Long-term Psychodynamic Psychotherapy Research Articles

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.

Policy, professionalism and psychotherapy; the clinical practice guidelines' dilemma.

To review a rebuttal to widely published concerns that the Clinical Practice Guidelines (CPG) devalues the role of long-term psychodynamic psychotherapy as a treatment in mood disorders. There is a wider context to this debate. The CPG presents the RANZCP with a dilemma about treatments, professionalism and policy; it requires amendment.

Ego Impairment Index (EII-2) as a predictor of outcome in short- and long-term psychotherapy during a 5-year follow-up.

ObjectiveThis study examined the predictive ability of the Rorschach‐based Ego Impairment Index (EII‐2) on outcome of psychotherapy in different types and durations of therapy.MethodA total of 326 outpatients suffering from depressive or anxiety disorders were randomized into receiving solution‐focused (n = 97), short‐term psychodynamic (n = 101), or long‐term psychodynamic psychotherapy (n = 128). Psychotherapy outcome assessments during the 5‐year follow‐up period covered psychiatric symptoms, social functioning, and work ability.ResultsLower EII‐2 values, which indicate less problematic ego functioning, were found to predict faster improvement in both short‐term therapies as compared to long‐term psychotherapy.ConclusionThe results provide preliminary support for the utility of EII‐2 as a complementary measure to interview‐based methods for selecting between short‐ and long‐term therapies.

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

BackgroundPatient suitability has been suggested to predict treatment non-attendance but information on its effect is limited. AimTo study the prediction of the Suitability for Psychotherapy Scale (SPS), on occurrence of treatment non-attendance. MethodsAltogether 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. ResultsTreatment 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. LimitationsThe 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. ConclusionsPoor suitability, apparently, predicts non-attendance in LPP and SFT, but not in SPP. More studies on large cohorts are needed.

Predicting improvement of work ability in modalities of short- and long-term psychotherapy: The differential impact of reflective ability and other aspects of patient suitability.

We investigated how patients' psychological capacities to engage in psychotherapy predict changes in work ability in short- and long-term psychotherapy. A cohort study of 326 patients, aged 20-46 years and suffering from mood and anxiety disorders, treated by short-term solution-focused, short-term psychodynamic, or long-term psychodynamic psychotherapy, followed-up for 5 years. The Suitability for Psychotherapy Scale, assessed at baseline, was the predictor. Outcomes were assessed at baseline and at six follow-up occasions using the Work Ability Index as the primary indicator. Patients with good pretreatment psychological suitability for psychotherapy, good reflective ability in particular, improved more than patients with poor suitability in short-term psychodynamic psychotherapy. Comparisons between therapy groups showed poorer suitability to predict more improvement in solution-focused and in long-term psychodynamic psychotherapy than in short-term psychodynamic psychotherapy. Patients' psychological suitability for psychotherapy has a different impact on work ability in different therapy modalities and durations.

Predicting the working alliance over the course of long-term psychodynamic psychotherapy with the Rorschach Ego Impairment Index, self-reported defense style, and performance-based intelligence: An evaluation of three methodological approaches.

Predicting the working alliance over the course of long-term psychodynamic psychotherapy with the Rorschach Ego Impairment Index, self-reported defense style, and performance-based intelligence: An evaluation of three methodological approaches.

INTENSIVE SHORT-TERM DYNAMIC PSYCHOTHERAPY (ISTDP) FOR OLDER ADULTS? EVIDENCE, THEORY, TECHNIQUE, AND CASE PRESENTATION

Psychotherapy is an evidence-based treatment for older adult mental health patients and is preferred by many older patients over pharmacotherapy. Conventional wisdom asserts that psychotherapy with older adults must be slow and limited to the pursuit of only modest goals. Yet clinical experience and recent research conducted by Brandon C. Yarns, MD, indicates that some older adults can make rapid, profound, and lasting change with a psychotherapeutic modality called Intensive Short-Term Dynamic Psychotherapy (ISTDP). ISTDP was developed by Habib Davanloo, MD, between the 1970s and early 2000s and is an experiential, emotion-focused, and psychoanalytically-oriented psychotherapy based on Freud's Second Theory of Anxiety. ISTDP is known for its rapid challenge to patients’ defenses, intensely emotional moments, and the use of specific techniques to pursue substantial treatment goals in a relatively short duration of treatment compared to psychoanalysis and long-term psychodynamic psychotherapy. ISTDP has been tested in many clinical trials and now meets evidence-based criteria for complex and challenging clinical problems, which include somatoform disorders, personality disorders, and treatment-resistant depression in adults. This session aims to introduce participants to the utility of ISTDP for some older adults. First, emerging evidence of the success and advantages over standard psychotherapy of an ISTDP-based group modality in older adults with chronic pain will be reviewed. Second, participants will be introduced to the theory and technique of ISTDP. The focus of this section will be not only to review basic ISTDP metapsychological and technical concepts but to address the rationale for why this technique is applicable to some older adults, appropriate patient selection, and the challenges commonly encountered in performing ISTDP with older adults. Practical information on how to provide ISTDP-based psychoeducation to patients about their clinical problems will be provided, including how clinicians can explain problems in terms of defenses against unwanted feelings (i.e., the Triangle of Conflict). Third, a video recorded patient session will be presented which demonstrates the successful application of ISTDP techniques to an older adult mental health patient. Finally, ample time will be provided to address questions, discuss audience reactions, and debate whether ISTDP is of potential utility for some older adults. Session presenters, including Brandon C. Yarns, MD, Ali Najafian Jazi, MD, and Allan A. Anderson, MD, have extensive research and clinical experience in the application of ISTDP to older adults.

Effects of long-term psychodynamic psychotherapy on life quality in mentally disturbed children

Objective: Long-term psychodynamic psychotherapy for children aims not only at improving symptoms but also at changing the quality of life. To our knowledge, no studies exist to date that focused on both aspects. In this paper, we investigated changes in problem behavior and health-related quality of life based on long-term psychodynamic psychotherapy with children suffering from emotional and behavioral disorders. Method: We investigated 76 children in the treatment group and analyzed pre- and post-treatment symptoms. Furthermore, we compared the outcome data with a control group of 27 children of similar age and diagnoses who received no psychotherapy, both under routine care conditions. The children included in the study were treated on average for 66 sessions. Parent and adolescent ratings on the Achenbach Scales and the Quality of Life Inventory for Adolescents were compared before and after treatment. Results: We found a highly significant improvement of internalizing symptomatology based on parent ratings with a large effect. Different from prior investigations based on short-term psychodynamic psychotherapy we found changes in quality of life with large effects. Conclusion: These findings indicate that long-term psychodynamic treatment can improve life quality in children beyond symptom change.

Interaction structures in the psychodynamic psychotherapy of a patient with chronic diseases and somatic symptoms.

This study aimed to identify and analyze the interaction structures (ISs) (patterns of reciprocal interaction between the patient-therapist dyad) that characterize the process of a successful long-term psychodynamic psychotherapy (28 months) of a patient with chronic diseases (lupus and fibromyalgia) and somatic symptoms. The 113 sessions were videotaped and analyzed alternately (n = 60) by independent judges using the Psychotherapy Process Q-Set. Inter-rater reliability ranged from 0.60 to 0.90, with a mean of r = 0.71 (Pearson's correlation). Through a principal component exploratory factor analysis, four ISs were identified. The patterns of interaction between patient and therapist showed clinical validity (i.e., they were easily interpretable in the context of the case under study). The ISs were non-linear and more or less prominent across different treatment sessions and stages. Some ISs were similar to those in other studies, and others were probably unique to the present process. In addition, some ISs were independent, whereas others were interrelated over time. Process studies, such as the present one, seek to address questions about the characteristics of the interaction between patient and therapist as well as to identify particular patterns of interaction that are most prominent with a specific patient at a specific condition or time. Therefore, these studies can provide some support in establishing knowledge for clinical practice, assisting in the training of therapists, as well as in the elaboration of general guidelines for the technical management of patients with specific characteristics.

The role of long-term psychodynamic psychotherapy in improving attachment patterns, defense styles, and alexithymia in patients with depressive/anxiety disorders.

Long-term psychodynamic psychotherapy (LTPP) emphasizes the centrality of intrapsychic and unconscious conflicts and their relation to development. Although there is evidence supporting the efficacy of LTPP in mental disorders, little research has been published on the efficacy of LTPP for depressive and anxiety disorders. To examine whether patients with anxiety and depressive disorders demonstrate improvement in their attachment styles, defense styles, psychiatric symptoms, anxiety/depressive symptoms, and alexithymia with LTPP. In this retrospective, descriptive study, the psychological outcomes of patients who were treated at the psychoanalytic clinic of Babol University of Medical Sciences were assessed. Fourteen patients diagnosed with depressive or anxiety disorder participated in the study of LTPP using the self-psychology approach. The Beck Depression Inventory II, Beck Anxiety Inventory, Adult Attachment Scale, 40-item Defense Style Questionnaire, and the 20-item Toronto Alexithymia Scale were administered at pre-treatment, post-treatment, and 6-month follow-up. Generalized estimating equations were used to analyze changes in psychological outcomes after each of the three assessments. The mean scores of depression and anxiety and secure attachment improved significantly after LTPP with self-psychology approach from baseline to post-treatment and follow-up. Also, the mean scores of neurotic and immature defenses, difficulty in identifying feelings, difficulty in describing feelings, externally oriented thinking, and total alexithymia scores decreased significantly from baseline to post-treatment and follow-up. Symptoms of anxiety disorders, depressive disorders, insecure attachment styles, alexithymia, and neurotic/immature defense styles improved after the LTPP with self-psychology approach. Moreover, the improvements persisted at the 6-month follow-up.

Effectiveness of psychoanalysis and long-term psychodynamic psychotherapy on personality and social functioning 10 years after start of treatment

The evidence on potentially greater benefits of psychoanalysis (PA) vs. long-term psychodynamic psychotherapy (LPP) is scarce. This study compared the effectiveness of PA and LPP on personality and social functioning during a 10-year follow-up from the beginning of the treatments. The eligible patients, 41 self-selected for PA and 128 assigned to LPP, were 20–45 years of age and had anxiety or mood disorder. Outcomes were analyzed using ten standard measures of personality and social functioning, carried out 5–9 times during the follow-up. Different change patterns by time in PA and LPP emerged, suggesting less benefit of PA during the first years of follow-up and more benefit in most outcomes thereafter. Greater post-treatment improvement in PA than in LPP was seen up to 1–2 years after PA had ended in more mature defense style (DSQ), level of personality organization (LPO), more positive self-concept (SASB), more improved social adjustment (SAS-SR) and sense of coherence (SOC). However, at the 10-year follow-up the differences were non-significant. In conclusion, PA may give some additional benefits when long-term aims are linked to personality and social functioning. The relatively small differences and higher costs in comparison to LPP may restrict the feasibility of PA.

Follow-up of the effectiveness of long-term psychodynamic psychotherapy and psychoanalysis 5 years after the end of psychoanalysis: Minor differences in psychiatric symptoms and work ability

BackgroundPsychoanalysis (PA) has been suggested to yield further continued symptomatic and functional improvement after the end of treatment. MethodsPost-treatment work ability, psychiatric symptoms, and need for treatment were compared between PA and long-term psychodynamic psychotherapy during a five-year follow-up. The study sample consisted of 169 outpatients, suffering from long-standing mood or anxiety disorder. ResultsA slightly greater reduction in psychiatric symptoms and improvement in work ability were found in the PA group. LimitationsThis was a naturalistic study. ConclusionsPA may not be a standard treatment in a patient population like this.

Značenje simptoma shizofrenog bolesnika tijekom trajanja grupne psihoterapije i nakon njenog završetka

Značenje simptoma shizofrenog bolesnika tijekom trajanja grupne psihoterapije i nakon njenog završetka

The Role of Sexual and Gender Identity in Long-Term Psychodynamic Therapy for Comorbid Social Anxiety and Depression in an Adolescent Female

Adolescence is a time of significant change with social, cognitive, and emotional alternations, and growth of autonomy and identity. This is a single clinical case study that uses long-term psychodynamic psychotherapy with an adolescent female diagnosed with comorbid social anxiety and persistent depression. The treatment initially focused on addressing the patient’s self-esteem, perfectionism, and self-criticism. During the treatment it was revealed that the patient’s sexual and gender identity contributed to social anxiety and depressive symptoms, and the therapy conceptualized the role of these identities as contributing to social discomfort which perpetuated her depressive symptoms. Through accepting her budding sexual and gender identity, the patient successfully became more comfortable in social settings which ultimately alleviated her depressive symptoms. This treatment highlights the unique nature of working with an adolescent apart of the sexual and gender minority, and how these identities contributed to her experience of social anxiety and depression.

Process-outcome relationships in short- and long-term psychodynamic group psychotherapy: Results from a randomized clinical trial.

Process-outcome relationships in short- and long-term psychodynamic group psychotherapy: Results from a randomized clinical trial.

Childhood adversities as predictors of improvement in psychiatric symptoms and global functioning in solution-focused and short- and long-term psychodynamic psychotherapy during a 5-year follow-up

BackgroundChildhood adversities are frequent among adults who seek treatment for depression or anxiety. These disorders are commonly treated by psychotherapy. Yet it is not known if specific types or durations of psychotherapy are particularly suited for patients who have suffered various early adversities. Methods221 depressed and anxious adult outpatients from community, student, occupational, and private healthcare services filled the Childhood Family Atmosphere Questionnaire. They were randomly assigned to short- (solution-focused or psychodynamic) or long-term (psychodynamic) psychotherapy. Outcome was assessed via patient questionnaires and clinician interviews of psychiatric symptoms and global functioning during a 5-year follow-up. Linear regression analyses were conducted. ResultsLess separations from caregivers expectedly predicted better outcomes in all therapies; unexpectedly, so did greater abuse. Family unhappiness and parental problems predicted faster or greater improvement when patients were assigned to a short- or long-term psychodynamic therapy model. LimitationsAs patients with psychotic, substance abuse, and severe personality disorders were screened out, findings might not generalize to these patient groups. ConclusionsPatients with certain childhood adversities appear to respond with faster or greater improvement when the psychotherapy model is explicitly focused on working through the potential connections between past and current problems. If confirmed by in-depth studies, the findings may help match psychotherapeutic models with given patient complaints, as well as fine-tune different psychosocial interventions to individual needs for optimizing treatment outcomes.

The effectiveness of three psychotherapies of different type and length in the treatment of patients suffering from anxiety disorder

IntroductionData on the comparative effect of short and long-term psychotherapy in anxiety disorder is scarce.AimTo compare the effectiveness of two short-term therapies and one long-term psychotherapy in the treatment of patients with anxiety disorder.MethodsAltogether 50 outpatients with anxiety disorder as the only axis I diagnosis, were randomly assigned to long-term psychodynamic psychotherapy (LPP), short-term psychodynamic psychotherapy (SPP), and solution-focused therapy (SFT) and were followed for 5 years. The outcome measures were psychiatric symptoms, working ability, need for psychiatric treatment, remission, and cost-effectiveness.ResultsDuring the first year of follow-up, no significant differences in the effectiveness between the therapies were noted. During the following 3 years, LPP and SFT more effectively reduced symptoms, improved work ability, and elevated the remission rate than SPP. No significant differences between LPP and SFT were seen. At the end of the follow-up, the use of auxiliary treatment was lowest in the SFT group whereas remission rates or changes in psychiatric symptom or work ability did not differ between the groups. The average total direct costs were about three times higher in the LPP group than in the short-term therapy groups.ConclusionsThe difference in effectiveness of LPP and SFT was negligible, whereas SPP appeared less effective. Thus, the resource-oriented SFT may be a cost-effective option in this selected patient group, while unconsidered allocation of patients to LPP does not appear to be cost-effective. Given the small number of patients, no firm conclusions should, however be drawn based on this study.Disclosure of interestThe authors have not supplied their declaration of competing interest.

Effectiveness of psychoanalysis and long-term psychodynamic psychotherapy 10 years after start of treatment

IntroductionThe evidence of potentially greater long-term benefits of psychoanalysis (PA) in comparison to long-term psychodynamic psychotherapy (LPP) is scarce.AimsThis study aimed to compare the effectiveness of PA and LPP on different aspects of functioning and wellbeing during a 10-year follow-up from the beginning of the treatments.MethodsAltogether 169 patients were included in the study: 41 patients self-selected for PA and 128 patients assigned to LPP in the Helsinki Psychotherapy Study. The eligible patients were 20–45 years of age and had a long-standing anxiety or mood disorder causing work dysfunction. Potential confounding factors were assessed at baseline and acknowledged in analyzing outcomes in personality (LPO, IIP-64, DSQ, SASB) and social functioning (SAS-SR, SOC, Perceived competence, LSS), psychiatric diagnoses (DSM-IV), symptoms (SCL-90, HDRS, HARS), work ability (SAS-work, WAI, PPF, GAF, work status), and remission, including the use of additional psychiatric treatment, measured 5 to 14 times during the 10-year follow-up.ResultsFrom the 5-year to the 7-year follow-up personality and social functioning improved significantly more in the PA than in the LPP group. In the domain of psychiatric symptoms and work ability practically no differences were found beyond the 5-year follow-up and at the final 10-year measurement, when psychiatric and work status was relatively good in both treatment groups.ConclusionsPA may give additional benefits especially when personality-related long-term aims are essential and less intensive treatments are not considered to be sufficient.Disclosure of interestThe authors have not supplied their declaration of competing interest.

Object relations and self-esteem in young adults with schizophrenia in long-term psychodynamic group psychotherapy

IntroductionPsychodynamic concepts describe object relations deficits in patients with schizophrenia originating from their earliest developmental stage, which is due to reduced ability of direct caregivers to adequately stimulate the child, as well as genetic factors. During psychodynamic group psychotherapy, members through psychotherapy gradually release the old family roles and experiment with new models of behaviour and thus change internalized object representations.AimThe aim of this study was to investigate changes in object relationships and self-esteem in the psychodynamic group psychotherapy in young patients suffering from schizophrenia.Subjects and methodsThe study included a total of 41 patients diagnosed with schizophrenia. Before joining the psychodynamic group therapy and after two years of participation in the treatment, all patients completed a test of object relations and the Rosenberg self-esteem scale.ResultsComparison of the results in two time periods showed downward trend results in all tested dimensions of object relations, a statistically significant difference was found for dimension symbiotic fusion: after two years of participation in the psychodynamic group psychotherapy, patients had significantly expressed less need for symbiotic relationships. Self-esteem was higher in the second period of testing, but without statistical significance.ConclusionTaking into account the limitations of this study, we can conclude that the results are encouraging. During psychodynamic group processes in young patients with schizophrenia there is a trend of positive changes in terms of object relations and self-esteem and a significant reduction in the need for symbiotic merging.Disclosure of interestThe authors have not supplied their declaration of competing interest.

Cost-Effectiveness and the Role of Psychodynamic Psychotherapies

Back to table of contents Previous article Psychiatry and PsychotherapyFull AccessCost-Effectiveness and the Role of Psychodynamic PsychotherapiesSusan G. Lazar,M.D.Susan G. Lazar,Search for more papers by this authorM.D.Published Online:15 Dec 2016https://doi.org/10.1176/appi.pn.2016.12b18AbstractIn our increasingly cost-conscious medical environment, research literature on studies investigating and documenting the cost-effectiveness of psychotherapy has grown substantially. Unfortunately, due to a combination of stigma and lack of knowledge of studies on efficacy and cost-effectiveness of treatment—and despite the Mental Health Parity and Addiction Equity Act—insurance companies continue to resist providing adequate coverage for mental health care, particularly psychotherapy. This article discusses evidence of the added value of psychodynamic therapies for patients with personality disorders, chronic anxiety and depression, and severe, chronic, and comorbid disorders.Inadequate treatment for all psychiatric patients is a hidden multiplier of morbidity, disability, and overall health care expenses. Compared with patients without psychiatric illness, chronically anxious, depressed and comorbid psychiatric patients have increased medical expenses beyond the costs of their psychiatric care, more primary care visits, higher outpatient charges, and longer hospital stays. A high percentage of those with psychiatric illness are never even diagnosed, and most of those who are receive inadequate treatment.Studies show that a number of psychotherapeutic approaches have efficacy for different diagnostic groups of psychiatric patients. Recent research demonstrates that psychodynamic psychotherapies have a particular role in the care of patients with chronic depression, anxiety, personality disorders, and chronic, complex, and comorbid disorders. While some psychiatric patients may improve with relatively brief treatment, patients with these disorders often require more intensive and/or extended psychotherapy. However, most insurance companies are unwilling to pay for treatments that allow them to achieve a recovery that would yield savings from decreased medical expenses and improved productivity. Insurance companies tend to favor the lower cost of medication, which, by itself, is often not the most cost-effective or definitive treatment over the course of a severe, chronic illness. In fact, psychotherapy often provides a higher effect size than medication alone, augments the effect of medication, has lower dropout rates than medication-only protocols, and lacks the side effects of medication treatments. Patients with personality disorders, affecting at least 30 million Americans, are often chronically impaired, costly to society, and unemployed. They have more suicide attempts, interpersonal difficulties, criminal behavior, divorce, child abuse, and heavy use of mental and general health care.Cognitive-behavioral therapies (CBT), psychodynamic, and other specialized treatments for personality disorders are all effective, leading to reduced symptomatology, improved functioning, and decreased hospitalization. However, patients with personality disorders and other chronic complex disorders often have deeply ingrained maladaptive thought processes and behaviors—leading to impaired interpersonal relationships that constitute a highly significant risk factor for increased mortality, exceeding the risks from smoking, alcoholism, obesity, and hypertension.While CBT-based treatments improve symptoms, studies show that long-term psychodynamic treatments are significantly superior in improving maladaptive interpersonal relationships. And while dialectical behavior therapy and supportive psychotherapy are helpful in diminishing symptoms of patients with borderline personality disorder, they do not address their core pathology (unstable relationships, primitive defenses, identity disorder, and boredom). Psychodynamic psychotherapy treats this core pathology more effectively, leading to broader personality changes. Patients treated with psychodynamic psychotherapy also maintain therapeutic gains better and continue to improve after treatment ends—the ”sleeper effect.”Depression is the most common diagnosis in primary care, with a lifetime prevalence of 20.8 percent in the United States. Yet primary care physicians miss the diagnosis 50 percent of the time. Depression’s costs to society include increased medical costs and suicide-related mortality costs. Impairment from depressive disorders is the greatest cause of global disability, according to the World Health Organization. The 20 percent of depressed patients who are treatment resistant have significantly greater health care costs, are twice as likely to be hospitalized both for depression and general medical problems, have 12 percent more outpatient visits, are prescribed 1.4 to 3 times more psychotropic medications, and incur over six times the mean total medical costs and 19 times greater total depression-related costs. For patients with unipolar depression, an extended course of CBT, dynamic psychotherapy, or a more intensive psychoanalysis all improve symptoms. Both psychodynamic and psychoanalytic treatments yield greater improvement in interpersonal problems with the best overall improvement provided by psychoanalysis. Other depressed patients with character traits such as perfectionism, with dysfunctional social and interpersonal patterns, or with residual depressive symptoms after a relatively successful brief treatment are at risk for recurring depressive episodes. Psychodynamic treatments have greater efficacy with these traits.Depressed patients with personality disorders have more treatment-resistant, persistent, and recurrent depression and more role limitations due to emotional problems, impaired social functioning, and general health perceptions than patients with major depressive disorder alone. Depressed patients who function the worst and take significantly longer to achieve remission are those with comorbid personality disorder. Borderline personality disorder emerges as a robust and independent predictor of chronicity (accounting for approximately 57 percent of persistent cases). It is also the strongest predictor of persistence of major depressive disorder, followed by schizoid and schizotypal personality disorder, any anxiety disorder (the strongest Axis I predictor), and dysthymic disorder. From a cost-effective perspective, patients with major depression and a comorbid personality disorder need treatment for both disorders to avoid recurrent and persistent depressive illness. For these patients, psychodynamic therapies are more likely to achieve improvement in core pathology and interpersonal functioning.Psychodynamic psychotherapies have also been found to be effective for anxiety disorders, eating disorders, substance abuse, somatic symptoms, and marital discord. Furthermore, studies of patients with a variety of common DSM-4 Axis 1 and 2 diagnoses treated with either long-term psychodynamic psychotherapy or psychoanalysis demonstrate large effect sizes for symptom reduction, personality change, and improvement in moderate pathology. These improvements are measurable both at termination and at follow-up. In addition, both psychoanalysis and long-term psychodynamic psychotherapy lead to reduced work absenteeism and lowered hospitalization at seven-year follow-up.In summary, in a climate in which each health care dollar counts, providers and insurance companies should recognize the cost-effectiveness of psychotherapy for many psychiatric patients and the specific advantages of psychodynamic therapies for those with personality disorders, chronic anxiety and depression, and severe, chronic, and comorbid disorders. ■