CRD summary

The review concluded that long-term psychodynamic psychotherapy was superior to less intensive forms of psychotherapy in patients with complex mental health disorders. Potential differences across the trials and the uncertain quality of the included trials make the reliability of the authors’ conclusions uncertain.

Authors' objectives

To examine the comparative efficacy of long-term psychodynamic psychotherapy versus shorter or less intensive psychotherapy in complex mental health disorders.

Searching

MEDLINE, PsycINFO and Current Contents were searched from 1960 to April 2010 for published articles. Search terms were reported. A previous-meta-analysis by the authors was used to identify further studies. Articles and text books were searched manually. Experts in the field were contacted.

Study selection

Prospective trials of long-term psychodynamic psychotherapy versus active control in adult patients (18 years or older) with complex mental health disorders (personality disorder, chronic mental health disorders or more than one mental disorder) were eligible for inclusion. Long-term psychodynamic psychotherapy had to last for at least one year or 50 sessions. Trials had to report valid and reliable outcome measures (not defined in review) and had to provide sufficient data to be able to calculate between-group effect sizes. Trials that did not terminate treatments at the time of outcome assessment were excluded.

The included trials studied long-term psychodynamic psychotherapy versus various comparators (including cognitive therapy, psychiatric treatment as usual, solution-focused therapy and short-term psychodynamic psychotherapy) in adult patients diagnosed with eating disorders, borderline personality disorder, depressive disorders, cluster C personality disorders and anxiety disorders. The mean number of sessions was 120.5 in the long-term psychodynamic psychotherapy groups and 45.4 in control groups. Mean duration of therapy was 78 weeks in the long-term psychodynamic psychotherapy group and 62.9 weeks in the control groups.

The authors did not state how many reviewers performed study selection.

Assessment of study quality

Validity assessment was undertaken using modified Jadad criteria to appraise randomisation, withdrawals and drop-outs, and masking of outcome assessor or use of reliable self-report instrument.

Two reviewers independently performed validity assessment.

Data extraction

Pre- and post-treatment data (on the intention-to-treat populations, where possible) were extracted on overall outcomes, personality outcomes, psychiatric symptoms and social functioning outcomes. These were used to calculate post-treatment differences for each arm, which were used to calculate Hedges’ d effect sizes, together with 95% confidence intervals (CIs).

Two reviewers independently performed data extraction, and disagreements were resolved by consensus. Trial authors were contacted for missing data, where necessary.

Methods of synthesis

A random-effect meta-analysis was used to calculate pooled effect sizes, together with 95% CIs. Statistical heterogeneity was assessed using Cochran's Q and Ι². Publication bias was assessed using funnel plots and file drawer analysis. Sensitivity analysis was undertaken on the basis of treatment duration and number of sessions.

Results of the review

Ten trials (971 patients, range 26 to 326) were included in the review. Nine trials were randomised controlled trials.

Long-term psychodynamic psychotherapy was statistically significantly superior than control for overall effectiveness (Hedges’ d 0.54, 95% CI 0.26 to 0.83, Ι²=23%; 10 trials), target problems (Hedges’ d 0.49, 95% CI 0.27 to 0.71, Ι²=12%; nine trials), psychiatric symptoms (Hedges’ d 0.44, 95% CI 0.15 to 0.73, Ι²=31%; nine trials), personality functioning (Hedges’ d 0.68, 95% CI 0.31 to 1.04, Ι²=0%; seven trials) and social functioning (Hedges’ d 0.62, 95% CI 0.18 to 1.06, Ι²=44%; eight trials).

Sensitivity analysis indicated that results were positively correlated with longer treatment durations and more sessions. There was no evidence of publication bias.

Authors' conclusions

Long-term psychodynamic psychotherapy was superior to less intensive forms of psychotherapy in patients with complex mental health disorders.

CRD commentary

Inclusion criteria for the review were clearly defined. Several relevant data sources were searched. Publication bias was assessed and not detected. Attempts were made to reduce reviewer error and bias during data extraction and quality assessment; the authors did not report the same methods for study selection.

Quality assessment was undertaken using a simple checklist, but the authors did not report the results and so it was not possible for the reader to evaluate the reliability of the included trials. Many of the trials had small sample sizes and there were notable differences across the trials for type of patient, duration of therapy and comparator, which limited the relevance of the pooled results in relation to specific treatments and patient groups. Trials were combined using appropriate statistical methods. Statistical heterogeneity was assessed. No sensitivity analyses were performed to investigate possible effect of the differences in population or comparator treatment.

Potential differences across the trials and the uncertain quality of the included trials make the reliability of the authors’ conclusions uncertain.

Implications of the review for practice and research

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

Research: The authors stated that further studies of long-term psychodynamic psychotherapy with specific therapies (short-term and long-term) were needed. They expressed and interest in comparing long-term and short-term cognitive-behavioural therapy and dialectical behavioural therapy (DBT) in specific mental disorders.

Funding

Not stated.

Bibliographic details

Leichsenring F, Rabung S. Long-term psychodynamic psychotherapy in complex mental disorders: update of a meta-analysis. British Journal of Psychiatry 2011; 199(1): 15-22. [PubMed: 21719877]

Original Paper URL

http://bjp.rcpsych.org/content/199/1/15.abstract

Other publications of related interest

Leichsenring F, Rabung S. The effectiveness of long-term psychodynamic psychotherapy: a meta-analysis. JAMA 2008; 300: 1551-1564.

Indexing Status

Subject indexing assigned by NLM

MeSH

Adolescent; Adult; Chronic Disease; Humans; Long-Term Care; Mental Disorders /therapy; Personality Disorders /therapy; Psychoanalytic Therapy; Psychotherapeutic Processes; Psychotherapy /methods; Randomized Controlled Trials as Topic; Time Factors; Treatment Outcome

AccessionNumber

12011004509

Database entry date

27/03/2012

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.