The efficacy of psychodynamic therapy is controversial. Previous meta-analyses
have reported discrepant results.
To test the efficacy of short-term psychodynamic psychotherapy (STPP)
in specific psychiatric disorders by performing a meta-analysis of more recent
studies. We assessed outcomes in target problems, general psychiatric symptoms,
and social functioning.
We identified studies of STPP published between January 1, 1970, and
September 30, 2004, by means of a computerized search using MEDLINE, PsycINFO,
and Current Contents. Rigorous inclusion criteria, included randomized controlled
trials, use of treatment manuals and ensurance of treatment integrity, therapists
experienced or specifically trained in STPP, treatment of patients with specific
psychiatric disorders, reliable and valid diagnostic measures, and data necessary
to calculate effect sizes. Studies of interpersonal therapy were excluded.
Seventeen studies fulfilled the inclusion criteria. The information was extracted
by 3 raters. Effect sizes were calculated for target problems, general psychiatric
symptoms, and social functioning using the data published in the original
studies. To examine the stability of outcome, we assessed effect sizes separately
for end of therapy and follow-up assessment. The effect sizes of STPP were
compared with those of waiting-list control patients, treatments as usual,
and other forms of psychotherapy.
Short-term psychodynamic psychotherapy yielded significant and large
pretreatment-posttreatment effect sizes for target problems (1.39), general
psychiatric symptoms (0.90), and social functioning (0.80). These effect sizes
were stable and tended to increase at follow-up (1.57, 0.95, and 1.19, respectively).
The effect sizes of STPP significantly exceeded those of waiting-list controls
and treatments as usual. No differences were found between STPP and other
forms of psychotherapy.
Short-term psychodynamic psychotherapy proved to be an effective treatment
in psychiatric disorders. However, further research of STPP in specific psychiatric
disorders is needed, including a study of the active ingredients of STPP.
Effectiveness studies should be included.
The place of psychoanalytic and psychodynamic treatments within psychiatryis controversial.1-4 Forlong-term psychoanalytic psychotherapy and psychoanalysis, convincing outcomeresearch is urgently needed.1,2 Inthe field of short-term psychodynamic psychotherapy (STPP), more evidenceof efficacy is available. Various meta-analyses have addressed the efficacyof STPP.5-7 Svartbergand Stiles6 found STPP to be superior to ano-treatment control condition, but inferior to alternative psychotherapies.According to Crits-Christoph,5 STPP achievedlarge effect sizes compared with untreated waiting-list control patients andwas found to be equally effective as other forms of treatment such as cognitive-behavioraltherapy (CBT) or psychopharmacological treatment. Although the effect sizesof STPP assessed by Anderson and Lambert7 werea bit lower than those reported by Crits-Christoph, their results corroboratedthe findings of Crits-Christoph.5 One factorthat heavily influences the outcome of a meta-analysis is the selection andthe quality of the studies included.8 UnlikeSvartberg and Stiles,6 Crits-Christoph5 and Anderson and Lambert7 includedstudies of interpersonal therapy (IPT) as representative of STPP. However,the relation of IPT to STPP is controversial.9 Accordingto empirical results, IPT seems to be very close to CBT.10
Furthermore, the methodological quality of the studies included in ameta-analysis plays an important role. As Messer and Warren11,12 havepointed out, many studies included in the meta-analysis of Svartberg and Stiles6 showed severe conceptual and methodological flaws.This is also true for the meta-analysis of Grawe et al,13,14 whichcompared STPP and CBT. To avoid these flaws, Crits-Christoph5 includedin his meta-analysis only studies that fulfilled rigorous inclusion criteria(eg, use of therapy manuals, experienced therapists, minimum number of sessions).Wampold et al15 assessed the efficacy of bonafide treatments and did not find differences between different methods ofpsychotherapy. Up to the present, 2 disorder-specific meta-analyses of STPPhave been published. The meta-analysis of Leichsenring,16 whichused criteria similar to those of Crits-Christoph,5 foundSTPP and CBT to be equally effective in the treatment of depression. For thetreatment of personality disorders, significant and large effect sizes forSTPP and CBT were found in the meta-analysis of Leichsenring and Leibing.17
Randomized controlled studies (RCTs) are regarded as the gold standardfor the demonstration that a treatment is effective. This applies not onlyto psychotherapy research but to the realm of evidence-based medicine in general.18-22 Thisassumption is reflected in the criteria proposed by the Task Force on Promotionand Dissemination of Psychological Procedures of Division 12 (Clinical Psychology)of the American Psychological Association for the definition of empiricallysupported treatments.23 According to thesecriteria, empirical support for psychotherapeutic methods can only be providedby RCTs in which a therapy group is compared with a control condition (waitinglist or placebo group) or with an already established therapy.8,23,24 Furthermore,the use of therapy manuals and the treatment of a specific disorder are required.
Since the publication of the meta-analyses of Svartberg and Stiles,6 Crits-Christoph,5 Graweet al,13 and Anderson and Lambert7 andthe report of the Task Force,23 several studiesof STPP have been published that have not yet been included in meta-analysesof STPP. The most recent study included by Anderson and Lambert was publishedin 1993, ie, more than 10 years ago.25 Forthis reason, we conducted a new meta-analysis that included the more recentstudies of STPP. As the results of a meta-analysis depend on the quality ofthe studies included, we applied rigorous inclusion criteria.
This meta-analysis addressed the following questions: (1) What is theevidence of improvement in target problems, general psychiatric symptoms,and social functioning after STPP? (2) Do the effects of STPP exceed the effectsof untreated control groups and treatment-as-usual (TAU) groups? (3) Are theredifferences in efficacy between STPP and other forms of psychotherapy? (4)How stable are the effects of STPP? and (5) Is there a correlation betweenoutcome and duration of treatment?
Apart from conceptual and technical differences, there are some therapeuticelements that the different models of STPP have in common.11,12 Withregard to formal characteristics, they are time limited (usually 16-30 sessionswith a range of 7-40 sessions) and performed in a face-to-face setting, with1 or 2 sessions a week.12,26-28 Therapiesincluding 6 or fewer sessions are regarded as ultrabrief.28 Thetherapeutic techniques of STPP are elaborations and modifications of generalprinciples of psychodynamic psychotherapy. Short-term psychodynamic psychotherapyis characterized by the following features.12 First,therapists are usually relatively active and foster the development of a therapeuticalliance and a positive transference. Second, STPP focuses on specific conflictsor themes that are formulated early in therapy. Third, attention is paid toadherence to the focus, the setting of achievable goals, and termination issues.The focus is on the patients’ experiences here and now, including theirsymptoms. With regard to transference, the emphasis is more on the here-and-nowdimension, ie, on the present relationship between the patient and the psychotherapist,which is not necessarily traced back to the past. In a review of empiricalstudies, Blagys and Hilsenroth29 identified7 features that were observed significantly more frequently in STPP comparedwith CBT, including focus on affect, resistance, identification of consistentpatterns (of relationships, feelings, and behaviors), past experiences, interpersonalexperiences, the therapeutic relationship, and wishes, dreams, or fantasies.
We collected studies of STPP that were published between January 1,1970, and September 30, 2004, by performing a computerized search using MEDLINE,PsycINFO, and Current Contents. The following key words were used: psychodynamic therapy, psychoanalytically oriented therapy, psychoanalytictherapy, and randomized controlled trial.A total of 141 partly overlapping journal articles were found. The only studiesincluded in the meta-analysis fulfilled the following methodological requirements:(1) a randomized controlled design was applied; (2) a specific form of STPPas represented in a treatment manual or manual-like guide was applied, andtreatment integrity was ensured; (3) therapists were specifically trainedand/or experienced in STPP techniques; (4) patients with specific psychiatricdisorders were treated (no mixed samples or analogue studies); (5) the patientsample was clearly described; (6) diagnostic procedures and outcome measuresfor which reliability and validity have been demonstrated were used; and (7)data were reported that are necessary to calculate pretreatment-posttreatmenteffect sizes.
Contrary to the meta-analyses of Crits-Christoph5 andAnderson and Lambert,7 studies of IPT werenot included (eg, Elkin et al30 and Wilfleyet al31), because the relation of IPT to STPPis controversial, and empirical results suggest that IPT is very close toCBT.9 Thus, this review includes only studiesfor which there is a general agreement that they represent models of STPP.As it is questionable to aggregate the results of very different outcome measuresthat refer to different areas of psychological functioning, we assessed theefficacy of STPP separately for target symptoms, general psychiatric symptoms(ie, comorbid symptoms), and social functioning.32 Thisprocedure is analogous to the meta-analysis of Crits-Christoph.5 Asoutcome measures of target problems, we included patient ratings of targetproblems and measures referring to the symptoms that are specific to the patientgroup under study, eg, measures of anxiety for studies investigating treatmentsof anxiety disorders.33 For the efficacy ofSTPP in general psychiatric symptoms, broad measures of psychiatric symptomssuch as the Symptom Checklist-90 and specific measures that do not refer specificallyto the disorder under study were included; eg, the Beck Depression Inventoryapplied in patients with personality disorders.34,35 Forthe assessment of social functioning, the Social Adjustment Scale and similarmeasures were included.36
Assessment of effect sizes
We calculated within-group effect sizes for all studies using the Cohen d statistic. For each measure, we subtracted the posttreatmentmean from the pretreatment mean and divided the difference by the pretreatmentstandard deviation of the measure.37 If therewas more than 1 patient group, we calculated a pooled baseline standard deviation,as suggested by Rosenthal.38 If necessary,signs were reversed so that a positive effect size always indicated improvement.We assessed effect sizes separately for measures of target problems, generalpsychiatric symptoms, and social functioning. Whenever multiple measures wereapplied in a study, we assessed the effect size for each measure separatelyand calculated the mean effect size to assess the overall outcome of the studyin the respective area of functioning. We computed effect sizes that wereunweighted and those weighted by the sample size to yield unbiased estimatorsof effect sizes.38,39 To examinethe stability of psychotherapeutic effects, we assessed effect sizes separatelyfor assessments at termination of therapy and follow-up.
Furthermore, between-group effect sizes were assessed according to themethod described by Cohen37 by calculatingthe difference between preoutcome and postoutcome (follow-up) measures ofthe STPP group minus the difference between preassessment and postassessment(follow-up) measures of the comparison group, divided by the pooled standarddeviation before therapy. These between-group effect sizes give the differencein the magnitude of change between STPP and the comparison group in unitsof standard deviation. An effect size of zero indicates that STPP and comparisongroups are equal in therapeutic effect. All calculations were made so thata positive effect size indicates superiority of STPP.
The first rater extracted the following information from the articles:(1) name of the authors, (2) year of publication,(3) psychiatric disordertreated with STPP, (4) model of STPP, (5) duration of STPP, (6) comparisongroup, (7) sample size in each group, and (8) means and standard deviationsfor each outcome measure. This information was checked by the second rater,and disagreements were resolved by consensus, including the ratings of thethird rater.
Seventeen studies of STPP met the inclusion criteria.40-57 Thestudies are described in Table 1 (datanecessary for the assessment of effect sizes were provided by Susan Bögels,PhD [written communication, January 23, 2004]; Paul Crits-Christoph, PhD [writtencommunication, November 11, 2003]; and P. J. Cooper, PhD, and Helena Romaniuk,PhD [written communication, November 24, 2003]).
Overlap with other meta-analyses
Of the 17 studies that were identified, 13 (76%) have not yet been includedin other meta-analyses of STPP. Only 2 of the 19 studies that Svartberg andStiles6 included in their meta-analysis metour inclusion criteria.45,54 Ofthe 26 studies in the meta-analysis of Anderson and Lambert,7 4could be included.41,54-56 Ofthe 11 studies included by Crits-Christoph,5 weincluded 4.41,54-56 Crits-Christoph5 and Anderson and Lambert7 includedstudies of IPT, which we excluded. Only 2 studies of the meta-analysis ofLeichsenring16 were included,52,54 andonly 1 study50 of the meta-analysis of Leichsenringand Leibing.17 Accordingly, only a limitedportion of the studies that were included in previous meta-analyses of STPPwas included in our meta-analysis. Thus, most of the studies included in ourmeta-analysis have not been included in the previous meta-analyses.
In the 17 studies included in our meta-analysis, different models ofSTPP were applied (Table 1). The mostfrequently applied concepts of STPP were the methods developed by Luborsky,65 Horowitz,73 Shapiroand Firth,66 and Davanloo.27
In the 17 studies of STPP, the number of sessions conducted ranged from7 to 40. Short therapies of 7 sessions were performed in the study of Hamiltonet al,48 whereas longer therapies were performedin the studies of Winston et al55 and Svartberget al,53 who studied the treatment of personalitydisorders (Table 1). The mean numberof sessions of STPP was 20.97 (SD, 10.90).
Mean length of follow-up was about 1 year (mean, 61.42 weeks; SD, 71.26weeks).
In the studies selected, the following psychiatric disorders were treatedwith STPP: major depression (2 studies), maternal depression (1), posttraumaticstress disorder (1), bulimia nervosa (2), anorexia nervosa (1), opiate dependence(2), cocaine dependence (1), cluster C personality disorders (3), borderlinepersonality disorder (1), somatoform pain disorder (1), chronic functionaldyspepsia (1), and social phobia (1).40-57 Itis desirable to perform meta-analyses of STPP separately for specific psychiatricdisorders, eg, for somatoform disorders or anxiety disorders. However, thenumber of RCTs of STPP is not yet large enough for that purpose. Nevertheless,it is still useful at the present state of research to evaluate the efficacyof STPP in psychiatric disoders in general, ie, across different psychiatricdisorders.
Within-group effect sizes of STPP, other forms of psychotherapy, TAU,and waiting list are presented in Table 2.
Short-term psychodynamic psychotherapy yielded an effect size of 1.39after therapy and of 1.57 at follow-up (Table2). To determine whether the effect sizes were different from zero,we performed unpaired, 2-tailed t tests. Both effectsizes differed significantly from zero (t16 = 6.94 [P<.001] and t15 = 7.10 [P<.001],respectively). The limits of a 95% confidence interval (CI) were 0.97 and1.82 at the posttherapy assessment and 1.10 and 2.04 at the follow-up assessment.Adjustment for sample size38,39 yieldednearly identical results (1.37, t16 = 7.00[P<.001] and 1.54, t15 = 7.15 [P<.001], respectively).
General Psychiatric Symptoms
Short-term psychodynamic psychotherapy yielded an effect size of 0.90after therapy and of 0.95 at follow-up. Both effect sizes differed significantlyfrom zero (t14 = 7.25 [P<.001] and t12 = 6.90[P<.001], respectively). The limits of a 95% CIwere 0.64 and 1.17 at the postassessment measurement and 0.65 and 1.25 atthe follow-up assessment. Adjustment for sample size again yielded nearlyidentical effect sizes of 0.89 (t14 = 7.29[P<.001]) and 0.93 (t12 = 6.95 [P<.001]).
Short-term psychodynamic psychotherapy yielded an effect size of 0.80after therapy and of 1.19 at follow-up. Both effect sizes differed significantlyfrom zero (t10 = 7.29[P<.001] and t7 = 4.65[P = .002], respectively). The limits ofa 95% CI were 0.56 and 1.05 at the posttherapy assessment and 0.58 and 1.79at the follow-up assessment. Again, adjustment for sample size yielded nearlyidentical effect sizes of 0.79 (t10 = 7.28;[P<.001]) and 1.16 (t7 = 4.64 [P = .002]).
Stability of effect sizes
To assess the stability of effects, we compared the pretherapy and posttherapyeffect sizes with the pre–follow-up effect sizes for only those studiesthat included follow-up assessments. For STPP, the pre–follow-up effectsizes were stable (target problems, 1.44 vs 1.57; general psychiatric symptoms,0.91 vs 0.95; social functioning, 0.89 vs 1.19). This was also true for CBT(target problems, 1.37 vs 1.33; general psychiatric symptoms, 1.01 vs 0.97;social functioning, 0.97 vs 1.05).
Effect sizes of no treatment
Four studies provided data for waiting-list control patients (Table 1). No treatment yielded small effect sizesthat ranged from 0.12 to 0.27 (Table 2).Because of the small number of studies (n = 4), we did not performtests of significance for the between-group effect sizes of STPP and no treatment.
Effect sizes of tau patients
Three studies provided data for TAU (Table1). We decided to regard the control condition of the study of Gowerset al47 as TAU rather than as no treatment,because some of these patients had “received extensive treatment elsewhere.”Treatment as usual yielded effect sizes that ranged from 0.22 to 0.95 (Table 2). Again, we did not perform tests ofsignificance for the between-group effect sizes of STPP and TAU because ofthe small number of studies (n = 3).
Stpp vs no treatment and tau
To compare STPP with no treatment and TAU, we tested whether the between-groupeffect sizes between STPP on the one hand and no treatment and TAU on theother significantly differed from zero (t tests forindependent samples). According to the results, STPP was significantly superiorto no treatment and TAU with regard to target problems, general psychiatricsymptoms, and social functioning (Table 3).Because of the small number of studies, these tests were performed only forthe posttherapy effect sizes. The between-group effect sizes were large fortarget problems and medium to large for general psychiatric symptoms and socialfunctioning (Table 3).
Stpp vs other forms of psychotherapy
Fifteen studies included a comparison of STPP with other forms of psychotherapy(Table 1). For these comparisons wecalculated between-group effect sizes (Table 3). They ranged from 0.02 to 0.23, thus corresponding to small effectsizes according to Cohen.37 To test for differencesbetween STPP and other forms of psychotherapy in these 15 studies, we performedmultiple analyses of variance (MANOVA).74 Ina first MANOVA, we compared the pretherapy-posttherapy effect sizes betweenSTPP and other forms of psychotherapy in target symptoms, general psychiatricsymptoms, and social functioning. In a second MANOVA, we compared the pre–follow-upeffect sizes between STPP and other forms of psychotherapy on the 3 outcomevariables. Both MANOVAs yielded an insignificant result at the posttherapyassessment (Wilks Λ = 0.92; F3,15 = 0.49[P = .69])and at follow-up (Wilks Λ = 0.89;F3,13 = 0.53 [P = .67]).According to these results, STPP and other forms of psychotherapy did notdiffer significantly concerning their effect sizes at the end of therapy orat follow-up.
Therapy duration and effect sizes
We tested whether the effect sizes of STPP correlate with the durationof therapy (number of sessions). For STPP, all Spearman rank correlationswith any outcome measure were insignificant (for all, rs ≤ 0.21 [P = .64]).
The place of psychoanalytic and psychodynamic treatments within psychiatryis controversial. This meta-analysis addressed the efficacy of STPP in specificpsychiatric disorders. At present, the number of RCTs is not yet large enoughto perform meta-analyses of STPP for specific psychiatric disorders separately.For this reason, our meta-analysis addressed the question of how effectiveSTPP is in general in the treatment of psychiatric disorders. We studied theeffects in target problems, general psychiatric problems, and social functioning.
The data presented herein corroborate the results reported by Crits-Christoph,5 Anderson and Lambert,7 andLeichsenring.16 However, this meta-analysisadds to the literature for several reasons. First, more rigorous inclusioncriteria were applied. As a consequence, only a minority of studies includedin previous meta-analyses were regarded as adequate for inclusion in thismeta-analysis. Second, studies of IPT were not included because the relationof IPT to STPP is controversial. Empirical results seem to support the exclusionof IPT from a meta-analysis of STPP.10 Thus,the database of this meta-analysis is different from those of previous meta-analyses.Third, 76% of more recently published studies included in this meta-analysishad not yet been included in other meta-analyses of STPP. Fourth, the stabilityof effects of STPP was assessed by studying the pretreatment and posttreatmenteffects and the effects yielded in follow-up studies.
According to the results, STPP yielded significant and large effectsizes. With regard to between-group effect sizes, which allow for a strictertest of efficacy and are more appropriate to the fact that only RCTs wereincluded, STPP was significantly superior to no treatment and TAU. No differencewas found between STPP on the one hand and CBT or other psychotherapies onthe other concerning changes in target problems, general psychiatric problems,and social functioning. These results differ in part from those reported bySvartberg and Stiles,6 who found STPP to besuperior to no-treatment controls but inferior to alternative psychotherapies.6 The discrepant results can be explained by the selectionof studies. In our meta-analysis, only studies were included that fulfilledrigorous inclusion criteria that, among other things, ensured that STPP wasdelivered competently. The results of this meta-analysis are consistent withthose of the meta-analysis of Wampold et al,15 whodid not find differences between bona fide methods of psychotherapy. The insignificantdifferences in effect size between STPP and other forms of psychotherapy foundin this meta-analysis correspond in magnitude quite well to the data reportedby Grissom,75 who found a mean difference ineffect size of 0.23 between different forms of psychotherapy.
Effect sizes can be transformed into percentages of nonoverlap.37,76,77 According to theseresults, patients treated with STPP are better off with regard to their targetproblems than 92% of the patients before therapy. At follow-up, which wason average 13 months after termination of therapy, they were better off than95% of the patients. As an effect size of 1.00 corresponds to a success rateof 72%, clearly more than 72% of the patients were successfully treated withSTPP.77 These results are highly relevant forclinical practice. This is true for another result as well. Comparing theeffect sizes yielded at the end of therapy and follow-up, the effects of STPPproved to be stable and even tended to increase. This result is consistentwith that reported by Anderson and Lambert,7 whofound a slight superiority of STPP at follow-up assessment. The effects ofCBT also were maintained to a high degree at follow-up.
For a valid evaluation of the efficacy of STPP, follow-up assessmentsseem to be necessary, as can be illustrated by the following example. In 2RCTs, significant improvements in bulimia nervosa after STPP were found.45,46,78 In the central measuresspecific to bulimia nervosa (ie, bulimic episodes and self-induced vomiting),STPP was as effective as CBT.45,46,78 Apartfrom this, CBT was superior to STPP on some other measures of psychopathology.45,46 However, a follow-up study of thesample of Fairburn et al45 that used a longerfollow-up period found that both forms of therapy (STPP and CBT) proved tobe equally effective and partly superior to a behavioral form of therapy.78 Results like this can only be detected by long-termfollow-up studies.
In this meta-analysis, TAU yielded effect sizes between those of psychotherapyand no treatment. These results are consistent with the overall findings accordingto which “the ranking for therapeutic success is generally therapy,placebo, and control (do nothing or wait).”75 Treatmentas usual generally can be expected to be superior to placebo and inferiorto psychotherapy. The relatively large effect sizes of TAU found in this meta-analysiscan be attributed to the study of Gowers et al,47 whichreported large effect sizes in target problems (1-year follow-up, 1.20; 2-yearfollow-up, 1.71) and measures of social functioning (2-year follow-up, 0.95).These large effect sizes achieved by TAU may be explained by the fact thatsome of the control patients of this study had “received extensive treatmentelsewhere.”47(p165) In thisstudy, patients with anorexia nervosa were treated, and outcome was assessedby weight gain and physical, nutritional, social, and sexual adjustment andmental state (Morgan and Russel scores). In this case, an “extensive”TAU, as described by the authors, can be expected to be relatively effective.
The studies reviewed herein refer to RCTs of STPP in specific psychiatricdisorders (Table 1). However, for somespecific psychiatric disorders, there are no RCTs of STPP at all. This istrue for dissociative disorders, and for some specific forms of personalitydisorders (eg, compulsive, avoidant, and narcissistic). This is also truefor CBT; however, to our knowledge, there are no studies of CBT in the treatmentof dissociative and conversion disorder. With regard to personality disorders,only studies of CBT in avoidant and borderline personality disorder exist.79,80 Furthermore, for some forms of anxietydisorders, RCTs of STPP are needed. For panic disorder and agoraphobia, onlyRCTs in which STPP was combined with pharmacological treatment exist.81-83 This is also surprising,as anxiety is one of the central concepts of psychoanalytic and psychodynamictheory and therapy.84 With regard to generalizedanxiety disorder, the study of Durham et al85 comparingSTPP and CBT did not fulfill the inclusion criteria of this meta-analysis(no manual for STPP, no specific training of therapists, no checks of adherenceto and competence for STPP). In addition, STPP and CBT were not equally carefullyperformed. In that study, STPP served as a kind of control group or a “strawman.” As Smith et al86 put it:
A comparison therapy might be set up as a kind of straw man overwhich the favored therapy would prevail. The comparison therapy (often an‘insight therapy’) would be treated with fairly obvious disdainand would be given not much opportunity for success.
This is known as the investigator-allegiance effect.86,87 Furthermore,studies of STPP in children and adolescents are urgently needed.88 Studiesof STPP can be one aspect of what Kazdin88 calleda research agenda for child and adolescent psychotherapy.
In the studies reviewed herein, different models of STPP were applied.It is an interesting question, if and how they empirically differ, as “brandnames of therapy can be misleading.”10 Studiesaddressing this problem are relevant for consideration if some of the differentmodels of STPP are close enough to be lumped together. Ablon and Jones10 recently compared CBT and IPT as they were performedin the National Institute of Mental Health Treatment of Depression Study.According to the results, both forms of therapy adhered most strongly to theideal prototype of CBT. In addition, adherence to the CBT prototype yieldedmore positive correlations with outcome measures across both types of treatment.However, STPP was not included in this comparison. Thus, it is not clear howSTPP, CBT, and IPT empirically differ with regard to therapist behavior. Comparingprototypic sessions of different variants of STPP empirically would be a veryinteresting and promising project of research. Other forms of therapy (eg,CBT) should be included.
The studies evaluated in this meta-analysis did not include comparisonswith pharmacological treatments. There are only a few randomized controlledstudies that examined the effects of a combination of STPP and pharmacologicaltreatments. In the RCT of Zitrin et al82 andKlein et al,81 STPP and CBT were combined withimipramine hydrochloride in the treatment of phobias. According to the results,STPP and CBT were equally effective in the treatment of agoraphobia, mixedphobia, and simple phobia.81 In this study,however, no manual of STPP was used. In the study of Wiborg and Dahl,83 STPP combined with clomipramine hydrochloride wasmore successful in the treatment of panic disorder at follow-up than an exclusivetreatment with clomipramine. In this study, 80% of the sample had panic disorderand agoraphobia. In 2 studies, the combined treatment of STPP and antidepressiveswas more successful than the pharmacological treatment alone.89,90 However,in the study reported by de Jonghe et al,89 andKool et al,91 this was true only for patientswith a comorbid personality disorder. In the mega-analysis of DeRubeis etal,92 CBT was as effective as pharmacologicaltherapy in the treatment of severe depression. According to the mega-analysisof Thase et al,93 the combined treatment ofpsychotherapy (CBT or IPT) and antidepressives was more successful in severedepression than was psychotherapy alone. In milder depression, psychotherapyand the combined treatment were equally effective. With regard to STPP, furtherstudies of STPP are necessary that examine the combined treatment comparedwith STPP alone and pharmacological treatment alone.
According to the results of this and other meta-analyses, STPP is aneffective treatment of psychiatric disorders and yields stable results. Furtherresearch should study not only the effects of STPP in specific psychiatricdisorders but also the active ingredients of STPP. In addition, the activeingredients of STPP should be compared with other forms of therapy, eg, CBT.Furthermore, effectiveness studies should address whether the methods of therapythat have proved to work in RCTs are effective in the field. Data on healtheconomics also should be included.
Correspondence: Falk Leichsenring, DSc,Department of Psychosomatics and Psychotherapy, University of Goettingen,von Siebold Str 5, 37075 Goettingen, Germany (email@example.com).
Submitted for Publication: March 9, 2004; finalrevision received May 25, 2004; accepted June 9, 2004.
P The place of psychoanalytic treatments within psychiatry. Arch Gen Psychiatry
2002;59505- 510PubMedGoogle ScholarCrossref
P The efficacy of brief dynamic psychotherapy: a meta-analysis. Am J Psychiatry
1992;149151- 158PubMedGoogle Scholar
TC Comparative effects of short-term psychodynamic psychotherapy: a meta-analysis. J Consult Clin Psychol
1991;59704- 714PubMedGoogle ScholarCrossref
MJ Short-term dynamically oriented psychotherapy: a review and meta-analysis. Clin Psychol Rev
1995;15503- 514Google ScholarCrossref
HA Is IPT time-limited psychodynamic psychotherapy? J Psychother Pract Res
1998;7185- 195PubMedGoogle Scholar
EE Validity of controlled clinical trials of psychotherapy: findings fromthe NIMH Treatment of Depression Collaborative Research Program. Am J Psychiatry
2002;159775- 783PubMedGoogle ScholarCrossref
CS Models of Brief Psychodynamic Therapy: A ComparativeApproach. New York, NY Guilford Press1995;
SB What makes brief psychodynamic therapy time efficient. Clin Psychol
2001;85- 22Google Scholar
F Psychotherapie im Wandel: von der Konfession zurProfession Göttingen, Germany Hogrefe1994;
F Comment on the meta-analysis of Grawe, Bernauer and Donati [in German] Gruppenpsychother Gruppendyn
1996;32205- 234Google Scholar
HA Meta-analysis of outcome studies comparing bona fide psychotherapies:empirically, “all must have prizes.” Psychol Bull
1997;122203- 215Google ScholarCrossref
F Comparative effects of short-term psychodynamic psychotherapy and cognitive-behavioraltherapy in depression: a meta-analytic approach. Clin Psychol Rev
2001;21401- 419PubMedGoogle ScholarCrossref
E The effectiveness of psychodynamic therapy and cognitive behavior therapyin the treatment of personality disorders: a meta-analysis. Am J Psychiatry
2003;1601223- 1232PubMedGoogle ScholarCrossref
Canadian Task Force on the Periodic Health Examination, The periodic health examination. CMAJ
1979;1211193- 1254Google Scholar
AD Cochrane reviewer’s handbook 4.1.6 [Cochrane Review on CD-ROM]. Oxford, England Cochrane Library, Update Software2003;
RJ Clinical recommendations using levels of evidence for antithromboticagents. Chest
227S- 230SPubMedGoogle ScholarCrossref
R User’s guides to the medical literature, IX: a method for gradinghealth care recommendations. JAMA
1995;2741800- 1804PubMedGoogle ScholarCrossref
JMed A Guide to Treatments That Work. 2nd New York, NY Oxford University Press Inc2002;
Task Force on Promotion and Dissemination of Psychological Procedures, Training and dissemination of empirically-validated psychological treatments:report and recommendations. Clin Psychol
1995;483- 23Google Scholar
TH Empirically supported psychological interventions: controversies andevidence. Annu Rev Psychol
2001;52685- 716PubMedGoogle ScholarCrossref
M Psychotherapy and bulimia nervosa: longer-term effects of interpersonalpsychotherapy, behavior therapy, and cognitive behavior therapy. Arch Gen Psychiatry
1993;50419- 428PubMedGoogle ScholarCrossref
RE A review of brief individual psychotherapies. Am J Psychiatry
1986;1431507- 1516PubMedGoogle Scholar
H Short-Term Dynamic Psychotherapy. New York, NY J Aronson1980;
M Time is of the essence: a selective review of the fall and rise ofbrief therapy research. Psychol Psychother
2003;76211- 235PubMedGoogle ScholarCrossref
MJ Distinctive features of short-term psychodynamic-interpersonal psychotherapy:a review of the comparative psychotherapy process literature. Clin Psychol
2000;7167- 188Google Scholar
MB National Institute of Mental Health Treatment of Depression CollaborativeResearch Program: general effectiveness of treatments. Arch Gen Psychiatry
1989;46971- 983PubMedGoogle ScholarCrossref
SD Group cognitive-behavioral therapy and group interpersonal psychotherapyfor the nonpurging bulimic individual: a controlled comparison. J Consult Clin Psychol
1993;61296- 305PubMedGoogle ScholarCrossref
DB Meta-analytic procedures for combining studies with multiple effectsizes. Psychol Bull
1986;99400- 406Google ScholarCrossref
JD Target complaints as criteria of improvement. Am J Psychother
1966;20184- 192PubMedGoogle Scholar
L The SCL-90 Manual I: Scoring, Administration andProcedures for the SCL-90-R. Baltimore, Md Clinical Psychometric Research1977;
J Statistical Power Analysis for the Behavioral Sciences. Hillsdale, NJ Lawrence A Erlbaum Associates1988;
R Meta-analytic Procedures for Social Research: AppliedSocial Research Methods. Thousand Oaks, Calif Sage Publications1991;
I Statistical Methods for Meta-analysis. Orlando, Fla Academic Press Inc1985;
S Analytic psychotherapy versus cognitive-behavioral therapy for socialphobia. Paper presented at : European Congress for Cognitive and BehaviouralTherapies September 10-13, 2003 Prague, Czech Republic
H Controlled trial of the short- and long-term effect of psychologicaltreatment of post-partum depression, I: impact on maternal mood. Br J Psychiatry
2003;182412- 419PubMedGoogle ScholarCrossref
AT Psychosocial treatments for cocaine dependence: National Instituteon Drug Abuse Collaborative Cocaine Treatment Study. Arch Gen Psychiatry
1999;56493- 502PubMedGoogle ScholarCrossref
ME Impact of psychosocial treatments on associated problems of cocaine-dependentpatients. J Consult Clin Psychol
2001;69825- 830PubMedGoogle ScholarCrossref
PJ A comparison of two psychological treatments for bulimia nervosa. Behav Res Ther
1986;24629- 643PubMedGoogle ScholarCrossref
M Comparison of cognitive-behavioral and supportive-expressive therapyfor bulimia nervosa. Am J Psychiatry
1993;15037- 46PubMedGoogle Scholar
AH Outcome of outpatient psychotherapy in a random allocation treatmentstudy of anorexia nervosa. Int J Eat Disord
1994;15165- 177PubMedGoogle ScholarCrossref
R A randomized controlled trial of psychotherapy in patients with chronicfunctional dyspepsia. Gastroenterology
2000;119661- 669PubMedGoogle ScholarCrossref
A A randomized prospective study comparing supportive and dynamic therapies:outcome and alliance. J Psychother Pract Res
1998;7261- 271PubMedGoogle Scholar
JT Chronic pain and psychodynamic body therapy: a controlled outcome study. Psychotherapy
2000;37257- 269Google ScholarCrossref
E A controlled trial of short-term group treatment for borderline personalitydisorder. J Personal Disord
1995;9190- 198Google ScholarCrossref
M Effects of treatment duration and severity of depression on the effectivenessof cognitive-behavioral and psychodynamic-interpersonal psychotherapy. J Consult Clin Psychol
1994;62522- 534PubMedGoogle ScholarCrossref
MH Randomized, controlled trial of the effectiveness of short-term dynamicpsychotherapy and cognitive therapy for cluster C personality disorders. Am J Psychiatry
2004;161810- 817PubMedGoogle ScholarCrossref
JS Comparative effectiveness of psychotherapies for depressed elders. J Consult Clin Psychol
1987;55385- 390PubMedGoogle ScholarCrossref
JC Short-term psychotherapy of personality disorders. Am J Psychiatry
1994;151190- 194PubMedGoogle Scholar
CP Corrections and revised analyses for psychotherapy in methadone maintenancepatients. Arch Gen Psychiatry
1990;47788- 789PubMedGoogle ScholarCrossref
CP Psychotherapy in community methadone programs: a validation study. Am J Psychiatry
1995;1521302- 1308PubMedGoogle Scholar
DH Toward the Validation of Dynamic Psychotherapy. New York, NY Plenum Publishing Corp1976;
M Stress Response Syndromes. New York, NY J Aronson1976;
U Outcome evaluation in brief mother-infant psychotherapy: a preliminaryreport. Infant Ment Health J
1990;11278- 300Google ScholarCrossref
L A Manual for the Use of Supportive-Expressive Psychotherapyin the Treatment of Cocaine Abuse. Philadelphia: Dept of Psychiatry University of Pennsylvania1992;
H Eating Disorders: Obesity, Anorexia Nervosa, andthe Person Within. New York, NY Basic Books Inc Publishers1973;
AJ The Pain of Obesity. Palo Alto, Calif Bull Publishing Co1976;
L Principles of Psychoanalytic Psychotherapy: Manualfor Supportive-Expressive Treatment. New York, NY Basic Books Inc Publishers1984;
JA Exploratory Therapy Manual for the Sheffield PsychotherapyProject (SAPU Memo 733). Sheffield, England University of Sheffield1985;
A Short-term Dynamic Psychotherapy Manual (STDP). Washington DC American Psychological Association1988;Social andBehavioral Sciences Documents Abstracts, No. 18. Manuscript No. 2887
OF Borderline Conditions and Pathological Narcissism. New York, NY J Aronson1975;
L Changing Character. New York, NY Basic Books Inc Publishers1997;
AH Anorexia Nervosa: Let Me Be. London, England Academic Press1980;
K Affects and affect consiousness: a psychotherapy model of integrating Silvan Tomkins’ affectand script theory within the framework of self-psychology. Goldberg
Aed. Pluralisms in Self-psychology: Progress in Self-psychology.
15 Hillsdale, NJ Analytic Press1999;287- 306Google Scholar
N Brief therapy of the stress response syndrome. Psychiatr Clin North Am
1979;2365- 377Google Scholar
MJ Phase oriented treatment of stress response syndromes. Am J Psychother
1973;27506- 515PubMedGoogle Scholar
SAS/STATTM: User’s Guide, Release6.03. Cary, NC SAS Institute Inc1988;
RJ The magical number.7 +/−.2: meta-meta-analysis of the probabilityof superior outcome in comparisons involving therapy, placebo, and control. J Consult Clin Psychol
1996;64973- 982PubMedGoogle ScholarCrossref
P What Works for Whom: A Critical Review of PsychotherapyResearch. New York, NY Guilford Publications1996;
BM The efficacy and effectiveness of psychotherapy. Lambert
MJed. Bergin and Garfield’sHandbook of Psychotherapy and Behavior Change
5th New York, NY John Wiley & Sons Inc2004;139- 193Google Scholar
RC A prospective study of outcome in bulimia nervosa and the long-termeffects of three psychological treatments. Arch Gen Psychiatry
1995;52304- 312PubMedGoogle ScholarCrossref
HE Interpersonal outcome of cognitive behavioral treatment for chronicallysuicidal borderline patients. Am J Psychiatry
1994;1511771- 1776PubMedGoogle Scholar
DC Treatment of phobias, II: behavior therapy and supportive psychotherapy:are there any specific ingredients? Arch Gen Psychiatry
1983;40139- 145PubMedGoogle ScholarCrossref
DC Treatment of phobias, I: comparison of imipramine hydrochloride andplacebo. Arch Gen Psychiatry
1983;40125- 138PubMedGoogle ScholarCrossref
AA Does brief dynamic psychotherapy reduce the relapse rate of panic disorder? Arch Gen Psychiatry
1996;53689- 694PubMedGoogle ScholarCrossref
KJ Through the storm: psychoanalytic theory in the psychotherapy of theanxiety disorders. Bull Menninger Clin
1990;54171- 183PubMedGoogle Scholar
GW Cognitive therapy, analytic psychotherapy and anxiety management trainingfor generalised anxiety disorder. Br J Psychiatry
1994;165315- 323PubMedGoogle ScholarCrossref
TI The Benefits of Psychotherapy. Baltimore, Md John Hopkins University Press1980;
E The researcher’s own allegiances: a “wild” card incomparison of treatment efficacy. Clin Psychol Sci Pract
1999;695- 106Google ScholarCrossref
J Combining psychotherapy and antidepressants in the treatment of depression. J Affect Disord
2001;64217- 229PubMedGoogle ScholarCrossref
N Psychodynamic psychotherapy and clomipramine in the treatment of majordepression. Psychiatr Serv
2002;53585- 590PubMedGoogle ScholarCrossref
B Efficacy of combined therapy and pharmacotherapy for depressed patientswith or without personality disorders. Harv Rev Psychiatry
2003;11133- 141PubMedGoogle ScholarCrossref
AD Medications versus cognitive behavior therapy for severely depressedoutpatients: mega-analysis of four randomized comparisons. Am J Psychiatry
1999;1561007- 1013PubMedGoogle Scholar
DJ Treatment of major depression with psychotherapy or psychotherapy-pharmacotherapycombinations. Arch Gen Psychiatry
1997;541009- 1015PubMedGoogle ScholarCrossref