In considering how best to disseminate the many psychotherapeutic techniques to practicing clinicians, the author reviews findings and changes to guidelines on depression treatments.
Characteristics Associated With Outcomes
SIGNIFICANCE FOR PRACTICING PSYCHIATRISTS
The American Psychological Association1 describes cognitive therapy (CT), behavioral activation (which can be administered alone but is also an important component of CT), interpersonal psychotherapy, and problem-solving therapy as having strong evidence of effectiveness in the treatment of major depressive disorder (MDD) using the criteria for evidence-based psychotherapies originally formulated by Chambless and Hollon.2 Short-term dynamic psychotherapy is listed as having only modest evidence of effectiveness.
In contrast, the American Psychiatric Association3 recommends CT, interpersonal therapy, problem-solving therapy, and psychodynamic psychotherapy as effective interventions for depression but limits the recommendation to only mild to moderate depression. Recent evidence on the effectiveness of psychotherapies in the treatment of depression suggests that another look should be taken at these guidelines. There is emerging evidence supporting the effectiveness of CT for severe depression and the effectiveness of dynamic psychotherapy for depression. In this article, I review some of the recent studies and possible changes to the guidelines that should be considered.
The efficacy and effectiveness of CT for MDD has been well established in controlled efficacy trials as well as in real world effectiveness trials.4-7 Given the substantial pain and suffering experienced by those who will encounter an episode of MDD in their lifetime, the research to date validating the effects of CT justify the time and costs necessary to implement this intervention in outpatient settings.
Hollon and colleagues8 demonstrated that CT reduced the risk of relapse after treatment was completed with continuation effects comparable to keeping patients on medication. The trial included only patients with severe depression, which indicates that the APA might reconsider its limited recommendation of psychotherapies for only mild to moderate depression.
Short-term dynamic psychotherapy
In contrast to the solid evidence base for CT in the treatment of depression, there has been substantial debate in the literature over the past 20 years regarding whether short-term dynamic psychotherapy, which targets maladaptive interpersonal patterns as the source of symptomatology, has sufficient research to support its dissemination as an intervention for MDD. Although dynamic psychotherapy has been and is currently practiced worldwide, the research literature across mental disorders is flooded with reviews that debate whether it has adequate evidence of effectiveness.
A comprehensive review concluded that dynamic psychotherapy has large pre-and post-effects that are maintained at 1 year and medium effect sizes relative to control conditions.9 Two trials provide strong evidence that dynamic psychotherapy combined with medication is superior to medication alone in the treatment of depression.10,11 These studies provide valuable insight into the utility of dynamic psychotherapy in real world practice where psychotherapies are often combined with medication treatment.
A recent trial of longer-term psychoanalytic treatment demonstrated superiority over treatment as usual for treatment-resistant MDD.12 At the 2-year follow-up, 44% of patients in the psychoanalytic treatment no longer met criteria for MDD compared with 10% of those receiving treatment as usual.
Dynamic versus cognitive therapy
In describing the evidence needed to define a psychotherapy as evidence based, Chambless and Hollon² assert that treatment efficacy is best demonstrated in controlled research. They suggest that studies with samples per condition of at least 25 that demonstrate an intervention is not significantly inferior to an already validated intervention can be considered evidence that treatments are equivalent. They warn that the interpretability of equivalence/non-inferiority trials is dependent on trials conducted with strong attention to internal validity.13
To add to the emerging evidence supporting the effectiveness of dynamic psychotherapy in the treatment of depression, 2 large-scale noninferiority trials demonstrated that dynamic psychotherapy is statistically noninferior to CT in the treatment of MDD. Driessen and colleagues14 randomized 341 patients in outpatient settings to short-term dynamic psychotherapy versus CT using research methods that included manualized treatments, training protocols, and blind independent assessments. They found there were no differences between treatments at termination or follow-up on either patient rated or observer rated outcome assessments.
My colleagues and I conducted a randomized non-inferiority trial comparing short-term dynamic psychotherapy to CT in the treatment of MDD specifically in the community mental health setting.15,16 We developed and implemented our randomized noninferiority trial in the community setting with a focus on internal validity, including:
• Expert, intensive, individual and group supervision in each treatment modality on par with the training procedures implemented in efficacy trials
• Blind fidelity ratings to ensure that treatments were delivered adequately and could be discriminated
• Blind expert assessments of the primary symptom outcome
We found that dynamic psychotherapy was statistically noninferior to CT, building on the Driessen trial14 to indicate that dynamic psychotherapy may be broadly effective across settings. Our blind assessments of adherence and competence demonstrated that the cognitive and dynamic psychotherapies could be discriminated and that the CT delivered in the community setting had adherence and competence ratings comparable to those demonstrated in efficacy trials.16
Our community trial also demonstrated that patients found both CT and short-term dynamic psychotherapy to be highly sensible, patients were very confident in the treatments, and patients would recommend these treatments to others.
CT focused on both behavioral activation techniques and cognitive restructuring techniques. Based on our blind expert adherence ratings, the specific techniques used most frequently included concrete activities like setting the agenda and assigning homework, as well as cognitive restructuring techniques that included encouraging the exploration of specific thoughts and beliefs and relating feelings to thoughts.
Short-term dynamic psychotherapy focused on both the supportive and expressive techniques described in the manual. Therapists used explicit alliance-enhancing techniques to build the collaborative relationship and used clarifications and interpretations of the relationship patterns interfering with patients’ goals in their current relationships.
Based on our blind expert adherence ratings, the specific interventions used most frequently in our community implementation of dynamic psychotherapy included supportive techniques like using mutual affect, conveying a sense of respect and liking, and using a high level of comments, as well as expressive techniques including exploration of patient wishes towards others, perceived responses of others, and responses.
Predictors of effectiveness
To date, the evidence supports the effectiveness of both cognitive and dynamic therapies in the treatment of MDD, which suggests that the American Psychological Association should also consider revising their treatment guidelines. At the population level, both treatments offer a reasonable approach to helping alleviate the symptoms of depression. In practice, however, clinicians must decide which treatments are best suited to individual patients.
Despite decades of research on predictors of effectiveness within these treatments, we still do not have reliable indicators of which treatment to provide to which patients.
DeRubeis and colleagues17,18 conducted innovative studies to evaluate a wide range of possible predictors of treatment effectiveness across CT and medication to build a comprehensive predictive model that could be used to personalize treatment for patients. They found chronicity of illness (more chronic), age (older), and intelligence (lower) were predictive of poor response across both CT and medication. Meanwhile, patients who were married, unemployed, or had higher number of life events had significantly better outcomes with CT compared with medication. The researchers have developed an algorithm that produces a personalized advantage index that indicates which modality might provide better outcomes.17
Such predictive models are sorely needed to help practicing clinicians decide which psychotherapeutic interventions are most likely to benefit any given patient. Most studies evaluate no more than a few predictors of treatment effectiveness within single treatment modalities. Since the prediction of which psychotherapy might benefit a specific patient is likely to be complex, studies are needed that can evaluate a range of possible treatment predictors and moderators across multiple evidence based psychotherapeutic approaches. Such a personalized approach to matching patients with psychotherapy may improve patient satisfaction with services and improve outcomes.
As we move forward with research to improve our ability to personalize psychotherapies to meet the needs of specific patients, we also need to think through how best to disseminate the many psychotherapeutic techniques to practicing clinicians. Most training programs remain focused on one school of psychotherapy and many clinicians graduating from these training programs have strong allegiances to a specific psychotherapeutic modality. In spite of this, we have found that clinicians are interested in gaining expertise in a variety of psychotherapeutic techniques.
Despite interest in an eclectic approach to psychotherapy, clinicians are not interested in completely replacing their preferred therapeutic modality. Rather, they prefer to bring in elements of other psychotherapies that may further benefit their patients. As a result, research examining whether briefer focused psychotherapy modules can address treatment personalization needs while meeting the practical needs of clinicians is needed to improve the effects of psychotherapies in clinical practice.
Dr Gibbons is Associate Professor Psychology, Department of Psychiatry, University of Pennsylvania, Philadelphia, PA.
The author reports no conflicts of interest concerning the subject matter of this article.
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