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Psychoanalytic and psychodynamic therapies for depression: the evidence base

  • David Taylor

Abstract

This article argues that the current approach to guideline development for the treatment of depression is not supported by the evidence: clearly depression is not a disease for which treatment efficacy is best determined by short-term randomised controlled trials. As a result, important findings have been marginalised. Different principles of evidence-gathering are described. When a wider range of the available evidence is critically considered the case for dynamic approaches to the treatment of depression can be seen to be stronger than is often thought. Broadly, the benefits of short-term psychodynamic therapies are equivalent in size to the effects of antidepressants and cognitive–behavioural therapy (CBT). The benefits of CBT may occur more quickly, but those of short-term psychodynamic therapies may continue to increase after treatment. There may be a ceiling on the effects of short-term treatments of whatever type. Longer-term psychodynamic treatments may improve associated social, work and personal dysfunctions as well as reductions in depressive symptoms.

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Psychoanalytic and psychodynamic therapies for depression: the evidence base

  • David Taylor
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eLetters

Bravo! Dr David Taylor

Sue L Doyle, Horse-Breeder. Painter. Reearch
12 December 2008

As a patient receiving long-term psychoanalytic psychotherapy I can totally concur with him that this is the way forward. This is good news for Health Insurers too, as it's the kindest and most effective way to cut back on 'revolving-door' patient stays! It makes ecomomical sense to support and 'shore-up' such patients with psychoanalytic psychotherapy as out-patients, thus allowing them to 'take root' in society again. Otherwise unnecessarily frequent retreats into the artificial protection of a psychiatric hospital soon feel like the real world! ... More

Conflict of interest: None Declared

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Therapies for depression must also be flexible to deliver.

Noel D Collins, SpR
18 November 2008

I enjoyed David Taylor’s spirited defence of the use of dynamic therapies in depression but feel that his clear model allegiance may have lead to the neglect of other practical considerations. The popular use of CBT in depression and other disorders is not solely due to a ‘homeopathic fantasy that short term psychological treatments are highly potent’. In comparing any NHS treatment, efficacy is only one consideration. Cost-effectiveness and flexibility in delivery are other issues to take into account. I believe CBT may be superior to dynamictherapy in these regards.The recent and compelling Layard economic argument for the cost effectiveness of CBT in adult depression has prompted the government’s Improved Access to Psychological Treatments (IAPT) initiative. It is difficult to see how psychodynamic therapies could be delivered in such a responsive way, consistent with a stepped care model. A relative advantage of CBT is that single threads of therapy at different levels of intensity can be titrated to patient need, rather than a blanket execution of the full CBT model in every case (Lovell and Richards, 2000). This is supported by Jacobson et al (1996) findings that many patients with depression improve with behavioural activation alone. What single threads of psychodynamictherapy could be similarly utilised, independent of the complex frame thatdynamic therapy usually demands?

Lovell and Richards (2000) argue that the traditional focus on ‘high intensity multiple-thread interventions’ to a select few, disenfranchises the remainder of people who would benefit from, but can’t access, briefer and simpler interventions. The current delivery of traditional psychodynamic therapy in traditional settings with traditionally long waiting lists is particularly vulnerable to this criticism. Whyte (1996) reports that a wider range of patients might be able to access dynamic therapy if their psychiatrists were not so deterred by long waiting lists. The coherence of CBT also lends itself more readily to training and the increased dispersion of less intensive treatments to patients directly through guided self help materials (including computerised or CCBT) or indirectly through the multi-disciplinary teamthrough new models of brief training such as the SPIRIT (Structured Psychosocial InteRventions In Teams) course (Whitfield & Williams 2003).

David Taylor makes a convincing case that dynamic therapy may be as effective as CBT in depression but he does not provide suggestions as to how dynamic therapy can be as coherent, cost effective and deliverable in busy clinical settings. His argument fuels the polarised argument of CBT verses dynamic therapy and ignores more integrative therapies such as Ryle’s Cognitive Analytical Therapy. Bateman (1997)argues that ‘a creative and constructive partnership between different psychotherapies needs to develop if psychotherapeutic psychiatry is to flourish’. He goes on to suggest the greatest threat to this ‘is the partisan approach of the psychotherapies themselves’.

REFERENCES:

1.Lovell, K., & Richards, D. (2000) Multiple Access Pointsand Levels of Entry (MAPLE): ensuring choice, accessibility and equity forCBT services. Behavioural and CognitivePsychotherapy, 28, 379–391

2. Jacobson, N., Dobson, K., Traux, P., et al (1996) A component analysis of cognitive behavioural treatment for depression. Journal of Consulting and Clinical Psychology,64, 295–304.

3. Whyte, C (1996) The need for dynamic therapy. Psychiatric Bulletin(1996), 20, 541-542

4. Whitfield, G. & Williams,C. (2003). The evidence base for cognitive–behavioural therapy in depression: delivery in busy clinical settings. Advances in Psychiatric Treatment; 9, 21–30

5. Bateman, A. (1997) Borderline Personality Disorder and Psychotherapeutic Psychiatry: An integrative ApproachBritish Journal of Psychotherapy; 13(4),489-498
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