Research paperEfficacy of an adjunctive brief psychodynamic psychotherapy to usual inpatient treatment of depression: Results of a randomized controlled trial
Introduction
Depression is among the most common reasons for psychiatric hospitalization (Schneider et al., 2005, Stensland et al., 2012). Inpatients with depression have a high degree of severity, comorbidity, chronicity and treatment resistance. They belong to the most severe and disabled patient populations (APA, 2010). Meta-analyses have consistently shown the advantage of combined treatment for patients with depressive disorders that are complicated by comorbidity, chronicity, treatment resistance, recurrence, or high severity (Cuijpers et al., 2009, de Maat et al., 2007, Imel et al., 2008). Current clinical guidelines recommend a combination of pharmacotherapy and psychotherapy to treat either moderate to severe depression (APA, 2010, NICE, 2009) or severe depression only (DGPPN, 2012). Different psychotherapeutic interventions for depression such as cognitive-behavioral (CBT), interpersonal (IPT), and psychodynamic therapies have shown efficacy with no significant association between effect size and type of psychotherapy (Barth et al., 2013). Furthermore, by both mental health professionals and their patients value psychotherapy alone or the combination of psychotherapy and pharmacotherapy is highly as a way of hastening recovery, either through additive effects or by compensating for the limitations of monotherapy (Lelliott and Quirk, 2004, Pampallona et al., 2004, Peeters et al., 2013).
Some studies have documented the possible advantages of brief psychodynamic psychotherapy combined with antidepressants, as compared to antidepressants alone. One study found that although both groups experienced significant improvement, the combined treatment group had fewer treatment failures, better work adjustment, better global functioning, and a lower rate of hospitalization than the medication alone group (Burnand et al., 2002). De Jonghe et al. (2001) showed that patients found combined treatment significantly more acceptable than medication alone. The patients receiving combined treatment were significantly less likely to drop out and were also more likely to recover. The authors concluded that combined therapy is preferable to pharmacotherapy alone in treating ambulatory patients with major depression (De Jonghe et al., 2001). A more recent study found no difference in remission rates at the end of a 6-month acute treatment phase between a group of patients who received a brief psychodynamic psychotherapy combined with an SSRI and a group of patients who received medication alone (Maina et al., 2009). However, more patients in the combined group achieved sustained remission at the end of the follow-up period compared with patients who had only received medication during the acute phase.
Several recent position papers call for better quality of inpatient care (Craig, 2016, Porter et al., 2016). These position papers suggest that the positive aspects of inpatient admission, including the opportunity for assessment and intensive treatment, should be emphasized (Porter et al., 2016). The treatment options for better quality care include psychotherapy. Psychological treatment may improve the recovery of depressed inpatients and reduce their suffering for themselves as well as that of their relatives (Porter et al., 2016). In a systematic review and meta-analysis based on 12 studies, Cuijpers et al. (2011) showed a small (ES=0.29) but robust additional effect of psychological treatment on depression in depressed inpatients (Cuijpers et al., 2011). A previous meta-analysis (Stuart and Bowers, 1995), based on 4 controlled studies, showed higher effect sizes with a difference between self-report measures (ES=1.13) and independent observer measures (ES=0.38) at discharge from the hospital in favor of adding CBT to the usual treatment. These results contrast with a review of 6 studies on inpatients with depressive disorder (Huber, 2005) that showed less conclusive results. Three studies showed an additional effect of psychotherapy (corresponding to a moderate ES). Combined treatment was superior to pharmacotherapy in terms of remissions rates and relapse rates. Additionaly, three studies showed no additional effect. The results were clearer for more severely depressed inpatients or chronic inpatients. The author concluded that combined treatment is advantageous in the case of treatment resistance, or chronic or severe illness, and depends on patient preferences. Although these reviews found some indications for the positive effects of combined treatment for depressed inpatients, the results are still ambiguous. The number of studies included in the reviews was relatively small and their quality was not optimal. The vast majority of the included studies had relatively small sample sizes. Good-quality studies with larger sample sizes are needed to further examine the effects of psychotherapy for depressed inpatients (Cuijpers et al., 2011).
Most of the above mentioned studies reported on the effectiveness of cognitive and/or behavioral inpatient psychotherapies. Cuijpers et al. (2011) retrieved only 3 studies out of 12 did not involve CBT, among which a single study involved interpersonal psychotherapy. Huber (2005) reported on 5 CBT studies and on one client-centered psychotherapy study, while Stuart and Bower (1995) only examined cognitive therapy. Early research on the effectiveness of outpatient psychotherapies for depression also found evidence for the effectiveness of CBT first. The place of psychoanalytic treatment within psychiatry had been controversial for a moment (Gabbard et al., 2002); however, an increasing scientific litterature has since shown the effectiveness of psychotherapy in treating depression (Fonagy, 2015). Recent meta-analyses converge to conclude that the differences between psychotherapies in treating depression are small and unstable (Barth et al., 2013). Some people may respond better to interventions other than CBT (Barth et al., 2013). It may also be true for inpatients; hence, the potential of psychodynamic psychotherapies to be useful for inpatients warrants further research.
The purpose of the current study was to estimate the relative efficacy of adjunctive psychodynamic psychotherapy compared to the usual psychiatric and pharmacologic treatment on the short- and long-term outcomes of inpatients with either moderate or severe depression.
Section snippets
Procedure and study design
This single-blind one-month randomized controlled add-on trial compared (1) an intervention arm with (2) a treatment-as-usual arm (TAU). Inpatients in the intervention arm received an intensive brief psychodynamic psychotherapy (IBPP) as an add-on therapy to the TAU. IBPP was initiated within a few days after admission. When patients were discharged before the end of IBPP, IBPP continued on an outpatient basis. This RCT was single-blind as the participants were aware of their allocation when
Patient flow
The numbers and percentages of retained participants at post-treatment as well as at the 3-month and 12 month follow-up points are shown in the CONSORT flow chart (Fig. 1). One hundred and fifty-three participants were randomized. Of these, 76 participants were allocated to receive IBPP and 73 to receive treatment-as-usual.
The proportion of complete cases (patients with all 4 scores measurements available) ranged from 57.0% to 71.0%, depending on the score and the treatment in consideration (
Discussion
Brief and effective psychotherapy programs for use in short-term inpatient units are of great importance given the current clinical guidelines recommending combined treatment of moderate to severe depression. The present study aimed to examine the efficacy of an adjunctive, brief, and intensive psychodynamic psychotherapy compared to treatment-as-usual for inpatients during the acute phase of a major depressive episode. The results mostly supported the efficacy of inpatient brief psychodynamic
Limitations
We need to acknowledge a number of limitations to this study. In order to increase the external validity of the trial, we limited the number of exclusion criteria. The sample is relatively heterogeneous in terms of diagnosis, with different subtypes of depression and comorbidity. As the heterogeneity increases the external validity and the generalizability of the study, we cannot rule out the influence of diagnosis or comorbid disorders on the treatment outcomes.
Also, the amount of therapeutic
Conclusions
In summary, while limited by some factors, the results of this study suggest that there are substantial benefits to adding IBPP to usual care for treating major depression in a psychiatric hospital. The current findings support recent propositions on the importance and feasibility of more intensive psychological treatment for depressed inpatients (Porter et al., 2016). The significance of the findings goes beyond the specific intervention and the characteristics of the medical system used to
Clinical vignette
April is a 35 years old patient with a diagnosis of recurrent depressive disorder who was hospitalized for the first time due to a third major depressive episode. During her first encounter with the therapist she has a neat presentation; she is smiling but she looks fearful. She states that this is her first time confiding and connecting to the verbal and physical abuse she suffered from her grandmother during her childhood and adolescence. “All of my grandmother's violence is in me,” she says.
Funding support
This study was funded by a grant from the Swiss National Science Foundation (FNS 32003B-135098).
Acknowledgments
We acknowledge the dedicated psychotherapists and the hospital staff for making this research possible. We thank the study participants for their participation in this RCT and their ongoing involvement in the study. We also thank the IBPP project team involved in the study: Dr Nicolas de Coulon, who participated in the elaboration of the IBPP manual and provided individual and group supervisions; Diana Ortega and Valentino Pomini, who elaborated upon the group intervention; Philippe Golay,
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2019, Journal of Psychiatric ResearchCitation Excerpt :However, particular forms of psychotherapy have an evidence base that supports their efficacy in the treatment of MDE. These include: Behavior Therapy (BT) (Harley et al., 2008; Lynch et al., 2015), Cognitive-Behavioral Therapy (CBT) (Cristea et al., 2015; Feng et al., 2012; Gould et al., 2012; Gregory, 2010; Tolin, 2017), Interpersonal Therapy (IPT) (Cuijpers et al., 2016; Markowitz and Weissman, 2012; Weissman et al., 2014), Problem-Solving Therapy (PST) (Bell and D'Zurilla, 2009; Cuijpers et al., 2018; Townsend et al., 2001), and Short-term Psychodynamic Psychotherapy (STPP) (de Roten et al., 2017; Driessen et al., 2015, 2018). Furthermore, in recent years, there has been a burgeoning literature establishing the efficacy of evidence-based psychotherapies specifically in the treatment of TRD (Fonagy et al., 2015; Souza et al., 2016; Town et al., 2017; Trivedi et al., 2011; van Bronswijk et al., 2018).
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The two first authors contributed equally to the writing of this paper.