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Psychodynamic Therapy Found ‘Equivalent’ to CBT Across Disorders

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Psychodynamic psychotherapy at the Austen Riggs Center, in Stockbridge, MA.

By Mark Moran

This article originally appeared in the August 4, 2017 issue of Psychiatric News (Volume 52, Number 15) and online on August 3, 2017.

Past meta-analyses have had mixed results, with some showing CBT as more effective, but the current study uses a more stringent methodology for determining “equivalence.”

Psychodynamic therapy (PDT) appears to be as effective at treating mental illness as other techniques with established efficacy, including cognitive-behavioral therapy (CBT), according to a meta-analysis in AJP in Advance.

A number of randomized, controlled trials comparing PDT and CBT have reported on “non-inferiority” of PDT—a conclusion that tends to understate PDT’s value, according to Eric Plakun, M.D., chair of APA’s Caucus on Psychotherapy and associate medical director and director of admissions at The Austen Riggs Center in Stockbridge, Mass. 

“This study demonstrates the ‘equivalence’ of PDT to CBT, as opposed to ‘non-inferiority,’ as in other comparable studies,” Plakun, who was not involved in the study, told Psychiatric News. “In doing so, it also is a big step toward ending what has frankly been an implicit bias against PDT that needs to come to an end.”

The meta-analysis included 23 randomized, controlled trials with 2,751 patients. Twenty-one of the trials compared PDT with other forms of psychotherapy, in most cases CBT. Two studies compared psychodynamic therapy with a selective serotonin reuptake inhibitor or with a serotonin-norepinephrine reuptake inhibitor in the treatment of depression. The majority of studies investigated participants with a depressive disorder (n=8), followed by anxiety disorders (n=4), eating disorders (n=4), personality disorders (n=4), substance dependence (n=2), and posttraumatic stress disorder (n=1).

The primary outcome was “target symptoms,” which included measures specific to the mental disorder under study (for example, measures of depressive symptoms in depressive disorders or of social anxiety in social anxiety disorder). General psychiatric symptoms and psychosocial functioning—including social, occupational, and personality functioning—were also examined.

Researchers found that regardless of whether efficacy results in the individual trials favored psychodynamic therapy or the comparator treatment, the pooled between-group difference in outcome for target symptoms at post-treatment for all studies was statistically small, suggesting PDT is as efficacious as the other treatments. In seven of the 23 studies, PDT was found to be more effective than the comparator treatment.

“This meta-analysis is the first in psychotherapy research to systematically investigate equivalence of a specific form of psychotherapy to established treatments by formally applying the logic of equivalence testing,” wrote lead author Christiane Steinert, Ph.D., of the University of Giessen in Germany and colleagues. 

Steinert and colleagues noted that “therapist effects” (the effects of the skills or experience a therapist brings to treatment as well as the “fit” between patient and therapist) are known to be a determinant in the effectiveness of psychotherapy.

“Because therapist effects seem to have a stronger impact on outcome than the treatments being compared and need to be taken into account, one promising strategy for improving treatments is enhancing therapist training and eventually therapist outcome,” they concluded. “Furthermore, different patients may benefit from different approaches, which is why a shift from one empirically supported treatment to another may be helpful in case of nonresponse.”

Plakun said, “Trainees and, sadly, often their psychotherapy teachers and textbook authors have for too long equated absence of evidence of efficacy of PDT with evidence of absence of efficacy. 

“This is not what the data have shown, but only the most careful psychotherapy researchers and clinicians who read the literature have paid attention to this level of detail.” 

Plakun characterized debates between adherents of CBT versus PDT as a “foolish circular firing squad.” Instead, he said he advocates for recognition of the growing evidence base for psychotherapy of multiple types. He also cited the 2015 Institute of Medicine (IOM) report on “Psychosocial Interventions for Mental Health and Substance Use Disorders,” which called for the elucidation of “shared elements” across psychotherapies that are found to be effective for a variety of conditions and a range of patients (Psychiatric News, December 4, 2015). 

“The future will not be about pitting one school of therapy against another, but about finding what works for whom,” Plakun said.

“Psychodynamic Therapy: As Efficacious as Other Empirically Supported Treatments? A Meta-Analysis Testing Equivalence of Outcomes” can be accessed here.

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