The Efficacy of Cognitive-Behavioral Therapy and Psychodynamic Therapy in the Outpatient Treatment of Major Depression: A Randomized Clinical Trial

Driessen, Ellen; Van, Henricus L.; Don, Frank J.; Peen, Jaap; Kool, Simone; Westra, Dieuwertje; Hendriksen, Mariëlle; Schoevers, Robert A.; Cuijpers, Pim; Twisk, Jos W. R.; Dekker, Jack

doi:10.1176/appi.focus.12.3.324

Cited by 38 publications

(66 citation statements)

References 28 publications

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“…No such effect has been found for ADM. As good as they are, medications only work for so long as you take them. Cuijpers et al (2013) found evidence for an enduring effect for prior CT v. prior ADM in six of eight comparisons (with non-significant differences favouring prior CT in the seventh). This is a remarkably robust finding.…”

Section: Do Ct and Ba Have Enduring Effects That Protects Against Relmentioning

confidence: 88%

“…The jury is still out with respect to dynamic psychotherapy. It did as well as ADM in a recent trial, but neither separated from pill-placebo (Barber et al 2012) and it did not differ from CT of unknown quality in another trial that lacked a nonspecific control or ADM comparison (Driessen et al 2013). Null findings can be hard to interpret.…”

Section: Must Interventions Be Competently Implemented To Generate a mentioning

confidence: 93%

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The efficacy and acceptability of psychological interventions for depression: where we are now and where we are going

Hollon

2015

Epidemiol Psychiatr Sci

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Depression is an eminently treatable disorder, although estimates of treatment efficacy have been inflated by publication bias. Patients with less severe depressions respond to even nonspecific interventions, whereas patients with more severe depressions require treatments that mobilize specific mechanisms. The cognitive and behavior therapies can be as efficacious as medications in the treatment of severe depression and have an enduring effect that medications lack. Medications may interfere with those enduring effects when added in combination and may prolong the life of the underlying episode when used alone. Thus the cognitive behavioral interventions might be the optimal first-line treatments for depression. First published online 27 August 2015Key words: Depression, precision medicine, prevention, treatment. Is treatment as efficacious as is currently believed?Several different types of interventions have been established in the treatment of major depressive disorder (MDD), but the efficacy of those interventions has been overestimated in the published literature. This appears to be true with respect to both the antidepressant medications (ADMs) and psychotherapy. Turner et al. (2008) found that only half the studies submitted to the Food and Drug Administration to secure marketing approval found active medication to be superior to pill-placebo and that over 90% of those positive studies ended up being published v. only about a third of those with null findings. Moreover, nearly all of the 'failed' studies that did get published were 'spun' to make it appear that ADM was superior to pill-placebo. Correcting for publication bias reduced the estimated effect of medication by about a third. Cuijpers et al. (2010) found comparable magnitude of publication bias in the psychotherapy literature, although this had to be inferred from a relative deficit of small studies with weak effects. What this means is that someone reading the published literature would come away thinking that both ADM and psychotherapy are more efficacious than they really are. It is not that they do not work; just that they do not work as well as the published literature would lead one to believe. Does treatment have a specific effect for less severe patients?Fournier et al. (2010) plotted treatment outcome as a function of initial severity at the level of the individual patient and found that ADM separated from pillplacebo only among patients with more severe depressions. Patients with less severe depressions (over half of the sample) did about as well on pill-placebo as they did on active medications. This means that they are responding to psychological rather than pharmacological mechanisms. Something similar appears to be the case for the psychosocial interventions. Driessen et al. (2010) found that psychosocial interventions only exceeded non-specific controls among patients with more severe depressions. As for medications, this suggests that non-specific factors account for a large portion of the effects of psychotherapy. Cuijpers e...

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Section: Do Ct and Ba Have Enduring Effects That Protects Against Relmentioning

confidence: 88%

Section: Must Interventions Be Competently Implemented To Generate a mentioning

confidence: 93%

The efficacy and acceptability of psychological interventions for depression: where we are now and where we are going

Hollon

2015

Epidemiol Psychiatr Sci

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“…In a separate trial conducted in the Netherlands, short-term dynamic psychotherapy did not differ from CBT with noninferiority shown for the continuous measures of depression but not for the somewhat disappointingly low categorical remission rates (22.7% overall). 39 It is not clear what conclusions can be drawn from these studies. On the one hand, dynamic psychotherapy was not inferior to two of the best-established interventions in the field (antidepressant medications and CBT), but on the other hand, neither study demonstrated either efficacy or specificity with what were essentially null findings.…”

Section: Mindfulness-based Cognitive Therapy (Mbct)mentioning

confidence: 94%

Innovative Psychological Treatments for Depression

Hollon

Williams

2016

FOC

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A number of high intensity psychosocial interventions have been shown to be as efficacious as and more enduring than medications in the treatment of nonpsychotic depression. Moreover there have been important advances in the development of strategies to facilitate the selection of the best treatment for a given patient. However, the demand for services is too great to be met by conventional high intensity approaches alone. Some of the most exciting work in recent years has focused on the development of low intensity approaches that can provide benefit to large numbers of people in a costeffective fashion.

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“…Neither the treating clinicians nor the independent observers were able to ascertain them.'' The second de Jonghe et al model of STPP study, conducted by Driessen et al, 5 was a noninferiority trial comparing STPP to cognitive-behavioural therapy (CBT), and its authors conclude that noninferiority was demonstrated at posttreatment but could not be demonstrated for remission rates and follow-up measures. Both trials lend support but together fail to establish level 1 evidence for efficacy of that model of STPP.…”

Section: Dear Editormentioning

confidence: 99%

Rating Short-Term Psychodynamic Therapy for the Canadian Network for Mood and Anxiety Treatments Depression Guidelines

et al. 2017

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Dear Editor:We thank the authors of 2 letters inquiring how ratings were established with regards to short-term psychodynamic psychotherapy (STPP) for major depressive disorder in the Canadian Network for Mood and Anxiety Treatments (CANMAT) guidelines.1 The second-line treatment recommendation for STPP captures the emerging nature of the evidence and clinical utility of STPP. Briefly, evidence from meta-analyses can result in the highest level of evidence, but we did not rely on abstracts for conclusions. 2 We examined key factors of each study from any meta-analysis, including whether at least 2 studies used the same manual, choice of control conditions, replication by another research group, overall sample size, and finally the multiple subanalyses conducted. When there are multiple outcomes, divergent findings weaken conclusions. Good scientists, and good clinicians, may reasonably disagree both on which subanalyses should have primacy, as well as the relative importance of study characteristics.Leichsenring and Steinert rightly mention that there are 2 studies of the de Jonghe et al.3 model of STPP-but one is a study designed to compare STPP alone to STPP with pharmacotherapy. 4 There was no control group for the psychotherapy, and in the results, the authors state, ''The advantage of combining antidepressants with STPP were equivocal. Neither the treating clinicians nor the independent observers were able to ascertain them.'' The second de Jonghe et al. model of STPP study, conducted by Driessen et al., 5 was a noninferiority trial comparing STPP to cognitive-behavioural therapy (CBT), and its authors conclude that noninferiority was demonstrated at posttreatment but could not be demonstrated for remission rates and follow-up measures. Both trials lend support but together fail to establish level 1 evidence for efficacy of that model of STPP. They subsequently cite the Connolly Gibbons et al.6 study, published after the review period of the CAN-MAT article, invoking the Luborsky 7 model of STPP. This, too, is a noninferiority trial without a control condition. As a single trial from a single research group, it does not satisfy the criterion of level 1 evidence. Furthermore, noninferiority was demonstrated on a primary outcome but not on 4 secondary outcomes, and both treatments had low remission rates.Town et al. cite various subanalyses from the Driessen et al. meta-analysis, but the issues of multiple divergent findings in that article and the use of many small and methodologically challenged studies do not allow for a clear, unequivocal conclusion as would be needed for a first-line treatment recommendation. Additionally, they state that other therapies may use different treatment manuals. While this is true, each of the other first-line treatments had evidence from at least 2 studies using the same specific type of therapy. Behavioural activation and mindfulness-based CBT each share many features with CBT, but each therapy has its own trials and evidence. Randomised controlled trials are needed in whic...

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The Efficacy of Cognitive-Behavioral Therapy and Psychodynamic Therapy in the Outpatient Treatment of Major Depression: A Randomized Clinical Trial

Cited by 38 publications

References 28 publications

The efficacy and acceptability of psychological interventions for depression: where we are now and where we are going

The efficacy and acceptability of psychological interventions for depression: where we are now and where we are going

Innovative Psychological Treatments for Depression

Rating Short-Term Psychodynamic Therapy for the Canadian Network for Mood and Anxiety Treatments Depression Guidelines

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