Long-term psychodynamic psychotherapy in complex mental disorders: update of a meta-analysis

Evaluative Research on Psychodynamic Therapy: Foundations and Recent Advances

Psychodynamic therapy (PDT), a technical adaptation of psychoanalysis, is one of the most widely practiced forms of psychotherapy, making evaluative research on it essential. Although research on PDT has been ongoing for several decades, theoretical and practical challenges initially hindered the adoption of evidence-based medicine standards in such research, a shift that has largely taken place over the past 20 years. This article reviews the evolution of evaluative research on PDT for mental disorders in adults, with a focus on those with complex conditions. Since the first prospective evaluative studies in the 1950s, an accumulating body of knowledge-including cohort studies, randomized controlled trials, and meta-analyses-has established PDT as an evidence-based treatment for common mental disorders such as depression, anxiety, somatic symptoms and related disorders, and personality disorders, as well as complex mental disorders involving combinations of these conditions. There is also evidence supporting PDT's usefulness in treating anorexia nervosa and opioid dependence, along with some findings suggesting its potential use for schizophrenia spectrum disorders, bulimia nervosa, and posttraumatic stress disorder. Recent studies indicate that PDT can serve as a personalized treatment, promoting deep and lasting psychopathological changes in patients with severe, complex, and chronic mental disorders, involving specific technical features and mechanisms of change. These findings support the inclusion of PDT in mental health care policies and training, while ongoing research continues to explore its optimal treatment parameters.

Empirical examination of long-term and intensive psychodynamic psychotherapy for severely disturbed patients

Objectives This study examines the effectiveness and efficiency of intensive psychodynamic psychotherapy for severely impaired patients. Method: 104 patients in four public mental health centers underwent intensive psychodynamic psychotherapy. The number and duration of psychiatric hospitalizations were monitored for these patients from one year before therapy to eight years after. Several outcome variables were measured every six months, six times in total over two and a half years, using a longitudinal design. A multi-level analytic approach was applied to account for repeated measurements and missing data. Results: Significant improvement was found in all three symptomatic outcome measures (SCL-90, OQ-45, BDI) throughout treatment. The numbers of psychiatric hospitalizations and psychiatric hospitalization days decreased significantly from the level they were in the year before the start of psychodynamic treatment to three years after the start of treatment. These results were maintained for at least up to eight years. After capitalization, the overall cumulative 127.47-day decrease in hospitalization days equals savings of 115,850 NIS. The average cost of treatment after capitalization was 26,770 NIS. The insurer's estimated direct savings is 89,080 NIS (24,054 $). Conclusion: These findings support the hypothesis that psychodynamic psychotherapy is clinically effective and economically efficient for severely impaired patients.

Psychotherapies for prolonged grief disorder in adults: A systematic review and network meta-analysis

BACKGROUND

Prolonged grief disorder (PGD), a condition characterized by severe, persistent, and disabling grief, is newly included in ICD-11 and DSM-5-TR. Psychotherapies are among the most recommended treatments for PGD, but which should be considered as first-line treatment needs to be clarified. The purpose of this systematic review and network meta-analysis was to synthesize the available evidence to compare five outcomes of different psychotherapies on PGD in adults and identify the optimal psychotherapy modality to inform clinical decision-making for the treatment of PGD.

METHOD

A comprehensive search was conducted in 7 databases from inception until March 20th, 2023. In the frequentist framework, pairwise and network meta-analyses using random-effects models were performed for outcomes with 95 % confidence interval (CI).

RESULTS

There were 2962 records found and 55 studies (1,0330 participants) assessing 11 different psychological interventions were included. Compared with the waiting list, behavioral therapy (SMD=-1.05; 95 %CI=-1.71, -0.38), third-wave cognitive behavior therapy (SMD=-1.00; 95 %CI =-1.41, -0.58), family therapy (SMD=-0.87; 95 %CI=-1.59, -0.16), psychodynamic therapy (SMD=-0.88; 95 %CI=-1.67, -0.10) and cognitive therapy (SMD=-0.84; 95 %CI=-1.57, -0.12) were statistically effective in reducing grief symptom. Only cognitive behavior therapy (OR =0.48; 95 %CI = 0.27, 0.85) was more acceptable than waiting list. In terms of secondary outcome, third-wave CBT can statistically significantly reduce depression (SMD= -0.60; 95 %CI =- 0.84, -0.36), PTSD (SMD=-0.99; 95 %CI =- 1.62, -0.36) and anxiety (SMD= -1.44; 95 %CI =-2.63, -0.25) respectively.

CONCLUSIONS

Most psychological interventions are effective, but only cognitive behavior therapy has the highest acceptability. Third-wave CBT with higher efficacy rates may be more beneficial for reducing secondary outcomes. To provide more robust evidence, high-quality trials should be conducted in the future.

Assessing the effectiveness of internet-based interventions for mental health outcomes: an umbrella review

Internet-based interventions (IBIs) for behavioural health have been prevalent for over two decades, and a growing proportion of individuals with mental health concerns prefer these emerging digital alternatives. However, the effectiveness and acceptability of IBIs for various mental health disorders continue to be subject to scholarly debate. We performed an umbrella review of meta-analyses (MAs), conducting literature searches in PubMed, Web of Science, Embase, Cochrane and Ovid Medline from their inception to 17 January 2023. A total of 87 MAs, reporting on 1683 randomised controlled trials and 295 589 patients, were included. The results indicated that IBIs had a moderate effect on anxiety disorder (standardised mean difference (SMD)=0.53, 95% CI 0.44 to 0.62) and post-traumatic stress disorder (PTSD) (SMD=0.63, 95% CI 0.38 to 0.89). In contrast, the efficacy on depression (SMD=0.45, 95% CI 0.39 to 0.52), addiction (SMD=0.23, 95% CI 0.16 to 0.31), suicidal ideation (SMD=0.23, 95% CI 0.16 to 0.30), stress (SMD=0.41, 95% CI 0.33 to 0.48) and obsessive-compulsive disorder (SMD=0.47, 95% CI 0.22 to 0.73) was relatively small. However, no significant effects were observed for personality disorders (SMD=0.07, 95% CI -0.13 to 0.26). Our findings suggest a significant association between IBIs and improved mental health outcomes, with particular effectiveness noted in treating anxiety disorders and PTSD. However, it is noteworthy that the effectiveness of IBIs was impacted by high dropout rates during treatment. Furthermore, our results indicated that guided IBIs proved to be more effective than unguided ones, playing a positive role in reducing dropout rates and enhancing patient adherence rates. PROSPERO registration number: CRD42023417366.

Transference interpretation and psychotherapy outcome: a systematic review of a no-consensus relationship

Despite its well-established importance in psychoanalytic theory, there is a scarcity of empirical evidence on the relationship between a therapist's transference interpretation (TI) and therapeutic outcome. The current scientific literature shows no consensus on the existence and nature of such an association. Therefore, the present study aimed to systematically review the literature on the link between TI and outcomes in psychodynamic psychotherapies. The American Psychological Association PsycInfo, MEDLINE, and the Web of Science Core Collection were selected as the primary databases for the literature search. Studies were included if they measured the frequency/ concentration of TI in psychodynamic psychotherapy [e.g., transference focused psychotherapy (TFP), supportive-expressive therapy] or compared a treatment group (e.g., high in TI and TFP) with a control group (e.g., low in TI supportive therapy) in an adult population with psychiatric symptoms. Out of 825 retrieved abstracts, 25 articles (21 studies) were included in the final synthesis. 13 out of 21 (62%) studies showed a significant improvement in at least one therapy outcome measure following the use of TI. The present systematic review also revealed high heterogeneity across studies in terms of TI measurement, outcome assessment (e.g., psychiatric symptoms, dynamic change, interpersonal functioning, therapeutic alliance), study design (e.g., experimental, quasi-experimental, naturalistic), patient population (e.g., anxiety disorders, personality disorders), and types of treatment (e.g., TFP, supportive-expressive therapy), preventing researchers from asserting solid conclusions. The results strongly highlight the urgent need for highquality research to understand which types of patients, how, and when TIs could be effective throughout the therapy process.

The effect of individual short- and long-term psychotherapy on perceived social support: analysis of secondary outcomes of a randomized clinical trial

PURPOSE

Social support is important for maintaining and restoring psychological well-being but the effects of individual psychotherapies on perceived social support are not well known. In this analysis of secondary outcomes from a randomized clinical study, we compared the effects of long-term psychotherapy and two short-term psychotherapies on social support during a 5-year follow-up.

MATERIALS AND METHODS

Altogether 326 adult outpatients suffering from depressive and/or anxiety disorders were randomly assigned to long-term psychodynamic psychotherapy (LPP, n = 126), short-term psychodynamic psychotherapy (SPP, n = 101) and solution-focused therapy (SFT, n = 97). Outcome was measured by the global index and six subscores of the self-reported Brief Inventory of Social Support and Integration scale (BISSI) at baseline and at 1, 2, 3, 4 and 5 years after the beginning of the therapy.

RESULTS

Social support improved in all therapy groups and the improvement was relatively stable, lasting several years after the end of therapy. Little difference in improvement was observed either between therapy orientations or durations.

CONCLUSIONS

While no major differences were observed between treatment groups, the slight differences call for further research to verify these findings and to better understand how different therapies may improve perceived social support.

Increasing Value and Reducing Waste of Research on Neurofeedback Effects in Post-traumatic Stress Disorder: A State-of-the-Art-Review

Post-Traumatic Stress Disorder (PTSD) is often considered challenging to treat due to factors that contribute to its complexity. In the last decade, more attention has been paid to non-pharmacological or non-psychological therapies for PTSD, including neurofeedback (NFB). NFB is a promising non-invasive technique targeting specific brainwave patterns associated with psychiatric symptomatology. By learning to regulate brain activity in a closed-loop paradigm, individuals can improve their functionality while reducing symptom severity. However, owing to its lax regulation and heterogeneous legal status across different countries, the degree to which it has scientific support as a psychiatric treatment remains controversial. In this state-of-the-art review, we searched PubMed, Cochrane Central, Web of Science, Scopus, and MEDLINE and identified meta-analyses and systematic reviews exploring the efficacy of NFB for PTSD. We included seven systematic reviews, out of which three included meta-analyses (32 studies and 669 participants) that targeted NFB as an intervention while addressing a single condition-PTSD. We used the MeaSurement Tool to Assess systematic Reviews (AMSTAR) 2 and the criteria described by Cristea and Naudet (Behav Res Therapy 123:103479, 2019, https://doi.org/10.1016/j.brat.2019.103479 ) to identify sources of research waste and increasing value in biomedical research. The seven assessed reviews had an overall extremely poor quality score (5 critically low, one low, one moderate, and none high) and multiple sources of waste while opening opportunities for increasing value in the NFB literature. Our research shows that it remains unclear whether NFB training is significantly beneficial in treating PTSD. The quality of the investigated literature is low and maintains a persistent uncertainty over numerous points, which are highly important for deciding whether an intervention has clinical efficacy. Just as importantly, none of the reviews we appraised explored the statistical power, referred to open data of the included studies, or adjusted their pooled effect sizes for publication bias and risk of bias. Based on the obtained results, we identified some recurrent sources of waste (such as a lack of research decisions based on sound questions or using an appropriate methodology in a fully transparent, unbiased, and useable manner) and proposed some directions for increasing value (homogeneity and consensus) in designing and reporting research on NFB interventions in PTSD.

Emotion-Focused Psychodynamic Interview for People with Chronic Musculoskeletal Pain and Childhood Adversity: A Randomized Controlled Trial

Childhood adversity and emotional conflicts are associated with the presence and severity of chronic musculoskeletal pain (CMP), yet common treatments for CMP do not address such risk factors. We developed a single session, emotion-focused psychodynamic interview, based on Emotional Awareness and Expression Therapy and Intensive Short-term Psychodynamic Therapy, and we tested the interview's effects on pain-related outcomes and potential psychological mediators in a randomized, controlled trial. Adults (N = 91; ages 21-70, M = 44.64; 87.9% women) reporting CMP and at least 3 adverse childhood experiences completed measures at baseline and 6-week follow-up. Participants were randomized to immediate interview or waitlist control conditions. The 90-minute interview was conducted via videoconference, and the interviewer elicited disclosure of adversities and conflicts, linked these with pain, and encouraged the experience and expression of adaptive emotions. Analyses indicated that conditions did not differ significantly on change in pain severity; however, compared to control, the interview led to a significantly greater reduction in pain interference (P = .016, ηp2 = .05) and a similar trend for anxiety (P = .058, ηp2 = .04). The interview also significantly changed several potential mediators: pain-related anxiety (P = .008, ηp2 = .06), pain controllability (P = .016, ηp2 = .06), and psychological (P < .001, ηp2 = .15) and brain attributions (P = .022, ηp2 = .05) for pain. Participants viewed the interview as very valuable. We conclude that addressing childhood adversities and conflicts in a psychodynamic interview is beneficial for people with CMP. PERSPECTIVE: This study found that, compared to waitlist control, a 90-minute, remotely-administered, emotion-focused, psychodynamic interview improved pain interference, and anxiety among adults with chronic musculoskeletal pain and childhood adversity. Intensive emotional work can be done in a single session to the benefit of patients with chronic musculoskeletal pain.

Trajectories of change among highly challenging patients in intensive long-term psychoanalytic psychotherapy

OBJECTIVES

This study aimed to identify and describe trajectories of change in distress among highly challenging patients who had received long and intensive psychoanalytic psychotherapy.

METHODS

The longitudinal version of the K-means algorithm was applied to the outcome measures data of 74 patients treated in four public mental health centers. The patients were measured five times at 6-month intervals for three outcome measures.

RESULTS

For the OQ45 and Symptom Checklist-90, one trajectory was marked by a lower initial distress level. In this trajectory, the improvement occurred in the first half of the measurements, with a plateau thereafter. A second trajectory was characterized by higher initial severity and an improvement, mainly in the second part of the measurements. For the Beck Depression Inventory, one trajectory was marked by lower initial distress. In this group, the improvement occurred throughout the entire period. The remaining patients were characterized by higher initial distress and a decreased level of distress in the last part of treatment. They began to improve only during the third year of therapy.

CONCLUSION

The response to treatment is not uniform in long-term treatment for highly challenging patients. A significant number of patients require a longer period of therapy to ignite improvement.

The Ghent Psychotherapy Study: A Pragmatic, Stratified, Randomized Parallel Trial into the Differential Efficacy of Psychodynamic and Cognitive-Behavioral Interventions in Dependent and Self-Critical Depressive Patients

INTRODUCTION

Different types of psychotherapy are effective for treating major depressive disorder across groups yet show large within-group differences. Patient personality style is considered a potentially useful variable for treatment matching.

OBJECTIVE

This study is the first experimental test of the interaction between therapeutic approach and patients' dependent versus self-critical personality styles.

METHODS

A pragmatic stratified parallel trial was carried out with 100 adult patients diagnosed with DSM-IV-TR major depressive disorder. They were randomly assigned to short-term (16-20 sessions) cognitive behavioral therapy (CBT) or short-term psychodynamic psychotherapy (STPP). Patients were assessed at baseline, during therapy, post-therapy, and at 3- and 6-month follow-up. Primary outcome is depression severity measured by the Hamilton Rating Scale for Depression posttreatment. Primary analysis was by intention to treat. This trial is registered with the ISRCTN registry (www.isrctn.com), number ISRCTN17130982.

RESULTS

The intention-to-treat sample consisted of 100 participants; 40 with self-critical and 60 with dependent personality styles were randomized to either CBT (n = 50) or STPP (n = 50). We observed no interaction effect (-0.34 [-6.14, 5.46]) between therapy and personality style and found no evidence for a difference in effectiveness between the treatments in general in terms of symptom reduction and maintained benefits at 6-month follow-up.

CONCLUSION

We found no evidence that dependent versus self-critical personality styles moderate the relation between treatment and outcome in depression. Research using individual patient data could gain further insight into why specific therapeutic approaches work better for specific patients.

Efficacy of high-intensity versus low-intensity psychoanalytically oriented long-term treatments and determinants of outcome: individual participant data Meta-analysis of Long-term Analytic treatment Studies (MeLAS)

INTRODUCTION

Long-term psychodynamic/psychoanalytic psychotherapy (LTPP) is a prevalent treatment option for complex mental disorders. Yet, little is known about the role of treatment intensity in LTPP. We present a study protocol for a systematic review and individual participant data (IPD) meta-analysis aggregating and analysing individual data from randomised and quasi-experimental trials by meta-analysis. The purpose is to (1) determine the treatment effectiveness of LTPP with low versus high intensity (up to 2 weekly sessions vs three or more), (2) compare their joint effectiveness to shorter therapies and treatments as usual, (3) identify predictors and moderators of treatment outcomes and (4) determine reciprocal relationships between different outcome domains (symptomatic and structural/personality change) over the courses of LTPP.

METHODS AND ANALYSIS

We include studies from (randomised controlled trial, RCT) and quasi-experimental trials, where at least one condition was LTPP of high or low frequency. Long-term treatment is defined as ≥1 year or ≥50 sessions. To be eligible studies must include a standardised outcome measure of symptoms (global or disorder specific) with at least one proof of reliability. The primary outcome is symptom reduction (global or specific), secondary outcome criteria are reliable change, remission, functional capacities, personality, personality functioning and interpersonal pathology. Relevant studies will mainly be identified by searching relevant databases: PubMed, PsycINFO (via EBSCO), Web of Science (via Elsevier), Chochrane's Central Register of Controlled Trials (via Wiley). Risk of bias will be evaluated in line with the Cochrane assessments tools for quasi-experimental trials and RCTs, respectively.

ETHICS AND DISSEMINATION

Aggregation of data from primary trials collected based on ethics votes. Dissemination into clinical practice via open access publications of findings.

PROSPERO REGISTRATION NUMBER

CRD42022304982; Pre-results.

Evidenzbasierung der psychodynamischen Psychotherapie anhand anerkannter Kriterien zur Bewertung der Wirksamkeit von Psychotherapieverfahren

Gemäß dem neuen Psychotherapeutengesetz (PsychThG) soll das zukünftige Approbationsstudium Studierende in die Lage versetzen, die Wirksamkeit von Psychotherapieverfahren anhand anerkannter Merkmale für die Bewertung ihrer wissenschaftlichen Evidenz beurteilen zu können. Vor diesem Hintergrund werden im vorliegenden Beitrag die nationalen und internationalen Kriterien zur Evidenzbewertung vorgestellt und anhand derer die Wirksamkeit von psychodynamischer Psychotherapie zusammengefasst. Berücksichtigt werden die im Methodenpapier des Wissenschaftlichen Beirats Psychotherapie geforderten Kriterien zur wissenschaftlichen Anerkennung von Psychotherapieverfahren, die lange Zeit international einflussreichsten Kriterien von Chambless et al. (1998) sowie die aktuellen Kriterien von Tolin et al. (2015). Es wird auf Kritik an den Kriterien zur Evidenzbewertung (unter anderem zur störungsspezifischen Indikation), auf aktuelle Kontroversen (unter anderem zur Wirksamkeit von psychodynamischer Langzeittherapie und analytischer Psychotherapie, zur Verfahrensorientierung) und die Relevanz der Beteiligung von praktizierenden psychodynamischen Psychotherapeut:innen an Forschungsprojekten eingegangen. Für die adäquate Beurteilung der Wirksamkeit der psychodynamischen Psychotherapie, insbesondere der Langzeittherapien und der analytischen Psychotherapie, ist es wichtig, längere Nachuntersuchungszeiträume einzubeziehen und Veränderungen auch in stärkerem Einklang mit psychodynamischen Annahmen zu therapeutischen Veränderungsprozessen zu erfassen.

Unipolare Depression – psychodynamische Vielfalt

Versorgungsengpässe in der ambulanten Psychotherapie haben in den letzten Jahren zu diversen Gesetzesinitiativen geführt. Eine davon war die Einführung von diagnosespezifischen Behandlungskontingenten. Ausgehend von diesem gesundheitspolitischen Vorhaben fragten wir uns, inwiefern empirische Daten für oder gegen eine solche Praxis sprechen, das heißt, wie „homogen“ Patient:innen mit derselben ICD-10-Diagnose aus psychodynamischer Sicht sind. Mithilfe der qualitativen Inhaltsanalyse wurden 13 Berichte von Patient:innen mit der Erstdiagnose F33.1 (Rezidivierende depressive Störung, gegenwärtig mittelgradige Episode) ausgewertet, die im Rahmen des Gutachtenverfahrens geprüft wurden. Zusätzlich schätzten wir das generelle Funktionsniveau ein und verglichen die Reife der Abwehr mit dem Vorliegen komorbider psychischer Diagnosen. Es wurden 56 Seiten Textmaterial analysiert. Wir identifizierten 4 Konflikttypen (Selbstwert, Nähe-Distanz, Unterwerfung, Schuld) sowie strukturelle Beeinträchtigungen in 4 Bereichen (Selbst- und Objektwahrnehmung, Selbstregulierung, Bindung und Identität), bei Vorliegen verschiedener Therapieziele und Interaktionsformen. Die Abwehr bewegte sich auf unreifem bis neurotischen Niveau, was nicht im Zusammenhang mit dem Vorliegen komorbider Diagnosen stand. Das Funktionsniveau ließ auf ein breites Spektrum genereller Beeinträchtigung schließen. Unsere Ergebnisse legen nahe, dass Depressionen vielfältige psychodynamische Hintergründe haben. Dies steht im Widerspruch zu der Idee einer Zuordnung von ICD-10-Diagnose und Behandlungskontingent.

Mentalization-oriented psychodynamic group therapy for patients with personality disorders: a naturalistic prospective cohort study

OBJECTIVES

Patients with personality disorders (PDs) are often treated with non-manualized psychodynamic group therapy (PDT) lasting for several years. Non-manualized PDT often combines a variety of therapeutic approaches from different PDT traditions, including mentalization-based therapy. Currently, little is known about the effect of this long-term, costly treatment. This study investigated the extent to which patients with different PDs benefit from mentalization-oriented PDT as it is implemented in clinical practice in terms of symptom severity, interpersonal problems, and general functioning.

METHODS

The design was a naturalistic, prospective cohort study. Seventy-five consecutive PD patients were assessed before treatment with the Symptom Checklist-90 Revised (SCL-90-R) as the primary outcome measure and the Inventory of Interpersonal Problems (IIP) and Global Assessment of Functioning (GAF) as secondary outcome measures. The sample was repeatedly assessed every 12 months for up to 36 months. Paired t-tests were applied to examine the effectiveness of the intervention.

RESULTS

Among completers (n = 42; 56%), improvement was observed on the SCL-90-R: Global Severity Index (mean change = -0.45 [95% CI = -0.72, -0.19]; Cohen's d = -0.55), Positive Symptom Distress Index (-0.40 [-0.63, -0.17]; -0.56); Positive Symptoms Total (-10.70 [-17.31, -4.09]; -0.52). Secondary outcomes also improved: IIP-total (mean change = -0.50 [95%CI = -0.74, -0.25]; Cohen's d = -0.66); GAF-Functioning (8.79 [6.32, 11.27]; 1.15); and GAF-Symptoms (10.67 [8.09, 13.25]; 1.34).

CONCLUSIONS

Completers improved on symptom severity, interpersonal problems, and general functioning, with within-group effect sizes ranging from medium to large. Approximately half the sample dropped out, suggesting that mentalization-oriented PDT spanning several years may be unrealistic for many patients with PD. Significant outcomesThere are no clear guidelines for psychological interventions targeting personality disorders (PDs), and currently eclectic and non-manualized psychodynamic approaches lasting for up to 3 years are prevailing in some clinical practices.Although this treatment approach may have an effect on compliant patients, the high drop-out rate indicates that it may not be suitable for a large proportion of PD patients since it requires long-term commitment. Furthermore, it is difficult to identify the content of the non-manualized psychodynamic therapy and what helps the patients.More specific clinical guidelines emphasizing the application of evidence-based treatments or at least manualized treatments are warranted for the treatment of emotionally unstable PDs and other PDs. LimitationsThe naturalistic study design, without any control group, limits conclusions about mechanisms of action of the intervention.Since the intervention was not manualized, it is unknown exactly which treatment was actually administered, which reduces external validity.The outcomes are based on completer data of a relatively small sample size with high drop-out rate.

Effectiveness of outpatient and community treatments for people with a diagnosis of 'personality disorder': systematic review and meta-analysis

BACKGROUND

Quality of care and access to effective interventions have been widely criticised as limited for people diagnosed with 'personality disorder' or who have comparable needs (described in some recent papers as "Complex Emotional Needs" (CEN). It is important to identify effective interventions and the optimal context and mode of delivery for people with CEN. We aimed to investigate the effectiveness of psychosocial interventions delivered in community and outpatient settings in treating symptoms associated with 'personality disorder', and the moderating effects of treatment-related variables.

METHODS

We systematically searched MEDLINE, EMBASE, PsycINFO, CINAHL, HMIC, ASSIA for articles published in English, from inception to November 23, 2020. We included randomized controlled trials examining interventions provided in community or outpatient settings for CEN. The primary outcome was 'personality disorder' symptoms, while secondary outcomes included anxiety symptoms, depressive symptoms, and global psychiatric symptoms. Random-effects meta-analysis was conducted for each outcome, and meta-regression analysis was performed to assess the moderating effects of treatment characteristics. The quality of the studies and the degree of publication bias was assessed.

RESULTS

We included 54 trials (n = 3716 participants) in the meta-analysis. We found a large effect size (g = 0.78, 95% CI: 0.56 to 1.01, p < 0.0001) favoring interventions for 'borderline personality disorder' (BPD) symptoms over Treatment as Usual or Waitlist (TAU/WL), and the efficacy was maintained at follow-up (g = 1.01, 95% CI: 0.37 to 1.65, p = 0.002). Interventions effectively reduced anxiety symptoms (g = 0.58, 95% CI: 0.21 to 0.95, p = 0.002), depressive symptoms (g = 0.57, 95% CI: 0.32 to 0.83, p < 0.0001), and global psychiatric symptoms (g = 0.50, 95% CI: 0.35 to 0.66, p < 0.0001) compared to TAU/WL. The intervention types were equally effective in treating all symptom categories assessed. Treatment duration and treatment intensity did not moderate the effectiveness of the interventions for any outcome.

CONCLUSIONS

People with a 'personality disorder' diagnosis benefited from psychological and psychosocial interventions delivered in community or outpatient settings, with all therapeutic approaches showing similar effectiveness. Mental health services should provide people with CEN with specialised treatments in accordance with the availability and the patients' preferences.

Comparative efficacy and acceptability of psychotherapies for panic disorder with or without agoraphobia: systematic review and network meta-analysis of randomised controlled trials

BACKGROUND

Psychotherapies are the treatment of choice for panic disorder, but which should be considered as first-line treatment is yet to be substantiated by evidence.

AIMS

To examine the most effective and accepted psychotherapy for the acute phase of panic disorder with or without agoraphobia via a network meta-analysis.

METHOD

We conducted a systematic review and network meta-analysis of randomised controlled trials (RCTs) to examine the most effective and accepted psychotherapy for the acute phase of panic disorder. We searched MEDLINE, Embase, PsycInfo and CENTRAL, from inception to 1 Jan 2021 for RCTs. Cochrane and PRISMA guidelines were used. Pairwise and network meta-analyses were conducted using a random-effects model. Confidence in the evidence was assessed using Confidence in Network Meta-Analysis (CINeMA). The protocol was published in a peer-reviewed journal and in PROSPERO (CRD42020206258).

RESULTS

We included 136 RCTs in the systematic review. Taking into consideration efficacy (7352 participants), acceptability (6862 participants) and the CINeMA confidence in evidence appraisal, the best interventions in comparison with treatment as usual (TAU) were cognitive-behavioural therapy (CBT) (for efficacy: standardised mean differences s.m.d. = -0.67, 95% CI -0.95 to -0.39; CINeMA: moderate; for acceptability: relative risk RR = 1.21, 95% CI -0.94 to 1.56; CINeMA: moderate) and short-term psychodynamic therapy (for efficacy: s.m.d. = -0.61, 95% CI -1.15 to -0.07; CINeMA: low; for acceptability: RR = 0.92, 95% CI 0.54-1.54; CINeMA: moderate). After removing RCTs at high risk of bias only CBT remained more efficacious than TAU.

CONCLUSIONS

CBT and short-term psychodynamic therapy are reasonable first-line choices. Studies with high risk of bias tend to inflate the overall efficacy of treatments. Results from this systematic review and network meta-analysis should inform clinicians and guidelines.

What Works for Whom: Patients' Psychological Resources and Vulnerabilities as Common and Specific Predictors of Working Alliance in Different Psychotherapies

Background

Across different types of psychotherapy, one of the most robust predictors of better therapeutic outcomes is a good working alliance between patient and therapist. Yet there is little comparative research on whether particular patients more likely achieve a better alliance in certain treatments which represent particular therapeutic approaches or durations.

Methods

326 patients suffering from depressive and/or anxiety disorder were randomized into two short-term (solution-focused or psychodynamic) and one long-term (psychodynamic) therapy models. Treatments lasted ~7 and 36 months, respectively. Before randomization, patients were assessed with the interview-based Suitability for Psychotherapy Scale and filled Childhood Family Atmosphere and Life Orientation Test questionnaires. Patients filled Working Alliance Inventory after 3rd therapy session and at end of treatment; the long-term therapy patients, additionally, at 7 months' time point. Linear regression models were used.

Results

Greater psychological resources (e.g., capacity for self-reflection, affect regulation, flexible interaction) had little effect on alliance during the course of the short-term therapies. However, they did predict better working alliances at end of long-term as opposed to short-term therapy. Childhood adversities impacted alliances already at 7 months.

Conclusions

Although patients with certain qualities achieve better alliances in long-term as opposed to short-term therapies, apparently the theoretical orientation of therapy makes little difference. For patients with childhood adversities, differences between long-term (psychodynamic) treatment vs. various brief therapy models may be particularly salient.

A clinical illustration of short-term mentalization-based therapy for borderline personality disorder

OBJECTIVE

Mentalization-based therapy (MBT) is an evidence-supported, long-term psychotherapy program developed to treat borderline personality disorder (BPD). A short-term, 20-week adaptation to the original MBT format including case formulation, psychoeducation, and group and individual therapy has recently been proposed. The current case material will illustrate how the recent adaptation to the mentalization-based practice can enhance personality functioning using a short-term format.

METHODS

Case material is presented to demonstrate the clinical application of short-term MBT in the treatment of a young woman diagnosed with BPD who has a history of failed treatment attempts and who showed signs of affective dysregulation, unstable relationships, and intense abandonment anxiety.

RESULTS

The case illustration shows how short-term MBT can facilitate improvement in personality functioning, specifically targeting situations in which the patient lost her temper and became overwhelmed by abandonment anxiety. By continuously employing therapeutic shifts toward greater autonomy and agency, and by maintaining a balanced empathetic therapeutic stance, the therapists were able to enhance the patients mentalizing and personality functioning.

CONCLUSIONS

Short-term MBT can be effectively implemented to enhance the mentalizing capacity and personality functioning in outpatients with BPD.

Buffering effect of in-patient psychiatric care on the link between fear of covid-19 and mental health consequences

Background& aimes

Psychiatric admissions during the covid-19 pandemic were limited, overlooking their possible benefit. This study focused on assessing the effect of the fear of covid on the mental health and well-being of inpatients as opposed to outpatients.

Methods

During the first lockdown, forty-four inpatients and day care patients (inpatient group) and 74 outpatients (outpatient group) were recruited after an informed consent procedure. Fear of the infection was assessed using the Fear of COVID-19 (FCV–19S); severity of mental health symptomatology was evaluated with the outcome questionnaire-45 (OQ-45); wellbeing was assessed with the Psychological well-being scale (PWB).

Outcomes

There was no difference between the inpatient group and outpatient group in their fear of COVID-19 levels.

FCV-19 predicted changes in the outpatient OQ total score (B ​= ​2.21, p ​< 0.001), OQ interpersonal relation subscale (B ​= ​0.34, p ​= 0.01), PWB total score (B ​= ​−0.05, p ​< 0.001), PWB environmental mastery subscale (B ​= ​−0.07, p ​< 0.001) and PWB positive relation subscale (B ​= ​−0.05, p ​< 0.001), but not in the inpatient group.

Conclusions

Mental health and wellbeing of the outpatient group, which had less therapeutic contact than the inpatient group, correlated with the fear of covid, supporting the hypothesis that intensive psychiatric therapy had a protective effect on the mental health consequences of “fear of covid”.

Recherche extra-clinique en psychanalyse : cadre conceptuel et exemple de recherche

La recherche en psychanalyse s’est développée en se centrant principalement sur la rencontre entre le patient et son analyste, donnant lieu à des recherches clinico-analytique et conceptuelle. Initiée par Freud dans une interconnexion étroite entre le cerveau et la psyché, la psychanalyse a été conçue d’emblée comme une science plurielle de l’inconscient. Cet article présente un cadre conceptuel de recherche en psychanalyse puis aborde les enjeux de cette recherche avec la conviction que le partage de résultats, de méthodes et de questions sur la recherche empirique soutient le développement des capacités cliniques et de la pensée critique tant des étudiants que des cliniciens confirmés.

Il ruolo della terapia psicodinamica e gli ostacoli alla sua diffusione

Dalle ricerche emerge che la terapia psicodinamica è efficace in modo specifico per pazienti con disturbi di personalità, disturbi cronici d'ansia e depressivi e anche disturbi cronici complessi. Inoltre, la frequenza settimanale e la durata della terapia hanno effetti positivi indipendenti tra loro. Uno degli ostacoli alla diffusione della terapia psicodinamica è il fatto che vengono preferiti i trattamenti brevi, in particolar modo la terapia cognitivo-comportamentale (CBT), considerata spesso il gold standard (cioè la terapia migliore che ci sia) nonostante i problemi che sono stati rilevati nelle metodologie delle ricerche sperimentali, nella validità dei risultati in suo favore, nella generalizzabilità dei risultati e nei metodi diagnostici utilizzati. Un altro ostacolo all'erogazione della terapia psicodinamica risiede nei protocolli delle compagnie assicurative vigenti in molti Paesi, che guardano al contenimento dei costi anziché fornire ai pazienti un trattamento ottimale; negli Stati Uniti, ad esempio, tradiscono il mandato del Mental Health Parity Act, la legge che obbliga che i limiti massimi di copertura assicurativa per i disturbi mentali non seguano criteri diversi da quelli per i trattamenti ottimali dei problemi medici o chirurgici.

Poor suitability for psychotherapy - a risk factor for treatment non-attendance?

BACKGROUND

Patient suitability has been suggested to predict treatment non-attendance but information on its effect is limited.

AIM

To study the prediction of the Suitability for Psychotherapy Scale (SPS), on occurrence of treatment non-attendance.

METHODS

Altogether 326 outpatients, with depressive or anxiety disorder, were randomized to short-term psychodynamic psychotherapy (SPP), long-term psychodynamic psychotherapy (LPP), and solution-focused therapy (SFT). SPS was based on seven components from three suitability domains: nature of problems, ego strength, and self-observing capacity. Treatment non-attendance was defined as refusal of engaging therapy and of premature termination. The Cox model and logistic regression were used.

RESULTS

Treatment non-attendance was significantly more common in LPP patients with poor SPS (RR = 2.76, 95% CI = 1.45-5.26). This was mainly due to poor flexibility of interaction, poor self-concept, and poor reflective ability. Premature termination in SFT showed a similar trend but due to other SPS components: absence of a circumscribed problem, poor modulation of affects, and poor response to trial interpretation. On the contrary, individuals with good values of SPS were more prone to premature termination in SPP.

LIMITATIONS

The prediction of suitability on refusal could only be studied in the LPP group due to few refusals in the short-term therapy groups. The sample consisted of patients who participated in a trial. Thus the findings may not be directly generalized to unselected patients in the public mental health setting.

CONCLUSIONS

Poor suitability, apparently, predicts non-attendance in LPP and SFT, but not in SPP. More studies on large cohorts are needed.

Adapting group schema therapy for older adults with personality disorders: lessons learnt

A first empirical study into group schema therapy in older adults with mood disorders and personality disorder (PD) features has shown that brief group schema therapy has potential to decrease psychological distress and to change early maladaptive schemas (EMS). Effect sizes however were smaller than those found in similar studies in younger adults. Therefore, we set out to adapt the treatment protocol for older adults in order to enhance its feasibility and outcome in this age group. We examined this adapted protocol in 29 older adults (mean age 66 years) with PDs from four Dutch mental health institutes. The primary outcome was symptomatic distress, measured by the Brief Symptom Inventory. Secondary outcomes were measured by the Young Schema Questionnaire, the Schema Mode Inventory, and the short version of the Severity Indices of Personality Problems. Contrary to our expectations, the adapted treatment protocol yielded only a small effect size in our primary outcome, and no significant improvement in EMS, modes and personality functioning. Patients pointed out that they were more aware of their dysfunctional patterns, but maybe they had not been able yet to work on behavioural change due to this schema therapy treatment being too brief. We recommend more intensive treatment for older patients with PDs, as they might benefit from more schema therapy sessions, similar to the treatment dosage in younger PD patients. They might also benefit from a combination of group therapy and individual treatment sessions.

Key learning aims

(1)

Does EMDR Therapy Have an Effect on Memories of Emotional Abuse, Neglect and Other Types of Adverse Events in Patients with a Personality Disorder? Preliminary Data

BACKGROUND

Little is known about the effectiveness of trauma-focused therapies for memories of events not meeting the A-criterion of post-traumatic stress disorder (PTSD).

OBJECTIVE

Determining the effect of EMDR therapy on memories of emotional abuse, neglect and other types of adverse events in patients with a personality disorder (PD).

METHOD

We conducted a secondary analysis of the data from our study, which aimed to determine the effectiveness of five sessions of EMDR therapy in 49 patients with a PD. Patients were divided into three different groups depending on their most prevalent type of adverse event. Data were analyzed with Generalized Estimating Equations.

RESULTS

Of all patients, 49% reported emotional neglect, 22.4% emotional abuse and 26.5% other types. Only one patient reported memories that predominantly fulfilled the A-criterion of PTSD. After five sessions of EMDR therapy, medium to large treatment effects for memories related to neglect (ds between 0.52 and 0.79), medium treatment effects for memories involving emotional abuse (ds between 0.18 and 0.59) and other types of adverse events were found (ds between 0.18 and 0.53). No significant differences in symptom reduction associated with the application of EMDR therapy among memories involving these three different types of adverse events could be revealed.

CONCLUSIONS

The results support the notion that EMDR therapy is not only an effective therapy for memories related to A-criteria-worthy events, but that it also has a symptom-reducing effect on memories involving other types of adverse events. This suggests that EMDR might be a valuable addition to the treatment of PD without PTSD.

Performance enhancement through meditation in athletes: Insights from a systematic review of randomized controlled trials

BACKGROUND

An increasing number of studies have examined the efficacy of meditation, showing performance enhancement in a variety of sports fields, but few attempts have been made to derive outcomes based on evidence from the preexisting groundwork. The present study empirically reviews reports on meditation in athletes to investigate (a) the efficacy of these interventions in augmenting athletic attainment, (b) the methodological quality of studies (risk of bias), and (c) a possible conceptual framework for how meditation affects athletes' performance.

METHODS

A systematic search was conducted in Ovid MEDLINE (Ovid Medline(R) In-Process & Other Non-Indexed Citations and Ovid Medline(R)); EMBASE; EBSCO; CINAHL; SPORTDiscuss; and SCOPUS from June 16, 2019 to July 18, 2019. All studies published were screened and included if they met the eligibility criteria. Two independent reviewers assessed the risk of bias and extracted the data. The available evidence was summarized.

RESULTS

Our initial search returned a total of 734 articles. After screening abstracts and full texts, 6 studies were included. Participants reported changes that might be considered positively in sports events after experiencing planned intervention. However, in the methodological quality assessment measured in seven domains of Cochrane criteria, the risk of bias of each study was generally high.

DISCUSSION

From the results derived, the theoretical insights of imagery, relaxation and self-talk, which can catalyze the development of a new form of meditation program, were obtained. However, given methodological defects of RCTs, further precisely designed RCTs are needed.

Intermittent Treatment with the Psychodynamic Psychiatrist: A Patient-Centered Approach

This study examines the experiences of patients in treatment with psychodynamic psychiatrists on an intermittent basis following an initial brief period of intensive psychotherapy and stabilization. Patients with non-psychotic disorders who received intermittent treatment answered a web-based questionnaire describing the usefulness of various supportive, cognitive-behavioral, and psychodynamic interventions. Forty-eight out of 58 patients invited to participate completed the survey (83% response rate). The majority (75%) of respondents welcomed the intermittent treatment frame. Therapeutic factors deemed to be most helpful included supportive interventions such as ability to relate to the clinician, ability of clinician to listen empathically, and feeling supported by a non-judgemental therapist when talking about private matters. The majority of respondents also endorsed as highly beneficial various cognitive-behavioral interventions such as understanding how thinking patterns impact behavior and feelings and discussing alternative coping skills. Also highly rated were psychodynamic interventions, including understanding how the present is modeled from past experiences and expression and regulation of affect. In the open-ended qualitative feedback, therapeutic factors including collaboration, forming an alliance, and empathic attunement emerged as important. Our preliminary findings suggest that the intermittent psychodynamic treatment frame is well received by patients. Patients welcome integration of different psychotherapeutic approaches to individualize treatment. The common factors in psychotherapy are important patient-reported therapeutic factors in the intermittent treatment approach.

Moving Forward While Standing Still: A Case of Mental Health Advocacy Evolving in the Time of COVID-19

There have been shifts over time in the value placed on long-term psychotherapeutic modalities even though they can be life-saving. For example, the province of Ontario in Canada has been dealing with a government proposal put forward in 2019 to limit the length of psychotherapy treatment. In response, stakeholders from numerous groups came together to advocate for the importance of continuing unrestricted access to long-term psychotherapy. Approaches to this advocacy then had to unexpectedly adapt to the Coronavirus Disease 2019 (COVID-19) pandemic that came to the forefront in 2020 and will continue to develop in response to this changing landscape.

Ten-week Intensive Group Program (IGP) for borderline personality disorder: making the case for more accessible and affordable psychotherapy

BACKGROUND

The availability of specialist psychotherapies for treating borderline personality disorder (BPD) is limited by costs associated with training, resourcing and treatment duration. Developing a programme that incorporates effective strategies from a range of evidence-based specialist treatments, concentrates their delivery and uses a group-based format will improve treatment access.

OBJECTIVE

To assess the short-term clinical efficacy, acceptability and feasibility of a bespoke manualised programme for the treatment of BPD. This 10-week group-based outpatient programme was delivered 2 days per week in 4 hour sessions; participants received 80 hours of treatment in total.

METHODS

Forty-three participants, many having severe BPD symptomatology, were assessed before and after the 10-week programme using a range of validated self-report questionnaires and a self-appraisal feedback form. The primary outcome measured was BPD symptom severity.

FINDINGS

Statistically significant improvements were measured in BPD symptom severity, depression, trait anxiety, emotional regulation, general health, hopefulness, self-compassion and anger, several with moderate to large effect sizes. Many of these improvements remained at 4-6 months post treatment. More than 90% of surveyed participants expressed a moderate or high level of satisfaction with the programme.

CONCLUSIONS

This integrated treatment programme delivered in a highly concentrated format demonstrated short-term efficacy across many BPD-relevant endpoints; its acceptability was endorsed by most clients.

CLINICAL IMPLICATIONS

Incorporation of key aspects of evidence-based treatment using a time-intensive group format could greatly enhance the capacity of mental health services to meet the needs of people who experience BPD within a population-based mental health service framework.

Mechanisms of change and heterogeneous treatment effects in psychodynamic and cognitive behavioural therapy for patients with depressive disorder: a randomized controlled trial

BACKGROUND

Major depressive disorder (MDD) is a prevalent psychiatric condition associated with significant disability, mortality and economic burden. Cognitive behavioral therapy (CBT) and psychodynamic psychotherapy (PDT) are found to be equally effective for patients with depression. However, many patients do not respond sufficiently to either treatment. To offer individualized treatment, we need to know if some patients benefit more from one of the two therapies. At present little is known about what patient characteristics (moderators) may be associated with differential outcomes of CBT and PDT, and through what therapeutic processes and mechanisms (mediators) improvements occur in each therapy mode. Presently only theoretical assumptions, sparsely supported by research findings, describe what potentially moderates and mediates the treatment effects of CBT and PDT. The overall aim of this study is to examine theoretically derived putative moderators and mediators in CBT and PDT and strengthen the evidence base about for whom and how these treatments works in a representative sample of patients with MDD.

METHODS

One hundred patients with a diagnosis of MDD will be randomized to either CBT or PDT. Patients will be treated over 28 weeks with either CBT (one weekly session over 16 weeks and three monthly booster sessions) or PDT (one weekly session over 28 weeks). The patients will be evaluated at baseline, during the course of therapy, at the end of therapy, and at follow-up investigations 1 and 3 years post treatment. A large range of patient and observer rated questionnaires (specific preselected putative moderators and mediators) are included.

DISCUSSION

The clinical outcome of this study may better guide clinicians when deciding what kind of treatment any individual patient should be offered. Moreover, the study aims to further our knowledge of what mechanisms lead to symptom improvement and increased psychosocial functioning.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT03022071.

www.psychopap.com : améliorer l’accès à la psychothérapie par le transfert des connaissances aux patients et aux futurs thérapeutes

La psychothérapie est un traitement efficace pour plusieurs troubles mentaux. Elle est, toutefois, peu accessible pour différentes raisons, dont son coût, la façon de l’offrir et la disponibilité locale des thérapeutes. Par ailleurs, l’accès à la formation en psychothérapie pour les futurs thérapeutes peut être compliqué par différents facteurs incluant le manque de ressources adaptées à différents contextes de pratique et la difficulté à obtenir une supervision. Dans ce contexte, un site web offrant des documents d’autothérapie aux patients, des miniguides de formation dans différents types de psychothérapies basées sur des données probantes, des suggestions d’articles et livres phares, des capsules vidéo expliquant les principes sous-tendant différents modèles théoriques et démontrant des techniques de psychothérapie, pourrait bénéficier autant aux patients qu’aux psychothérapeutes débutants.

L’Hôpital en santé mentale Albert-Prévost (HSMAP), impliqué dès ses origines dans la formation et la pratique de la psychothérapie, conçoit un tel outil pour célébrer son centenaire, le site www.psychopap.com. Le présent article propose de décrire la genèse et le déploiement de ce projet de transmission de connaissances en psychothérapie en décrivant d’abord le contexte et l’implication des membres de l’HSMAP dans l’enseignement de la psychothérapie puis une brève recension des écrits concernant l’autothérapie pour les troubles mentaux, l’utilisation des ordinateurs/Internet pour l’enseignement de la psychothérapie et comment ces données ont été appliquées dans la création de www.psychopap.com.

[Efficacy of psychodynamic therapies: A systematic review of the recent literature]

AIM

A French governmental institute published, in February 2004, a report assessing the efficacy of psychotherapies in the light of the biomedical literature. It concluded that cognitive psychotherapies effectively cure common mental disorders, while the efficacy of psychodynamic therapies is not proven by scientific studies. Because many French mental health professionals are practicing with reference to psychoanalysis, this conclusion stirred up heated controversy. Since February 2004, numerous studies assessing psychodynamic therapies have been published in peer-reviewed biomedical journals. Moreover, these primary studies have been meta-analyzed in dozens of review articles. Here, we systematically review these meta-analysis articles.

METHODS

A systematic search for meta-analyses assessing psychodynamic therapies was performed using PubMed and identified 71 articles published from January 2004 to December 2019. Among them, 25 articles were judged to be relevant because they reported meta-analyses assessing the symptoms of common mental disorders in at least three distinct cohorts of adult patients. Although the primary studies included in these 25 meta-analysis articles often overlap, the selection criteria, calculation methods and results always differ between them. Therefore, we reviewed all of them without further selection. From all the meta-analyses reported in these 25 articles, we systematically present here the most compelling ones, i.e. those calculated from the largest number of primary studies. Results were quantified in terms of effect size (i.e. standardized mean difference). Effect sizes below 0.25 were considered as without clinical significance, whereas those superior to 0.8 were regarded as robust. Because short-term psychodynamic therapies had been assessed in 20 meta-analysis articles published until 2017, we did not search for more recent primary studies. However, because the most recent meta-analysis article about long-term psychodynamic therapies was published in 2013, we also searched, using PubMed, for primary studies assessing psychodynamic therapies lasting for at least one year and published from January 2013 to December 2019. Among the 57 publications retrieved by PubMed, three were identified as randomized controlled trials not included in meta-analyses and were extensively described here.

RESULTS

Eight meta-analysis articles have assessed symptom improvement at treatment termination by comparing with baseline symptoms. According to all of them, psychodynamic therapies alleviate symptoms and their effect sizes are always robust. Three meta-analysis articles compared psychodynamic therapies with inactive treatments (e.g. placebo medication, waiting list) and reported clinically significant differences in favor of psychodynamic therapies. Ten meta-analysis articles compared, at treatment termination, psychodynamic therapies to active treatments, including medication and cognitive psychotherapies. Nine of them reported no difference. Only one article concluded that psychodynamic therapies are clinically inferior to cognitive psychotherapies (d=-0.28). Seven meta-analysis articles compared psychodynamic therapies to active treatment at follow-up (i.e. months or years after treatment termination). Five of them reported no significant difference, one reported a medium effect size in favor of psychodynamic therapies over various active treatments (d=0.38), while the other reported a clinically significant difference in favor of cognitive psychotherapies (d=-0.55). Because short-term treatments are often insufficient to prevent relapse, investigations about long-term treatments (i.e. more than one year) are needed, but such published studies are still scarce. Five meta-analysis articles and three primary studies published since 2013 compared long-term psychodynamic therapies to various active treatments of similar duration. According to them, psychodynamic therapies were at least as effective as other active treatments.

CONCLUSION

A systematic review about psychodynamic therapies, published in 2015 in Lancet Psychiatry, included 64 randomized controlled trials of which 37 were published after 2003. Therefore, most quality studies assessing psychodynamic therapies have been published since 2003 and have been reviewed in recent meta-analysis articles. All together, this recent literature leads to the conclusion that psychodynamic therapies are as effective as active treatments, including cognitive psychotherapies, to help patients suffering from common mental disorders (unipolar depression, anxiety disorders, eating disorders and personality disorders). Beside this overall conclusion, it appears that randomized controlled trials are not well suited for answering why psychotherapies work in some patients but not in others, and how they work in general. Other approaches are needed, including case studies.

Access to psychotherapy for patients with personality disorders

The best evidence for effective treatment of personality disorder supports the use of specialized forms of psychotherapy. However, these forms of treatment are generally unavailable in health care systems. This may be partly due to the expense of routinely offering long-term therapies. There is evidence that psychotherapy for personality disorder is cost-effective. One way to address this problem is to treat most patients more briefly. © 2020 John Wiley & Sons, Ltd.

Symptoms of depersonalization/derealization are independent risk factors for the development or persistence of psychological distress in the general population: Results from the Gutenberg health study

BACKGROUND

Symptoms of depersonalization (DP) and derealization (DR) have a high prevalence in patient and community samples. Previous studies suggested that DP/DR symptoms might represent a marker of disease severity and poor prognosis. However, population-based studies investigating the impact of DP/DR symptoms on the course of depression and anxiety are sparse. Therefore, we aimed to analyze whether symptoms of DP/DR are longitudinally associated with the persistence or incidence of elevated symptoms of depression/anxiety.

METHODS

We analyzed observational data from a sample of 13.182 participants of the Gutenberg Health Study. The outcomes were elevated symptoms of depression/anxiety at the 2.5 years follow-up as determined by the 2-item depression scale (PHQ-2), the 2-item anxiety scale (GAD-2), and the compound measure PHQ-4 respectively. The predictor was the 2-item Cambridge Depersonalization Scale (CDS-2).

RESULTS

8.7% of the sample were bothered by symptoms of DP/DR at baseline. They had an increased risk for elevated symptoms of depression/anxiety at the 2.5-year follow-up beyond baseline depression/anxiety and other factors. Each point increment in the CDS-2 scale, ranging from 0-6, was associated with a 21% increase of risk for PHQ-4 ≥ 3 at the follow-up (odds ratio 1.21, 95% confidence interval 1.11-1.32).

LIMITATIONS

The study was mostly questionnaire-based.

CONCLUSION

Symptoms of DP/DR are independent risk factors for the persistence or incidence of elevated symptoms of depression/anxiety. Symptoms of DP/DR represent an easily assessable risk factor for the course of mental disorders. Treatment and prevention of mental disorders might benefit from the broader recognition of these phenomena.

The influence of depressive symptoms on the effectiveness of a short-term group form of Schema Cognitive Behavioural Therapy for personality disorders: a naturalistic study

BACKGROUND

This naturalistic study examined the outcomes of Short-Term Schema Cognitive Behavioural Therapy in groups with personality disorders, and with high and low severity of depressive symptoms.

METHODS

Assessments were made at baseline, at mid-treatment (week 10), at treatment termination (week 20) and at three-month follow-up (week 32) of 225 patients with personality disorders and high severity of depressive symptoms (PD-Hi) and patients with low severity of depressive symptoms (PD-Lo). The assessments focused on symptom (Symptom Checklist-90) and schema severity (Young Schema Questionnaire) and coping styles (Utrecht Coping List). We also measured the rate of symptom remission. The data obtained were subjected to multilevel analysis.

RESULTS

Psychiatric symptoms and maladaptive schemas improved in both patient groups. Effect sizes were moderate, and even small for the coping styles. Symptom remission was achieved in the minority of the total sample. Remission in psychiatric symptomatology was seen in more PD-Lo patients at treatment termination. However, the difference in levels of remission between the two patient groups was no longer apparent at follow-up.

CONCLUSION

A short-term form of schema therapy in groups proved to be an effective approach for a broad group of patients with personality disorders. However, the majority of patients did not achieve symptom remission.

TRIAL REGISTRATION

Not applicable.

Coordinated Specialty Care Discharge, Transition, and Step-Down Policies, Practices, and Concerns: Staff and Client Perspectives

OBJECTIVE

In recent years, optimizing the process of transition and discharge from coordinated specialty care (CSC), a program that provides early intervention in psychosis, has emerged as an important focus area for program administrators, clinicians, and policy makers. To explore existing CSC policies and practices and to understand frontline provider and client views on discharge, the authors conducted a comprehensive analysis of staff and client interview data from the Mental Health Block Grant 10% Set-Aside Study.

METHODS

Data from 66 interviews with groups of CSC providers and administrators representing 36 sites and 22 states were analyzed, as well as data from interviews with 82 CSC clients at 34 sites. Transcripts were coded by using systematic content analyses.

RESULTS

Analyses of data from providers and administrators showed the heterogeneity of CSC program practices and strategies regarding discharge and highlighted a range of concerns related to postdischarge service accessibility and quality. Analysis of data from client interviews reflected the heterogeneity of transition challenges that clients confront. A significant number of participants reported concerns about their readiness for discharge.

CONCLUSIONS

CSC discharge policies and practices vary across CSC programs and states. Frequent clinician and client concerns about optimal program length, transition, and postdischarge services highlight the importance of sustained policy and research efforts to develop evidence-informed practice guidelines and possible modifications to the time-limited CSC model that currently dominates the field.

A Series of Meta-Analytic Tests of the Efficacy of Long-Term Psychoanalytic Psychotherapy

Abstract. Recent meta-analyses come to conflicting conclusions about the efficacy of long-term psychoanalytic psychotherapy (LTPP). Our first goal was to reproduce the most recent meta-analysis by Leichsenring, Abbass, Luyten, Hilsenroth, and Rabung (2013) who found evidence for the efficacy of LTPP in the treatment of complex mental disorders. Our replicated effect sizes were in general slightly smaller. Second, we conducted an updated meta-analysis of randomized controlled trials comparing LTPP (lasting for at least 1 year and 40 sessions) to other forms of psychotherapy in the treatment of complex mental disorders. We focused on a transparent research process according to open science standards and applied a series of elaborated meta-analytic procedures to test and control for publication bias. Our updated meta-analysis comprising 191 effect sizes from 14 eligible studies revealed small, statistically significant effect sizes at post-treatment for the outcome domains psychiatric symptoms, target problems, social functioning, and overall effectiveness (Hedges’ g ranging between 0.24 and 0.35). The effect size for the domain personality functioning (0.24) was not significant ( p = .08). No signs for publication bias could be detected. In light of a heterogeneous study set and some methodological shortcomings in the primary studies, these results should be interpreted cautiously. In conclusion, LTPP might be superior to other forms of psychotherapy in the treatment of complex mental disorders. Notably, our effect sizes represent the additional gain of LTPP versus other forms of primarily long-term psychotherapy. In this case, large differences in effect sizes are not to be expected.