Pragmatic randomized controlled trial of long-term psychoanalytic psychotherapy for treatment-resistant depression: the Tavistock Adult Depression Study (TADS)

Therapeutic Approaches to Tackle the Challenge of Depression That Is Resistant to Treatment-A Narrative Review

Background and Aims

The lack of therapeutic response characterizes treatment-resistant depression despite undergoing at least two adequate monotherapy trials with medications from distinct pharmacologic classes. The inability to attain remission in patients diagnosed with major depressive disorder (MDD) is a significant issue of concern within public health. Therefore, the management of treatment-resistant depression (TRD) poses significant obstacles for both patients and healthcare professionals. Our goal was to investigate the published literature concerning different options for treatment for TRD, including those that do not involve the use of medications.

Methods

We thoroughly searched the literature in the Google Scholar, PubMed, and ScienceDirect databases to find publications relevant to our narrative review and extracted data from appropriate data. For this review, literary works written solely in English were chosen.

Results

Ongoing research is being conducted to explore the treatment options for TRD, including pharmacological and nonpharmacological interventions. Pharmacological interventions include a wide range of therapeutic approaches, including but not limited to investigating innovative medications and strategies such as augmentation, switching, and combination therapies involving established and emerging drugs. Nonpharmacological interventions, including brain stimulation such as theta burst stimulation, deep brain stimulation, electroconvulsive therapy, repetitive transcranial magnetic stimulation, intermittent transcranial magnetic stimulation, and magnetic seizure therapy, as well as psychotherapeutic approaches, are being explored for the management of TRD in both present and future contexts.

Conclusion

Researchers are dedicating significant resources to the aforementioned therapeutic interventions to advance the development of novel and efficacious treatment options for TRD and enhance our comprehension of the underlying disease. This review focused on looking at recent research concerning therapeutic interventions for TRD.

Evaluative Research on Psychodynamic Therapy: Foundations and Recent Advances

Psychodynamic therapy (PDT), a technical adaptation of psychoanalysis, is one of the most widely practiced forms of psychotherapy, making evaluative research on it essential. Although research on PDT has been ongoing for several decades, theoretical and practical challenges initially hindered the adoption of evidence-based medicine standards in such research, a shift that has largely taken place over the past 20 years. This article reviews the evolution of evaluative research on PDT for mental disorders in adults, with a focus on those with complex conditions. Since the first prospective evaluative studies in the 1950s, an accumulating body of knowledge-including cohort studies, randomized controlled trials, and meta-analyses-has established PDT as an evidence-based treatment for common mental disorders such as depression, anxiety, somatic symptoms and related disorders, and personality disorders, as well as complex mental disorders involving combinations of these conditions. There is also evidence supporting PDT's usefulness in treating anorexia nervosa and opioid dependence, along with some findings suggesting its potential use for schizophrenia spectrum disorders, bulimia nervosa, and posttraumatic stress disorder. Recent studies indicate that PDT can serve as a personalized treatment, promoting deep and lasting psychopathological changes in patients with severe, complex, and chronic mental disorders, involving specific technical features and mechanisms of change. These findings support the inclusion of PDT in mental health care policies and training, while ongoing research continues to explore its optimal treatment parameters.

Uncovering deep-rooted conflicts: the role of psychoanalytic psychotherapy in treating athletes' social media-related psychological distress

The use of social media by athletes can support them in difficult moments, but it can also become a source of negative emotions and psychological distress. This perspective critically examines psychoanalytic psychotherapy as a method for restoring athletes' psychological well-being after experiencing negative effects from social media use. The paper characterizes the key elements of psychoanalytic psychotherapy relevant to athletes, discusses the role of the psychoanalytic psychotherapist in working with athletes and describes the specifics of the psychoanalytic therapeutic process in this context. The potential advantages of psychoanalytic approaches over cognitive-behavioral methods are examined in treating the psychological impacts of problematic social media use among athletes. The analysis suggests that hate speech and negative online interactions can activate athletes' unprocessed life experiences rooted in early developmental stages. Psychoanalytic psychotherapy may offer a particularly effective method for restoring athletes' psychological wellbeing in such cases by addressing deep-rooted intrapsychic conflicts. However, a comprehensive approach integrating multiple therapeutic modalities is recommended to address the complex challenges athletes face in the digital age. This perspective acknowledges limitations in current research and suggest directions for future studies to develop and validate tailored interventions for athletes grappling with social media-related psychological distress.

Childhood trauma and differential response to long-term psychoanalytic versus cognitive-behavioural therapy for chronic depression in adults

BACKGROUND

Childhood trauma is a major risk factor for chronic depression. It has been suggested that adults with chronic depression who have experienced childhood trauma may require long-term treatment owing to a breakdown of basic trust and related difficulties in developing a productive therapeutic relationship.

AIMS

As empirical studies have been preliminary and scarce, we studied the effects of psychoanalytic therapy (PAT) versus cognitive-behavioural therapy (CBT) for chronic depression in adults with a history of childhood trauma. In this subgroup, we expected a greater symptom reduction in PAT compared with CBT.

METHOD

In a large trial of long-term psychotherapies for chronic depression (LAC-Study; Clinical Trial Register ISRCTN91956346), 210 adults received open-ended CBT or PAT in an out-patient setting and were examined yearly over 5 years on the Beck Depression Inventory - II (BDI-II). Based on a linear mixed model approach, we tested participant-reported childhood trauma based on the Childhood Trauma Questionnaire (CTQ) as a predictor and moderator of treatment outcome. CTQ subscales were examined exploratively.

RESULTS

Depressive symptoms decreased over time (b = -4.55, s.e. = 0.90, 95% CI -6.32 to -2.81, T = -5.08; P < 0.001). A significant three-way interaction between childhood trauma, time and therapy group (b = -0.05, s.e. = 0.02, 95% CI -0.09 to -0.01, T = -2.42; P = 0.016) indicated that participants with childhood trauma profited especially well from PATs.

CONCLUSIONS

Our results indicate differential benefits from PAT compared with CBT among adults with chronic depression and a history of childhood trauma. The results have important implications for differential indication and policy.

Empirical examination of long-term and intensive psychodynamic psychotherapy for severely disturbed patients

Objectives This study examines the effectiveness and efficiency of intensive psychodynamic psychotherapy for severely impaired patients. Method: 104 patients in four public mental health centers underwent intensive psychodynamic psychotherapy. The number and duration of psychiatric hospitalizations were monitored for these patients from one year before therapy to eight years after. Several outcome variables were measured every six months, six times in total over two and a half years, using a longitudinal design. A multi-level analytic approach was applied to account for repeated measurements and missing data. Results: Significant improvement was found in all three symptomatic outcome measures (SCL-90, OQ-45, BDI) throughout treatment. The numbers of psychiatric hospitalizations and psychiatric hospitalization days decreased significantly from the level they were in the year before the start of psychodynamic treatment to three years after the start of treatment. These results were maintained for at least up to eight years. After capitalization, the overall cumulative 127.47-day decrease in hospitalization days equals savings of 115,850 NIS. The average cost of treatment after capitalization was 26,770 NIS. The insurer's estimated direct savings is 89,080 NIS (24,054 $). Conclusion: These findings support the hypothesis that psychodynamic psychotherapy is clinically effective and economically efficient for severely impaired patients.

Examination of a case of "treatment failure" in long-term psychoanalytic psychotherapy for treatment-resistant depression

Randomized controlled trials have reported psychoanalytic psychotherapy to improve longer-term post-treatment outcomes in patients with treatment-resistant depression. In this case study, we examine the therapy process of a female trial participant diagnosed with treatment-resistant depression. Structured clinical assessments indicated that the patient's level of depression remained unchanged during and after treatment. Over the course of the therapy, she repeatedly broke away from important others and finally also from the therapy itself, which we linked to the impact of earlier experiences of abandonment on her internal world. In the discussion, we present a variety of reflections that were put forward by the authors during a series of case discussion meetings. Some of these reflections relate to how the inner world of this patient might have triggered a negative therapeutic reaction and a destructive pattern of repetition. The interpretative stance, in which the therapist interpreted this reaction as indicative of a psychic conflict and linked this conflict to the therapeutic relationship, seemed to be experienced by the patient as unhelpful and persecutory. Other elements that were brought up include basic distrust, lack of symbolization and trauma in the patient, as well as the constraints of the research context.

The complexity of treatment-resistant depression: A data-driven approach

BACKGROUND

Recent systematic reviews highlight great variability in defining and assessing treatment-resistant depression (TRD). A key problem is that definitions are consensus rather than data-led. This study seeks to offer a comprehensive socio-demographic and clinical description of a relevant sample.

METHODS

As part of a pragmatic randomized controlled trial, patients (N = 129) were managed in primary care for persistent depression and diagnosed with TRD. Data included previous treatment attempts, characteristics of the depressive illness, functioning, quality of life, co-occurring problems including suicidality, psychiatric and personality disorders, physical health conditions, and adverse events.

RESULTS

Findings show a severe and chronic course of depression with a duration of illness of 25+ years. Overall, 82.9 % had at least one other psychiatric diagnosis and 82.2 % at least one personality disorder; 69.8 % had significant musculoskeletal, gastrointestinal, genitourinary, or cardiovascular and respiratory physical health problems. All but 14 had severe difficulties in social and occupational functioning and reported severely impaired quality of life. Suicidal ideation was high: 44.9 % had made at least one serious suicide attempt and several reported multiple attempts with 17.8 % reporting a suicide attempt during childhood or adolescence. Of the patients, 79.8 % reported at least one adverse childhood experience.

LIMITATIONS

Potential for recall bias, not examining possible interactions, and absence of a control group.

CONCLUSIONS

Our findings reveal a complex and multifaceted condition and call for an urgent reconceptualization of TRD, which encompasses many interdependent variables and experiences. Individuals with TRD may be at a serious disadvantage in terms of receiving adequate treatment.

Prevalence Increases as Treatments Improve: An Evolutionary Perspective on the Treatment-Prevalence Paradox in Depression

Depression is an eminently treatable disorder that responds to psychotherapy or medications; the efficacy of each has been established in hundreds of controlled trials. Nonetheless, the prevalence of depression has increased in recent years despite the existence of efficacious treatments-a phenomenon known as the treatment-prevalence paradox. We consider several possible explanations for this paradox, which range from a misunderstanding of the very nature of depression, inflated efficacy of the established treatments, and a lack of access to efficacious delivery of treatments. We find support for each of these possible explanations but especially the notion that large segments of the population lack access to efficacious treatments that are implemented as intended. We conclude by describing the potential of using lay therapists and digital technologies to overcome this lack of access and to reach historically underserved populations and simultaneously guarantee the quality of the interventions delivered.

A Systematic Review and Narrative Analysis of the Evidence for Individual Psychodynamically Informed Psychotherapy in the Treatment of Dissociative Identity Disorder in Adults

Dissociative Identity Disorder (DID) is a highly disabling diagnosis, characterized by the presence of two or more personality states which impacts global functioning, with a substantial risk of suicide. The International Society for the Study of Trauma and Dissociation (ISSTD) published guidelines for treating DID in 2011 that noted individual Psychodynamically Informed Psychotherapy (PDIP) was a cornerstone of treatment. This paper systematically reviews the evidence base for PDIP in the treatment of adults with DID according to the 2009 Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Thirty-five articles were located and reviewed: seven prospective longitudinal publications, 13 case series and 15 case studies. Results suggested that PDIP has been widely deployed in DID to reported good effect with a range of treatment protocols and using multiple theoretical models. Despite the positive findings observed, the evidence base remains at the level of observational-descriptive design. Creative approaches in recent years have been developed, which add empirical weight to the use of PDIP as an effective treatment. The elevation to observational-analytic designs in the Evidence-Based Medicine hierarchy has yet to take place. Bearing in mind the challenges of research in PDIP, suggestions are offered for how the evidence base might develop.

The Melbourne Study of Psychoanalytic Psychotherapy low‐cost clinic I: Implementation, mental health and life functioning gains

The Melbourne Study of Psychoanalytic Psychotherapy examined the implementation, lived experience, and perceived therapeutic gains of psychoanalytic psychotherapy in a low‐cost, private‐sector community clinic. A first in Australia, this 8‐year demonstration project allowed naturalistic study of the impact and process of intensive, long‐term, time‐limited psychoanalytic psychotherapy delivered to self‐referred adults by clinicians with a common theoretical frame of practice. Presented in three papers, the research employed the RE‐AIM planning and evaluation framework, using complementary quantitative and qualitative methods, to study the psychotherapy service in terms of Reach, Effectiveness, Adoption, Implementation and Maintenance. This first paper reports the Reach of the program to be 67% for those presenting for assessment for psychoanalytic psychotherapy, with Adoption of the full 2‐year treatment program being 60%. Improvements in mental health and life functioning provided quantitative evidence of Effectiveness for those completing the 2‐year treatment program, with Maintenance at 8‐month follow‐up. Patient age, gender and personality characteristics did not modify these improvements. In‐depth qualitative exploration of patient and psychotherapist perspectives regarding the psychotherapy is reported in the second paper highlighting expectations, experience and benefits of the psychotherapy. The third companion paper presents the qualitative findings concerning factors experienced as facilitating or challenging therapeutic progress. Each of the three related papers amplifies understandings of how low‐cost, long‐term but time‐limited psychoanalytic psychotherapy can be implemented in the community with adults otherwise unable to afford such treatment, and discusses lessons learned.

Trajectories of change among highly challenging patients in intensive long-term psychoanalytic psychotherapy

OBJECTIVES

This study aimed to identify and describe trajectories of change in distress among highly challenging patients who had received long and intensive psychoanalytic psychotherapy.

METHODS

The longitudinal version of the K-means algorithm was applied to the outcome measures data of 74 patients treated in four public mental health centers. The patients were measured five times at 6-month intervals for three outcome measures.

RESULTS

For the OQ45 and Symptom Checklist-90, one trajectory was marked by a lower initial distress level. In this trajectory, the improvement occurred in the first half of the measurements, with a plateau thereafter. A second trajectory was characterized by higher initial severity and an improvement, mainly in the second part of the measurements. For the Beck Depression Inventory, one trajectory was marked by lower initial distress. In this group, the improvement occurred throughout the entire period. The remaining patients were characterized by higher initial distress and a decreased level of distress in the last part of treatment. They began to improve only during the third year of therapy.

CONCLUSION

The response to treatment is not uniform in long-term treatment for highly challenging patients. A significant number of patients require a longer period of therapy to ignite improvement.

Which patients benefit from adding short-term psychodynamic psychotherapy to antidepressants in the treatment of depression? A systematic review and meta-analysis of individual participant data

BACKGROUND

Adding short-term psychodynamic psychotherapy (STPP) to antidepressants increases treatment efficacy, but it is unclear which patients benefit specifically. This study examined efficacy moderators of combined treatment (STPP + antidepressants) v. antidepressants for adults with depression.

METHODS

For this systematic review and meta-analysis (PROSPERO registration number: CRD42017056029), we searched PubMed, PsycINFO, Embase.com, and the Cochrane Library from inception to 1 January 2022. We included randomized clinical trials comparing combined treatment (antidepressants + individual outpatient STPP) v. antidepressants in the acute-phase treatment of depression in adults. Individual participant data were requested and analyzed combinedly using mixed-effects models (adding Cochrane risk of bias items as covariates) and an exploratory machine learning technique. The primary outcome was post-treatment depression symptom level.

RESULTS

Data were obtained for all seven trials identified (100%, n = 482, combined: n = 238, antidepressants: n = 244). Adding STPP to antidepressants was more efficacious for patients with high rather than low baseline depression levels [B = -0.49, 95% confidence interval (CI) -0.61 to -0.37, p < 0.0001] and for patients with a depressive episode duration of >2 years rather than <1 year (B = -0.68, 95% CI -1.31 to -0.05, p = 0.03) and than 1-2 years (B = -0.86, 95% CI -1.66 to -0.06, p = 0.04). Heterogeneity was low. Effects were replicated in analyses controlling for risk of bias.

CONCLUSIONS

To our knowledge, this is the first study that examines moderators across trials assessing the addition of STPP to antidepressants. These findings need validation but suggest that depression severity and episode duration are factors to consider when adding STPP to antidepressants and might contribute to personalizing treatment selection for depression.

Treatment-resistant depression: definition, prevalence, detection, management, and investigational interventions

Treatment-resistant depression (TRD) is common and associated with multiple serious public health implications. A consensus definition of TRD with demonstrated predictive utility in terms of clinical decision-making and health outcomes does not currently exist. Instead, a plethora of definitions have been proposed, which vary significantly in their conceptual framework. The absence of a consensus definition hampers precise estimates of the prevalence of TRD, and also belies efforts to identify risk factors, prevention opportunities, and effective interventions. In addition, it results in heterogeneity in clinical practice decision-making, adversely affecting quality of care. The US Food and Drug Administration (FDA) and the European Medicines Agency (EMA) have adopted the most used definition of TRD (i.e., inadequate response to a minimum of two antidepressants despite adequacy of the treatment trial and adherence to treatment). It is currently estimated that at least 30% of persons with depression meet this definition. A significant percentage of persons with TRD are actually pseudo-resistant (e.g., due to inadequacy of treatment trials or non-adherence to treatment). Although multiple sociodemographic, clinical, treatment and contextual factors are known to negatively moderate response in persons with depression, very few factors are regarded as predictive of non-response across multiple modalities of treatment. Intravenous ketamine and intranasal esketamine (co-administered with an antidepressant) are established as efficacious in the management of TRD. Some second-generation antipsychotics (e.g., aripiprazole, brexpiprazole, cariprazine, quetiapine XR) are proven effective as adjunctive treatments to antidepressants in partial responders, but only the olanzapine-fluoxetine combination has been studied in FDA-defined TRD. Repetitive transcranial magnetic stimulation (TMS) is established as effective and FDA-approved for individuals with TRD, with accelerated theta-burst TMS also recently showing efficacy. Electroconvulsive therapy is regarded as an effective acute and maintenance intervention in TRD, with preliminary evidence suggesting non-inferiority to acute intravenous ketamine. Evidence for extending antidepressant trial, medication switching and combining antidepressants is mixed. Manual-based psychotherapies are not established as efficacious on their own in TRD, but offer significant symptomatic relief when added to conventional antidepressants. Digital therapeutics are under study and represent a potential future clinical vista in this population.

Efficacy of high-intensity versus low-intensity psychoanalytically oriented long-term treatments and determinants of outcome: individual participant data Meta-analysis of Long-term Analytic treatment Studies (MeLAS)

INTRODUCTION

Long-term psychodynamic/psychoanalytic psychotherapy (LTPP) is a prevalent treatment option for complex mental disorders. Yet, little is known about the role of treatment intensity in LTPP. We present a study protocol for a systematic review and individual participant data (IPD) meta-analysis aggregating and analysing individual data from randomised and quasi-experimental trials by meta-analysis. The purpose is to (1) determine the treatment effectiveness of LTPP with low versus high intensity (up to 2 weekly sessions vs three or more), (2) compare their joint effectiveness to shorter therapies and treatments as usual, (3) identify predictors and moderators of treatment outcomes and (4) determine reciprocal relationships between different outcome domains (symptomatic and structural/personality change) over the courses of LTPP.

METHODS AND ANALYSIS

We include studies from (randomised controlled trial, RCT) and quasi-experimental trials, where at least one condition was LTPP of high or low frequency. Long-term treatment is defined as ≥1 year or ≥50 sessions. To be eligible studies must include a standardised outcome measure of symptoms (global or disorder specific) with at least one proof of reliability. The primary outcome is symptom reduction (global or specific), secondary outcome criteria are reliable change, remission, functional capacities, personality, personality functioning and interpersonal pathology. Relevant studies will mainly be identified by searching relevant databases: PubMed, PsycINFO (via EBSCO), Web of Science (via Elsevier), Chochrane's Central Register of Controlled Trials (via Wiley). Risk of bias will be evaluated in line with the Cochrane assessments tools for quasi-experimental trials and RCTs, respectively.

ETHICS AND DISSEMINATION

Aggregation of data from primary trials collected based on ethics votes. Dissemination into clinical practice via open access publications of findings.

PROSPERO REGISTRATION NUMBER

CRD42022304982; Pre-results.

Cost-effectiveness of long-term psychoanalytic psychotherapy for treatment-resistant depression: RCT evidence from the Tavistock Adult Depression Study (TADS)

BACKGROUND

Treatment-resistant depression (TRD) accounts for a large fraction of the burden of depression. The interventions currently used are mostly pharmacological and short-term psychotherapies, but their effectiveness is limited. The Tavistock Adult Depression Study found evidence for the effectiveness of long-term psychoanalytic psychotherapy (LTPP) plus treatment as usual (TAU), versus TAU alone, for TRD. Even after a 2-year follow-up, moderate effect sizes were sustained. This study assessed the cost-effectiveness of this LTPP + TAU.

METHODS

We conducted a within-trial economic evaluation using a Bayesian framework.

RESULTS

Quality-adjusted life years (QALYs) were 0.16 higher in the LTPP + TAU group compared with TAU. The direct cost of LTPP was £5500, with no substantial compensating savings elsewhere. Overall, average health and social care costs in the LTPP + TAU group were £5000 more than in the TAU group, employment rates were unchanged, and effects on other non-healthcare costs were uncertain. Accordingly, the incremental cost-effectiveness ratio was ≈£33,000/QALY; the probability that LTPP + TAU was cost-effective at a willingness to pay of £20,000/QALY was 18 %.

LIMITATIONS

The sample size of this study was relatively small, and the fraction of missing service-use data was approximately 50 % at all time points. The study was conducted at a single site, potentially reducing generalizability.

CONCLUSIONS

Although LTPP + TAU was found to be clinically effective for treating TRD, it was not found to be cost-effective compared with TAU. However, given the sustained effects over the follow-up period it is likely that the time horizon of this study was too short to capture all benefits of LTPP augmentation.

Group music therapy with songwriting for adult patients with long-term depression (SYNCHRONY study): a feasibility and acceptability study of the intervention and parallel randomised controlled trial design with wait-list control and nested process evaluation

BACKGROUND

Despite effective treatments, one fifth of patients develop chronic depression. Music therapy may offer a different approach. This study aimed to assess feasibility and acceptability of a music therapy intervention and trial methodology.

METHODS

A parallel two-arm randomised controlled trial with wait-list control, mixed feasibility/acceptability measures and nested process evaluation. Adults with long-term depression (symptom duration > 1 year) were recruited from community mental health services and computer randomised to 42 sessions of group music therapy with songwriting three times per week or wait-list control. Depression, social functioning, distress, quality of life, satisfaction and service use were assessed by blinded researchers at enrolment, 1 week and 3 and 6 months post-therapy. Outcomes were analysed descriptively, controlling for baseline covariates. Recruitment (number eligible, participation and retention rates) and intervention (fidelity, adherence) feasibility were assessed using pre-defined stop-go criteria. Attendance, adverse events, mood, relationship satisfaction and semi-structured interviews were analysed in a nested process evaluation.

RESULTS

Recruitment processes were feasible with 421 eligible, 12.7% participation and 60% (18/30) retention. Thirty participants were randomised to intervention (N = 20) and control (N = 10). Session attendance was low (mean 10.5) with four withdrawals. Music therapist adherence was good but changes to session frequency were suggested. Outcomes were available for 10/20 treatment and 9/10 wait-list participants. Depression increased in both arms post-therapy. Treatment depression scores fell below baseline 3 and 6 months post-therapy indicating improvement. Wait-list depression scores increased from baseline 3 and 6 months post-therapy. At 3 months, the treatment arm improved from baseline on all measures except satisfaction and functioning. At 6 months, quality of life, distress and functioning improved with reduction in health service contacts. High-attending participants improved more than low-attending. Seven adverse events (one serious) were reported.

LIMITATIONS

As this was a feasibility study, clinical outcomes should be interpreted cautiously.

CONCLUSION

A randomised controlled trial of group music therapy using songwriting is feasible with inclusion criteria and session frequency modifications, but further intervention development is required.

TRIAL REGISTRATION

ISRCTN18164037 on 26.09.2016.

Recovery from chronic depression and structural change: 5-year outcomes after psychoanalytic and cognitive-behavioural long-term treatments (LAC depression study)

OBJECTIVE

Psychotherapy of chronic depression has remained a challenge due to limited prognosis and high rates of recurrence. We present 5-year outcome data from a multicentre trial comparing psychoanalytic (PAT) and cognitive-behavioural (CBT) long-term treatments with randomized and preferred allocations analysing symptom (N = 227) and structural change (N = 134) trajectories.

METHOD

Self- and blinded expert ratings of depression symptoms were performed at yearly intervals using the Beck Depression Inventory-II (BDI-II) and Quick Inventory of Depressive Symptoms (QIDS-C). Blinded expert ratings of Operationalized Psychodynamic Diagnosis (OPD) and the Heidelberg Restructuring Scale (HRS) at baseline, 1, 3, and 5 years assessed structural change in a subsample.

RESULTS

Lasting and comparable symptom changes were achieved by PAT and CBT. However, compared to CBT, PAT was more successful in restructuring, a major goal of long-term psychodynamic treatments with high frequency and duration.

LIMITATIONS

Due to practical reasons, the time criterion for chronic depression of an acute phase had to be defined for over 1 year in the present study, which does not correspond to the DSM-5 criterion of 2 years. Therapy duration and session frequency were not incorporated into the statistical models.

CONCLUSION

Long-term psychotherapy helps patients with a yearlong history of depression and often multiple unsuccessful treatment attempts to achieve lasting symptom changes. Future follow-up will clarify whether restructuring promotes further sustainable improvements.

Clinical wisdom, science and evidence: The neglected gifts of psychodynamic thinking

We review five key areas of contemporary psychodynamic practice and research to highlight the contributions psychodynamic concepts can make to clinical psychiatry. These areas are as follows: (1) Contributions to understanding the development of subjectivity. (2) The psychodynamic understanding of the effects of early childhood trauma and their consequences in adult life. (3) The vital importance of the psychodynamic notion of the 'holding environment' based on an understanding of the dynamics of the development of subjectivity and trauma which, if applied, might improve the quality of psychiatric care in the public mental health system and enhance both the clinical competence and morale of clinicians in the system. (4) The emerging scientific disciplines of Neuropsychoanalysis and Affective Neuroscience, which illustrate the importance of seriously studying the mind as well as the brain. (5) A brief summary of some research into the clinical effectiveness and efficacy of psychoanalysis and its related psychodynamic therapies.

Clinical- and cost-effectiveness of a technology-supported and solution-focused intervention (DIALOG+) in treatment of patients with chronic depression-study protocol for a multi-site, cluster randomised controlled trial [TACK]

Background

Many with an acute depressive disorder go on to develop chronic depression, despite ongoing care. There are few specifically designed interventions to treat chronic depression. DIALOG+, a technology-assisted intervention based on the principles of solution-focused therapy, may be beneficial. It has been shown to be effective as a treatment for patients with psychotic disorders, especially in regards to increasing quality of life. DIALOG+ was designed to be flexibly applied and not diagnosis-specific, aiming to structure communication and generate a personally-tailored care plan. This cluster randomised controlled trial (RCT) is part of a programme of research to adapt and test DIALOG+ for patients with chronic depression.

Methods

Patients will be eligible for the trial, if they have exhibited symptoms of depression or non-psychotic low mood for at least 2 years, have regular contact with a clinician and have a low subjective quality of life and moderate depressive symptoms. Clinicians, who routinely see eligible patients, will be recruited from a number of sites across NHS England. Clusters will have between 1 and 6 patients per clinician and will be randomised in a 1:1 ratio to either the intervention (DIALOG+) or active control group (treatment as usual + DIALOG scale). Clinicians in the intervention group are trained and asked to deliver the intervention regularly for 12 months. Active control participants receive treatment as usual and are asked to rate their satisfaction with areas of life and treatment on the DIALOG scale at the end of the clinical session. Approximately 112 clinician clusters will be recruited to reach a total patient sample size of 376. Clinical and social outcomes including costs are assessed at baseline and 3, 6 and 12 months post randomisation. The primary outcome will be subjective quality of life at 12 months.

Discussion

This definitive multi-site, cluster RCT aims to evaluate the clinical- and cost-effectiveness of DIALOG+ for people with chronic depression. If shown to be effective for this patient population it could be used to improve outcomes of mental health care on a larger scale, ensuring that patients with complex and co-morbid diagnoses can benefit.

Trial registration

ISRCTN11301686. Registered on 13 Jun 2019.

Out of time: adolescents and those who wait for them

This paper draws on the scholarship of an inter-disciplinary project about time and waiting in healthcare to explore questions of urgency and risk in clinical work with depressed and suicidal young people, and how the feeling of being compelled to act can be meaningfully explored from a psychoanalytic perspective. The paper examines adolescence as both a time of inherent crisis and one in which self-harm and suicidal ideation represent particular challenges. It then considers Child and Adolescent Mental Health Service practice in relation to acute mental health crisis, and in the context of the chronic crisis affecting the UK National Health Service. Considering both formal psychoanalytic psychotherapy and the contribution of psychoanalytic thinking to multidisciplinary discussions and emergency work in CAMHS, the author then considers the anticipatory anxieties that affect such work, and the particular role of psychoanalytic thinking for young people burdened by suicidal ideation and the professionals caring for them.

The clinical and cost-effectiveness of a self-management intervention for patients with persistent depressive disorder and their partners/caregivers: study protocol of a multicenter pragmatic randomized controlled trial

BACKGROUND

After regular treatment, patients with persistent depressive disorder (PDD) may remain in specialized psychiatric outpatient care without achieving remission. Lacking other options, these patients often receive long-term, non-protocolized care as usual (CAU) that does not involve the partner/caregiver of the patient. Although the revised depression treatment guidelines suggest focusing on psychiatric rehabilitation and self-management as the next treatment step for PDD, an evidence-based cost-effective self-management protocol for PDD is lacking. This study investigates the "Patient and Partner Education Program for All Chronic Illnesses" (PPEP4All) as a brief self-management protocol that could lead to lower costs, higher quality of life, and less disease burden in PDD patients and their partners/caregivers.

METHODS

Presented is the rationale and methods of a multicenter pragmatic randomized controlled trial to evaluate the clinical efficacy and cost-effectiveness of PPEP4All for patients with PDD and their partners/caregivers. In accordance with current recommendations, a mixed methods research approach is used with both quantitative and qualitative data. A total of 178 eligible outpatients with PDD and their partners/caregivers are recruited and randomized to either PPEP4All or CAU. Those assigned to PPEP4All receive nine weekly self-management sessions with a trained PPEP4All therapist. Primary and secondary outcome measurements are at 0, 3, 6, and 12 months.

DISCUSSION

This project will result in the implementation of a self-management intervention for patients with PDD, meeting an urgent need in mental healthcare. Using PPEP4All can optimize the quality and efficiency of care for both patients with PDD and their partners/caregivers.

TRIAL REGISTRATION

Netherlands Trial Register Identifier NTR5973 . Registered on 20 July 2016.

Real-world evidence from a European cohort study of patients with treatment resistant depression: Treatment patterns and clinical outcomes

BACKGROUND

Treatment resistant depression (TRD) characterizes a subgroup of 10-30% of patients with major depressive disorder, and is associated with considerable morbidity and mortality. A consensus treatment for TRD does not exist, which often leads to wide variations in treatment strategies. Real-world studies on treatment patterns and outcomes in TRD patients in Europe are lacking and could help elucidate current treatment strategies and their efficacy.

METHODS

This non-interventional cohort study of patients with TRD (defined as treatment failure on ≥2 oral antidepressants given at adequate dose and duration) with moderate to severe depression collected real-world data on treatment patterns and outcomes in several European countries. Patients were started on a new treatment for depression according to routine clinical practice.

RESULTS

Among 411 patients enrolled, after 6 months, only 16.7% achieved remission and 73.5% showed no response. At Month 12, while 19.2% achieved remission and 69.2% showed no response, 33.3% of those in remission at Month 6 were no longer in remission. Pharmacological treatments employed were heterogenous; 54 different drugs were recorded at baseline, and the top 5 treatment types according to drug classes accounted for 40.0% of patients. Even though remission rates were very low, at Month 12, 60.0% of patients had not changed treatment since enrolment.

CONCLUSIONS

The heterogeneity of treatments highlights a lack of consensus. Moreover, despite low response rates, patients often remained on treatments for substantial periods of time. These data further support existence of an unmet treatment need for TRD patients in Europe.

Acceptability of a technology-supported and solution-focused intervention (DIALOG+) for chronic depression: views of service users and clinicians

BACKGROUND

Treating chronic depression represents a significant burden for the NHS, yet there is a lack of evidence-based interventions and research specifically focused on this condition. DIALOG+, a technology-assisted and resource-oriented intervention found effective for people with psychosis, may improve care for this service user group. The aim of this study was to explore the acceptability and relevance of DIALOG+ for the treatment of chronic depression in community-based settings.

METHODS

A convenience sample of 16 mental health professionals and 29 service users with chronic depression tested the DIALOG+ intervention in routine community care appointments for 3 months across 3 different mental health NHS Trusts in England. Of these, 15 clinicians and 19 service users were individually interviewed about their experiences. Interview transcripts were analysed using thematic analysis by an analytic team which included a service user researcher.

RESULTS

Analysis of the combined dataset identified five overarching themes: DIALOG+ Structure; Therapeutic Communication; Reflecting and Monitoring; Empowerment and Powerlessness; and The Impact of Technology. Overall, service users and clinicians were interested in the continued use of DIALOG+ as part of routine care.

CONCLUSIONS

DIALOG+ was viewed as acceptable by both service users with chronic depression and their clinicians who work in community care settings, albeit with some caveats. Clinician training required significant improvements to address the issues that were referenced, most notably around support with using technology.

Clinical Features and Outcomes of 124 Italian Patients With Treatment Resistant Depression: A Real-World, Prospective Study

Introduction: Treatment-resistant depression (TRD) is a debilitating condition affecting 20-30% of patients with major depressive disorders (MDD). Currently, there is no established standard of care for TRD, and wide variation in the clinical approach for disease management has been documented. Real-world data could help describe TRD clinical features, disease burden, and treatment outcome and identify a potential unmet medical need. Methods: We analyzed the Italian data from a European, prospective, multicentric, observational cohort study of patients fulfilling TRD criteria by the European Medicine Agency, with moderate to severe major depressive episode, and starting a new antidepressant treatment according to routinary clinical practice. They were followed up for minimum 6 months. Treatments received throughout the study period, disease severity, health-related quality of life and functioning were prospectively recorded and analyzed. Results: The Italian subcohort included 124 TRD patients (30.2% of patients of the European cohort; mean age 53.2 [sd = 9.8], women: 82, 66.1%). At enrollement, the mean (SD) duration of MDD was 16 years (sd = 11.1) and the mean duration of the ongoing major depressive episode (MDE) was 97.5 weeks (sd = 143.5); low scores of quality of life and functioning were reported. The most frequently antidepressant classes started at baseline (data available for 98 subjects) were selective serotonin reuptake inhibitors (SSRI, 42 patients [42.9%]) and serotonin-norepinephrine reuptake inhibitors (SNRI, 32 patients [32.7%]). In terms of treatment strategies, 50 patients (51%) started augmentation therapies, 18 (18.4%) combination therapies and 24 (24.5%) monoterapies (6 patients [6%] started a non-antidepressant drug only). Fourteen patients (11.3%) were treated with a psychosocial approach, including psychotherapy. After 6 months of treatment, clinical assessments were collected for 89 patients: 64 (71.9%) showed no response, 9 (10.1%) response without remission and 16 (18.0%) were in remission; non-responder patients showed lower quality of life and higher disability scores than responder patients. Conclusions: In our sample of TRD patients, we documented substantial illness burden, low perceived quality of life and poor outcome, suggesting an unmet treatment need in TRD care in Italy. Registration Number: ClinicalTrials.gov, number: NCT03373253.

[Efficacy of psychodynamic therapies: A systematic review of the recent literature]

AIM

A French governmental institute published, in February 2004, a report assessing the efficacy of psychotherapies in the light of the biomedical literature. It concluded that cognitive psychotherapies effectively cure common mental disorders, while the efficacy of psychodynamic therapies is not proven by scientific studies. Because many French mental health professionals are practicing with reference to psychoanalysis, this conclusion stirred up heated controversy. Since February 2004, numerous studies assessing psychodynamic therapies have been published in peer-reviewed biomedical journals. Moreover, these primary studies have been meta-analyzed in dozens of review articles. Here, we systematically review these meta-analysis articles.

METHODS

A systematic search for meta-analyses assessing psychodynamic therapies was performed using PubMed and identified 71 articles published from January 2004 to December 2019. Among them, 25 articles were judged to be relevant because they reported meta-analyses assessing the symptoms of common mental disorders in at least three distinct cohorts of adult patients. Although the primary studies included in these 25 meta-analysis articles often overlap, the selection criteria, calculation methods and results always differ between them. Therefore, we reviewed all of them without further selection. From all the meta-analyses reported in these 25 articles, we systematically present here the most compelling ones, i.e. those calculated from the largest number of primary studies. Results were quantified in terms of effect size (i.e. standardized mean difference). Effect sizes below 0.25 were considered as without clinical significance, whereas those superior to 0.8 were regarded as robust. Because short-term psychodynamic therapies had been assessed in 20 meta-analysis articles published until 2017, we did not search for more recent primary studies. However, because the most recent meta-analysis article about long-term psychodynamic therapies was published in 2013, we also searched, using PubMed, for primary studies assessing psychodynamic therapies lasting for at least one year and published from January 2013 to December 2019. Among the 57 publications retrieved by PubMed, three were identified as randomized controlled trials not included in meta-analyses and were extensively described here.

RESULTS

Eight meta-analysis articles have assessed symptom improvement at treatment termination by comparing with baseline symptoms. According to all of them, psychodynamic therapies alleviate symptoms and their effect sizes are always robust. Three meta-analysis articles compared psychodynamic therapies with inactive treatments (e.g. placebo medication, waiting list) and reported clinically significant differences in favor of psychodynamic therapies. Ten meta-analysis articles compared, at treatment termination, psychodynamic therapies to active treatments, including medication and cognitive psychotherapies. Nine of them reported no difference. Only one article concluded that psychodynamic therapies are clinically inferior to cognitive psychotherapies (d=-0.28). Seven meta-analysis articles compared psychodynamic therapies to active treatment at follow-up (i.e. months or years after treatment termination). Five of them reported no significant difference, one reported a medium effect size in favor of psychodynamic therapies over various active treatments (d=0.38), while the other reported a clinically significant difference in favor of cognitive psychotherapies (d=-0.55). Because short-term treatments are often insufficient to prevent relapse, investigations about long-term treatments (i.e. more than one year) are needed, but such published studies are still scarce. Five meta-analysis articles and three primary studies published since 2013 compared long-term psychodynamic therapies to various active treatments of similar duration. According to them, psychodynamic therapies were at least as effective as other active treatments.

CONCLUSION

A systematic review about psychodynamic therapies, published in 2015 in Lancet Psychiatry, included 64 randomized controlled trials of which 37 were published after 2003. Therefore, most quality studies assessing psychodynamic therapies have been published since 2003 and have been reviewed in recent meta-analysis articles. All together, this recent literature leads to the conclusion that psychodynamic therapies are as effective as active treatments, including cognitive psychotherapies, to help patients suffering from common mental disorders (unipolar depression, anxiety disorders, eating disorders and personality disorders). Beside this overall conclusion, it appears that randomized controlled trials are not well suited for answering why psychotherapies work in some patients but not in others, and how they work in general. Other approaches are needed, including case studies.

A NICE game of Minecraft: philosophical flaws underpinning UK depression guideline nosology

Categorising mental disorders for purposes of diagnosis, research and practice has historically been justified on philosophical terms as a pragmatic activity; categories which have been subject to wide-ranging philosophical critique have been defended on the grounds that they serve as heuristic devices providing loose representations of shared experiences, not labels for real structures. In acknowledgement of this, there has been increasing recognition that subclassifying multiple discrete forms of persistent depression moves too far away from the notion of a heuristic and that attempts to create more precise categories become less clinically useful. Hence the most recent Diagnostic and Statistical Manual of Mental Disorders (V.5) and International Classification of Diseases (V.11) both group persistent forms of depression together. However, the UK National Institute for Health and Care Excellence has delineated certain subclassifications of persistent depression in its new guideline, which grossly distorts the phenomenology of depression. This approach commits a fundamental philosophical error in conflating absence of knowledge with knowledge of absence. In this sense, the new guideline appears to be engaging in an activity akin to the digital game Minecraft, in which the craft of building structures from units of construction is largely divorced from the laws of physics. The risk of ignoring these philosophical errors and making false claims about scientific plausibility is that the guideline recommendations inevitably represent a highly distorted phenomenology of depression and will be of very little value to patients or practitioners looking for guidance on best possible treatment options.

Relative effectiveness of augmentation treatments for treatment-resistant depression: a systematic review and network meta-analysis

Most interventions for treatment-resistant depression (TRD) are added as augmenters. We aimed to determine the relative effectiveness of augmentation treatments for TRD. This systematic review and network meta-analysis (NMA) sought all randomized trials of pharmacological and psychological augmentation interventions for adults meeting the most common clinical criteria for TRD. The NMA compared the intervention effectiveness of depressive symptoms for TRD augmentation. Of 36 included trials, 27 were suitable for inclusion in NMA, and no psychological trials could be included in the absence of a common comparator. Antipsychotics (13 trials), mood stabilizers (three trials), NMDA-targeting medications (five trials), and other mechanisms (3 trials) were compared against placebo. NMDA treatments were markedly superior to placebo (ES = 0.91, 95% CI 0.67 to 1.16) and head-to-head NMA suggested that NMDA therapies had the highest chance of being an effective treatment option compared to other pharmacological classes. This study provides the most comprehensive evidence of augmenters' effectiveness for TRD, and our GRADE recommendations can be used to guide guidelines to optimize treatment choices. Although conclusions are limited by paucity of, and heterogeneity between, trials as well as inconsistent reports of treatment safety. This work supports the use of NMDA-targeting medications such as ketamine.

Efficacy and cost-effectiveness of intensive short-term dynamic psychotherapy for treatment resistant depression: 18-Month follow-up of the Halifax depression trial

BACKGROUND

Depressed patients with chronic and complex health issues commonly relapse; therefore, examining longer-term outcomes is an important consideration. For treatment resistant depression (TRD), the post-treatment efficacy of time-limited Intensive Short-Term Dynamic Psychotherapy (ISTDP) has been demonstrated but longer-term outcomes and cost-effectiveness are unclear.

METHOD

In this superiority trial, 60 patients referred to Community Mental Health Teams (CMHT) were randomised to 2 groups (ISTDP=30 and CMHT=30). The primary outcome was Hamilton Depression Rating scale (HAM-D) scores at 18 months. Secondary outcomes included Patient Health Questionnaire (PHQ-9) depression scores and dichotomous measure remission. A health economic evaluation examined mental health costs with quality-adjusted life years (QALYs).

RESULTS

Statistically significant treatment differences in depression previously found at 6 months favouring ISTDP were maintained at 18-month follow-up. Group differences in depression were in the moderate to large range on both the observer rated (Cohen's d = .64) and self-report measures (Cohen's d = .70). At 18 months follow-up the remission rate in ISTDP patients was 40.0%, and 23.4% had discontinued antidepressants. Health economic analysis suggests that ISTDP was more cost-effective than CMHT at 18 months. Probabilistic analysis suggests that there is a 64.5% probability of ISTDP being cost-effective at a willingness to pay for a QALY of $25,000 compared to CMHT at 18 months.

LIMITATIONS

Replication of these findings is necessary in larger samples and future cost analyses should also consider indirect costs.

CONCLUSIONS

ISTDP demonstrates long-term efficacy and cost-effectiveness in TRD.

The Digital Phenotyping Project: A Psychoanalytical and Network Theory Perspective

A new method of observation is currently emerging in psychiatry, based on data collection and behavioral profiling of smartphone users. Numerical phenotyping is a paradigmatic example. This behavioral investigation method uses computerized measurement tools in order to collect characteristics of different psychiatric disorders. First, it is necessary to contextualize the emergence of these new methods and to question their promises and expectations. The international mental health research framework invites us to reflect on methodological issues and to draw conclusions from certain impasses related to the clinical complexity of this field. From this contextualization, the investigation method relating to digital phenotyping can be questioned in order to identify some of its potentials. These new methods are also an opportunity to test psychoanalysis. It is then necessary to identify the elements of fruitful analysis that clinical experience and research in psychoanalysis have been able to deploy regarding the challenges of digital technology. An analysis of this theme’s literature shows that psychoanalysis facilitates a reflection on the psychological effects related to digital methods. It also shows how it can profit from the research potential offered by new technical tools, considering the progress that has been made over the past 50 years. This cross-fertilization of the potentials and limitations of digital methods in mental health intervention in the context of theoretical issues at the international level invites us to take a resolutely non-reductionist position. In the field of research, psychoanalysis offers a specific perspective that can well be articulated to an epistemology of networks. Rather than aiming at a numerical phenotyping of patients according to the geneticists’ model, the case formulation method appears to be a serious prerequisite to give a limited and specific place to the integration of smartphones in clinical investigation.

Long-term effectiveness of two models of brief psychotherapy for depression: A three-year follow-up randomized clinical trial

Major depressive disorder (MDD) is a disease that severely impairs psychosocial functioning and decreases the subject's quality of life. Patients who received psychotherapy have a better long-term therapeutic response than those who have only been treated with antidepressants or have not been treated. There are few studies in the literature that follow the outcomes of psychotherapeutic treatments for depression for more than two years. The aim of this study is to compare the therapeutic response of two models of brief psychotherapy for MDD treatment (Cognitive Behavioral Therapy and Short-term Psychodynamic Psychotherapy) with naturalistic controls who received treatment as usual in a three-year follow-up. This is a sample of 75 outpatients, mostly women (82.7%), with a median age of 33 (27-44). The interventions took place in 50-minute sessions once a week for 14 to 16 weeks. Outcomes were assessed at baseline and three years after the intervention. Regarding depressive symptoms, the therapeutic response was maintained three years after the conclusion of the brief models of psychotherapy. Functional capacity long-term maintenance depended not only on the intervention but also on the education level, the work situation and the severity of depressive symptoms at the beginning of the treatment.

What do we know about long-term treatment outcomes for severe depressive disorders?

In a recent issue of BJPsych Open, McPherson & Hengartner (see https://doi.org/10.1192/bjo.2019.65) reviewed 11 trials examining psychological and pharmacological treatment outcomes for chronic or treatment-resistant depression. They concluded that when assessed in the long term, antidepressants become less effective whereas psychological therapies become more effective. We argue that the evidence does not support this; indeed, most of the studies reviewed do not directly compare antidepressant with psychological therapy treatments and there is little consistency between them in terms of populations and interventions examined. The issue of long-term outcomes is key for optimising clinical guidelines and deserves more intensive research and scrutiny to improve patient response in routine practice.

Annual Research Review: Defining and treating pediatric treatment-resistant depression

BACKGROUND

Adolescent major depressive disorder (MDD) is a significant health problem, associated with substantial morbidity, cost, and mortality. Depression is a significant risk factor for suicide, which is now the second leading cause of death in young people. Up to twenty per cent of adolescents will experience MDD before adulthood, and while a substantial proportion will improve with standard-of-care treatments (psychotherapy and medication), roughly one third will not.

METHODS

Here, we have reviewed the literature in order to discuss the concept of treatment-resistant depression (TRD) in adolescence, examine risk factors, diagnostic difficulties, and challenges in evaluating symptom improvement, and providing guidance on how to define adequate medication and psychotherapy treatment trials.

RESULTS

We propose a staging model for adolescent TRD and review the treatment literature. The evidence base for first- and second-line treatments primarily derives from four large pediatric clinical trials (TADS, TORDIA, ADAPT, and IMPACT). After two medications and a trial of evidence-based psychotherapy have failed to alleviate depressive symptoms, the evidence becomes quite thin for subsequent treatments. Here, we review the evidence for the effectiveness of medication switches, medication augmentation, psychotherapy augmentation, and interventional treatments (i.e., transcranial magnetic stimulation, electroconvulsive therapy, and ketamine) for adolescent TRD. Comparisons are drawn to the adult TRD literature, and areas for future pediatric depression research are highlighted.

CONCLUSIONS

As evidence is limited for treatments in this population, a careful consideration of the known risks and side effects of escalated treatments (e.g., mood stabilizers and atypical antipsychotics) is warranted and weighed against potential, but often untested, benefits.

A Series of Meta-Analytic Tests of the Efficacy of Long-Term Psychoanalytic Psychotherapy

Abstract. Recent meta-analyses come to conflicting conclusions about the efficacy of long-term psychoanalytic psychotherapy (LTPP). Our first goal was to reproduce the most recent meta-analysis by Leichsenring, Abbass, Luyten, Hilsenroth, and Rabung (2013) who found evidence for the efficacy of LTPP in the treatment of complex mental disorders. Our replicated effect sizes were in general slightly smaller. Second, we conducted an updated meta-analysis of randomized controlled trials comparing LTPP (lasting for at least 1 year and 40 sessions) to other forms of psychotherapy in the treatment of complex mental disorders. We focused on a transparent research process according to open science standards and applied a series of elaborated meta-analytic procedures to test and control for publication bias. Our updated meta-analysis comprising 191 effect sizes from 14 eligible studies revealed small, statistically significant effect sizes at post-treatment for the outcome domains psychiatric symptoms, target problems, social functioning, and overall effectiveness (Hedges’ g ranging between 0.24 and 0.35). The effect size for the domain personality functioning (0.24) was not significant ( p = .08). No signs for publication bias could be detected. In light of a heterogeneous study set and some methodological shortcomings in the primary studies, these results should be interpreted cautiously. In conclusion, LTPP might be superior to other forms of psychotherapy in the treatment of complex mental disorders. Notably, our effect sizes represent the additional gain of LTPP versus other forms of primarily long-term psychotherapy. In this case, large differences in effect sizes are not to be expected.