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Original Investigation
September 2016

Comparative Effectiveness of Cognitive Therapy and Dynamic Psychotherapy for Major Depressive Disorder in a Community Mental Health SettingA Randomized Clinical Noninferiority Trial

Author Affiliations
  • 1Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, Philadelphia
  • 2NHS Human Services, Erdenheim, Pennsylvania
JAMA Psychiatry. 2016;73(9):904-912. doi:10.1001/jamapsychiatry.2016.1720
Key Points

Question  Is short-term dynamic psychotherapy not inferior to cognitive therapy in the treatment of major depressive disorder (MDD) in the community mental health setting?

Findings  In this randomized noninferiority trial that included 237 adults, short-term dynamic psychotherapy was statistically significantly noninferior to cognitive therapy in decreasing depressive symptoms among patients receiving services for MDD in the community mental health setting.

Meaning  Short-term dynamic psychotherapy and cognitive therapy may be effective in treating MDD in the community.


Importance  Dynamic psychotherapy (DT) is widely practiced in the community, but few trials have established its effectiveness for specific mental health disorders relative to control conditions or other evidence-based psychotherapies.

Objective  To determine whether DT is not inferior to cognitive therapy (CT) in the treatment of major depressive disorder (MDD) in a community mental health setting.

Design, Setting, and Participants  From October 28, 2010, to July 2, 2014, outpatients with MDD were randomized to treatment delivered by trained therapists. Twenty therapists employed at a community mental health center in Pennsylvania were trained by experts in CT or DT. A total of 237 adult outpatients with MDD seeking services at this site were randomized to 16 sessions of DT or CT delivered across 5 months. Final assessment was completed on December 9, 2014, and data were analyzed from December 10, 2014, to January 14, 2016.

Interventions  Short-term DT or CT.

Main Outcomes and Measures  Expert blind evaluations with the 17-item Hamilton Rating Scale for Depression.

Results  Among the 237 patients (59 men [24.9%]; 178 women [75.1%]; mean [SD] age, 36.2 [12.1] years) treated by 20 therapists (19 women and 1 man; mean [SD] age, 40.0 [14.6] years), 118 were randomized to DT and 119 to CT. A mean (SD) difference between treatments was found in the change on the Hamilton Rating Scale for Depression of 0.86 (7.73) scale points (95% CI, −0.70 to 2.42; Cohen d, 0.11), indicating that DT was statistically not inferior to CT. A statistically significant main effect was found for time (F1,198 = 75.92; P = .001). No statistically significant differences were found between treatments on patient ratings of treatment credibility. Dynamic psychotherapy and CT were discriminated from each other on competence in supportive techniques (t120 = 2.48; P = .02), competence in expressive techniques (t120 = 4.78; P = .001), adherence to CT techniques (t115 = −7.07; P = .001), and competence in CT (t115 = −7.07; P = .001).

Conclusions and Relevance  This study suggests that DT is not inferior to CT on change in depression for the treatment of MDD in a community mental health setting. The 95% CI suggests that the effects of DT are equivalent to those of CT.

Trial Registration  clinicaltrials.gov Identifier: NCT01207271