Estudios y profesionalización 12

BACKGROUND

Short-term psychodynamic psychotherapy (SDPP) is derived from psychoanalysis and longer term psychodynamic psychotherapy. SDPP is defined as psychodynamic psychotherapy of approximately 10 to 20 weeks duration. It focuses on the patient gaining insight into unconscious conflicts as they are manifested in the patient’s life and relationships, including his/her relationship with his/her therapist (i.e., transference). It is thought that these conflicts have their origin in the past, usually childhood relationships to parental figures. Patients gain insight into and work through such conflicts through exploration of their feelings along with interpretations offered by his/her therapist. Of note, one intervention that can be considered a SDPP, interpersonal psychotherapy (IPT) is described in a separate annotation because it has a distinct body of literature (see IPT above).

ACTION STATEMENT

Short-term psychodynamic psychotherapy (SDPP) is an option for treating mild to moderate MDD in an outpatient mental health setting.

RECOMMENDATIONS

1. Short-term psychodynamic psychotherapy (SDPP) may be considered for achieving reduction in depressive symptoms for mild to moderate MDD in adults, depending on patient preference and on the presence of other complex comorbidities. [C]

RATIONALE

Psychodynamic psychotherapy is the longest established psychotherapy, and SDPP is a more recent development. Of note, with the exception of IPT, good quality research studies of SDPP are rare, limiting the ability to determine the efficacy and effectiveness of these interventions. In addition, there is significant variability among SDPP; the interventions are frequently not manualized when used in research trials, reducing replicability, and adherence and competence ratings of the intervention are not frequently reported, reducing the ability of readers to clearly understand what the intervention entailed. Despite these limitations, the fact that it does not appear significantly inferior to other common treatments in clinical research studies may make it of value if patients prefer this kind of treatment.

EVIDENCE STATEMENTS

The evidence for SDPP was derived from the NICE guidelines (2004). The NICE guidelines found the following 4 RCTs of sufficient quality addressing SDPPs:

o There is insufficient evidence to determine if there are clinically significant differences between short-term psychodynamic psychotherapy and CBT in reducing depressive symptoms at the end of treatment, at 6 or 12 months after treatment; or of achieving remission of MDD at the end of treatment, or 3 months after the end of treatment. One study compared CBT and psychodynamic therapy for major depression in older caregivers with MDD (20 sessions; N=66; Gallagher-Thompson & Steffen, 1994). Participants who had been caregivers for more than 3.5 years benefited more from CBT, while those who had been caregivers less than 3.5years benefited more from SDPP.

o One study compared CBT and SDPP in adults with MDD (8 or 16 sessions depending on randomization; N=117; Shapiro et al., 1994). In general, there were no significant differences on outcomes, although there was some benefit for CBT on self reported depression at the end of treatment. There were no differences on treatment outcomes at 8 vs. 16 sessions except for patients with severe depression.

o One study compared psychodynamic therapy, BT, relaxation and pharmacotherapy (10 sessions; N=178; McLean & Hakstian, 1979). BT was superior to other treatments on 9 of 10 outcome measures at end of treatment, although these benefits were reduced at 3 months post- treatment. Psychodynamic therapy performed the most poorly on outcome measures of any treatment in this study.

o Based on these studies, there is not sufficient evidence to determine whether psychodynamic therapy differs from CBT, behavioral therapy or pharmacotherapy for treatment response. o One study found that 10 weeks of psychodynamic psychotherapy combined with clomipramine

was superior to clomipramine plus supportive care for reducing depressive symptoms and improving functioning in patients with severe depression (HRSD ≥ 20).

Limitations of the literature

o None of the studies with short-term psychodynamic psychotherapy (SDPP) have been adequately replicated. They represent single tests of specific hypotheses, and therefore making general conclusions about the efficacy and effectiveness of SDPPs is premature.

o Magnitude of effect for psychotherapy trials may be overestimated because of study design issues, including patients not being blind to treatment.

o Some trials provide additional clinical contact in the pharmacotherapy condition. This design feature is likely to improve the benefits of the pharmacotherapy and reduce differences with CBT.

o The antidepressant medication comparisons used medications that are no longer first line medications, reducing generalizability to current practice.

EVIDENCE TABLE

Evidence Source QE Overall

Quality

Benefit SR 1 SDPP reduces depression:

SDPP is more effective for symptom reduction and remission than no treatment or placebo, and similarly effective to other evidence-based treatments

NICE, 2004 I Fair Small C

2 Depression in older adults: SDPP is better than CBT for older patients who have been caregivers less than 3.5 years

SDPP is less efficacious than CBT for older patients who have been caregivers more than 3.5 years

Gallagher-Thompson & Steffen, 1994

I Good Mod C

3 Psychodynamic therapy combined with pharmacotherapy:

SDPP plus antidepressant medication is superior to antidepressant medication and supportive care for initial treatment response

NICE, 2004 I Good Mod B

QE = Quality of Evidence; SR = Strength of Recommendation (See Appendix A)