Efficacy of an adjunctive brief psychodynamic psychotherapy to usual inpatient treatment of depression: rationale and design of a randomized controlled trial.

BACKGROUND: A few recent studies have found indications of the effectiveness of inpatient psychotherapy for depression, usually of an extended duration. However, there is a lack of controlled studies in this area and to date no study of adequate quality on brief psychodynamic psychotherapy for depression during short inpatient stay exists. The present article describes the protocol of a study that will examine the relative efficacy, the cost-effectiveness and the cost-utility of adding an Inpatient Brief Psychodynamic Psychotherapy to pharmacotherapy and treatment-as-usual for inpatients with unipolar depression. METHODS/DESIGN: The study is a one-month randomized controlled trial with a two parallel group design and a 12-month naturalistic follow-up. A sample of 130 consecutive adult inpatients with unipolar depression and Montgomery-Asberg Depression Rating Scale score over 18 will be recruited. The study is carried out in the university hospital section for mood disorders in Lausanne, Switzerland. Patients are assessed upon admission, and at 1-, 3- and 12- month follow-ups. Inpatient therapy is a manualized brief intervention, combining the virtues of inpatient setting and of time-limited dynamic therapies (focal orientation, fixed duration, resource-oriented interventions). Treatment-as-usual represents the best level of practice for a minimal treatment condition usually proposed to inpatients. Final analyses will follow an intention-to-treat strategy. Depressive symptomatology is the primary outcome and secondary outcome includes measures of psychiatric symptomatology, psychosocial role functioning, and psychodynamic-emotional functioning. The mediating role of the therapeutic alliance is also examined. Allocation to treatment groups uses a stratified block randomization method with permuted block. To guarantee allocation concealment, randomization is done by an independent researcher. DISCUSSION: Despite the large number of studies on treatment of depression, there is a clear lack of controlled research in inpatient psychotherapy during the acute phase of a major depressive episode. Research on brief therapy is important to take into account current short lengths of stay in psychiatry. The current study has the potential to scientifically inform appropriate inpatient treatment. This study is the first to address the issue of the economic evaluation of inpatient psychotherapy. TRIAL REGISTRATION: Australian New Zealand Clinical Trial Registry (ACTRN12612000909820)

State of the psychoanalytic nation: Switzerland

Psychoanalytic psychotherapy holds a prominent place in the Swiss health care system. In addition to the rich history of psychoanalysis in Switzerland, the dual qualification in psychiatry and psychotherapy for medical specialists and the recent federal recognition of the title of psychologist-psychotherapist support the continuation of rigorous psychotherapy training in mental health institutions with the patients suffering the most. In Switzerland, there is a lively discussion on the treatment modalities in different forms of talking psychotherapy, in a perspective of integration with other dimensions of psychiatric care. New models of care have emerged, inspired by psychoanalytical psychotherapy, bringing hope to the discipline because they are adapted to the difficulties of our patients and to the demands of the contemporary world. In parallel, exacting training in classical psychoanalytical models continues to be practiced and fostered

Early change in maladaptive defense style and development of the therapeutic alliance

Background: Empirical research on defense mechanisms found a sound support for the relationship of these mechanisms to adaptation. Instruments exploring the defensive operations patients use to help themselves deal with emotional and difficult experiences might assist the psychiatrist in providing treatment. Methods: This study examined the early change in Maladaptive Defense Style (MDS), the development of the Therapeutic Alliance, and the relationship between MDS and alliance, in a short psychodynamic intervention. Outpatients from a psychiatric clinic completed a four-session psychodynamic intervention (Gilliéron, 1989). Defenses were assessed with the Defense Style Questionnaire (DSQ-88) developed by Bond et al (1983). Alliance was measured with the Helping Alliance Questionnaire (Luborsky 2000). Results: Patients who began the intervention with a poor alliance but ended with a good alliance significantly decreased their use of maladaptive defenses over the course of therapy. Results showed that at the end of the intervention, MDS and alliance were related across all patients, and particularly across patients who developed a good alliance. Conclusions: Our results suggest that the DSQ is sensitive to acute MDS changes. As a self report instrument it is a practical tool for clinical evaluation. Change in MDS found after such a brief treatment suggests that the psychiatrist's support and exploration may diffuse the sense of threat induced by the crisis and reduce the patient's maladaptive defense activation. This might help develop a psychiatrist-patient working collaboration, fostering their agreement on a treatment plan and its implementation

Early change in maladaptive defence style and development of the therapeutic alliance

This study examined the early change in maladaptive defence style (MDS), the development of the therapeutic alliance and the relationship between MDS and alliance in a short psychodynamic intervention. Sixty-eight outpatients from a psychiatric clinic completed a four-session psychodynamic intervention. Defence and alliance measures were collected at the intake and the final session. Patients who began the intervention with a poor alliance but ended with a good alliance (linear growth therapeutic alliance group) significantly decreased their use of maladaptive defences over the course of therapy, while patients in the high and low alliance groups did not. Results showed that at the end of the intervention, MDS and alliance were related across all patients. This relation concerned particularly the linear growth therapeutic alliance profile. These results suggest that the developing therapeutic alliance might reflect the collaborative work between the patient and the therapist as they try to understand the causes of the crisis. This understanding might help reduce maladaptive defences that were initially activated to ward off anxiety and distress