Psychodynamic Psychotherapy (PP)

Evidence for psychodynamic psychotherapy for the management of eating disorders in children and young people is limited. Best available evidence includes an RCT of young people with Bulimia Nervosa (Stefini et al 2017). This paper included 81 female adolescents. Treatment included a mean of 36.6 sessions and the primary outcome was remission from symptoms. Follow up was 12 months.

Outcomes

Children and Young People Outcomes for Eating Disorders 

Compared to FBT, the following outcomes were observed; 

• Comparability in full remission between treatment groups at post-treatment and 12 month follow up (Stefini et al, 2017) 

Some of the best available evidence for PP in the management of depression in children and young people include three Randomised Controlled Trials (RCTs). These are described below. 

• Recently, Lindqvist et al (2020) conducted a RCT to compare the effectiveness of affect-focused internet-based psychodynamic therapy (IPDT) (delivered with therapist support) to an internet-based supportive control for depression management in adolescents. The RCT included 76 adolescents, aged 15-18 years, who fulfilled the criteria for unipolar major depressive disorder. IPDT was delivered over 8 weeks via a secure online platform. The study was conducted by researchers in Sweden. 
• Goodyer et al (2017) conducted a multi-centre RCT to compare psychological therapies in the management of adolescents with unipolar major depression. The RCT included 465 adolescents, aged 11–17 years, who met the diagnostic criteria for major depression including those with suicidality, depressive psychosis and conduct disorder. Short-term psychodynamic psychotherapy was delivered over 30 weeks in up to 28 individual sessions plus up to seven parent/guardian sessions. The study was conducted in England. 
• Trowell et al (2007) conducted an RCT to determine the effectiveness of individual psychodynamic psychotherapy in childhood depression. The study included 72 patients aged 9–15 years, who met diagnostic criteria for major depressive disorder and/or dysthymia. Treatment was delivered over 9 months, and consisted of sixteen to thirty 50 min sessions of individual therapy, plus individual parent sessions (one per 2 sessions of child’s psychotherapy). The multi-centre study was conducted in London, Athens, and Helsinki.   

Outcomes

Children and young people Outcomes for Depression 

Compared to internet-based supportive control conditions and other treatment models groups (i.e. CBT, brief psychosocial intervention, and family therapy), the following outcomes were observed: 

• Comparable reduction (compared to active control) in the prevalence of major depressive disorder and dysthymia at post-treatment in between group analysis. Effects were sustained at 6-months (Trowell et al, 2007) 
• Comparable reduction (compared to active control including CBT and Brief Psychosocial Intervention) in the depressive symptom score and quality of life score at post-treatment in between group analysis. Effects were sustained at 1-year after treatment (Goodyer et al, 2017) 
• Significantly greater reduction in depression and anxiety symptoms (compared to internet based supportive control) at post-treatment, sustained at 6-months follow-up (Lindqvist et al, 2020) 
• Significantly greater improvement in emotion regulation and self-compassion at post-treatment (Lindqvist et al, 2020) 

The evidence for PP in the management of SAD in CYP is limited. Best available evidence which focused specifically on CYP with SAD comes from one RCT (Salzer et al, 2018). The multi-centre study compared the efficacy of psychological interventions (i.e. CBT and PP) in 107 adolescents aged 14-20 years. The psychological interventions were delivered in 25 individual sessions. The study was conducted in Germany. 

Outcomes

Children and Young People Outcomes for Anxiety 

Compared to wait-list control, the following outcomes were observed; 

• Significantly greater reduction in emotional symptoms at post-treatment, maintained at 6-months follow-up (Göttken et al, 2014) 

Significantly greater reductions in internalising problems, externalising problems, total problems, and total difficulty scores at post-treatment, maintained at 6-months follow-up (Göttken et al, 2014) 

Children and Young People Outcomes for SAD 

Compared to waitlist control, the following outcomes were observed: 

• Significantly reduced anxiety symptoms at post-treatment, sustained at 12-month follow-up (Salzer et al, 2018) 
• Significantly improved remission rates at post-treatment, sustained at 12 months follow-up (Salzer et al, 2018) 

Adults PP Outcomes for Anorexia Nervosa and Bulimia Nervosa

• Significantly increased BMI in AN at end-of-treatment, and up to 12-months follow-up (Zipfel et al, 2014).
• Significantly higher recovery rate in AN at 12-months follow-up in between-group analysis (compared with optimised treatment as usual) (Zipfel et al, 2014)
• Improvements from both CBT and PP at the end of treatment, at 2 years’ follow up, 44% in the CBT and 15% in the PP group had stopped binge eating and purging.

Best available evidence for PP in the treatment of AN includes an RCT that evaluated the effectiveness of focal psychodynamic psychotherapy in adult outpatients with anorexia nervosa (Zipfel et al, 2014). It included 242 females, aged 18 years or over, with AN or subsyndromal AN, and BMI of 15.0 to 18.5 kg/m². FPT was delivered in 40 sessions over a period of 10 months. The study was conducted in Germany. A systematic review identified two RCTs that evaluated psychodynamic psychotherapy for BN (Steinert et al, 2017). Both papers compared PP to CBT. One RCT had 50 participants and the other 70 participants.

Outcomes

Adults PP Outcomes for Anorexia Nervosa and Bulimia Nervosa 

• Significantly increased BMI in AN at end-of-treatment, and up to 12-months follow-up (Zipfel et al, 2014). 

• Significantly higher recovery rate in AN at 12-months follow-up in between-group analysis (compared with optimised treatment as usual) (Zipfel et al, 2014) 

• Improvements from both CBT and PP at the end of treatment, at 2 years’ follow up, 44% in the CBT and 15% in the PP group had stopped binge eating and purging.  

Best available evidence for PP in the treatment of AN includes an RCT that evaluated the effectiveness of focal psychodynamic psychotherapy in adult outpatients with anorexia nervosa (Zipfel et al, 2014). It included 242 females, aged 18 years or over, with AN or subsyndromal AN, and BMI of 15.0 to 18.5 kg/m². FPT was delivered in 40 sessions over a period of 10 months. The study was conducted in Germany. A systematic review identified two RCTs that evaluated psychodynamic psychotherapy for BN (Steinert et al, 2017). Both papers compared PP to CBT. One RCT had 50 participants and the other 70 participants.

Outcomes

Adults PP Outcomes for Anorexia Nervosa and Bulimia Nervosa 

• Significantly increased BMI in AN at end-of-treatment, and up to 12-months follow-up (Zipfel et al, 2014). 

• Significantly higher recovery rate in AN at 12-months follow-up in between-group analysis (compared with optimised treatment as usual) (Zipfel et al, 2014) 

• Improvements from both CBT and PP at the end of treatment, at 2 years’ follow up, 44% in the CBT and 15% in the PP group had stopped binge eating and purging.  

Some of the best available evidence for Short-term PP in adult depression management includes meta-analytic studies. These are described below. 

• Lindegaard et al (2020) conducted a meta-analytic study to determine the effectiveness of internet delivered interventions based on psychodynamic therapy models on mental health conditions. The review included 7 studies, involving 1,080 participants. Primary mental health issues targeted in these studies included depression, anxiety disorders, return to work, and transdiagnostic focus (i.e. targeting both depression and anxiety). 
• Cuijpers et al (2020) conducted another meta-analytic study to determine the effectiveness of psychological therapies in adult depression management. The review included 309 RCTs that involved 385 comparisons. Of these, 12 comparisons (i.e. 3%) involved psychodynamic therapy.  
• Lilliengren et al (2016) also conducted a meta-analytic study to determine the effectiveness of Experiential Dynamic Therapy (EDT) (a subgroup of short-term psychodynamic psychotherapy) in the management of psychiatric conditions. The meta-analysis included 28 studies involving 1,782 adult patients presenting with depression, anxiety, personality, or mixed disorders. Seven of these studies primarily targeted depression. EDT was delivered in individual, group or guided self-help formats, over 20 sessions, delivered once weekly.  
• Driessen et al (2015) conducted a meta-analytic study to determine the efficacy of short-term psychodynamic psychotherapy (short-term PP) for depression management. The meta-analysis included 54 studies involving 3946 participants. Participants were adults (aged at least 18 years), who met diagnostic criteria for major depressive disorder, another mood disorder, or presented with elevated depression scores. Interventions were classified as STPP if they were founded on psychoanalytic theories, were time-limited from the onset, and applied verbal techniques. 
• A Cochrane review by Abbass et al (2014) was conducted to determine the effectiveness of Short-Term Psychodynamic Psychotherapies (short-term PP) in the management of mental health disorders. The meta-analysis included 33 studies with 2173 participants. Participants were adults (aged 17 years or over) diagnosed with common mental health disorders including anxiety, depression, and somatoform disorders. Eighteen studies with 1415 participants were included in determination of depression outcomes in the short-term (i.e. less than three months). Interventions were classified as STPP if they were psychodynamic in nature, and delivered over 40 sessions or less, with each session lasting 45-60 minutes.    
• An RCT of long-term psychoanalytic psychotherapy for treatment resistant depression (Fonagy et al (2015) assesses outcomes during 18 months of treatment and at 24, 30 and 42 month follow up.

Outcomes

Adult Outcomes for Depression 

Compared to control groups (including waiting list, care as usual, placebo), the following outcomes were observed: 

• Significantly reduced depression symptoms at post-treatment (Cuijpers et al, 2020; Lindegaard et a, 2020; Lilliengren et al, 2016; Driessen et al, 2015), sustained at up to 6-months after treatment (Abbass et al, 2014), at more than 6-months follow-up (Lilliengren et al, 2016; Driessen et al, 2015) and at long-term (42 month) follow up (Fonagy et al 2015).
• Significantly reduced anxiety symptoms at post-treatment (Lindegaard et al, 2020; Lilliengren  et al, 2016; Driessen et al, 2015), sustained at more than 6-months follow-up (Lilliengren  et al, 2016; Driessen et al, 2015) 
• Significantly improved interpersonal functioning and general psychopathology at post-treatment, sustained at more than 6-months follow-up (Driessen et al, 2015) 
• Significantly improved quality of life at post-treatment (Lindegaard et al, 2020; Lilliengren et al, 2016; Driessen et al, 2015), sustained at more than 6-months follow-up (Driessen et al, 2015) 

Significantly reduced general psychiatric symptoms and interpersonal problems at post-treatment (Lilliengren et al, 2016)

Some of the best available evidence for PP in the treatment of PD in adults come from systematic reviews and meta-analysis/ network meta-analysis, and one Randomised Controlled Trial (RCT).

• Papola et al (2021) conducted a network meta-analytic study to evaluate the efficacy of psychotherapies for the treatment of acute phase of panic disorder with or without agoraphobia. The study included 103 RCTs (N=7352) of studies that compared any kind of psychotherapy (including short-term psycho-dynamic therapy) in adults (≥18 years). Adults diagnosed with panic disorder and other comorbid disorders were also included. Delivery formats of psychotherapies were wide ranging and included individual or group formats, face-to-face or remote delivery, and guided/ unguided self-help or therapist delivered interventions. There were no limits set for duration of treatment or number of treatment sessions.
• Keefe et al (2014) conducted a meta-analytic review to evaluate the effectiveness of psychodynamic therapies for anxiety disorders including PD, GAD, and social anxiety. 14 RCTs with1073 adults were included in this review, and PP was delivered in individual or group formats, over the short or long term.
• Svensson et al (2021) conducted a Randomised Controlled Trial (RCT) to evaluate the effectiveness of PFPP or CBT. The study was conducted in Sweden and included 221 adults with panic disorder with/without agoraphobia. PFPP comprised of 19– 24 individual sessions completed in 10–16 weeks, with 2 sessions per week.

Outcomes

Adult Outcomes Achieved for Panic Disorder

Compared to treatment as usual, wait-list control, or control group who received minimal support, the following outcomes were observed in participants who received PP;

• Significantly reduced panic symptoms (Papola et al, 2021)
• Significantly reduced severity of panic disorder at post-treatment, with continued reduction observed at up to 24 months follow-up (Svensson et al, 2021)
• Significantly reduced anxiety symptoms at post-treatment (Keefe et al, 2014)

Some of the best available evidence for PP in the management of SAD include meta-analytic studies. These are described below. 

• Recently, Zhang et al (2022) conducted a meta-analytic study to determine the efficacy of psychodynamic therapy in the management of social anxiety disorder. The study included 12 RCTs that involved 1,213 participants diagnosed with SAD or social phobia. Mean ages of participants in the included studies ranged from 17-43 years. The review included psychodynamic therapy delivered in various formats including individual, group, short-term, and long-term.  
• Mayo-Wilson et al (2014) conducted a network meta-analytic study to determine the effectiveness of psychological and pharmacological interventions for SAD management in adults. The meta-analysis included 101 trials (n=13,164 participants) involving 41 interventions or control conditions. Psychodynamic therapy was evaluated in 3 studies (n=185). Participants in the meta-analysis were adults aged at least 18 years who met the diagnostic criteria for SAD.   

Keefe et al (2014) conducted a meta-analytic study to determine the effectiveness of psychodynamic therapies for anxiety disorders. The meta-analysis included 14 RCTs involving 1073 participants (aged 18 years or over) with one or more specific class of anxiety disorder (e.g., GAD, panic disorder or SAD). SAD/ social phobia was the most frequently studied anxiety disorder as it was examined exclusively in 4 studies. The review included psychodynamic therapy delivered in different formats including short term, long term, individual and group.   

Outcomes

Adult Outcomes for SAD 

Compared to inactive controls the following outcomes were observed: 

• Significantly reduced symptoms of SAD/ anxiety at post-intervention (Zhang et al, 2022; Mayo-Wilson et al,2014; Keefe et al, 2014). Effect of psychodynamic therapy on was similar to other active treatment at post-intervention (Zhang et al 2022; Keefe et al, 2014), at follow-up up to 1 year (Keefe et al, 2014).