Chester Clinic

 

The effectiveness of psychodynamic psychotherapies: an update

The effectiveness of psychodynamic psychotherapies:an updatePETER FONAGY Research Department of Clinical, Educational and Health Psychology, University College London, and The Anna Freud Centre, London, UK This paper provides a comprehensive review of outcome studies and meta-analyses of effectiveness studies of psychodynamic therapy (PDT)for the major categories of mental disorders. Comparisons with inactive controls (waitlist, treatment as usual and placebo) generally but byno means invariably show PDT to be effective for depression, some anxiety disorders, eating disorders and somatic disorders. There is littleevidence to support its implementation for post-traumatic stress disorder, obsessive-compulsive disorder, bulimia nervosa, cocaine depen-dence or psychosis. The strongest current evidence base supports relatively long-term psychodynamic treatment of some personality disorders,particularly borderline personality disorder. Comparisons with active treatments rarely identify PDT as superior to control interventions andstudies are generally not appropriately designed to provide tests of statistical equivalence. Studies that demonstrate inferiority of PDT toalternatives exist, but are small in number and often questionable in design. Reviews of the field appear to be subject to allegiance effects.
The present review recommends abandoning the inherently conservative strategy of comparing heterogeneous "families" of therapies for het-erogeneous diagnostic groups. Instead, it advocates using the opportunities provided by bioscience and computational psychiatry to creative-ly explore and assess the value of protocol-directed combinations of specific treatment components to address the key problems of individualpatients.
Key words: Psychodynamic psychotherapy, psychoanalysis, depression, anxiety disorders, eating disorders, somatic disorders, personalitydisorders (World Psychiatry 2015;14:137–150) Psychodynamic therapy (PDT) is on the retreat around the py as "evidence-based" (e.g., practice-based evidence) (23).
world in the face of critique of its scientific credibility. Empiri- However, it is misguided to deny that RCTs are key to estab- cally substantiated clinical judgement underpins professional lishing the validity of a therapeutic modality.
accountability and transparency in health care and increas- The history of medicine is littered with interventions that ingly so in mental health (1). One would therefore expect em- did remarkable duty as therapies and yet, when subjected to pirically supported therapies to gradually replace treatment RCT methodology, were shown either to have no benefit over as usual in everyday clinical care (2-5). Many outside the alternative treatments or even to prevent the patient from cognitive-behavioural therapy (CBT) community have ob- benefitting, in terms of effect size or speed, from a superior jected to this, raising concerns about the generalizability of intervention. Perhaps the most dramatic example is the RCT findings from randomized controlled trials (RCTs) (6).
that ended 100 years of radical mastectomies for breast carci- The issue of external validity of RCTs in the context of noma only 30 years ago. The study showed that half a million health care policy was recently exposed to philosophical women who had been subjected to disabling, mutilating oper- scrutiny (7), leading to the suggestion that the key issue may ations, performed with the best of intentions on the basis of a not be the theory-driven question of whether an intervention fallacious theory about how carcinoma spreads, could have works, but the implementation question "Will it work for had equally good outcomes with lumpectomies (24).
us?". For example, multisystemic therapy for conduct disor- Empirical knowledge in psychological therapies is multi- der is supported by trials in the U.S. and Norway, but these faceted and complex, and requires sophistication in the scru- results were not replicated in Sweden and Canada (8-19).
tiny of research data. While critical reviews that summarize Along with other researchers, we have argued that, in or synthesize a body of research are not without value, they order for a treatment to be considered as empirically sup- also have major limitations. They rely on the statistical signif- ported, evidence beyond that provided by RCTs is required icance of a study to determine an intervention's efficacy, yet (20,21). However, this does not imply, as many have as- statistical significance is primarily determined by sample sumed, that RCTs can be replaced by methods that do not size. Meta-analyses can pool multiple studies where each comply with Mill's "method of difference" maxim (stating has low statistical power (a pervasive problem in psychother- that where you have one situation that leads to an effect, apy research), but are potentially misleading when the RCTs and another which does not, and the only difference is the being aggregated are not homogeneous in terms of the target presence of a single factor in the first situation, you can infer population, the treatment method and the outcome mea- this factor as the cause of the effect) (22).
sures. This is often the case for trials of PDT.
Some have argued that not only are RCTs for psycho- A recent meta-review of 61 meta-analyses covering 21 therapy flawed because of issues of generalizability, but also psychiatric disorders containing 852 trials and 137,126 par- that there are alternative ways of establishing psychothera- ticipants yielded slightly larger effect sizes for psychotherapy (0.58; 95% CI: 0.42 to 0.76) than pharmacotherapy (0.40; fied by the work of those around the boundaries of both 95% CI: 0.28 to 0.52) studies (25), but the applicability of domains (33-36). The common distinction between inter- these figures is brought into question by the null results from pretive and supportive approaches (37) speaks to a clinical dichotomy that existed 30-40 years ago, but hardly applies The limitations of meta-analyses have generated concern today. Certain manualized treatments are labelled as psy- among a number of reviewers (26,27) that undue weight is chodynamic (38,39), but a thorough content analysis of given to heterogeneous small-scale studies, which are con- these remains to be done. The pragmatic approach adopted sidered in preference to well-designed and well-conducted in this review has been to use self-declared allegiance as the RCTs that converge in their results. While hard-pressed guiding principle as to what constitutes PDT.
readers may understandably wish to take an intellectual This review focuses on effectiveness and ignores ques- short-cut to a pooled effect size rather than considering tions of mechanism and treatment process. This was, again, individual investigations, it is important to remember that a decision of expedience given the space limitations and the meta-analyses lack individual patient data – they are based wish to provide a comprehensive survey. The literature on response rates and mean values. This masks important search on which this contribution depends was based on heterogeneity that is often revealed by careful scrutiny of the methodology evolved for two previous large-scale sur- veys (20,40) and involved a computer search of all major This review has opted to prioritize individual studies. The databases using 100 terms referring to different aspects of key limitation of small studies is the so-called "file drawer" mental health problems and 11 terms describing psycho- problem. Insufficient patients are sampled in small studies. As therapy (the search algorithm and full inclusion criteria are a consequence, relying on underpowered studies means that available on request). Studies were selected if they reported there is a risk that the likely effectiveness of a therapy is over- outcomes that were directly related to the disorder or to stated simply because a study with the same sample size but intermediate variables. The review is limited to experimental chance negative findings is unlikely to have been published.
designs involving some degree of random assignment.
Further, it is important to recognize that the absence of a significant difference between two conditions in a studyshould not be considered evidence for equivalence. The lat- ter requires a different statistical procedure and a larger sam-ple size than the so-called "superiority trials" which most psychotherapy trials are (28). Lack of significant differencedoes not mean that two interventions are equally effective, Several studies have compared PDT to waitlist (41,42), but only that it is impossible to rule out their equivalence placebo (43-46) or usual care controls (47-50) in the short- (29). A confident statement of superiority requires a trial term treatment of depression. The results are mixed, with with at least 50 individuals per arm for a medium effect size some favouring PDT (41-43,47,49,51) while others report (30). Equivalence trials are expected to have sample sizes no superiority to controls (44-46,48,50).
several times larger. Sadly, few of the trials which are re- A number of these studies are methodologically too weak viewed here meet this elementary criterion.
to permit definitive conclusions, either due to small sample Finally, how do we define psychodynamic psychotherapy? size (41-43,50) or because their implementation of PDT fails A recent meta-analysis likened the family of psychodynamic to meet criteria (52) for a bona fide treatment (44,48).
therapies to an actual, if somewhat dysfunctional, family Among the good studies, results are still mixed. Some stud- whose many members hardly spoke to each other and some- ies report medium effect sizes: 20.57 (95% CI: 20.99 to times even spoke different languages (31). This review uses a 20.14) (47) and 20.53 (95% CI: 20.92 to 20.13) (49). Per- broad definition of psychodynamic treatment as a stance tak- haps the most rigorous study comparing supportive expres- en to human subjectivity that is inclusive and aimed at a com- sive therapy with placebo medication reported no superior prehensive understanding of the interplay between aspects effects at the end of treatment on either depression (45) or of the individual's relationship with his/her environment, quality of life (46). However, a recent well-conducted study whether external or internal (32). It refers to the extraordi- of women with depressive disorders and breast cancer found nary human potential for dynamic self-alteration and self- that significantly more of the PDT group achieved remission correction. This definition incorporates a developmental from depression than the usual care group (44% vs. 23%) perspective, and assumes limitations on conscious influence, (53). An RCT of a mixed anxiety and depression group also ubiquity of conflict, internal representation of relationships, reported favourable post-treatment results for PDT on clini- mental defences, and that complex meanings can be attached cian and self-report measures (54).
to experience (32).
An intriguing meta-analysis of studies carried out in China The boundaries of PDT have become blurred over recent lists six controlled trials that reported substantial treatment decades by changes in both CBT approaches and psychody- success from psychodynamic psychotherapy as an adjunct to namic theory and technique, leading to increasing conver- medication and conventional nursing in the treatment of gence of both understanding and clinical methods, exempli- depression in patients with Parkinson's disease (55).
World Psychiatry 14:2 - June 2015 Since in clinical practice psychological therapies for reporting too limited to permit reliable inferences about depression are mostly offered in combination with medi- equivalence or even superiority (76-82). If CBT is superior cation, the potential value added by brief dynamic thera- to PDT, it is so only in very brief (8-session) implementa- py is a key question for practitioners. A well-constructed, tions (77). PDT and solution-focused therapy appear com- appropriately powered RCT found combined treatment parable in effectiveness (83).
to be more acceptable (reducing refusal and premature A recently advanced innovative approach used the Inter- termination of medication) and associated with higher net to deliver PDT based on a self-help manual in a pro- recovery rates (41% vs. 59%) (56). These findings were gramme lasting 10 weeks. Compared to a structured support confirmed for self-reported depression and quality of life condition, recovery rates of 35% vs. 9% were reported, which outcomes, but not for clinician-rated outcomes (57). A were maintained at 10-month follow-up (84). A second trial further smaller study comparing clomipramine with or based on a different model also yielded good outcomes com- without PDT reported reduced depression, lower hospi- pared to online therapist support without treatment modules talization rates, better work adjustment and better global in a mixed mood and anxiety disorder population (85).
functioning in the combined treatment group (58). Acombined analysis of three RCTs (56,59,60), in whichdata were pooled to enable contrasts between pharmaco- therapy alone and combination treatment, yielded betterobserver-rated and self-reported outcomes in terms of In normal practice, PDT is often offered as a long-term remission and response rates at treatment termination for (50 sessions or more) treatment. However, only a handful of combination treatments (61).
studies have explored the effectiveness of long-term PDT.
There may be moderators of the superior effect of com- The Helsinki study showed long-term PDT to be inferior bination treatments. So far, unreplicated findings suggest to short-term PDT initially, but superior after 3-year follow- that PDT may be particularly indicated if depression is up (86-88). In an intriguing comparison between intensive accompanied by personality disorder (62,63) or child- long-term PDT (psychoanalysis), long-term PDT and short- hood trauma (64), and findings are restricted to long-term term PDT, psychoanalysis was initially inferior to both other follow-ups (42,65,66). Dose-effect relations associated therapies, but was more effective at 5-year follow-up (89).
with the length of therapy (8 vs. 16 sessions) have not A large-scale naturalistic study randomized 272 depressed been found for combination treatments (59).
patients to unmanualized long-term PDT, fluoxetine or their When pharmacotherapy is contrasted head-to-head with combination for 24 months (51). Long-term PDT on its own PDT, studies fail to identify differential effects (45,46,67,68).
or in combination was more effective in reducing depression Adding pharmacotherapy to PDT brings equivocal benefit scores than fluoxetine alone, with a medium effect size.
(60), an important observation in the light of consistent find- A study in which participants with major depressive dis- ings of patient preference for PDT (69). A meta-analysis order were randomized to psychoanalysis or long-term PDT comparing psychotherapies to treatment with selective sero- found significant superiority of psychoanalysis on self-rated tonin reuptake inhibitors demonstrated that the former were measures of depression at 3-year follow-up, but no differen- comparable to medication and that PDT was as efficacious ces at 1 and 2 years (90). A quasi-experimental comparison as other therapies. However, psychotherapies that were not found psychoanalysis but not long-term PDT to be superior bona fide (i.e., those delivered by professionals without sub- to CBT on measures of depression at 3 year follow-up (91).
stantial training in psychotherapy) had significantly worse A recently completed study of 18 months of once-weekly outcomes (70).
psychoanalytic psychotherapy for patients with two previous Several high-quality trials reported comparisons between documented treatment failures reported the psychotherapy CBT and PDT. A well-powered equivalence trial (N5341) to be superior to U.K. practice guidelines-based treatment, reported no observer-rated, patient-rated or therapist-rated but superiority was not apparent until 2 years after the end of differences at treatment termination or follow-up, although treatment (92).
overall the remission rate was low at 22.7% (71-73). Anothertrial found PDT, but not counselling or CBT, to be superiorto a control in reducing the rate of postnatal depression at termination (49), although the treatments were equivalent atshort-term and long-term follow-up. By contrast, an RCT of Meta-analytic findings on the whole reveal large pre-post 291 inpatients reported that CBT was equally effective in treatment effects (93,94) for PDT maintained at 1-year those selected for CBT or PDT, while PDT benefitted only follow-up, with medium effect sizes indicating superiority to those who were specifically selected for that treatment (74).
inactive controls (31,95) but either no difference (31) or Consequently, CBT was superior for the randomly rather slight inferiority (94) in relation to alternative interventions than systematically assigned group of patients (75).
post-treatment. Checking for publication bias revealed the Earlier studies tended to show negligible differences existence of "file drawer" studies favouring PDT, which abol- between PDT and CBT, but the trials were too small and ished the inferiority.
Effect sizes at follow-up relative to other treatments are A health economics study reported that the end of treat- insignificant overall (31,94,96), but PDT performed signifi- ment cost-effectiveness of CBT and PDT compared to wait- cantly worse against CBT (31) and in geriatric studies (31).
list was uncertain and depended on societal willingness to PDT is comparable to alternative treatments at long-term pay (WTP): CBT proved cost-effective at WTP  e16,100 follow-up. It also increases the effect of antidepressant med- per responder and PDT at WTP  e27,290 (106).
ication (31,96).
There are no studies of PDT against inactive controls in generalized anxiety disorder, except a study of Internet-based PDT, which yielded no evidence of superiority to waitlist control on anxiety ratings (107). An early study of apoorly specified PDT showed it to be inferior to both anxiety On the whole, evidence supports the use of PDT in the management training and cognitive therapy at termination treatment of depression, although its effects compared to and short-term follow-up (108). A small study comparing placebo and other inactive control treatments are moderate PDT to supportive therapy failed to find superiority of PDT rather than large. There is evidence that the effects are main- for interpersonal problems (109). An RCT contrasting CBT tained in both the short and long term. PDT may be a pre- with PDT found the former to be superior on self-reported ferred alternative to pharmacotherapy and certainly adds to measures of anxiety, but this was not confirmed by indepen- the effectiveness of medication. If CBT is more effective dent observer ratings (110). At 12-month follow-up, signifi- than PDT, this difference is neither large nor reliable. How- cant differences favouring CBT remained on two of the ever, there are too few large-scale trials to fully establish measures (110).
Two small studies of panic disorder have been reported.
The dynamic therapies considered under the heading In one study, panic-focused PDT was clearly superior to "PDT" are probably quite similar in practice, but vary in the- applied relaxation (73% vs. 39% response) (111), specifically oretical orientation, content focus, and style of delivery for those with comorbid personality disorders (112). A simi- (supportive vs. confrontational), and no single type of PDT lar study contrasted this treatment with CBT and found no emerges as particularly efficacious. The literature on long- significant differences, although a larger sample with the term PDT, which is still in its infancy, suggests that this same response ratios (47% PDT vs. 72% CBT) would lead to approach may have value, perhaps particularly with more statistical significance (H50.52) (113).
complex and chronic cases of depression. There is a ques- There is no evidence that PDT is helpful for obsessive- tion over the issue of cost-effectiveness of these therapies.
compulsive disorder (114). The single study adding PDT to Both established and currently emerging Internet applica- pharmacotherapy reported no significant clinical effect tions of PDT are of particular interest, because of their from this supplemental treatment (115).
potential for efficient dissemination.
There is only one study of PDT as an approach to post- traumatic stress disorder (PTSD) (116), which shows a sig-nificant reduction of intrusion and avoidance compared to waitlist, to about the same extent as hypnotherapy and trau-ma desensitization. Systematic reviews found insufficient evidence in relation to PTSD to warrant comment (117-119), although strong theoretical and clinical arguments Notwithstanding the high lifetime prevalence of anxiety have been advanced for incorporating a psychodynamic disorders (97), few studies have examined the effectiveness approach into PTSD treatment programmes (120).
of PDT for these conditions.
PDT has been shown to be superior to enhanced waitlist for social anxiety and social phobia (98-102). The most recent study, with 207 PDT and 79 waitlist patients, yieldedlarge differences in remission rates (26% vs. 9%) (100). A Meta-analyses have tended to combine different anxiety smaller study showed that adding group PDT to medication disorders when providing effect sizes (31,121). PDT is re- (clonazepam) reduced social anxiety (103) and immature ported to be significantly more effective than inactive control defence styles (104).
conditions with a medium effect size, and to be overall insig- Whilst short-term PDT outperformed applied relaxation, nificantly different when compared with alternative treat- it was equivalent or inferior to prolonged exposure in two ments. However, substantial heterogeneity is reported in small, early studies (98,99). More recent trials contrasting both primary and secondary outcomes. These conclusions PDT with CBT found small between-group differences differ from those of other reviewers (122,123) who compared in remission (100,102). Continuous measures of phobia PDT only with CBT and claimed definite superiority for the favoured CBT at termination. Between 6-month and 2-year latter. This claim, however, has been questioned (121) and follow-up, the differences between the two treatments dis- significant errors may indeed have crept into one of the appeared (105).
above meta-analyses (122).
World Psychiatry 14:2 - June 2015 than routine treatment (21%) and achieved outcomes com-parable to family therapy (41%) and cognitive analytic thera- The effectiveness of PDT for anxiety is crucial in the debate py (32%) (131).
between those who argue for specific treatment approaches, In a recent, exceptionally high-quality study (Anorexia as in CBT, versus those who support a generic approach Nervosa Treatment of OutPatients, ANTOP) (132,133), focal seeking to identify similar unconscious content across diag- dynamic psychotherapy was contrasted with enhanced CBT nostic groups.
and treatment as usual, which incorporated the same intensi- In relation to social anxiety and perhaps generalized anx- ty of psychotherapy, offered by community experts. Weight iety disorder and panic disorder, promising emerging evi- gains were comparable across the three groups over 12 dence supports the argument for a generic approach. The months. With respect to global outcome measures, patients case is weakened, however, by the absence of evidence for allocated to PDT had higher recovery rates than the control PTSD and the evidence of absence of effect for obsessive- group; this was the first study to show superiority to CBT.
compulsive disorder. In general, the methodological weak- Patients in the control group more frequently required inpa- nesses of earlier studies call meta-analytic findings into tient treatment (41%) than those receiving PDT (23%) or CBT (35%). Although full syndrome anorexia nervosa per- Overall, there is considerable potential for further sound sisted in 21% of PDT patients (versus 28% of controls), the research aiming to identify the anxiety conditions for which findings, in association with other studies (134), suggest that PDT may be particularly helpful.
a focus on intra- and interpersonal factors is beneficial forindividuals with this disorder (135).
PDT in the treatment of anorexia nervosa in 12-19-year olds was found to be comparable to family-based treat-ment after 12-18 months of implementation in terms of A small study showed self-psychology oriented PDT to be achieving a target weight, but slightly inferior in terms of superior to nutritional counselling in treating a combination change in body mass index and more frequent hospitaliza- of anorexia and bulimia nervosa. The comparison with an tion (136,137). In an independent study of PDT versus active treatment in the same study (cognitive orientation family-based therapy, age appeared to be a significant therapy) favoured PDT, particularly for bulimia nervosa moderator, with older patients benefitting more from indi- (124). By contrast, two studies focusing on bulimia nervosa vidual therapy and younger patients from family-based found both PDT and CBT to be effective in reducing eating approaches in both short-term (138) and long-term fol- disorder symptoms, but CBT was slightly superior on global low-up (139). A definitive study with larger samples found measures of clinical outcome, self-rated psychopathology that, even for older adolescents, family-based treatment and some indicators of social adjustment (125,126).
achieved higher rates of remission and larger treatment A 16-week course of group psychodynamic psychothera- effects than individual treatment (140).
py for binge eating disorder was superior to treatment asusual on all measures, and mostly equivalent to group CBTin reducing binge eating and overall improvement (79% PDT vs. 73% CBT) (127). PDT resulted in lower depressionand more improvement in self-esteem, but greater suscepti- There is strong evidence (two independent RCTs, one of bility to hunger. There was some indication that patients which is large) that PDT can contribute to recovery from with higher attachment anxiety benefitted more from PDT.
anorexia nervosa. This is underscored by the fact that treat- A recent report of an RCT of 70 patients with bulimia ner- ment as usual in the ANTOP trial included psychotherapy, vosa, contrasting 2 years of once-weekly PDT with 20 ses- which, given the location of the study (Germany), was most sions of CBT over 5 months, found CBT to be more effective likely to have been non-manualized PDT.
in both the short (5 months) and long (2 years) term (128).
While available studies are small and conflicting, there is Both treatments were effective in reducing eating disorder sufficient uncertainty about the relevance of PDT for bulim- symptoms and general psychopathology. On the face of it, ia nervosa to warrant further research in which the imple- this finding might be considered to have appropriately chal- mentation of the therapy is more appropriately symptom- lenged the value of PDT, except that, strangely, this manual- ization of PDT precluded addressing bingeing and purgingunless the topic was volunteered by the patient (129). Thefindings drew attention to the importance of adapting PDT to the patient's presenting problems (130).
An RCT comparing focal PDT with family therapy, cogni- A number of studies have examined the usefulness of tive analytic therapy and routine treatment of anorexia ner- interpersonally oriented PDT for individuals presenting with vosa found that PDT achieved more improvement (52%) a range of pain symptoms.
A relatively large study of irritable bowel syndrome pa- significant differences between groups for follow-up hospi- tients, randomized to usual (medical) care or PDT (plus usual tal costs (151).
care), reported substantial changes in somatic symptoms,abdominal pain and bowel dysfunction at 3 and 15 months inthe PDT group (141). A 12-week trial found that women pre- senting with irritable bowel syndrome benefitted more fromPDT than from active listening in terms of self- and doctor- No meta-analyses have been reported recently. A limited rated symptoms (142). Those in the control group who ac- review identified only 13 RCTs and a moderate effect size cepted psychotherapy after the end of treatment improved, for somatic symptoms (d520.59; 95% CI: 20.78 to 20.40), and those who declined relapsed.
but the random effects model failed to reach significance A further study with people with the same clinical prob- (152). The effects are clearer for psychiatric symptoms and lems contrasted eight sessions of PDT with pharmacological social adjustment than somatic symptoms.
treatment (paroxetine) and treatment as usual (143). Bothactive treatments reduced physical distress but neither im-proved pain ratings. Psychotherapy reduced health care costs during the follow-up year. Patients with a history ofsexual abuse particularly benefitted from PDT, but those The evidence base for PDT in somatoform disorders com- with depression did better with paroxetine treatment.
pared to control treatments is quite robust. Although there A comparison of PDT with supportive psychotherapy in are no adequate meta-analytic summaries, this narrative patients with dyspepsia reported that at 1 year 54% felt review clearly reveals that an interpersonal form of dynamic physically much better with the former treatment, com- therapy has substantial and relatively long-term effects, with pared to 28% of those receiving the latter (144). The physi- medium effect sizes compared to enhanced treatment as cal improvements were in line with improvements in usual, and that PDT may be able to reduce long-term health psychological symptoms in the PDT group. These findings care costs for somatic disorders.
were replicated in a small Iranian RCT, indicating cultural Interestingly, there appear to have been no comparisons with active symptom-focused psychosocial treatments such A well-powered trial in patients with chronic pain symp- as CBT. Yet, a comparison may be relatively easy, since in toms, randomized to PDT or enhanced medical care, yielded this context PDT is mostly offered as a particularly brief medium between-group effects (d50.42) for physical quality intervention (8-10 sessions).
of life at 9-month follow-up (146). An earlier study with a The overall impression is that PDT may be more effective smaller sample of patients with somatoform pain disorder when somatoform disorders are associated with adverse and a much longer (33 sessions) treatment also yielded sig- social histories rather than manifest psychiatric problems.
nificant pain reductions, in addition to improvements insomatization, mood and social adjustment (147).
An evaluation of 25 sessions of PDT compared to four consultations over 6 months for patients with fibromyalgiafound no evidence of superiority of PDT for symptoms spe- RCTs suggest that the value of PDT in the treatment of cific to this disorder or general psychiatric problems (148).
drug dependence is moderated by the substance involved.
However, the training offered to the therapists was brief An early study of methadone-maintained opiate dependence (4 hours) and focused on insight rather than interpersonal found drug counselling plus either supportive-expressive emotional awareness, which has been found to be more rel- PDT or CBT to be beneficial relative to drug counselling evant (149).
alone, but there were no differences between the two psy- An imaginative study randomized general practitioners chotherapies (153-155). Patients with psychiatric morbidity to be trained to work jointly with psychodynamic psycho- benefitted most from the psychotherapies (156). A replica- therapists to deliver 10 weekly group therapy sessions tion study of methadone users with psychiatric morbidity in addition to the diagnosis and psychological management contrasted only PDT with counselling and observed a reduc- of medically unexplained symptoms (150). This large trial tion of cocaine-positive but not opiate-positive urine sam- found significant small to medium health benefits over ples during the treatment period (157). Importantly, this enhanced medical care from this psychodynamic group study demonstrated better maintenance of abstinence at 6 months, lower-dose methadone use and a significant reduc- A large quasi-experimental study compared pre- and tion in psychiatric morbidity.
post-treatment health care costs for 890 patients treated A study of cocaine dependence, contrasting CBT, PDT with brief PDT for a broad range of somatic and psychiatric and individual drug counselling based on the 12-step philos- disorders with those of a control group (N5192) who were ophy (all incorporating group drug counselling) with group referred but never treated, and found an average cost reduc- drug counselling alone, found individual drug counselling tion per treated case of $12,628 over 3 follow-up years, with to be most efficacious (158). Neither CBT nor PDT added World Psychiatry 14:2 - June 2015 benefit to group drug counselling, and they did not differ is limited even for CBT. The available evidence for PDT sug- from each other in terms of effectiveness. Thirty-eight per- gests some possible immediate benefit from dynamic ap- cent of individual drug counselling patients compared to proaches, but benefits are not sustained in the longer term.
18% of PDT patients maintained 3 months of consecutiveabstinence. However, individual drug counselling did notreduce psychiatric symptoms, unemployment, or medico- PERSONALITY DISORDERS legal, social, alcohol or interpersonal problems to a greaterextent than the other treatments (159).
A relatively wide range of dynamic therapies have been evaluated for a number of personality disorders, against bothactive and inactive control treatments. A number of small tri- als report intensive, relatively brief (25-40 sessions) PDT tobe superior to minimal contact (166), waitlist (167,168) and It is unclear whether PDT should be recommended to treatment as usual (169-172). Some studies demonstrated supplement the treatment of opiate-dependent individuals.
the value of longer-term treatments for specific diagnoses, Individual drug counselling clearly has benefit and, since for example, borderline personality disorder (173,174).
contingency management has become a preferred treatment Brief therapies do less well against active controls. In for dependency problems (20,40), the role of PDT in the mixed personality disorder populations, manualized PDT treatment of drug dependence is currently doubtful.
was not superior to supportive psychotherapy (175), adap-tive psychotherapy (167) or non-manualized community-delivered PDT (176). In a comparison of non-manualized PDT with CBT, the latter was more efficacious over a20-session treatment and follow-up for avoidant personality A Cochrane review of individual PDT for schizophrenia disorder (168). In contrast, a trial of manualized PDT versus and severe mental illness, including four randomized trials CBT for cluster C personality disorder patients reported no with 528 participants, found that patients who had received significant differences and a somewhat more rapid reduction PDT used less medication, were no more or less likely to be of symptom distress in the PDT group (177). A further com- rehospitalized, but were less likely to be discharged (160).
parison between PDT, CBT and brief relational therapy There was no clear evidence of any positive effect of PDT (which focuses on ruptures in the therapeutic alliance) found and adverse effects were not considered. Another meta- that the latter two treatments were associated with a higher analytic review (161), which identified 37 studies with 2,642 percentage of clinically significant and reliable change in the patients, incorporated many studies from the 1950s to the treatment of cluster C personality disorder, although the dif- 1970s, when treatment pathways and practices were quite ferences were not significant (178).
different, which makes the pooled estimates impossible to There have been larger trials with active treatment com- parisons focused on borderline personality disorder. Trans- In a partial RCT, the Danish National Schizophrenia ference-focused psychotherapy was shown to be superior to Project (162), patients with first episode psychosis received supportive psychotherapy and dialectical behaviour thera- one of three treatment packages: one including PDT, the py on some symptom measures (improving irritability, second multi-family treatment, and the third treatment as anger and assault and impulsivity) (179) as well as a num- usual. Only a small subgroup of patients was randomized.
ber of attachment-related measures (180). Similarly, When controlled for drug and alcohol use, the 1-year com- mentalization-based treatment was shown to be superior parison revealed benefit from PDT (162). A further analysis to structured clinical management of equal intensity (181), after 2 years contrasted treatment as usual (N5150) with particularly for patients with more than two personality PDT (N5119) (only 72 patients had been randomly allocat- disorder diagnoses (182). Mentalization-based treatment ed). Patients receiving PDT had higher Global Assessment was also found to be superior to supportive group therapy, of Functioning scores (medium effect size) (163). Benefits but only in terms of global assessment of functioning, at were no longer evident at 5-year follow-up (164).
termination (183) and at 18-month follow-up (184). How- A pilot study of psychodynamic art therapy vs. treatment ever, an RCT comparing transference-focused psychother- as usual with a small sample found a post-treatment reduc- apy and CBT (schema-focused therapy) found CBT to be tion in positive psychotic symptoms, which dissipated 6 more effective, particularly because early dropout rates weeks later (165).
were higher for the former treatment (185). In this context,it is noteworthy that the introduction of mentalization-based treatment to a specialist unit for borderline personal- ity disorder was historically associated with a substantialreduction of dropouts (from 15% to 2%) (186).
There is increasing optimism about the value of psycholog- While the inclusion of general psychiatric management ical therapy for psychosis, although the supporting evidence in a review of PDT may perhaps be controversial, this "dynamically informed" intervention, manualized by two while mentalization-based treatment is deemed probably ef- psychodynamic practitioners (187), owes much to dynamic ficacious. In fact, a number of the comparator treatments techniques and conceptualization of borderline personality considered above also have strong claims to being empirical- disorder. It has been shown to be comparable to dialectical ly supported, notably relational psychotherapy for general behaviour therapy at termination (188) and 2-year follow- personality disorder (193), manualized dynamic supportive therapy (194) and brief adaptive psychotherapy (195).
A review of the treatment of personality disorders (196) summarizes the characteristics required for an effective treat- ment as structured, focused on developing agency, integrativeof feelings and actions, active and validating, and incorporat- There are few meta-analyses specific to PDT for personal- ing supervision. Most dynamic therapies will incorporate ity disorders, although a number of the meta-analyses focus- these features. Their relative efficacy is thus hardly surprising.
ing on long-term psychotherapy capture many if not all ofthe relevant studies (190,191).
One meta-analysis of controlled and uncontrolled studies for patients with comorbid depression reported large pre-post effect sizes (d51-1.27) and superiority to waitlist, but What can be concluded about the efficacy of PDT? In- no significant differences in efficacy compared to other triguingly, different reviews of the same literature appear treatments (63). The most comprehensive meta-analysis sometimes to reach dramatically different conclusions (190, reported medium effect sizes compared to inactive controls 191,197-201). There is a clear need for authors to declare (31). Active treatment comparisons yield insignificant but interests, since the conclusions of reviews often appear to negative effect sizes (g520.15, 95% CI: 20.3 to 0.1) and no reflect the authors' theoretical orientation, just as the out- significant difference at follow-up.
comes of individual studies appear to be highly correlated Breaking down outcomes to symptomatology, global func- with the first author's affiliation (202). This tendency is tioning, interpersonal problems, depression and suicidality regrettable, because the lack of balance and the determina- also revealed no significant differences between PDT and tion to use statistics primarily for support leads to entrenched other therapies on any of these dimensions, but medium traditions and conflicts with the need to innovate through effect sizes in relation to control treatments. A marginally sig- the process of collaboration that is so characteristic of discov- nificant association between the number of sessions and ery science.
effect size is reported.
The extension of the evidence-based movement to psycho- However, it would be wrong to argue that complex disor- therapy, which we strongly support, may have reinforced a ders always require complex and long-term PDT interven- conservatism by raising the bar for accepting innovative ap- tions. Patients with chronic mental disorders (average 5-year proaches. Could CBT be discovered and disseminated now chronicity), who were frequent utilizers of mental health under the empirically supported therapies paradigm (203)? services, were randomized to treatment as usual or very brief Complex combinations of techniques have been packaged as (8-session) PDT (192). Six months post-treatment there were empirically supported therapies. Increasingly, developers significant benefits in terms of general psychiatric distress, have prioritized the implementation of packages without social functioning, quality of life, and resource utilization in regard to the unique value of each component. These treat- terms of outpatient attendance, general practitioner contacts, ment packages evolve in relation to what many now consider nurse contacts and medication. The cost of psychotherapy a less-than-adequate system of diagnostic classification (204- was recouped through reductions in resource use. The study 206). Transdiagnostic considerations will ultimately out- underscores the absence of a simple linear relationship be- weigh syndrome-specific treatment recommendations.
tween the length of a dynamic treatment and the severity of Given all this, is it possible to make meaningful recom- mendations about PDT based on the evidence? The follow-ing suggestions seem to be well grounded in data:  Treatment approaches generated from PDT principles appear to benefit individuals who present with depres- The evidence concerning personality disorders is rela- sion, some forms of anxiety, eating disorders and so- tively robust in highlighting the superiority of PDT over matic problems.
controls across key clinical variables including suicidality,  Implementations of the same principles in long-term treat- global and interpersonal functioning, as well as comorbid ments (1 year and longer) appear to benefit individuals with complex disorders where the severity manifests as a The American Psychological Association (Division 12) combination of syndromal and spectral-level problems (a has designated transference-focused psychotherapy a well- generally high level of vulnerability to psychopathology) established treatment for borderline personality disorder, World Psychiatry 14:2 - June 2015  There is little evidence to suggest that PDT is superior to Gardner and Dr. A. Higgitt for assistance with the litera- other therapeutic approaches. Its implementation in ture review and drafting the manuscript, and Dr. P. Luyten most instances will depend on the availability of appro- for helpful discussions.
priately trained personnel and their willingness to ac-quire the specific techniques that have been shown to be efficacious to a level of competence on a par with per-sonnel delivering treatments in RCTs.
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