Psychodynamic Research
In the following section,
(1) evidence for the efficacy of psychodynamic therapy (PDT) in specific mental disorders in adults will be briefly summarized by listing relevant publications,
(2) in addition, open questions of research will be listed. These open questions may guide future research and give young researchers an orientation for their own studies
1. Evidence for psychodynamic therapy in adults
Randomized controlled trials, reviews and meta-analyses
A growing number of randomized controlled trials (RCTs), reviews and meta-analyses for psychodynamic therapy (PDT) in specific mental disorders is available showing not only thatt PDT is efficacious but also that it is as efficacious as other empirically supported treatments. This is demonstrated, for example, by
Peter Lilliengren´s list of RCTs (https://www.kbap.de/fileadmin/users/redakteur/redakteur_upload/Liliengrenliste.pdf)
Reviews on PDT (Fonagy, 2015, Leichsenring et al., 2015a, Leichsenring et al., 2015b, Shedler, 2010)
Meta-analyses of PDT in specific mental disorders or groups providing evidence for efficacy indepressive disorders (Barber et al., 2021, Driessen et al., 2020, Driessen et al., 2015, Leichsenring et al., 2023a)
anxiety disorders (Barber et al., 2021, Keefe et al., 2014, Leichsenring et al., 2023a) personality disorders (Barber et al., 2021, Leichsenring et al., 2023a)
somatoform disorders (Abbass et al., 2021, Gutkin et al., 2020, Leichsenring et al., 2023a) complex mental disorders (Leichsenring et al., 2013, Leichsenring and Rabung, 2008, 2011b)
transdiagnostic evaluations (Leichsenring et al., 2004, Steinert et al., 2017b)
Comparison of PDT with other empirically supported treatments (Barber et al., 2021, Driessen et al., 2015, Keefe et al., 2014, Keefe et al., 2020, Leichsenring et al., 2023a, Smith and Hewitt, 2024; Steinert et al., 2017b; Miggiels et al, 2024) showing no clinically significant differences in efficacy.
RCTs, reviews and meta-analyses of long-term psychodynamic therapy (Clarkin et al., 2007, Doering et al., 2010, Fonagy et al., 2015, Heim et al., in press, Leichsenring et al., 2013, Leichsenring and Rabung, 2008, 2011b, Leuzinger-Bohleber et al., 2019)
Studies and meta-analyses of combined PDT and pharmacotherapy indepressive disorders (de Jonghe et al., 2004, de Jonghe et al., 2001, Driessen et al., 2020)
anxiety disorders(Wiborg and Dahl, 1996)
OCD (Maina et al., 2010)
schizophrenic spectrum disorders (Montag et al., 2014, Øhlenschlæger et al., 2007, Weijers et al., 2021)
In addition, there are several ongoing studies: e.g. examining PDT in
PTSD (Milrod et al, Leichsenring et al. 2023),
OCD (Leichsenring et al.)
Additional gain of psychodynamic therapy compared to other evidence-based therapies
PDT has been shown to achieve additional gains compared to other evidence-based therapies with regard to
attachment, reflective functioning (Levy et al., 2006)
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Research on Internet-guided psychodynamic therapy
There is evidence that internet-guided PDT is efficacious in
depressive disorders (Johansson et al., 2012)
anxiety disorders (Andersson et al., 2012, Johansson et al., 2017)
...
Effectiveness studies
There is evidence that PDT is effective under real-world conditions (e.g. Stiles et al., 2008).
Research on Cost-effectiveness
There is evidence that PDT is cost-effective. (Abbass, 2003, Bothe et al., 2023, Dams et al., 2017, Dührssen, 1962, Egger et al., 2016, Konnopka et al., 2009, Lilliengren et al., 2020, Town et al., 2020)
Efficacy of PDT in minority groups
There is first evidence that PDT is efficacious in
LGPTQ (Keefe et al., 2023)
minority groups (Barber et al., 2012)
...
Studies, reviews and meta-analyses of general relevance for psychotherapy
Effect sizes of psychotherapy and pharmacotherapy in comparison to TAU or placebo (Leichsenring et al., 2022b)
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2. Open questions and future research on outcome of psychodynamic therapy in adults
Informing about open questions and giving hints for future directions of research may be even more important than informing about the available evidence for PDT. Formulating open questions of research may direct and promote psychodynamic research and may especially be helpful for young researchers, e.g. for writing grant applications. In the following, areas and questions of outcome research are listed for which further research is required.
Evidence on dose effect relationships is required
It is has not yet been clarified how many sessions of which treatment in which conditions work for whom. A recent RCT by Kool et al (2024) showed that both 50 sessions (twice wekly) of PDT and scheme therapy are more efficacius than 25 sessions in adults with depression and comorbid personality disorders. However, it is not clear whether the majority of patients benefitted sufficiently from 50 sessions and which patients may need more than 50 sessionss to achieve a substantial improvement. This applies to other mental disorders as well.
Long-term psychodynamic therapy
At present, only relatively few RCTs and meta-analyses on long-term PDT (LTPP) are available (Clarkin et al., 2007, Doering et al., 2010, Fonagy et al., 2015, Leichsenring et al., 2013, Leichsenring and Rabung, 2008, 2011b). This is especially true for psychoanalytic therapy (Huber et al., 2013, Huber et al., 2012, Leuzinger-Bohleber et al., 2019).
Thus, further evidence on long-term treatments is required.
Long-term outcome
Further RCTs and meta-analyses on long-term outcome of PDT are required.
The meta-analyses providing evidence for PDT in depressive, anxiety, and personality disorders according to the 2015 criteria of the APA (Tolin et al., 2015) showed that PDT did not differ from active therapies in follow-ups with regard to reducing target symptoms. However, this does not necessarily imply that effects are stable. In the worst case, active therapies were not efficacious in follow-ups as well, implying that both PDT and active therapies did not yield stable effects.
As the only exception, meta-analytic results of PDT in somatoform disorders showed that PDT was superior to controls in follow-ups (Abbass et al., 2021, Leichsenring et al., 2023a).
For depression, the meta-analysis by Driessen et al. (2015) showed that the treatment effects of PDT were maintained or significantly improve further between end of therapy and follow-up.
For these reasons, further RCTs and meta-analyses are required showing that PDT is superior to controls in follow-ups, especially in anxiety and personality disorders (Bateman and Fonagy, 2009, Keefe et al., 2020).
Functioning
Further RCTs and meta-analyses of PDT on functioning especially in anxiety disorders are required.
The meta-analyses providing evidence for PDT in anxiety disorders according to the 2015 criteria of the APA (Tolin et al., 2015) showed that PDT did not differ from active therapies with regard to improving functioning (Barber et al., 2021, Keefe et al., 2014, Leichsenring et al., 2023a). Again, in the worst case, active therapies were not efficacious in improving functioning, too, implying that both PDT and active therapies were both not efficacious in improving functioning.
For this reason, further RCTs and meta-analyses are required showing that PDT is superior to controls in improving functioning in anxiety disorders.
American Psychological Association 2015 criteria for empirically supported psychotherapies
PDT fulfills the 2015 criteria of the American Psychological Association (Leichsenring et al., 2023a, Tolin et al., 2015) for empirically supported therapies for depressive, anxiety, personality and somatoform disorders (Leichsenring et al., 2023a).
For other mental disorders, however, some RCTs exist but the number of RCTs is limited and meta-analyses which are required by the criteria proposed by Tolin et al. (2015) are not yet available. This applies to the following disorders for which further RCTs and meta-analyses are required to fulfil the 2015 APA criteria (Tolin et al., 2015):
Cluster C personality disorders (Muran et al., 2005, Svartberg et al., 2004, Winston, 1994)
eating disordersbulimia nervosa (Garner et al., 1993, Poulsen and Lunn, 2014, Poulsen et al., 2014, Stefini et al., 2017, Tasca et al., 2014)
binge eating (Tasca et al., 2012)
anorexia nervosa (Dare, 2001, Gowers et al., 1994, Lock et al., 2010, Zipfel et al., 2013)
addictionsopiate (Woody et al., 1985, Woody et al., 1983, Woody et al., 1990)
cocaine (Crits-Christoph et al., 1999, Crits-Christoph et al., 2001)
alcohol (Sandahl et al., 1998), Frederikson?
PTSD (Brom et al., 1989, Steinert et al., 2017a, Steinert et al., 2016a), with ongoing studies by Barbara Milrod et al. and Falk Leichsenring et al. (Leichsenring et al., 2020)
Further RCTs
Independent of but related to the APA criteria further RCTs of psychodynamic therapy in specific disorders are required. This applies to
schizophrenic spectrum disorder
bipolar disorders
PTSD
non-substance related addictions for example, gambling, shopping, sex, pornography.
further high quality evidence for PDT in specific anxiety disorders. Several studies are of low study quality (Leichsenring et al., 2023a). For generalized anxiety disorder, for example, only a few RCTs of PDT exist (Papola et al., 2023).
OCD
adjustment disorders
sexual dysfunctions
Specific outcomes
Future studies of PDT focusing on specific outcomes are required, such as
functioning (Leichsenring et al., 2023a)
attachment
reflective functioning
cost-effectiveness?
xxxx
Additional gain of PDT
Future studies are required focusing on outcomes which may specific to PDT, e.g.
conflicts
attachment
reflective functioning
defense mechanisms
….
Transdiagnostic approaches, unified protocols
Unified transdiagnostic psychodynamic protocols are available for several disorders, but further studies testing their efficacy are required, this applies to
emotional disorders (Leichsenring and Steinert, 2018)
depressive disorders(Leichsenring and Schauenburg, 2014, Steinert et al., 2016b)
anxiety disorders (Busch et al., 2012, Leichsenring and Salzer, 2014)
personality disorders (Caligor et al., 2018)
transdiagnostic features (e.g. perfectionism Hewitt et al., 2023, Hewitt et al., 2020)
Cost-effectiveness studies
Further studies of cost-effectiveness of psychodynamic therapy in specific disorders required.
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