Short-term Psychodynamic Supportive Psychotherapy Research Articles

Individual psychotherapy for cluster-C personality disorders: protocol of a pragmatic RCT comparing short-term psychodynamic supportive psychotherapy, affect phobia therapy and schema therapy (I-FORCE)

BackgroundCluster-C personality disorders (PDs) are highly prevalent in clinical practice and are associated with unfavourable outcome and chronicity of all common mental health disorders (e.g. depression and anxiety disorders). Although several forms of individual psychotherapy are commonly offered in clinical practice for this population, evidence for differential effectiveness of different forms of psychotherapy is lacking. Also, very little is known about the underlying working mechanisms of these psychotherapies. Finding evidence on the differential (cost)-effectiveness for this group of patients and the working mechanisms of change is important to improve the quality of care for this vulnerable group of patients.ObjectiveIn this study, we will compare the differential (cost)-effectiveness of three individual psychotherapies: short-term psychodynamic supportive psychotherapy (SPSP), affect phobia therapy (APT) and schema therapy (ST). Although these psychotherapies are commonly used in clinical practice, evidence for the Cluster-C PDs is limited. Additionally, we will investigate predictive factors, non-specific and therapy-specific mediators.MethodsThis is a mono-centre randomized clinical trial with three parallel groups: (1) SPSP, (2) APT, (3) ST. Randomization on patient level will be pre-stratified according to type of PD. The total study population to be included consists of 264 patients with Cluster-C PDs or other specified PD with mainly Cluster-C traits, aged 18–65 years, seeking treatment at NPI, a Dutch mental health care institute specialized in PDs. SPSP, APT and ST (50 sessions per treatment) are offered twice a week in sessions of 50 min for the first 4 to 5 months. After that, session frequency decreases to once a week. All treatments have a maximum duration of 1 year. Change in the severity of the PD (ADP-IV) will be the primary outcome measure. Secondary outcome measures are personality functioning, psychiatric symptoms and quality of life. Several potential mediators, predictors and moderators of outcome are also assessed. The effectiveness study is complemented with a cost-effectiveness/utility study, using both clinical effects and quality-adjusted life-years, and primarily based on a societal approach. Assessments will take place at baseline, start of treatment and at 1, 3, 6, 9, 12, 18, 24 and 36 months.DiscussionThis is the first study comparing psychodynamic treatment to schema therapy for Cluster-C PDs. The naturalistic design enhances the clinical validity of the outcome. A limitation is the lack of a control group for ethical reasons.Trial registrationNL72823.029.20 [Registry ID: CCMO]. Registered on 31 August 2020. First participant included on 23 October 2020.

The D*Phase-study: study protocol for a pragmatic two-phased, randomised controlled (non-inferiority) trial\xa0that addresses treatment\xa0non-response and\xa0compares cognitive behavioural therapy and short-term psychodynamic supportive psychotherapy for major depression

BackgroundSeveral evidence-based psychotherapeutic treatment options are available for depression, but the treatment results could be improved. The D*Phase study directly compares short-term psychodynamic supportive psychotherapy (SPSP) and cognitive behavioural therapy (CBT) for Major Depressive Disorder (MDD). The objectives are 1. to investigate if, from a group level perspective, SPSP is not inferior to CBT in the treatment of major depressive disorder, 2. to build a model that may help predict the optimal type of treatment for a specific individual; and 3. to determine whether a change of therapist or a change of therapist and treatment method are effective strategies to deal with non-response. Furthermore (4.), the effect of the therapeutic alliance, treatment integrity and therapist allegiance on treatment outcome will be investigated.MethodIn this pragmatic randomised controlled trial, 308 patients with a primary diagnosis of MDD are being recruited from a specialised mental health care institution in the Netherlands. In the first phase, patients are randomised 1:1 to either SPSP or CBT. In case of treatment non-response, a second phase follows in which non-responders from treatment phase one are randomised 1:1:1 to one of three groups: continuing the initial treatment with the same therapist, continuing the initial treatment with another therapist or continuing the other type of treatment with another therapist. In both treatment phases, patients are offered sixteen twice-weekly psychotherapy sessions. The primary outcome is an improvement in depressive symptoms. Process variables, working alliance and depressive symptoms, are frequently measured. Comprehensive assessments take place before the start of the first phase (at baseline), in week one, two and four during the treatment, and directly after the treatment (week eight).DiscussionWhile the naturalistic setting of the study involves several challenges, we expect, by focusing on a large and diverse number of research variables, to generate important knowledge that may help enhance the effect of psychotherapeutic treatment for MDD.Trial registrationThe study was registered on 26 August 2016 with the Netherlands Trial Register, part of the Dutch Cochrane Centre (NL5753), https://www.trialregister.nl/trial/5753

The effect of comorbid personality disorder on depression outcome after short-term psychotherapy in a randomised clinical trial.

Time-limited psychotherapy for depression is effective. However, comorbid personality disorders affect therapy outcomes negatively. Studies of follow-up effects and results relating to the influence of comorbid personality disorder and treatment modality are scarce. To determine the influence of comorbid personality disorder and treatment modality on outcomes after cognitive-behavioural therapy (CBT) or short-term psychodynamic supportive psychotherapy (SPSP) for depression. This study draws on data from a previously published randomised clinical trial contrasting SPSP and CBT for depression (both 16 sessions). We compared the effectiveness of these psychotherapies for patients with and without personality disorder (n = 196). The primary measure was depression outcome; the secondary measurements were interpersonal functioning and quality of life. Collected data were analysed using multilevel analysis. Trial registration: ISRCTN31263312 (http://www.controlled-trials.com). Although participants with and without comorbid personality disorder improved at treatment termination (d = 1.04, 95% CI 0.77-1.31 and d = 1.36, 95% CI 0.97-1.76, respectively) and at follow-up (d = 1.15, 95% CI 0.87-1.43 and d = 2.12, 95% CI 1.65-2.59 respectively), personality disorder had a negative effect on depression outcome at both measurement points (P < 0.05). A similar negative effect on interpersonal functioning was no longer apparent at follow-up. Comorbid personality disorder had no influence on social functioning or quality of life outcomes, irrespective of treatment modality. CBT and SPSP contribute to the improvement of depressive symptoms and interpersonal problems in depressed patients with and without comorbid personality disorder. Both treatments are an effective first step in a stepped care approach, but - given remaining levels of depression in patients with personality disorder - they are probably inadequate for large numbers of patients with this comorbidity. None.

Optimizing psychotherapy dosage for comorbid depression and personality disorders (PsyDos): a pragmatic randomized factorial trial using schema therapy and short-term psychodynamic psychotherapy

BackgroundPatients with comorbid depression and personality disorders suffer from a heavy disease burden while tailored treatment options are limited, accounting for a high psychological and economic burden. Little is known about the effect of treatment dosage and type of psychotherapy for this specific co-morbid patient population, in terms of treatment-effect and cost-effectiveness. This study aims to compare treatment outcome of 25 versus 50 individual therapy sessions in a year. We expect the 50-session condition to be more effective in treating depression and maintaining the effect. Secondary objectives will be addressed in order to find therapy-specific and non-specific mechanisms of change.MethodsIn a mono-center pragmatic randomized controlled trial with a 2 × 2 factorial design, 200 patients with a depressive disorder and personality disorder(s) will be included. Patients will be recruited from a Dutch mental health care institute for personality disorders. They will be randomized over therapy dosage (25 vs 50 sessions in a year) and type of therapy (schema therapy vs short-term psychodynamic supportive psychotherapy). The primary clinical outcome measure will be depression severity and remission. Changes in personality functioning and quality of life will be investigated as secondary outcomes. A priori postulated effect moderators and mediators will be collected as well. All patients are assessed at baseline and at 1, 2, 3, 6, 9–12 months (end of therapy) and at follow up (6 and 12 months after end of treatment). Alongside the trial, an economic evaluation will be conducted. Costs will be collected from a societal perspective.DiscussionThis trial will be the first to compare two psychotherapy dosages in patients with both depression and personality disorders. Insight in the effect of treatment dosage for this patient group will contribute to both higher treatment effectiveness and lower costs. In addition, this study will contribute to the limited evidence base on treating patients with both depression and personality disorders. Understanding the processes that account for the therapeutic changes could help to gain insight in what works for whom.Trial registrationThis trial has been registered on July 20th 2016, Netherlands Trial Register, part of the Dutch Cochrane Centre (NTR5941).

Moderation of the Alliance-Outcome Association by Prior Depressive Episodes: Differential Effects in Cognitive-Behavioral Therapy and Short-Term Psychodynamic Supportive Psychotherapy

Prior studies have suggested that the association between the alliance and depression improvement varies as a function of prior history of depression. We sought to replicate these findings and extend them to short-term psychodynamic supportive psychotherapy (SPSP) in a sample of patients who were randomized to one of these treatments and were administered the Helping Alliance Questionnaire (N=282) at Week 5 of treatment. Overall, the alliance was a predictor of symptom change (d=0.33). In SPSP, the alliance was a modest but robust predictor of change, irrespective of prior episodes (d=0.25–0.33). By contrast, in CBT, the effects of the alliance on symptom change were large for patients with 0 prior episodes (d=0.86), moderate for those with 1 prior episode (d=0.49), and small for those with 2+ prior episodes (d=0.12). These findings suggest a complex interaction between patient features and common vs. specific therapy processes. In CBT, the alliance relates to change for patients with less recurrent depression whereas other CBT-specific processes may account for change for patients with more recurrent depression.

The role of avoidant and obsessive-compulsive personality disorder traits in matching patients with major depression to cognitive behavioral and psychodynamic therapy: A replication study

BackgroundBarber and Muenz (1996) reported that cognitive behavior therapy (CBT) was more effective than interpersonal therapy (IPT) for depressed patients with elevated levels of avoidant personality disorder, while IPT was more effective than CBT in patients with elevated levels of obsessive-compulsive personality disorder. These findings may have important clinical implications, but have not yet been replicated. MethodsWe conducted a study using data from a randomized clinical trial comparing the efficacy of CBT and short-term psychodynamic supportive psychotherapy in the outpatient treatment of depression. ResultsWe found no evidence indicating that avoidant patients may benefit more from CBT compared to short-term psychodynamic supportive therapy (SPSP). ConclusionsOur results indicate that treatment effect does not depend on the level of avoidance, or obsessive-compulsiveness personality disorders further examine the influence of personality disorders on the effectiveness of CBT or psychodynamic therapy in the treatment of depression.

A Short-term Psychodynamic Supportive Psychotherapy for Adolescents with Depressive Disorders: A New Approach

ABSTRACTDepression is one of the most common psychiatric disorders in both adolescents and adults. In this article, we introduce Short-term Psychodynamic Supportive Psychotherapy (SPSP) for adolescents, a relatively new form of psychodynamic therapy for depression that has been studied in a range of randomized controlled trials with adult patients. SPSP emphasizes the relational aetiology and significance of depression and is characterized by a supportive attitude which focuses more on working in the here-and-now relational patterns rather than interpreting transference manifestations. The supportive attitude of the therapist is advocated to engage the adolescent in the therapeutic relationship and to foster his or her innate developmental capacities by attending to previously unaddressed developmental needs. The developmental perspective’s interest in defense styles and stagnation resulting from problems in past and current relationships opens up opportunities for acquiring insight and change. The focus on relational functioning makes it a promising approach for adolescents because they can implement any positive change immediately in their actual environment, immersed as they are in many new and varied relationships.

Evidence-Based, Non-Pharmacological Treatment Guideline for Depression in Korea

Although pharmacological treatment constitutes the main therapeutic approach for depression, non-pharmacological treatments (self-care or psychotherapeutic approach) are usually regarded as more essential therapeutic approaches in clinical practice. However, there have been few clinical practice guidelines concerning self-care or psychotherapy in the management of depression. This study introduces the 'Evidence-Based, Non-Pharmacological Treatment Guideline for Depression in Korea.' For the first time, a guideline was developed for non-pharmacological treatments for Korean adults with mild-to-moderate depression. The guideline development process consisted of establishing several key questions related to non-pharmacologic treatments of depression, searching the literature for studies which answer these questions, assessing the evidence level of each selected study, drawing up draft recommendation, and peer review. The Scottish Intercollegiate Guidelines Network grading system was used to evaluate the quality of evidence. As a result of this process, the guideline recommends exercise therapy, bibliotherapy, cognitive behavior therapy, short-term psychodynamic supportive psychotherapy, and interpersonal psychotherapy as the non-pharmacological treatments for adult patients with mild-to-moderate depression in Korea. Hence, it is necessary to develop specific methodologies for several non-pharmacological treatment for Korean adults with depression.

Non-pharmacological treatment for depression

In treatment of depression, non-pharmacological treatment is as important as pharmacological treatment. However, in clinical practice in Korea, non-pharmacological treatment is not provided sufficiently and patients are not satisfied with psychiatric interviews. Accordingly, patients ask for more information from clinicians. Clinicians should be aware of the characteristics of depression in Korean patients, because the manifestations of symptoms are influenced by cultural factors. In particular, depressed patients complain about somatic symptoms more frequently than they complain about depressed mood itself. In order to establish a therapeutic relationship with depressed patients, clinicians should be aware of these characteristics of depressed patients and clinicians should also address the needs of their patients. The author introduces evidence-based self-care methods for Korean patients with depression. St. John’s wort, acupuncture, air ionization, light therapy, massage bibliotherapy, exercise, meditation, relaxation, and yoga can be helpful for overcoming depression. Among them, the Clinical Research Center for Depression, an organization supported by the Ministry of Health and Welfare, has recommended several nonpharmacological treatments for depression. First of all, exercise, such as walking more than 30 min. everyday, is strongly recommended. Other recommendations include bibliotherapy, interpersonal psychotherapy, cognitive behavioral therapy, and short-term psychodynamic supportive psychotherapy. For the nationwide management of depression, social bias against the treatment of depression should be reduced and non-pharmacological treatment for depression should be encouraged.

Patient preference compared with random allocation in short-term psychodynamic supportive psychotherapy with indicated addition of pharmacotherapy for depression

Depressed patients randomized to psychotherapy were compared with those who had been chosen for psychotherapy in a treatment algorithm, including addition of an antidepressant in case of early nonresponse. There were no differences between randomized and by-preference patients at baseline in adherence and outcome. About half of the early nonresponders refused the additional medication. However, no clear effect of medication addition on ultimate outcome could be demonstrated. In total, 37% of the patients achieved remission. The study suggested that randomization of patients does not induce a great influence on outcome. It might be warranted to continue an initially ineffective psychotherapy for depression, because a considerable number of patients do have a pattern of delayed response.

Predictive Value of Self-Reported and Observer-Rated Defense Style in Depression Treatment

This study explored the predictive value of observer-rated and self-reported defensive functioning on the outcome of psychotherapy for the treatment of depression. Defense styles were measured according to the Developmental Profile (DP) and the Defense Style Questionnaire (DSQ) in 81 moderately severely depressed patients. All patients were treated with Short-term Psychodynamic Supportive Psychotherapy (SPSP). At baseline, women appeared to have a more mature level of overall defensive functioning. A lower level of defensive function was found in patients with recurrent depressions. We also found a rather modest relationship between self-reported and observer-rated defense. Remitted patients had a more mature overall defensive functioning on the DP and the DSQ. In particular, patients with a symbiotic defense style (giving up, apathetic withdrawal) were at risk for poor outcome. This exploratory study provides further evidence of the relevance of defense styles for depression. It suggests a differential predictive value of separate defense levels, which may help to tailor psychotherapeutic strategies.

Predictive Value of Object Relations for Therapeutic Alliance and Outcome in Psychotherapy for Depression

The concept of object relations has been shown to be relevant for the process and outcome of psychodynamic psychotherapies. However, little is known about its relevance for the psychotherapeutic treatment of depression. In this study, we explored the predictive value of object relational functioning (ORF) for the therapeutic alliance and outcome of short-term psychodynamic supportive psychotherapy in patients with mild to moderately severe depression. The ORF of 81 patients was rated by using the Developmental Profile. The overall maturity of ORF measured at baseline was higher in patients who showed a better treatment response. In multiple regression analysis, the adaptive level of individuation appeared to be specifically predictive of outcome. Patients with a recurrent depression showed less mature levels of ORF, lower adaptive levels and a higher score on the symbiotic level. No association was found between ORF and therapeutic alliance during treatment. In contrast to the single measure of alliance early in therapy, the growth of the alliance was related to outcome. The study indicated the relevance of ORF for depression and established that it is distinctive from the actual therapeutic alliance.

Identifying Patients at Risk of Complete Nonresponse in the Outpatient Treatment of Depression

Background: Although complete nonresponse in depression treatment is considered to be a major problem in clinical practice, research in this area is very limited. The objective of this preliminary study was to determine the frequency and predictors of complete nonresponse in different treatments for depression. Methods: Post hocanalysis of the pooled data of 3 consecutive randomized controlled trials of outpatient depression treatment was conducted. The subjects were 313 patients with major depressive disorder and 17-item Hamilton Rating Scale for Depression (HAM-D-17) scores between 14 and 25 who were treated for 6 months with either pharmacotherapy, short-term psychodynamic supportive psychotherapy or combined therapy. Complete nonresponse was defined as a <25% response according to the HAM-D-17. Sociodemographic factors, depression features and adherence were investigated as predictors in a multivariate stepwise logistic regression analysis. Results: Overall, nonresponse occurred in 34% of the patients. In pharmacotherapy this was 46%, in psychotherapy 39% and in combined therapy 28%. The severity of somatic symptoms was associated with nonresponse in both combined therapy and psychotherapy. No predictive factors were found in the case of pharmacotherapy. In psychotherapy, nonresponse was related to age above 40 years, chronic depression and nonadherence by the patient. In the case of combined therapy, younger age, previous use of an antidepressant and having a previous depressive episode were associated with nonresponse. Conclusion: Easily measurable patient characteristics may help to identify patients at risk of complete nonresponse to treatment. It is suggested that predictors may differ across treatment modalities. However, head-to-head comparisons are required before it can be recommended to take this into account when selecting the most appropriate treatment for individual depressed patients.

Speed of action: The relative efficacy of short psychodynamic supportive psychotherapy and pharmacotherapy in the first 8 weeks of a treatment algorithm for depression

Objective To examine the efficacy and speed of action of short-term psychodynamic supportive psychotherapy (SPSP) in comparison to pharmacotherapy (PhT) in the acute treatment of depression. Method This study reported on the first 8 weeks of a treatment algorithm for depression. 70 patients with a depressive episode according to DSM-IV were randomized to PhT, 71 patients were randomized to SPSP. The acceptability of the psychotherapy was greater than pharmacotherapy. Results At the end of the first 8 weeks of treatment, attrition rates were similar in both conditions. PhT-patients were better off at 4 weeks according to two of the four measures The superiority of PhT was clearer on the self-report than on the independent measure. Conclusions There are signs that the benefits of PhT over SPSP—where detected—are short-lived and cover mostly the first month of treatment. The progression of these patients through the rest of their treatments, and afterwards, will be reported in further contributions.

Does early response predict outcome in psychotherapy and combined therapy for major depression?

Background To examine the predictive value of early response for final outcome of psychotherapy and combined therapy in major depression. Methods Mild- to moderately depressed patients were treated with either Short-Term Psychodynamic Supportive Psychotherapy (SPSP) ( N = 63) only, or combined with an antidepressant ( N = 127). Early response was defined as a reduction of more than 25% on the HAM-D-17 after 2 months. Outcome was determined in terms of complete nonresponse and remission rates. Associations between early response and outcome were examined using logistic regression analysis. Results In SPSP, early nonresponse was clearly related to final nonresponse (OR = 3.57). Nevertheless, remission was not predicted by early response, and 26% of the early nonresponders ultimately achieved remission. In combined therapy, both final nonresponse (OR 7.13) and remission (OR 3.66) were associated with early nonresponse. Limitations In this study, SPSP was the only psychotherapy examined. The design did not provide feedback to the therapist of the independently measured depression score after two months. Conclusion Although a number of early nonresponsive patients will achieve remission, this study points out that these patients are at risk factor for ultimate treatment failure. This could be an indication for clinicians to adapt their treatment strategy.