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Lancet Psychiatry 2015; Psychodynamic therapy (PDT) is an umbrella concept for treatments that operate on an interpretive-supportive
2: 64860 continuum and is frequently used in clinical practice. The use of any form of psychotherapy should be supported by
Department of Psychosomatics sucient evidence. Ecacy research has been neglected in PDT for a long time. In this review, we describe
and Psychotherapy, Justus-
methodological requirements for proofs of ecacy and summarise the evidence for use of PDT to treat mental
Liebig-University Giessen,
Giessen, Germany health disorders. After specifying the requirements for superiority, non-inferiority, and equivalence trials, we did a
(F Leichsenring Dsc, F Leweke MD, systematic search using the following criteria: randomised controlled trial of PDT; use of treatment manuals or
C Steinert MSc); Faculty of manual-like guidelines; use of reliable and valid measures for diagnosis and outcome; adults treated for specic
Psychology and Educational
Sciences, University of Leuven,
mental problems. We identied 64 randomised controlled trials that provide evidence for the ecacy of PDT in
Leuven, Belgium, and Research common mental health disorders. Studies suciently powered to test for equivalence to established treatments did
Department of Clinical, not nd substantial dierences in ecacy. These results were corroborated by several meta-analyses that suggest
Educational and Health PDT is as ecacious as treatments established in ecacy. More randomised controlled trials are needed for some
Psychology, University College
London, Gower Street, London,
mental health disorders such as obsessive-compulsive disorder and post-traumatic stress disorder. Furthermore,
UK (P Luyten PhD); The Derner more adequately powered equivalence trials are needed.
Institute of Advanced
Psychological Studies, Adelphi Introduction of a study, ie, the observed eects can be causally
University, NY, USA
(M J Hilsenroth PhD,
Psychotherapy is eective for the treatment of a broad related to the applied treatments, at the possible expense
J P Barber PhD); Department of range of mental disorders, symptoms, and problems.1 of external validity, ie, generalisability to real-world
Psychiatry, Dalhousie The use of any form of psychotherapy should be sup- conditions in clinical practice. In contrast, eectiveness
University, Centre for Emotions ported by sucient evidence.2 studies investigate the eects of an intervention in
and Health, Halifax, NS, Canada
(A Abbass MD FRCP);
Psychodynamic therapy is an umbrella concept for routine clinical care and therefore have high external
Department of Psychology, treatments that operate on an interpretive-supportive validity, but at the possible expense of internal validity.
University of Pennsylvania, continuum.3 By interpretive interventions insight into Thus, ecacy and eectiveness studies address dierent
Philadelphia, PA, USA wishes, aects, object relations or defence mechanisms research questions. For treatments that have been
(J R Keefe MA); and Department
of Psychology, Alpen-Adria-
is enhanced. Supportive interventions include fostering evaluated in RCTs, studies are needed to investigate their
Universitt Klagenfurt, a therapeutic alliance, setting goals, or strengthening eectiveness in real-life conditions.6
Klagenfurt, Austria, and psychosocial capacities such as reality testing or impulse In an RCT, a treatment might be compared with
Department of Medical
control.3 The use of more supportive or more interpretive dierent control conditions, eg, no treatment, a placebo, a
Psychology, University Medical
Center Hamburg-Eppendorf, (insight-enhancing) interventions is tailored to the treatment as usual, an alternative treatment, or a treatment
Hamburg, Germany patients needs.3 There is a range of manualised psycho- with known ecacy. The strictest test of ecacy is to
(S Rabung MSc) dynamic therapies4 that vary in the extent to which they compare the novel treatment with a treatment of proven
Correspondence to: focus on supportive or expressive elements. ecacy, because this study design controls for both
Dr Falk Leichsenring, In this review, we address the methodological and specic and non-specic (or common) factors.7
Department of Psychosomatics
and Psychotherapy,
statistical requirements to determine ecacy in psycho- A treatment comparison with a waiting list condition (no
Justus-Liebig-University Giessen, therapy. We dierentiate between testing superiority, treatment) controls for the natural course of the disorder
D-35392 Giessen, Germany non-inferiority, and equivalence. We focus specically only, whereas comparison with another psychotherapy, a
falk.leichsenring@psycho.med. on the latter, because testing equivalence has not yet placebo, or a treatment as usual controls for factors
uni-giessen.de
been widely implemented in psychotherapy research. common to all types of psychotherapy (eg, therapeutic
Although studies often claim to have shown equivalence alliance, expectations, motivation, general support and
in outcome they often do not meet the requirements to attention).8 This implies that the dierent study designs
do so. We apply these considerations specically to PDT, and comparison conditions are associated with dierent
which is frequently used in clinical practice,5 to update research questions (ie, is a treatment ecacious when
and expand on the evidence for PDT in specic mental controlling for the natural course, for common factors or
disorders (panel 1).4 However, these considerations apply for common and and specic factors?). Furthermore, a
to any psychotherapeutic or pharmacological treatment. treatment might be expected to be superior, non-inferior,
or equivalent to another treatment or condition. Thus, to
Methodology to determine ecacy: Grades of distinguish between testing for superiority, equivalence,
evidence and non-inferiority is important.
Randomised controlled trials (RCTs) are viewed by most
as the gold standard, but RCT methodology has both Superiority
strengths and weaknesses.2 For example, a randomised For a treatment to be considered superior to another
controlled ecacy study maximises the internal validity treatment, the treatment group must show a statistically
BT=behaviour therapy. DC=drug counselling. ICBT=internet cognitive-behavioural therapy. LTPP=long-term psychodynamic therapy. PDT=psychodynamic therapy.
TAU=treatment as usual. STPP=short-term psychodynamic therapy. SFT= Solution-focused therapy. The outcome was evaluated separately for depressive and anxiety
disorders; only results of STPP were included in this Review as for LTTP no manuals were used. *The outcome was evaluated separately for depressive and anxiety disorders.
The outcome was evaluated separately for depressive and anxiety disorders; only results of STPP were included in this Review as for LTTP no manual was used.
With regard to comparisons of established treatments inferiority.21,23 No signicant dierences in outcome were
such as CBT or pharmacotherapy, two studies were found in these RCTs. However, the rst study applied
suciently powered to test for equivalence or non- the traditional two-sided test rather than the TOST
procedure.23 The other RCT tested for non-inferiority.21 Rating Scale), but the study was not suciently powered
In this RCT, non-inferiority of PDT compared with CBT for an equivalence trial.46 In secondary measures (eg, worry
was not shown for remission rates but was shown for and depression), CBT achieved statistically signicant
continuous measures of depression post treatment.21 better outcomes.46,93 Treatment eects were stable
However, the dierence in remission rates (21% for PDT 12 months after the end of therapy.93 In another RCT,
vs 24% for CBT) was minimal from a clinical perspective. internet-guided psychodynamic self-help proved to be
Results from several RCTs showed no dierences in superior to a waiting list control condition in generalised
outcome between PDT and treatments with known anxiety disorder.47 No dierences compared with internet-
ecacy, but the studies were not suciently powered to guided CBT were reported, but this study was not
demonstrate equivalence if the criterion of at least suciently powered to demonstrate equivalence (table 2).
70 patients per group is applied.18,19,25,26,29 Because meta- For a mixed sample including various categories of
analyses of relatively few studies achieve a higher anxiety disorders, short-term PDT was superior to long-
statistical power than individual studies, it is of note that term PDT (and as ecacious as solution-focused
results from several meta-analyses showed individual therapy) with regard to recovery at the 7-month follow-
PDT to be ecacious in depressive disorders with no up.37 In a mixed sample of patients with either depressive
dierences to other established treatments.9092 disorder or anxiety disorders, or both, PDT was superior
to treatment as usual (pharmacotherapy).35
Complicated grief Combination of PDT plus pharmacotherapy was shown
The ecacy of PDT in complicated grief was demon- to be superior to pharmacotherapy alone in the treatment
strated in two RCTs.38,39 In these studies, PDT was of social anxiety disorder44,45 and panic disorder.50 For
superior to a waiting list condition or a supportive panic disorder, rates of remission and relapse prevention
treatment. in PDT combined with pharmacotherapy was superior to
pharmacotherapy alone.50
Anxiety disorders In a recent meta-analysis, PDT was superior to inactive
Results from several RCTs have provided evidence for the control conditions in anxiety disorders.94 No dierences
ecacy of PDT in the treatment of anxiety disorders were found between PDT and other bona-de treat-
(table 2). For panic disorder, PDT was superior to applied ments.94 For this meta-analysis, the authors reported that
relaxation.48 In an RCT of PDT versus CBT in panic large and medium eect sizes between PDT and
disorder, no signicant dierences in remission rates alternative active treatments at termination would be
were found, but the study was not suciently powered to detected with a power of about 100 regardless of the
show equivalence.49 For social anxiety disorder, PDT was degree of heterogeneity.94
superior to a credible placebo or as ecacious as CBT.40,41
Results from a recent RCT showed PDT to be superior to Post-traumatic stress disorder
a waiting list control condition and to be as ecacious as Results from an RCT showed no signicant dierences
CBT in all outcomes (social anxiety, general psycho- in outcome between PDT, hypnotherapy, and CBT.52
pathology, and defence mechanisms).40 Success rates However, this study was not suciently powered to show
were above 50% and were found to be stable at the equivalence (table 2). PDT was superior to a waiting list
3-month and 12-month follow-up. For comparison with control condition in two of three measures and achieved
CBT, the authors reported the study to be suciently the largest within-group eect sizes at follow-up.
powered to detect medium dierences.40 In a large
multicentre RCT, both PDT and CBT were superior to a Somatoform disorders or somatic symptom disorder
waiting list control condition.42 No dierences between There is a substantial body of evidence for the ecacy of
PDT and CBT were found with regard to response rates PDT in somatoform disorders, now referred to as somatic
and reduction of depression.42 CBT showed statistically symptom disorder in DSM-5 (table 2). Evidence from
signicant better outcomes on remission rates, self- RCTs is available for irritable bowel syndrome,53,55,57
reported social anxiety and interpersonal problems, yet functional dyspepsia,54,56 and somatoform pain disorder.58,59
these dierences were small and below the threshold In each of these RCTs, PDT was superior to treatment as
dened a priori as clinically meaningful.42 Furthermore, usual or supportive therapy. Furthermore, results from a
there were no dierences in long-term eects on any meta-analysis showed PDT to be ecacious in patients
outcome measure 6, 12, and 24 months after the end of with somatic disorders.95
therapy.43 Although originally designed as a superiority
study to detect small dierences in outcome, this study Eating disorders
was suciently powered to test for equivalence if the Results from a bulimia nervosa study61 showed that PDT
power criterion proposed above is applied. was superior to CBT and nutritional counselling. Results
For generalised anxiety disorder, results from one study from two other studies60,62 showed no dierence in
showed no signicant dierences between PDT and CBT primary outcome measure (bulimic episodes and
in the primary outcome measure (Hamilton Anxiety vomiting) between PDT, and CBT but these studies were
not suciently powered to demonstrate equivalence with regard to improvements in reective functioning and
(table 2). Dierences in favour of CBT were found in attachment.76 Only TFP and SPT were associated with
secondary measures.60,62 In another RCT,63 CBT was improvements in anger and impulsivity, and only TFP
superior to PDT, but the study was controversial because was associated with change in irritability and verbal and
PDT was manualised but not symptom-focused.96,97 direct assault.75 TFP produced signicant improvements
Results from two studies provided evidence for PDT in in ten of 12 outcome measures, DBT in ve of 12 measures
anorexia nervosa.65,66 One RCT compared manual-guided and SPT in six of 12 measures.75 The ecacy of TFP was
PDT, enhanced CBT, and optimised treatment as usual corroborated by another RCT showing that TFP was
in the treatment of anorexia nervosa.66 At the end of superior to a treatment by experienced community
treatment, signicant improvements were noted in all therapists.77 Gregory and colleagues79 reported PDT
treatments, with no dierences in the primary outcome (deconstructive therapy) to be superior to a treatment as
measure (body-mass index, BMI). At 12-month follow- usual condition in borderline patients with co-occurring
up, however, PDT was signicantly superior to optimised alcohol use disorder. Another RCT compared PDT (ie,
treatment as usual on rates of recovery, whereas transference-focused psychotherapy, TFP) with schema-
enhanced CBT was not signicantly superior.66 Recovery focused therapy (SFT).78 The authors reported statistically
rates were 35% for PDT, 19% for enhanced CBT and 13% and clinically signicant improvements for both
for optimised treatment as usual. This study was treatments. However, SFT was reported to be superior to
suciently powered to show equivalence (table 2). In a TFP in several outcome measures. Furthermore, a
binge-eating-disorder study, PDT was superior to a signicantly higher dropout was reported in TFP.
waiting list control condition and as ecacious as CBT.64 Concerns on the methodology used in this study, in
Two eating-disorder studies were not suciently particular regarding treatment integrity of TFP have been
powered to demonstrate equivalence to active treatments published.102,103 The two studies that compare PDT to
(table 2).64,65 For the comparison with routine treatment65 another active treatment were not suciently powered to
and waiting list,64 these studies were suciently powered show equivalence, but both studies reported superiority of
to show superiority. PDT or SFT at least in some measures.76,78
Several open questions remain that require further 15 Treadwell JR, Uhl S, Tipton K, et al. Assessing equivalence and
research on PDT: new RCTs are needed, particularly for noninferiority. J Clin Epidemiol 2012; 65: 114449.
16 Borenstein M, Hedges LV, Higgins JPT, Rothstein HR.
disorders such as obsessive-compulsive disorder and Introduction to meta-analysis. Chichester, UK: Wiley; 2011.
post-traumatic stress disorder for which only one 17 Hedges LV, Pigott TD. The power of statistical tests in
relatively old RCT exists.52 More adequately powered meta-analysis. Psychol Methods 2001; 6: 20317.
equivalence trials are needed. Future studies on PDT 18 Barber JP, Barrett MS, Gallop R, Rynn MA, Rickels K. Short-term
dynamic psychotherapy versus pharmacotherapy for major
should measure not only symptoms or DSM criteria, but depressive disorder: a randomized, placebo-controlled trial.
also measures that are more specic to PDT. Future J Clin Psychiatry 2012; 73: 6673.
studies should also examine whether there are specic 19 Barkham M, Rees A, Shapiro DA, et al. Outcomes of time-limited
psychotherapy in applied settings: replicating the Second Sheeld
gains achieved only by PDT. Added value of PDT was Psychotherapy Project. J Consult Clin Psychol 1996; 64: 107985.
demonstrated, for example, by Levy and colleagues76 who 20 Gibbons MB, Thompson SM, Scott K, et al. Supportive-expressive
compared improvements in reective functioning and dynamic psychotherapy in the community mental health system:
a pilot eectiveness trial for the treatment of depression.
attachment between PDT and DBT. To further improve Psychotherapy (Chic) 2012; 49: 30316.
PDT, future research should address the mechanisms of 21 Driessen E, Van HL, Don FJ, et al. The ecacy of cognitive-
change. The question of what works for whom should behavioral therapy and psychodynamic therapy in the outpatient
treatment of major depression: a randomized clinical trial.
also be examined. Am J Psychiatry 2013; 170: 104150.
Contributors 22 Cooper PJ, Murray L, Wilson A, Romaniuk H. Controlled trial
FaL and CS conceptualised and designed the Review, did literature of the short- and long-term eect of psychological treatment of
searches, assessed eligibility of the studies for inclusion, extracted the post-partum depression. I. Impact on maternal mood.
data, and double checked extracted information. FaL drafted the report, to Br J Psychiatry 2003; 182: 41219.
which all authors contributed signicantly. All authors critically revised 23 de Jonghe F, Hendricksen M, van Aalst G, et al. Psychotherapy
the Review for important intellectual content. All authors had access to alone and combined with pharmacotherapy in the treatment of
all data and the nal manuscript has been approved by all authors. depression. Br J Psychiatry 2004; 185: 3745.
24 Johansson R, Ekbladh S, Hebert A, et al. Psychodynamic guided
Declaration of interests self-help for adult depression through the internet: a randomised
We declare no competing interests. controlled trial. PLoS One 2012; 7: e38021.
Acknowledgments 25 Salminen JK, Karlsson H, Hietala J, et al. Short-term
psychodynamic psychotherapy and uoxetine in major depressive
We thank Emmanuel Lesare (L-Biostat, KU Leuven, Belgium) for
disorder: a randomized comparative study.
helpful comments on statistical analysis.
Psychother Psychosom 2008; 77: 35157.
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