Letters to the Editor

Short-Term Dynamic Psychotherapies in the Treatment of Major Depression

Dear Editor:

I commend the excellent work of Dr Kennedy, Dr Lam, and the working group that provided the Clinical Guidelines for the Treatment of Depressive Disorders (1). This letter is to provide updated information from a systematic review of short-term dynamic psychotherapies (STDPs) currently being conducted under the Cochrane Collaboration (2) and to demonstrate that converging data now support STDP as a valid first-line treatment for depression.

Although their first point is that few published trials exist, we have found over 40 published controlled trials of STDP, including 9 studies assessing 888 patients with depression (3–11). This represents at least 20 more studies than Anderson and Lambert’s review (12) which, unlike our review, included studies of interpersonal therapy (IPT). Further, 4 of these studies included patients diagnosed with personality disorders treated with Davanloo’s version of STDP (intensive STDP), with one-third of the samples having comorbid depression or dysthymic disorder (13–16). Another study examined patients with personality disorders and depression or anxiety disorders (17).

In terms of relative efficacy, a recent review showed STDP to be as effective as cognitive-behavioural therapy (CBT) for reducing symptoms in patients with depression (18). In one head-to-head study, ISTDP outperformed a “more cognitive” dynamic treatment on the depression subscale of the Symptom Checklist-90 (SCL-90) with an effect size of 1.35 (15).

STDPs appear to have a broad applicability, with studies showing efficacy in patients with personality disorders and depression or dysthymic disorder, as noted above. Conversely, the National Institutes of Mental Health (NIMH) depression study identified limitations in both CBT and IPT treatment for patients with personality disorders (19).

The authors point out the “wide use of psychodynamic psychotherapy in clinical practice”(1, p 32S). According to the authors, then, psychodynamic models are many clinicians’ primary instruments, with or without training in newer, empirically validated brief psychodynamic therapies.

When one combines these practice patterns with the substantial number of newer controlled trials showing efficacy, the demonstrated equal efficacy with CBT, and the broad scope of applicability, one has to consider variants of STDPs as potential first-line treatments of depression.

References

1. Kennedy SH, Lam R Clinical guidelines for the treatment of depression. Can J Psychiatry 2001;46 (Suppl 1).
2. Abbass A. A systematic review of short term psychodynamic psychotherapies. Proceedings of The 8th International Cochrane Colloquium; October 25–29, 2000; Cape Town (SA).
3. Barkham M., Shapiro DA, Hardy GE, Rees A. Psychotherapy in two-plus-one sessions: outcomes of a randomized controlled trial of cognitive-behavioral and psychodynamic-interpersonal therapy for subsyndromal depression. J Consult Clin Psychol 1999;67: 201–11.
4. Gallagher DE, Thompson LW. Treatment of major depressive disorder in older adult outpatients with brief psychotherapies. Psychotherapy: Theory, Research and Practice 1982;19:482–90.
5. Thompson LW, Gallagher D, Steinmentz Breckenridge J. Comparative effectiveness of psychotherapies for depressed elders. J Consult Clin Psychol 1983;55:385–90.
6. Hersen M, Bellack AS, Himmelhoch JM, Thase ME. Effects of social skill training, amitriptyline, and psychotherapy in unipolar depressed women. Behavior Therapy 1984;15:21–40.
7. McLean PD, Hakstian AR. Clinical depression: comparative efficacy of outpatient treatments. J Consult Clin Psychol 1979;47:818–36.
8. Reynolds S, Stiles WB, Barkham M, Shapiro DA, Hardy G, Rees A. Acceleration of changes in session impact during contrasting time-limited psychotherapies. J Consult Clin Psychol 1996;64:577–86.
9. Shapiro DA, Barkham M, Rees A, Hardy GE, Reynolds S, Startup M. Effects of treatment duration and severity of depression on the effectiveness of cognitive-behavioral and psychodynamic-interpersonal psychotherapy. J Consult Clin Psychol 1994;62:522–34.
10. Shapiro DA, Rees A, Barkham M, Hardy G, Reynolds S, Startup M. Effects of treatment duration and severity of depression on the maintenance of gains after cognitive-behavioral and psychodynamic-interpersonal psychotherapy. J Consult Clin Psychol 1995;63:378–87.
11. Shapiro DA, Firth J. Prescriptive v. explorative psychotherapy: outcomes of the Sheffield psychotherapy project. Br J Psychiatry 1987;151:790–9.
12. Anderson E, Lambert M. Short-term dynamically oriented psychotherapy: a review and meta-analysis. Clin Psychol Rev 1995;15:503–14.
13. Hellerstein DJ, Rosenthal RN, Pinsker H, Samstag LW, Muran JC, Winston A. A randomized prospective study comparing supportive and dynamic therapies. J Psychother Pract Res 1998;7:261–71.
14. Winston A, Laikin M, Pollack J, Wallner Samstag L, McCullough L, Muran C. Short-term psychotherapy of personality disorders. Am J Psychiatry 1993;151:190–4.
15. Winston A, Pollack J, McCullough L, Flegenheimer W, Kestenbaum R, Trujillo M. Brief psychotherapy of personality disorders. J Nerv Ment Dis 1991;179:188–93.
16. Abbass A. A multicentre controlled evaluation of short-term dynamic psychotherapy of patients with personality disorders. Proceedings of the Canadian Psychiatric Association Annual Meeting; October, 2000; Victoria (BC).
17. Andreoli A, Frances A, Gex-Fabry M, Aapro N, Gerin P, Dazord A. Crisis intervention in depressed patients with and without DSM-III-R personality disorders. J Nerv Ment Dis 1993;181:732–7.
18. Leichsenring F. Comparative effects of short-term dynamic psychodynamic psychotherapy and cognitive-behavior therapy in depression: a meta-analytic approach. Clin Psychol Rev 2001;21:401–19.
19. Shea MT. Psychosocial treatment of personality disorders. J Personal Disord 1993; (Suppl):167–80.

Allan Abbass, MD, FRCPC
Halifax, Nova Scotia