Letters to the Editor

Re: Short-Term Dynamic Psychotherapies in the Treatment of Major Depression

Dear Editor:

We thank Dr Abbass for his comments on the Clinical Guidelines for the Treatment of Depressive Disorders and his attention to short-term dynamic psychotherapies (STDPs), which he contends have a sufficient evidence base to be a first-line psychotherapy treatment.

We are grateful to him for drawing attention to Leichsenring’s recent metaanalysis of short-term psychodynamic psychotherapy (STPP) and cognitive-behavioural therapy (CBT) in depression (1); the conclusions seem to support Dr Abass’s call to reconsider the STPP evidence base. In our review of psychodynamic psychotherapy (2), we acknowledged 2 metaanalyses of brief dynamic psychotherapy and STDP (3,4), but we indicated our concern that in both instances, interpersonal psychotherapy (IPT) was included within the broader term, brief dynamic psychotherapy.

Unfortunately, this practice is repeated in Leichsenring’s review.

Statistical approaches like metaanalysis use the principle of aggregation to their advantage to pool findings from a range of research settings. However, unless there is consistency within the category across which information is being pooled, this singular advantage can become a liability. When effect sizes for STPP are calculated in part from the efficacy of treatments not placed within this category, the true magnitude of STPP’s effect is obscured. With respect to the point under discussion, Markowitz, Svartberg and Swartz have affirmed that “IPT is distinct from STPP” (5).

In Leichsenring’s review, 6 studies meet the author’s inclusion criteria, which include a minimum of 11 sessions, with in all cases “a focus on specific conflicts or themes.” Again, the author includes IPT in 1 of the eligible 6 studies; a further 2 of the remaining 5 are follow-up reports (6,7). Dr Abbass cites a series of references (his references 3–11) as controlled trials for patients with depression. In fact, these references deal with subsyndromal depression (8) and depression in elderly populations (9,10) and, again, refer frequently to “psychodynamic interpersonal psychotherapy” (7,11). Dr Abbass also cites several studies dealing with short-term psychotherapy of personality disorders (12–14).

We agree with Leichsenring’s conclusion that “to date, there are no 2 studies by independent research groups demonstrating equal effectiveness of the same form of STPP compared to CBT/BT in the treatment of depression . . . further study should focus on specific versions of STPP rather than a broadly defined model of STPP.”

A more rigorous definition of STPP, together with replicated clinical trials involving comparable manual-driven approaches to therapy, would allow this form of psychotherapy to be recommended with a higher level of evidence.

Thank you for allowing us to respond to this important issue.

References

1. 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.
2. Kennedy SH, Lam R. Clinical guidelines for the treatment of depression. Can J Psychiatry 2001;46 (Suppl 1):32S.
3. Crits-Christoph P. The efficacy of brief dynamic psychotherapy: a meta-analysis. Am J Psychiatry 1992; 149:151–8.
4. Anderson E, Lambert M. Short-term dynamically oriented psychotherapy: a review and meta-analysis. Clin Psychol Rev 1995;15:503–14.
5. Markowitz JC, Svartberg M, Swartz HA. Is IPT time-limited psychodynamic psychotherapy? J Psychother Pract Res 1998; 7:185–95.
6. Gallagher RM. Training issues at the interface between consultation-liaison psychiatry and behavioural medicine. Adv Psychosom Med. 1990; 20:33–52.
7. 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.
8. 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.
9. 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.
10. Thompson LW, Gallagher D, Steinmentz Breckenridge J. Comparative effectiveness of psychotherapies for depressed elders. J Consult Clin Psychol 1983;55:385–90.
11. 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.
12. 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.
13. 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.
14. 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.

Sidney H Kennedy, MD, FRCPC
Zindel V Segal, PhD, C Psych
Toronto, Ontario
Raymond W Lam, MD, FRCPC
Vancouver, British Columbia
Diane K Whitney, MD, FRCPC
London, Ontario