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Krakau L, Ernst M, Hautzinger M, Beutel ME, Leuzinger-Bohleber M. Childhood trauma and differential response to long-term psychoanalytic versus cognitive-behavioural therapy for chronic depression in adults. Br J Psychiatry 2024:1-8. [PMID: 39119997 DOI: 10.1192/bjp.2024.112] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/10/2024]
Abstract
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.
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Affiliation(s)
- Lina Krakau
- Department of Psychosomatic Medicine and Psychotherapy, University Medical Center of the Johannes Gutenberg-University Mainz, Mainz, Germany
| | - Mareike Ernst
- Department of Clinical Psychology, Psychotherapy and Psychoanalysis, Institute of Psychology, University of Klagenfurt, Klagenfurt am Woerthersee, Austria
| | - Martin Hautzinger
- Department of Psychology, Section Clinical Psychology and Psychotherapy, Eberhard Karls University, Tübingen, Germany
| | - Manfred E Beutel
- Department of Psychosomatic Medicine and Psychotherapy, University Medical Center of the Johannes Gutenberg-University Mainz, Mainz, Germany
| | - Marianne Leuzinger-Bohleber
- Department of Psychosomatic Medicine and Psychotherapy, University Medical Center of the Johannes Gutenberg-University Mainz, Mainz, Germany
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Ambresin G, Leuzinger-Bohleber M, Fischmann T, Axmacher N, Hattingen E, Bansal R, Peterson BS. The multi-level outcome study of psychoanalysis for chronically depressed patients with early trauma (MODE): rationale and design of an international multicenter randomized controlled trial. BMC Psychiatry 2023; 23:844. [PMID: 37974088 PMCID: PMC10652457 DOI: 10.1186/s12888-023-05287-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2023] [Accepted: 10/17/2023] [Indexed: 11/19/2023] Open
Abstract
BACKGROUND Whether and how psychotherapies change brain structure and function is unknown. Its study is of great importance for contemporary psychotherapy, as it may lead to discovery of neurobiological mechanisms that predict and mediate lasting changes in psychotherapy, particularly in severely mentally ill patients, such as those with chronic depression. Previous studies have shown that psychoanalytic psychotherapies produce robust and enduring improvements in not only symptom severity but also personality organization in patients who have chronic depression and early life trauma, especially if therapy is delivered at a high weekly frequency. METHODS/DESIGN Patients with chronic major depression and a history of early life trauma will be recruited, assessed, and treated across 3 international sites: Germany, Switzerland, and the United States. They will be randomized to one of two treatment arms: either (1) once weekly psychoanalytic psychotherapies, or (2) 3-4 times weekly psychoanalytic psychotherapies. They will have full clinical characterization as well as undergo MRI scanning at study baseline prior to randomization and again one year later. A group of matched healthy controls will undergo similar assessments and MRI scanning at the same time points to help discern whether study treatments induce brain changes toward or away from normal values. Primary study outcomes will include anatomical MRI, functional MRI, and Diffusion Tensor Imaging measures. Study hypotheses will be tested using the treatment-by-time interaction assessed in multiple general linear models with repeated measures analyses in an intent-to-treat analysis. DISCUSSION MODE may allow the identification of brain-based biomarkers that may be more sensitive than traditional behavioral and clinical measures in discriminating, predicting, and mediating treatment response. These findings could help to personalize care for patients who have chronic depression patients and early life trauma, and they will provide new therapeutic targets for both psychological and biological treatments for major depressive illness.
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Affiliation(s)
- Gilles Ambresin
- Department of Psychiatry-CHUV, University Institute of Psychotherapy, The University of Lausanne, Lausanne, Switzerland.
| | | | | | - Nikolai Axmacher
- Research Department of Neurosciences, Ruhr University, Bochum, Germany
| | - Elke Hattingen
- Department for Neuroradiology, University Hospital, Frankfurt, Germany
| | - Ravi Bansal
- Department of Pediatrics, Keck School of Medicine at the University of Southern California, Los Angeles, CA, USA
- Institute for the Developing Mind, Children's Hospital Los Angeles, Los Angeles, CA, USA
| | - Bradley S Peterson
- Institute for the Developing Mind, Children's Hospital Los Angeles, Los Angeles, CA, USA
- Department of Psychiatry at the Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
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Beutel M, Krakau L, Kaufhold J, Bahrke U, Grabhorn A, Hautzinger M, Fiedler G, Kallenbach-Kaminski L, Ernst M, Rüger B, Leuzinger-Bohleber M. Recovery from chronic depression and structural change: 5-year outcomes after psychoanalytic and cognitive-behavioural long-term treatments (LAC depression study). Clin Psychol Psychother 2023; 30:188-201. [PMID: 36239414 DOI: 10.1002/cpp.2793] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2022] [Revised: 09/07/2022] [Accepted: 10/10/2022] [Indexed: 02/03/2023]
Abstract
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.
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Affiliation(s)
- Manfred Beutel
- Department of Psychosomatic Medicine and Psychotherapy, University Medical Center of the Johannes-Gutenberg University Mainz, Mainz, Germany
| | - Lina Krakau
- Department of Psychosomatic Medicine and Psychotherapy, University Medical Center of the Johannes-Gutenberg University Mainz, Mainz, Germany
| | | | | | | | - Martin Hautzinger
- Department of Clinical Psychology, University of Tübingen, Tübingen, Germany
| | - Georg Fiedler
- Center for Suicidal Research, University Hospital Eppendorf, Hamburg, Germany
| | | | - Mareike Ernst
- Department of Psychosomatic Medicine and Psychotherapy, University Medical Center of the Johannes-Gutenberg University Mainz, Mainz, Germany
| | | | - Marianne Leuzinger-Bohleber
- Department of Psychosomatic Medicine and Psychotherapy, University Medical Center of the Johannes-Gutenberg University Mainz, Mainz, Germany.,Department of Psychoanalysis, University of Kassel, Kassel, Germany.,IDeA Center (Center for Adaptive and Individual Development and Adaptive Education for Children-at-Risk), Frankfurt, Germany
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Leuzinger-Bohleber M, Kaufhold J, Kallenbach L, Negele A, Ernst M, Keller W, Fiedler G, Hautzinger M, Bahrke U, Beutel M. How to measure sustained psychic transformations in long-term treatments of chronically depressed patients: Symptomatic and structural changes in the LAC Depression Study of the outcome of cognitive-behavioural and psychoanalytic long-term treatments. THE INTERNATIONAL JOURNAL OF PSYCHOANALYSIS 2019; 100:99-127. [PMID: 33945717 DOI: 10.1080/00207578.2018.1533377] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Worldwide, the pressure on psychoanalysis to prove the results of its treatments according to the criteria of so-called evidence-based medicine has increased. While a large number of studies on the results of psychoanalytic short-term therapies are now available, such studies are still largely lacking on psychoanalysis and psychoanalytic long-term therapies. In a large multicentre study, the results of psychoanalytical and cognitive-behavioural longterm therapies in chronically depressed patients were compared, Both psychotherapies led to statistically highly significant changes in depressive symptoms three years after the start of the treatments However, the focus of psychoanalytic treatments is not exclusively on reducing psychopathological symptoms, but on changes in the inner world of the patients that are reminiscent of the goal of psychoanalyses that Freud has characterized as developing "the ability to love, work and enjoy life." In the German-speaking community, such transformations are called "structural changes." This article reports results on such structural changes achieved with the help of a sophisticated measuring instrument, the Operationalized Psychodynamic Diagnostics (OPD). These so-called structural changes are compared with symptomatic changes. Three years after the start of the treatments, significantly more patients in psychoanalytical treatments show such structural changes than patients in cognitive-behavioural treatments.
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Affiliation(s)
- Marianne Leuzinger-Bohleber
- IDeA Center (Center for Adaptive and Individual Development and Adaptive Education for Children-at-Risk), Sigmund-Freud-Institut, Frankfurt a.M., Germany.,Department of Psychosomatic Medicine and Psychotherapy, University Medical Center, Mainz, Germany
| | | | - Lisa Kallenbach
- Sigmund-Freud-Institut, Frankfurt a.M., Germany.,University of Kassel, Department of Educational Sciences and Psychoanalysis
| | - Alexa Negele
- Department of Psychosomatic Medicine and Psychotherapy, University Medical Center, Mainz, Germany
| | - Mareike Ernst
- Department of Psychosomatic Medicine and Psychotherapy, University Medical Center, Mainz, Germany
| | - Wolfram Keller
- Medical Hospital in the Theodor-Wenzel-Werk, Berlin, Germany
| | - Georg Fiedler
- Hamburg (Center for Suicidal Research), University Hospital Eppendorf, Germany
| | | | - Ulrich Bahrke
- University of Kassel, Department of Educational Sciences and Psychoanalysis.,Ludwig-Maximilian-University of Munich
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Radcliffe J, Yeomans F. Transference-focused Psychotherapy for Patients with Personality Disorders: Overview and Case Example with a Focus on the Use of Contracting. BRITISH JOURNAL OF PSYCHOTHERAPY 2019. [DOI: 10.1111/bjp.12421] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Moorey S. The cognitive therapy of depression rests on substantial theoretical, empirical and clinical foundations: a reply to Dr Gipps. BJPsych Bull 2017; 41:272-275. [PMID: 29018552 PMCID: PMC5623886 DOI: 10.1192/pb.bp.116.055616] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Dr Gipps claims that the cognitive therapy for depression rests on a mistake. But his anachronistic analysis of Beck's early research from the perspective of current psychoanalytic theory misses the point. The value of the research was not that it disproved psychoanalytic theory, but that it generated a model of depression that has revolutionised psychotherapy research. Psychoanalysts are belatedly adopting research methods that Beck pioneered half a century ago. The cognitive model of depression has explanatory power for both maintenance and vulnerability and has substantial research underpinning it. Cognitive therapy for depression has a larger body of evidence for its efficacy and relapse prevention effect than any other psychotherapy. Transference-focused approaches to depression have yet to establish themselves in the same way.
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Beutel ME, Bahrke U, Fiedler G, Hautzinger M, Kallenbach L, Kaufhold J, Keller W, Negele A, Rüger B, Leuzinger-Bohleber M, Ernst M. LAC-Depressionsstudie. PSYCHOTHERAPEUT 2016. [DOI: 10.1007/s00278-016-0144-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Fonagy P, Rost F, Carlyle JA, McPherson S, Thomas R, Pasco Fearon RM, Goldberg D, Taylor D. Pragmatic randomized controlled trial of long-term psychoanalytic psychotherapy for treatment-resistant depression: the Tavistock Adult Depression Study (TADS). World Psychiatry 2015; 14:312-21. [PMID: 26407787 PMCID: PMC4592654 DOI: 10.1002/wps.20267] [Citation(s) in RCA: 106] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
This pragmatic randomized controlled trial tested the effectiveness of long-term psychoanalytic psychotherapy (LTPP) as an adjunct to treatment-as-usual according to UK national guidelines (TAU), compared to TAU alone, in patients with long-standing major depression who had failed at least two different treatments and were considered to have treatment-resistant depression. Patients (N=129) were recruited from primary care and randomly allocated to the two treatment conditions. They were assessed at 6-monthly intervals during the 18 months of treatment and at 24, 30 and 42 months during follow-up. The primary outcome measure was the 17-item version of the Hamilton Depression Rating Scale (HDRS-17), with complete remission defined as a HDRS-17 score ≤8, and partial remission defined as a HDRS-17 score ≤12. Secondary outcome measures included self-reported depression as assessed by the Beck Depression Inventory - II, social functioning as evaluated by the Global Assessment of Functioning, subjective wellbeing as rated by the Clinical Outcomes in Routine Evaluation - Outcome Measure, and satisfaction with general activities as assessed by the Quality of Life Enjoyment and Satisfaction Questionnaire. Complete remission was infrequent in both groups at the end of treatment (9.4% in the LTPP group vs. 6.5% in the control group) as well as at 42-month follow-up (14.9% vs. 4.4%). Partial remission was not significantly more likely in the LTPP than in the control group at the end of treatment (32.1% vs. 23.9%, p=0.37), but significant differences emerged during follow-up (24 months: 38.8% vs. 19.2%, p=0.03; 30 months: 34.7% vs. 12.2%, p=0.008; 42 months: 30.0% vs. 4.4%, p=0.001). Both observer-based and self-reported depression scores showed steeper declines in the LTPP group, alongside greater improvements on measures of social adjustment. These data suggest that LTPP can be useful in improving the long-term outcome of treatment-resistant depression. End-of-treatment evaluations or short follow-ups may miss the emergence of delayed therapeutic benefit.
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Affiliation(s)
- Peter Fonagy
- Research Department of Clinical, Educational and Health Psychology, University College London, London, UK
| | - Felicitas Rost
- Adult Department, Tavistock & Portman NHS Foundation Trust, London, UK
| | - Jo-Anne Carlyle
- Adult Department, Tavistock & Portman NHS Foundation Trust, London, UK
| | - Susan McPherson
- School of Health and Human Sciences, University of Essex, Colchester, UK
| | - Rachel Thomas
- Adult Department, Tavistock & Portman NHS Foundation Trust, London, UK
| | - R M Pasco Fearon
- Research Department of Clinical, Educational and Health Psychology, University College London, London, UK
| | - David Goldberg
- Institute of Psychiatry, Psychology and Neuro science, King's College London, London, UK
| | - David Taylor
- Adult Department, Tavistock & Portman NHS Foundation Trust, London, UK
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