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Database of Abstracts of Reviews of Effects (DARE): Quality-assessed Reviews [Internet].

The efficacy of short-term psychodynamic psychotherapy for depression: a meta-analysis

E Driessen, P Cuijpers, SC de Maat, AA Abbass, F de Jonghe, and JJ Dekker.

Review published: 2009.

Link to full article: [Journal publisher]

CRD summary

The authors concluded that short-term psychodynamic therapy was effective for treatment of depression in adults, but failed to fully qualify this by explaining that other psychotherapies were found to be superior to short-term psychodynamic therapy. Given that the authors' conclusions do not reflect all the evidence reported, together with several methodological weaknesses, caution is warranted when interpreting these conclusions.

Authors' objectives

To assess the efficacy of short-term psychodynamic psychotherapy for depression and to identify treatment moderators.

Searching

PubMed, PsycINFO, EMBASE, Web of Science, the Cochrane Central Register of Controlled Trials (CENTRAL) and Current Controlled Trials were searched electronically. No language or date restrictions were imposed. Search terms were reported. UMI ProQuest Digital Dissertations and the Psychotherapy Database of Randomised and Controlled Trials databases were also searched. Unpublished studies were searched for using the Global Legal Information Network (GLIN) database and through contact with authors. Review articles were also consulted for relevant trials.

Study selection

Studies involving at least ten depressed adult patients (aged 18 years or older) receiving short-term psychodynamic psychotherapy were eligible for inclusion. Eligible trials had to reported depression scores on standardised measurement scales. Participants were considered depressed if they met specified criteria for major depressive disorder or mood disorders, or if they presented an elevated score on a standardised measure of depression. Short-term psychodynamic psychotherapy had to be based on verbal psychoanalytic theories and practices, and had to be time-limited from the onset (not in retrospect). Studies assessing the efficacy of interpersonal psychotherapy were excluded, as were case studies.

The included studies were all in adult participants diagnosed with various types of depression including major depression, mood disorder and subsyndromal depression. The treatment format was either group or individual, and the number of sessions of short-term psychodynamic psychotherapy ranged from three to 80. The majority of studies compared short-term psychodynamic psychotherapy with a comparator, such as cognitive behavioural therapy (CBT) and antidepressant medication, or with a control group such as usual care and waiting list. The outcome measures included the Beck Depression Inventory (BDI) and the Hamilton Depression Rating Scale (HAM-D).

Two reviewers independently applied the selection criteria and disagreements were resolved by consensus or consultation with a third reviewer.

Assessment of study quality

The authors stated that quality assessment was undertaken, but they did not report how this was undertaken or how many reviewers performed the task.

Data extraction

Data on the pre- and post-study effects were extracted and used to calculate the change in effect size (post-treatment compared to pre-treatment) and 95% confidence intervals (CI) for each study. Authors were contacted for additional information, where necessary.

The authors did not state how the data were extracted for the review, or how many reviewers performed the data extraction.

Methods of synthesis

The pooled mean effect sizes were calculated using a random-effects model. Statistical heterogeneity was assessed using the Q statistic and the I2 statistic. Publication bias was evaluated using the Duval and Tweedie trim and fill method. Subgroup analysis was also conducted on a number of factors including: study type, use of antidepressants during short-term psychodynamic psychotherapy, depression diagnosis, and blinding.

Results of the review

Twenty-three studies (n=1,365 participants) were included in the review, including 13 randomised controlled trials (RCTs). The quality of the studies was deemed ‘not optimal.’ Several of the studies were not randomised and/or blinded, and there was an absence of, or lack of reporting of, several other key items such as use of antidepressants during STPP (short-term psychodynamic psychotherapy) and treatment integrity checking. Seven studies used intention-to-treat analysis. There was some evidence of publication bias but the authors concluded that it did not significantly influence the results.

STPP versus control groups: Five studies (n=196 participants) compared STPP with waiting list (four studies) or usual care (one study). The pooled effect size was significantly in favour of STPP (0.69, 95% CI 0.30 to 1.08). The level of heterogeneity was low (I2=33%). No subgroup analyses were undertaken for this comparison due to the small number of included studies.

STPP pre- to post-treatment change: Twenty-one studies (n=641 participants) provided information on change in effect size pre- and post-treatment with STPP. STPP was found to significantly improve depression scores post-treatment compared with pre-treatment (1.34, 95% CI 1.13 to 1.55). The level of heterogeneity was moderate (I2 = 60%). Subgroup analyses indicated that similar results were observed in RCTs only and excluding certain outcome measures.

STPP post-treatment to follow-up change: When post-treatment effect sizes were compared with follow-up effect sizes, little difference between time periods were observed, and none of the results were significant.

STPP versus other psychotherapies: Thirteen studies (n=735 participants) compared STPP with a range of therapies including cognitive behavioural therapy, behavioural therapy, cognitive therapy and supportive therapy at post-treatment. Other psychotherapies were found to be statistically superior to STPP in terms of the pooled mean post-treatment effect size difference (-0.30, 95% CI -0.54 to -0.06). The level of heterogeneity was moderate (I2=51%). The superiority of other psychotherapies compared with STPP was also observed at three months and one-year follow-up, but the results were not statistically significant. Subgroup analyses indicated that similar results were observed when considering RCTs only.

Authors' conclusions

Short-term psychodynamic psychotherapy was effective in the treatment of depression in adults.

CRD commentary

The review addressed a clear question and undertook a thorough review of the literature without imposing language restrictions. The potential implications of publication bias were considered and the authors attempted to locate unpublished information. Study selection was undertaken in duplicate using pre-defined methodology, but it was not clear how data extraction or validity assessment were performed, which may have introduced error and bias into the analysis. Meta-analysis was undertaken, which appeared appropriate given the available data, and heterogeneity was explored. The authors’ conclusion that short-term psychodynamic psychotherapy was effective did not take into consideration that their review found that other psychotherapy treatments were statistically superior to short-term psychodynamic psychotherapy post-treatment, so it did not fully match with the data presented. It also appeared that two studies containing less than 10 participants were included, which was contradictory of the authors’ inclusion/exclusion criteria. Overall, the review was well planned but may not have been undertaken or interpreted adequately, so the authors’ conclusions need to be viewed with caution.

Implications of the review for practice and research

Practice: The authors did not state any implications for practice.

Research: The authors stated that more high-quality RCTs are necessary to assess the efficacy of short-term psychodynamic psychotherapy within different patient groups.

Funding

Not stated.

Bibliographic details

Driessen E, Cuijpers P, de Maat SC, Abbass AA, de Jonghe F, Dekker JJ. The efficacy of short-term psychodynamic psychotherapy for depression: a meta-analysis. Clinical Psychology Review 2009; 30(1): 25-36. [PubMed: 19766369]

Indexing Status

Subject indexing assigned by NLM

MeSH

Depression /therapy; Depressive Disorder /therapy; Humans; Psychoanalytic Therapy /methods; Psychotherapy, Brief /methods; Treatment Outcome

AccessionNumber

12009108773

Database entry date

03/02/2010

Record Status

This is a critical abstract of a systematic review that meets the criteria for inclusion on DARE. Each critical abstract contains a brief summary of the review methods, results and conclusions followed by a detailed critical assessment on the reliability of the review and the conclusions drawn.

CRD has determined that this article meets the DARE scientific quality criteria for a systematic review.

Copyright © 2014 University of York.

PMID: 19766369