The WHO treatment guideline for mental disorders

The World Health Organization (WHO) recently issued updated guidelines for treating mental health conditions, emphasizing evidence-based manual-guided psychotherapeutic treatments.1 We applaud the WHO's effort to broaden access to evidence-based psychotherapy. Yet, we are concerned that the recommendations predominantly endorse behavior therapy (BT) and cognitive-behavior therapy (CBT) methods, for both adults and young people. This selection overlooks the significant evidence supporting other therapeutic approaches, including but not limited to psychodynamic therapy, except for a brief acknowledgment of its use in treating adult depression. Recent high-quality research reviews, which have been published in high-ranking and leading scientific journals2, have demonstrated that manual-guided psychodynamic therapy meets the updated American Psychological Association's (APA) criteria for empirically supported treatments 3, based on several comprehensive meta-analyses.2 This endorsement covers the psychodynamic treatment of depressive, anxiety, somatoform, and personality disorders, with clinically meaningful effects over controls and no meaningful differences in efficacy compared to other evidence-based treatments and confidence intervals comparable to, for example, CBT.2 The quality (certainty) of evidence was comparable to that of the evidence on which the WHO based their recommendations, for example, for depressive disorders, anxiety disorders, or self-harm and suicide.4, p. XVIII-XXX In line with APA’s criteria for evidence-based treatments, this substantial body of evidence for psychodynamic therapy was shown to warrant a “strong recommendation” of psychodynamic therapy in the conditions listed above.

Therapist-guided internet-based psychodynamic therapy versus cognitive behavioural therapy for adolescent depression in Sweden: a randomised, clinical, non-inferiority trial

BACKGROUND: Adolescent major depressive disorder (MDD) is highly prevalent and associated with lifelong adversity. Evidence-based treatments exist, but accessible treatment alternatives are needed. We aimed to compare internet-based psychodynamic therapy (IPDT) with an established evidence-based treatment (internet-based cognitive behavioural therapy [ICBT]) for the treatment of adolescents with depression. METHODS: In this randomised, clinical trial, we tested whether IPDT was non-inferior to ICBT in the treatment of adolescent MDD. Eligible participants were 15-19 years old, presenting with a primary diagnosis of MDD according to DSM-5. Participants were recruited nationwide in Sweden through advertisements on social media, as well as contacts with junior and senior high schools, youth associations, social workers, and health-care providers. Adolescents who scored 9 or higher on the Quick Inventory of Depressive Symptomatology for Adolescents (QIDS-A17-SR) in an initial online screening were contacted by telephone for a diagnostic assessment using the Mini International Neuropsychiatric Interview. Participants were randomly assigned to ICBT or IPDT. Both interventions comprised eight self-help modules delivered over 10 weeks on a secure online platform. The primary outcome was change in depression severity measured weekly by the QIDS-A17-SR. Primary analyses were based on an intention-to-treat sample including all participants randomly assigned. A non-inferiority margin of Cohen's d=0·30 was predefined. The study is registered at ISRCTN, ISRCTN12552584. FINDINGS: Between Aug 19, 2019, and Oct 7, 2020, 996 young people completed screening; 516 (52%) were contacted for a diagnostic interview. 272 participants were eligible and randomly assigned to ICBT (n=136) or IPDT (n=136). In the ICBT group, 51 (38%) of 136 participants were classified as remitted, and 54 (40%) of 136 participants were classified as remitted in the IPDT group. Within-group effects were large (ICBT: within-group d=1·75, 95% CI 1·49 to 2·01; IPDT: within-group d=1·93, 1·67 to 2·20; both p<0·0001). No statistically significant treatment difference was found in the intention-to-treat analysis. Non-inferiority for IPDT was shown for the estimated change in depression during treatment (d=-0·18, 90% CI -0·49 to 0·13; p=0·34). All secondary outcomes showed non-significant between-group differences. INTERPRETATION: IPDT was non-inferior to ICBT in terms of change in depression for the treatment of adolescents with MDD. This finding increases the range of accessible and effective treatment alternatives for adolescents with depression. FUNDING: Kavli trust

Tavistock Adult Depression Study (TADS): a randomised controlled trial of psychoanalytic psychotherapy for treatment-resistant/treatment-refractory forms of depression

ABSTRACT: BACKGROUND: Long-term forms of depression represent a significant mental health problem for which there is a lack of effective evidence-based treatment. This study aims to produce findings about the effectiveness of psychoanalytic psychotherapy in patients with treatment-resistant/treatment-refractory depression and to deepen the understanding of this complex form of depression. METHODS: INDEX GROUP: Patients with treatment resistant/treatment refractory depression. DEFINITION & INCLUSION CRITERIA: Current major depressive disorder, 2 years history of depression, a minimum of two failed treatment attempts, [greater than or equal to]14 on the HRSD or [greater than or equal to]21 on the BDI, plus complex personality and/or psycho-social difficulties. EXCLUSION CRITERIA: Moderate or severe learning disability, psychotic illness, bipolar disorder, substance dependency or receipt of test intervention in the previous two years. DESIGN: Pragmatic, randomised controlled trial with qualitative and clinical components. TEST INTERVENTION: 18 months of weekly psychoanalytic psychotherapy, manualised and fidelity-assessed using the Psychotherapy Process Q-Sort. CONTROL CONDITION: Treatment as usual, managed by the referring practitioner. RECRUITMENT: GP referrals from primary care. RCT MAIN OUTCOME: HRSD (with [less than or equal to]14 as remission). SECONDARY OUTCOMES: depression severity (BDI-II), degree of co-morbid disorders Axis-I and Axis-II (SCID-I and SCID-II-PQ), quality of life and functioning (GAF, CORE, Q-les-Q), object relations (PROQ2a), Cost-effectiveness analysis (CSRI and GP medical records). FOLLOW-UP: 2 years. Plus: a). Qualitative study of participants' and therapists' problem formulation, experience of treatment and of participation in trial. (b) Narrative data from semi-structured pre/post psychodynamic interviews to produce prototypes of responders and non-responders. (c) Clinical case-studies of sub-types of TRD and of change. DISCUSSION: TRD needs complex, long-term intervention and extended research follow-up for the proper evaluation of treatment outcome. This pushes at the limits of the design of randomised therapeutic trials,. We discuss some of the consequent problems and suggest how they may be mitigated. Trial registration Current Controlled Trials ISRCTN40586372

Exploring therapeutic action in psychoanalytic psychotherapy : Attachment to therapist and change

The overall aim of this thesis was to explore therapeutic action in psychoanalytic psychotherapy from different perspectives (patient, therapist, observer), using different methodological approaches (qualitative and quantitative). Study I explores patients’ views of therapeutic action with grounded theory methodology. The results indicated that talking openly in a safe therapeutic relationship led to new relational experiences and expanding self-awareness. Hindering factors included difficulties “opening up” and experiencing something missing in treatment. Study II investigates experienced therapists’ views of therapeutic action. The development of a close and trusting relationship was perceived as the core curative factor. Patients’ fear of closeness hindered treatment from the therapists’ perspective. Study III involves the development and psychometric examination of a new rating scale for patient-therapist attachment (Patient Attachment to Therapist Rating Scale; PAT-RS). Inter-rater reliability was good for three of the subscales (Security, Deactivation, Disorganization), but poor for one (Hyperactivation). Patterns of correlations with other measures suggest construct validity for the reliable subscales. Study IV examines the relationships between secure attachment to therapist, alliance, and outcome. Linear mixed-effects models, controlling for therapist effects, treatment length and patient-rated alliance, indicated that secure attachment to therapist relates to outcome. Further, the unique variance associated with secure attachment to therapist predicted continued gains in functioning during follow-up. The results of this thesis suggest that the development of a secure attachment to the therapist is a central mechanism of therapeutic change. The results are discussed in relation to established notions of therapeutic action in psychoanalytic psychotherapy. Two tentative process models that may be useful for clinical practice and future research are proposed. At the time of the doctoral defense, the following paper was unpublished and had a status as follows: Paper 4: Epub ahead of print.</p

The Relationship Between Alexithymia and Emotional Awareness: A Meta-Analytic Review of the Correlation Between TAS-20 and LEAS

Background: Alexithymia and emotional awareness may be considered overlapping constructs and both have been shown to be related to psychological and emotional well-being. However, it is not clear how the constructs relate to each other empirically or if they may overlap more or less in different populations. The aim of this review was therefore to conduct a meta-analysis of correlations between the most commonly used measures of alexithymia (i.e., the self-report instrument Toronto Alexithymia Scale; TAS-20) and emotional awareness (i.e., the observer-rated instrument Level of Emotional Awareness Scale; LEAS) and to explore potential moderators of their relationship.Methods: Electronic databases were searched for studies published until the end of February 2018. Study samples were coded as medical conditions, psychiatric disorders and/or healthy controls and sample mean age and gender distribution were extracted. Correlations between the TAS-20 and the LEAS were subjected to a random effect of meta-analysis and moderators were explored in subgroup analyses and meta-regressions. Publication bias was considered.Results: 21 studies reporting on 28 independent samples on correlation analysis were included, encompassing a total of 2857 subjects (57% women). The aggregated correlation between TAS-20 and LEAS was r = −0.122 (95% CI [−0.180, −0.064]; Z = −4.092; p &lt; 0.001), indicating a significant, but weak, negative relationship between the measures. Heterogeneity was moderate, but we found no indication of significant differences between patients with medical conditions, psychiatric disorders or healthy controls, nor that mean age or percentage of female subjects moderated the relationship. The overall estimate became somewhat weaker after adjusting for possible publication bias.Conclusions: Our results indicate that TAS-20 and LEAS measure different aspects of emotional functioning. The small overlap suggests that alexithymia and emotional awareness are distinct constructs of emotional well-being. Clinicians need to assess both aspects when considering treatment options for individual patients. Moreover, from the clinical standpoint, an easy reliable and valid way of measuring emotional awareness is still needed. More research should be focus on the differences between alexithymia and emotional awareness in specific conditions, but also how to integrate self-report instrument and observed based measures in a clinical situation

Short-term psychodynamic infant–parent interventions at Child health centers : Outcomes on parental depression and infant social–emotional functioning

Randomized controlled trials (RCTs) demonstrate efficacy of parent–infant psychotherapy, but its applicability and effectiveness in public health care are less known. The method followed is Naturalistic study evaluating Short-term Psychodynamic Infant–Parent Interventions at Child Health Centers (SPIPIC) in Stockholm, Sweden. One hundred distressed mothers with infants were recruited by supervised nurses. Six therapists provided 4.3 therapy sessions on average (SD = 3.3). Sessions typically included the mothers, often with the baby present, while fathers rarely attended sessions. The Edinburgh Postnatal Depression Scale (EPDS) and the Ages and Stages Questionnaire: Social–Emotional (ASQ: SE) were distributed at baseline and at 3 and 9 months later. Data from a nonclinical group were collected simultaneously to provide norm data. Multilevel growth models on the mothers’ questionnaire scores showed significant decreases over time on both measures. Nine months after baseline, 50% achieved a reliable change on the EPDS and 14% on the ASQ: SE. Prepost effect-sizes (d) were 0.70 and 0.40 for EPDS and ASQ: SE, figures that are comparable to results of other controlled studies. Psychotherapists integrated with public health care seem to achieve good results when supporting distressed mothers with brief interventions in the postnatal period. SPIPIC needs to be compared with other modalities and organizational frameworks

Major flaws in a meta-analysis of short-term psychodynamic therapy (STPP) for depression

In this journal, Caselli and colleagues recently published a meta-analysis on short-term psychodynamic therapy (STPP) for depression (Caselli et al., 2023). Although we welcome their attempt to evaluate the efficacy of STPP in depression, their systematic review and meta-analysis contains a large number of serious shortcomings, listed in the following

Clinical- and cost-effectiveness of intensive short-term dynamic psychotherapy for chronic pain in a tertiary psychotherapy service

The objective of this study is to assess the clinical- and cost-effectiveness of intensive short-term dynamic psychotherapy (ISTDP) for patients with chronic pain.A sample of 228 pain patients was drawn from a larger naturalistic study of ISTDP. They received an average of 6.1 sessions delivered by 31 therapists. Psychiatric symptoms and interpersonal problems were assessed at three time points. Healthcare data from baseline year and three years following treatment came from independent governmental databases.Multilevel models indicated significant reductions in symptoms and interpersonal problems during treatment, including a moderate to large pre-post effect size ( = 0.76) for somatization. Further, the sample had successive reductions in yearly healthcare costs, reaching the normal population mean two years post-treatment.Within the limitations of the uncontrolled design, our study suggests that ISTDP may be both clinically effective and cost-effective for patients with chronic pain

Intensive Short-Term Dynamic Psychotherapy for generalized anxiety disorder: A pilot effectiveness and process-outcome study

The objective of this study was to evaluate the clinical- and cost-effectiveness of Intensive Short-Term Dynamic Psychotherapy (ISTDP) for generalized anxiety disorder (GAD). We further aimed to examine if a key clinical process within the ISTDP framework, termed the level of mobilization of unprocessed complex emotions (MUCE), was related to outcome. The sample consisted of 215 adult patients (60.9% female) with GAD and comorbid conditions treated in a tertiary mental health outpatient setting. The patients were provided an average of 8.3 sessions of ISTDP delivered by 38 therapists. The level of MUCE in treatment was assessed from videotaped sessions by a rater blind to treatment outcome. Year-by-year healthcare costs were derived independently from government databases. Multilevel growth models indicated significant decreases in psychiatric symptoms and interpersonal problems during treatment. These gains were corroborated by reductions in healthcare costs that continued for 4\ua0years post-treatment reaching normal population means. Further, we found that the in-treatment level of MUCE was associated with larger treatment effects, underlining the significance of emotional experiencing and processing in the treatment of GAD. We conclude that ISTDP appears to reduce symptoms and costs associated with GAD and that the ISTDP framework may be useful for understanding key therapeutic processes in this challenging clinical population. Controlled studies of ISTDP for GAD are warranted

Secure Attachment to Therapist, Alliance, and Outcome in Psychoanalytic Psychotherapy With Young Adults

Using a novel approach to assess attachment to therapist from patient narratives (Patient Attachment to Therapist Rating Scale; PAT-RS), we investigated the relationships between secure attachment to therapist, patient-rated alliance, and outcome in a sample of 70 young adults treated with psychoanalytic psychotherapy. A series of linear mixed-effects models, controlling for length of therapy and therapist effects, indicated that secure attachment to therapist at termination was associated with improvement in symptoms, global functioning, and interpersonal problems. After controlling for the alliance, these relationships were maintained in terms of symptoms and global functioning. Further, for the follow-up period, we found a suppression effect indicating that secure attachment to therapist predicted continued improvement in global functioning, whereas the alliance predicted deterioration when both variables were modeled together. Although limited by the correlational design, this study suggests that the development of a secure attachment to therapist is associated with treatment gains as well as predictive of posttreatment improvement in functioning. Future research should investigate the temporal development of attachment to therapist and its interaction with alliance and outcome more closely. To ensure differentiation from patient-rated alliance, observer-based measurement of attachment to therapist should be considered