively unknown. This paper investigates whether the measurements obtained with these subscales are comparable with the original HDRS measurements. METHODS: Data from 2 randomized controlled trials in 482 male and female patients, diagnosed with a major depression (with or without dysthymia) according to Diagnostic and Statistical Manual of Mental Disorders, Revised Third Edition, of whom 219 participated in the trials, were reanalyzed. A standardized stepwise psychopharmacological treatment was compared with a combination of pharmacotherapy with Short Psychodynamic Supportive Psychotherapy in a psychiatric outpatient department. Outcome measures were internal consistency and concurrent validity of HDRS, Maier, Bech, Clinical Global Impression scales, and Symptom Checklist depression subscale. Effect sizes of HDRS, Maier, and Bech were used to compare measured treatment effects for the randomized subjects participating in the trials. Item Response Theory was used to obtain conversion tables for the HDRS, Maier, Bech, and Symptom Checklist depression subscale. RESULTS: We found moderate internal consistency (Cronbach alpha approximately 0.6-0.7) and high correlations of the Maier and Bech subscales with overall HDRS scores. Overall, there were no clinically relevant differences in effect sizes between Maier, Bech, and HDRS, although some differences were statistically significant. Receiver operating characteristic curves showed no difference between Maier and Bech to define remission but showed the Clinical Global Impression ratings to be unreliable. A cutoff < or =4 corresponded with an HDRS < or =7 criterion in both subscales. CONCLUSION: In clinical practice, both Maier and Bech scales can be used as equivalents of the HDRS, but will be more efficient.

Psychotherapy alone and combined with pharmacotherapy in the treatment of depression.

BACKGROUND: The relative efficacy of psychotherapy and combined therapy in the treatment of depression is still a matter of debate. AIMS: To investigate whether combined therapy has advantages over psychotherapy alone. METHOD: A 6-month randomised clinical trial compared Short Psychodynamic Supportive Psychotherapy (n=106) with combined therapy (n=85) in ambulatory patients with mild or moderate major depressive disorder diagnosed using DSM-IV criteria. Antidepressants were prescribed according to a protocol providing four successive steps in case of intolerance or inefficacy: venlafaxine, selective serotonin reuptake inhibitor, nortriptyline and nortriptyline plus lithium. Efficacy was assessed using the 17-item Hamilton Rating Scale for Depression, the Clinical Global Impression of Severity and of Improvement, and the depression sub-scale of the Symptom Checklist. RESULTS: The advantages of combining antidepressants with psychotherapy were equivocal. Neither the treating clinicians nor the independent observers were able to ascertain them, but the patients experienced them clearly. CONCLUSIONS: The advantages of combining antidepressants with psychotherapy are equivocal.

Efficacy of combined therapy and pharmacotherapy for depressed patients with or without personality disorders.

In general, depressed patients with personality pathology--Axis II disorders--respond less well or less quickly to the various kinds of individual treatment that are available, whether pharmacotherapy, psychotherapy, or both combined. This article sets forth the results of a six-month, randomized clinical trial of antidepressants and combined therapy in ambulatory patients with major depression and a baseline score of at least 14 on the 17-item Hamilton Rating Scale for Depression (HAM-D-17). The presence or absence of Axis II pathology was determined on the basis of a self-report version of the International Personality Disorder Examination. The study's antidepressant protocol provided for three successive steps in case of intolerance or inefficacy: fluoxetine, amitriptyline, and moclobemide. In addition to pharmacotherapy, the combined-therapy condition included 16 sessions of Short Psychodynamic Supportive Psychotherapy. Efficacy of the therapy provided was assessed using the HAM-D-17 and also other instruments. According to the results in secondary analyses, it emerged that combined therapy was more effective than pharmacotherapy for depressed patients with personality disorders. Combined therapy was not more effective than pharmacotherapy alone for depressed patients without personality disorders. It is recommended that depressed patients with comorbid personality pathology should be treated with combined therapy, with the focus of psychotherapy being not on the patient's symptoms and complaints, but on all aspects of the patient's actual relationships.

Changes in personality pathology after pharmacotherapy and combined therapy for depressed patients.

The central question addressed by this article is whether courses of treatment consisting of pharmacotherapy or pharmacotherapy combined with psychotherapy (combined therapy) produce different changes in personality pathology at follow-up after 40 weeks. We also examined whether recovery from depression has an influence on outcome. The study population consisted of 128 outpatients in whom personality pathology and severity of depression were determined at the start of the study. For 72 patients, personality pathology and severity of depression were determined again after 40 weeks. Of the group of 72 patients, 25 patients received only pharmacotherapy for 6 months, and 47 patients received combined treatment (pharmacotherapy and psychodynamic supportive psychotherapy). The antidepressant protocol provides for three successive steps in case of intolerance or inefficacy: fluoxetine, amitriptyline, and moclobemide. The combined therapy condition consisted of 16 sessions of Short Psychodynamic Supportive Psychotherapy in addition to pharmacotherapy. In the combined therapy condition there was a significant reduction in personality pathology in patients who recovered from depression but also in patients who had not. In the pharmacotherapy condition the significant decrease was restricted to patients who recovered from depression. The results were most striking for Cluster C psychopatology. Patients with cluster B pathology changed the least. Depressed patients with comorbid personality pathology appear to benefit most from a combination of pharmacotherapy and a form of short, psychodynamic, supportive psychotherapy.