Psychodynamic Research
Depressive disorders
At present, 29 + X randomized controlled trials (RCTs) for psychodynamic therapy (PDT) in depressive disorders exist. Twenty-seven RCTs were included in a recent meta-analysis (Barber et al., 2021; Keefe, 2022). Meanwhile, two further RCTs and another meta-analysis have been published (Kool et al., 2024; Miggiels et al., 2024; Smith & Hewitt, 2024). The quality of most RCTs was found to be sufficient (Barber et al., 2021; Leichsenring et al., 2023) and does not differ from that of, for example, cognitive-behavior therapy (CBT) (Thoma et al., 2012).
Efficacy (PDT vs controls): PDT was found to be significantly superior to waiting list controls with a large effect size (g=–14, 95% CI: –1.66 to –0.62, k=3, N=115). Compared to active controls PDT achieved a significant medium effect size (g=–0.51, 95% CI: –0.68 to –0.35, I2=26%, k=9, N=945) (Barber et al., 2021; Leichsenring et al., 2023). Thus, PDT achieved clinically meaningful effect sizes in comparison to controls (Barber et al., 2021; Leichsenring et al., 2023). The width of the confidence intervals is comparable to other treatments such as CBT compared to treatment as usual (TAU) (Leichsenring et al., 2023).
Comparative efficacy: Compared to other active therapies, PDT did not differ significantly on the primary outcome, i.e. severity of depression (g=0.10, 95% CI: –0.06 to 0.26, I2=62%, k=19, N=2,154). (Barber et al., 2021; Leichsenring et al., 2023).
Comparison to CBT: A recent meta-analysis testing equivalence of PDT and CBT in outcome of depressive disorders found PDT to be as efficacious as CBT. (Smith & Hewitt, 2024). This result is consistent with a recent RCT which found PDT to be non-inferior to CBT (Miggiels et al., 2024).
Stability of effects: In follow-ups ranging from 2 to 55 months, the difference between PDT and active therapies remained insignificant (g=0.08, 95% CI: –0.14 to 0.30, I2=50%, k=9, N=1,096) (Leichsenring et al., 2023).
Quality of life: PDT was found to be superior to control conditions with regard to improving quality of life, with a medium effect size (d=–0.49, 95% CI: –0.73 to –0.24, k=3, I2=0%, N=293), while there was no difference compared to other psychotherapies in improving interpersonal functioning, either post-therapy (d=0.05, 95% CI: –0.23 to 0.34, k=5, I2=40%, N=408) or at follow-up (d=–0.15, 95% CI: –0.70 to 0.40, k=4, I2=74%, N=288) (Driessen et al., 2015)
Effectiveness under real world conditions: A recent meta-analysis on effectiveness of routinely delivered psychotherapies (Gaskell et al., 2022) found large pre-post effect sizes in depression outcomes (d=0.96, 95% CI: 0.88-1.04), with no differences between CBT and PDT (d=–0.07 in favor of PDT). This was true for longer-term psychotherapies of an average of 48.68 sessions across disorders, too (Gaskell et al., 2023).
Mechanisms of change: In addition, there is evidence for mechanisms of change of PDT in depressive disorders (Leichsenring et al., 2023).
Internet-delivered PDT: A meta-analysis of Internet-delivered PDT43 reported a medium effect size compared to controls in depression outcomes (g=–0.46, 95% CI: –0.73 to –0.19, I2=23%, k=5, N=359) (Lindegaard et al., 2020)
Complex depression. There is evidence that PDT is efficacious in treatment resistant or chronic depression(Fonagy et al., 2015; Leuzinger-Bohleber et al., 2019; Town et al., 2017; Town et al., 2020). Furthermore, an earlier meta-analysis suggests that PDT is efficacious in depression with a comorbid personality disorder(Abbass et al., 2011).
Adverse events: No or only a few adverse events were reported in studies of PDT in depression, with no differences to other bona fide therapies(Barber et al., 2012; Bastos et al., 2015; Connolly Gibbons et al., 2016; Driessen et al., 2013; Town et al., 2017).
Summing up, in depressive disorders PDT achieves clinically significant effects in comparison to controls and is as efficacious as other active treatments such as CBT. In addition, PDT achieves clinically significant effects in improving quality of life and interpersonal functioning. Effects are stable in follow-ups. Furthermore PDT is efficacious under real world conditions and there is evidence for mechanisms of change of PDT.
As a result, PDT fulfils the updated criteria of the American Psychological Association for empirically supported therapies (Tolin et al., 2015), warranting a strong recommendation for the treatment of depressive disorders (Leichsenring et al., 2023)
References
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