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Rost F, Booker T, Gonsard A, de Felice G, Asseburg L, Malda-Castillo J, Koutoufa I, Ridsdale H, Johnson R, Taylor D, Fonagy P. The complexity of treatment-resistant depression: A data-driven approach. J Affect Disord 2024; 358:292-301. [PMID: 38697222 DOI: 10.1016/j.jad.2024.04.093] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2023] [Revised: 03/27/2024] [Accepted: 04/21/2024] [Indexed: 05/04/2024]
Abstract
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.
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Affiliation(s)
- Felicitas Rost
- Tavistock and Portman NHS Foundation Trust, London, UK; The Open University, School of Psychology and Psychotherapy, Faculty of Arts and Social Sciences, Milton Keynes, UK.
| | - Thomas Booker
- Tavistock and Portman NHS Foundation Trust, London, UK; Research Department of Clinical, Educational and Health Psychology, University College London, UK
| | | | | | | | | | | | | | | | - David Taylor
- Tavistock and Portman NHS Foundation Trust, London, UK
| | - Peter Fonagy
- Research Department of Clinical, Educational and Health Psychology, University College London, UK
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Yeates S, Korner A, McLean L. A Systematic Review and Narrative Analysis of the Evidence for Individual Psychodynamically Informed Psychotherapy in the Treatment of Dissociative Identity Disorder in Adults. J Trauma Dissociation 2024; 25:248-278. [PMID: 38146918 DOI: 10.1080/15299732.2023.2293802] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2023] [Accepted: 09/30/2023] [Indexed: 12/27/2023]
Abstract
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.
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Affiliation(s)
- Steven Yeates
- Psychotherapy Educator Westmead/Cumberland Hospitals, Faculty Westmead Psychotherapy Program for Complex Traumatic Disorders, Cumberland Hospital, North Parramatta, Australia
| | - Anthony Korner
- Westmead Psychotherapy Program for Complex Traumatic Disorders, University of Sydney, North Parramatta, Australia
| | - Loyola McLean
- Cumberland Hospital, Westmead Psychotherapy Program for Complex Traumatic Disorders, Course Co-Coordinator, Brain and Mind Centre, Discipline of Psychiatry, The University of Sydney, Research Psychiatrist (HMO) Consultation-Liaison Psychiatry, RNSH, Camperdown, Australia
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Koeser L, Rost F, Gabrio A, Booker T, Taylor D, Fonagy P, Goldberg D, Knapp M, McCrone P. Cost-effectiveness of long-term psychoanalytic psychotherapy for treatment-resistant depression: RCT evidence from the Tavistock Adult Depression Study (TADS). J Affect Disord 2023; 335:313-321. [PMID: 37164066 DOI: 10.1016/j.jad.2023.04.109] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2022] [Revised: 04/21/2023] [Accepted: 04/28/2023] [Indexed: 05/12/2023]
Abstract
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.
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Affiliation(s)
- Leonardo Koeser
- King's Health Economics, Health Services and Population Research Department, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - Felicitas Rost
- The Open University, School of Psychology and Psychotherapy, Faculty of Arts and Social Sciences, Milton Keynes, UK; Tavistock and Portman NHS Foundation Trust, London, UK.
| | - Andrea Gabrio
- Department of Methodology and Statistics, Faculty of Health, Medicine and Life Sciences, Maastricht University, Maastricht, the Netherlands
| | - Thomas Booker
- Tavistock and Portman NHS Foundation Trust, London, UK
| | - David Taylor
- Tavistock and Portman NHS Foundation Trust, London, UK
| | - Peter Fonagy
- Research Department of Clinical, Educational and Health Psychology, University College London, UK
| | - David Goldberg
- Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - Martin Knapp
- Personal Social Services Research Unit, London School of Economics and Political Science, London, UK
| | - Paul McCrone
- King's Health Economics, Health Services and Population Research Department, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
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O’Driscoll D. Psychoanalysis, the NHS and mental health work today. PSYCHOANALYTIC PSYCHOTHERAPY 2020. [DOI: 10.1080/02668734.2020.1802616] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Affiliation(s)
- David O’Driscoll
- Conveyor, Learning Disabilities Section, Association for Psychoanalytic Psychotherapy in the National Health Service (APP) and psychotherapist in the NHS, UK
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Knox J. The Harmful Effects of Psychotherapy: When the Therapeutic Alliance Fails. BRITISH JOURNAL OF PSYCHOTHERAPY 2019. [DOI: 10.1111/bjp.12445] [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: 12/30/2022]
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McPherson S, Rost F, Sidhu S, Dennis M. Non-strategic ignorance: Considering the potential for a paradigm shift in evidence-based mental health. Health (London) 2018; 24:3-20. [DOI: 10.1177/1363459318785720] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Randomised controlled trials form a central building block within the prevailing evidence-based mental health paradigm. Both methodology and paradigm have been widely problematised since their emergence in the mid-late twentieth century. We draw on the concept of ‘strategic ignorance’ to understand why the paradigm still prevails. We present focus group data gathered from 37 participants (service users, public, carers, general practitioners, commissioners) concerning the way they made sense of a randomised controlled trial of psychotherapy for treatment-resistant depression. Thematic analysis of the findings revealed an overall critique of randomised controlled trial methods which we refer to as ‘non-strategic ignorance’. Specifically, participants problematised the construct of depression, unseating the premise of the randomised controlled trial; they were sceptical about the purpose and highlighted its failure to show how therapy works or who might benefit; the randomised controlled trial was seen as inadequate for informing decisions about how to select a therapy. Participants assumed the treatment would be cost-effective given the client group and nature of the therapy, irrespective of any randomised controlled trial findings. Each area of lay (‘non-strategic’) critique has an analogous form within the methodological expert domain. We argue that ‘expert’ critiques have generally failed to have paradigmatic impact because they represent strategic ignorance. Yet parallel non-strategic critiques have common sense appeal, highlighting the potential power of lay voices. The discussion considers whether the evidence-based mental health paradigm is faced with epistemological problems of such complexity that the conditions exist for a new paradigm in which service user views are central and randomised controlled trials peripheral.
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Pec O, Bob P, Pec J, Hrubcova A. Psychodynamic day treatment programme for patients with schizophrenia spectrum disorders: Dynamics and predictors of therapeutic change. Psychol Psychother 2018; 91:157-168. [PMID: 28901691 DOI: 10.1111/papt.12153] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2016] [Revised: 05/07/2017] [Indexed: 11/29/2022]
Abstract
OBJECTIVES The purpose of this study was to test whether a psychodynamically based group psychotherapeutic programme might improve symptoms, social functions, or quality of life in patients with schizophrenia spectrum disorders and to investigate factors that might predict clinical improvement or dropouts from the programme. DESIGN A quantitative prospective cohort study. METHODS We have investigated 81 patients with schizophrenia spectrum disorders who participated in a 9-month psychodynamically based psychotherapeutic day programme. The patients were assessed at the beginning and end of the programme, and then at 1-year follow-up. The assessment included psychotic manifestations (HoNOS), quality of life (WHOQOL-BREF), demographic data, and daily doses of medication. 21 patients dropped out from the programme, and 46 patients succeeded in undergoing follow-up assessment. RESULTS The psychotic manifestations (self-rating version of HoNOS) and quality of life measured with WHOQOL-BREF (domains of social relationships and environment) were significantly improved at the end of the programme and at follow-up. However, the manifestations on the version for external evaluators of HoNOS were improved only at follow-up. Years of psychiatric treatment, number of hospitalizations or suicide attempts, and experience of relationships with a partner were negatively related to clinical improvement, whereas symptom severity, current working, or study activities were related positively. CONCLUSIONS The results show that a group psychodynamic programme may improve the clinical status and quality of life of patients with schizophrenia spectrum disorders. This type of programme is more beneficial for patients with higher pre-treatment symptom severity and the presence of working or study activities. PRACTITIONER POINTS A psychodynamically based group programme improves the clinical status and quality of life in patients with schizophrenia spectrum disorders. Data indicate that changes on the subjective level are detectable by the end of the programme, while changes on the objective level are detectable at follow-up assessment. Symptom severity and working or study activities are positively related to the clinical improvement in this type of programme, while a high number of years in psychiatric treatment or psychiatric hospitalizations are negatively related. The doses of medication (antipsychotics or antidepressants) show no significant relationship to clinical improvement.
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Affiliation(s)
- Ondrej Pec
- Center for Neuropsychiatric Research of Traumatic Stress, Department of Psychiatry and UHSL, First Faculty of Medicine, Charles University, Prague, Czech Republic.,Psychotherapeutic and Psychosomatic Clinic, ESET, Prague, Czech Republic
| | - Petr Bob
- Center for Neuropsychiatric Research of Traumatic Stress, Department of Psychiatry and UHSL, First Faculty of Medicine, Charles University, Prague, Czech Republic
| | - Jan Pec
- Psychotherapeutic and Psychosomatic Clinic, ESET, Prague, Czech Republic
| | - Adela Hrubcova
- Psychotherapeutic and Psychosomatic Clinic, ESET, Prague, Czech Republic
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Ijaz S, Davies P, Williams CJ, Kessler D, Lewis G, Wiles N. Psychological therapies for treatment-resistant depression in adults. Cochrane Database Syst Rev 2018; 5:CD010558. [PMID: 29761488 PMCID: PMC6494651 DOI: 10.1002/14651858.cd010558.pub2] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND Antidepressants are a first-line treatment for adults with moderate to severe major depression. However, many people prescribed antidepressants for depression don't respond fully to such medication, and little evidence is available to inform the most appropriate 'next step' treatment for such patients, who may be referred to as having treatment-resistant depression (TRD). National Institute for Health and Care Excellence (NICE) guidance suggests that the 'next step' for those who do not respond to antidepressants may include a change in the dose or type of antidepressant medication, the addition of another medication, or the start of psychotherapy. Different types of psychotherapies may be used for TRD; evidence on these treatments is available but has not been collated to date.Along with the sister review of pharmacological therapies for TRD, this review summarises available evidence for the effectiveness of psychotherapies for adults (18 to 74 years) with TRD with the goal of establishing the best 'next step' for this group. OBJECTIVES To assess the effectiveness of psychotherapies for adults with TRD. SEARCH METHODS We searched the Cochrane Common Mental Disorders Controlled Trials Register (until May 2016), along with CENTRAL, MEDLINE, Embase, and PsycINFO via OVID (until 16 May 2017). We also searched the World Health Organization (WHO) trials portal (ICTRP) and ClinicalTrials.gov to identify unpublished and ongoing studies. There were no date or language restrictions. SELECTION CRITERIA We included randomised controlled trials (RCTs) with participants aged 18 to 74 years diagnosed with unipolar depression that had not responded to minimum four weeks of antidepressant treatment at a recommended dose. We excluded studies of drug intolerance. Acceptable diagnoses of unipolar depression were based onthe Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR) or earlier versions, International Classification of Diseases (ICD)-10, Feighner criteria, or Research Diagnostic Criteria. We included the following comparisons.1. Any psychological therapy versus antidepressant treatment alone, or another psychological therapy.2. Any psychological therapy given in addition to antidepressant medication versus antidepressant treatment alone, or a psychological therapy alone.Primary outcomes required were change in depressive symptoms and number of dropouts from study or treatment (as a measure of acceptability). DATA COLLECTION AND ANALYSIS We extracted data, assessed risk of bias in duplicate, and resolved disagreements through discussion or consultation with a third person. We conducted random-effects meta-analyses when appropriate. We summarised continuous outcomes using mean differences (MDs) or standardised mean differences (SMDs), and dichotomous outcomes using risk ratios (RRs). MAIN RESULTS We included six trials (n = 698; most participants were women approximately 40 years of age). All studies evaluated psychotherapy plus usual care (with antidepressants) versus usual care (with antidepressants). Three studies addressed the addition of cognitive-behavioural therapy (CBT) to usual care (n = 522), and one each evaluated intensive short-term dynamic psychotherapy (ISTDP) (n = 60), interpersonal therapy (IPT) (n = 34), or group dialectical behavioural therapy (DBT) (n = 19) as the intervention. Most studies were small (except one trial of CBT was large), and all studies were at high risk of detection bias for the main outcome of self-reported depressive symptoms.A random-effects meta-analysis of five trials (n = 575) showed that psychotherapy given in addition to usual care (vs usual care alone) produced improvement in self-reported depressive symptoms (MD -4.07 points, 95% confidence interval (CI) -7.07 to -1.07 on the Beck Depression Inventory (BDI) scale) over the short term (up to six months). Effects were similar when data from all six studies were combined for self-reported depressive symptoms (SMD -0.40, 95% CI -0.65 to -0.14; n = 635). The quality of this evidence was moderate. Similar moderate-quality evidence of benefit was seen on the Patient Health Questionnaire-9 Scale (PHQ-9) from two studies (MD -4.66, 95% CI 8.72 to -0.59; n = 482) and on the Hamilton Depression Rating Scale (HAMD) from four studies (MD -3.28, 95% CI -5.71 to -0.85; n = 193).High-quality evidence shows no differential dropout (a measure of acceptability) between intervention and comparator groups over the short term (RR 0.85, 95% CI 0.58 to 1.24; six studies; n = 698).Moderate-quality evidence for remission from six studies (RR 1.92, 95% CI 1.46 to 2.52; n = 635) and low-quality evidence for response from four studies (RR 1.80, 95% CI 1.2 to 2.7; n = 556) indicate that psychotherapy was beneficial as an adjunct to usual care over the short term.With the addition of CBT, low-quality evidence suggests lower depression scores on the BDI scale over the medium term (12 months) (RR -3.40, 95% CI -7.21 to 0.40; two studies; n = 475) and over the long term (46 months) (RR -1.90, 95% CI -3.22 to -0.58; one study; n = 248). Moderate-quality evidence for adjunctive CBT suggests no difference in acceptability (dropout) over the medium term (RR 0.98, 95% CI 0.66 to 1.47; two studies; n = 549) and lower dropout over long term (RR 0.80, 95% CI 0.66 to 0.97; one study; n = 248).Two studies reported serious adverse events (one suicide, two hospitalisations, and two exacerbations of depression) in 4.2% of the total sample, which occurred only in the usual care group (no events in the intervention group).An economic analysis (conducted as part of an included study) from the UK healthcare perspective (National Health Service (NHS)) revealed that adjunctive CBT was cost-effective over nearly four years. AUTHORS' CONCLUSIONS Moderate-quality evidence shows that psychotherapy added to usual care (with antidepressants) is beneficial for depressive symptoms and for response and remission rates over the short term for patients with TRD. Medium- and long-term effects seem similarly beneficial, although most evidence was derived from a single large trial. Psychotherapy added to usual care seems as acceptable as usual care alone.Further evidence is needed on the effectiveness of different types of psychotherapies for patients with TRD. No evidence currently shows whether switching to a psychotherapy is more beneficial for this patient group than continuing an antidepressant medication regimen. Addressing this evidence gap is an important goal for researchers.
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Affiliation(s)
- Sharea Ijaz
- Population Health Sciences, Bristol Medical School, University of BristolNIHR CLAHRC West at University Hospitals Bristol NHS Foundation TrustLewins Mead, Whitefriars BuildingBristolUKBS1 2NT
| | - Philippa Davies
- University of BristolPopulation Health Sciences, Bristol Medical SchoolCanynge HallBristolUKBS8 2PS
| | - Catherine J Williams
- University of BristolSchool of Social and Community Medicine39 Whatley RoadBristolUKBS8 2PS
| | - David Kessler
- University of BristolSchool of Social and Community Medicine39 Whatley RoadBristolUKBS8 2PS
| | - Glyn Lewis
- UCLUCL Division of Psychiatry67‐73 Riding House StLondonUKW1W 7EJ
| | - Nicola Wiles
- University of BristolPopulation Health Sciences, Bristol Medical SchoolCanynge HallBristolUKBS8 2PS
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Abstract
Psychoanalytic psychotherapy can afford a viable treatment option for certain carefully chosen patients whose needs go beyond the immediate control of substance use. Though the evidence base specifically for addictions is lacking, an emerging body of evidence has demonstrated good effect in the commonly seen co-morbid conditions such as depression, anxiety and personality pathology.
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McCrone P, Rost F, Koeser L, Koutoufa I, Stephanou S, Knapp M, Goldberg D, Taylor D, Fonagy P. The economic cost of treatment-resistant depression in patients referred to a specialist service. J Ment Health 2017; 27:567-573. [PMID: 29275697 DOI: 10.1080/09638237.2017.1417562] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
BACKGROUND Patients with treatment-resistant depression (TRD) suffer very significant morbidity and are at a disadvantage concerning optimal clinical management. There are high associated societal costs. AIMS A detailed analysis of health economic costs in the United Kingdom in a group manifesting a severe form of TRD in the 12 months before their participation in a major randomized controlled treatment trial. METHODS The sample consisted of 118 participants from the Tavistock Adult Depression Study. Recruitment was from primary care on the basis of current major depression disorder of at least 2 years' duration and two failed treatment attempts. Service utilization was assessed based on self-report and general practitioner (GP) medical records. Generalized linear models were used to identify predictors of cost. RESULTS All participants used GP services. Use of other doctors and practice nurses was also high. The mean total societal cost was £22 124, 80% of which was due to lost work and care required of families. Level of general functioning was found to be the most consistent predictor of costs. CONCLUSIONS Severe forms of TRD are associated with high costs in which unpaid care and lost work predominate. Treatments that improve functioning may reduce the large degree of burden.
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Affiliation(s)
- Paul McCrone
- a Health Services and Population Research Department , King's Health Economics, Institute of Psychiatry, Psychology and Neuroscience, King's College London , London , UK
| | - Felicitas Rost
- b Portman Clinic, Tavistock and Portman NHS Foundation Trust , London , UK
| | - Leonardo Koeser
- a Health Services and Population Research Department , King's Health Economics, Institute of Psychiatry, Psychology and Neuroscience, King's College London , London , UK
| | - Iakovina Koutoufa
- c Research Department of Clinical , Educational and Health Psychology, University College London , London , UK
| | - Stephanie Stephanou
- d Tavistock Clinic, Tavistock and Portman NHS Foundation Trust , London , UK
| | - Martin Knapp
- e Personal Social Services Research Unit, London School of Economics and Political Science , London , UK , and
| | - David Goldberg
- f Institute of Psychiatry, Psychology and Neuroscience, King's College London , London , UK
| | - David Taylor
- d Tavistock Clinic, Tavistock and Portman NHS Foundation Trust , London , UK
| | - Peter Fonagy
- c Research Department of Clinical , Educational and Health Psychology, University College London , London , UK
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Rost F, Luyten P, Fonagy P. The Anaclitic-Introjective Depression Assessment: Development and preliminary validity of an observer-rated measure. Clin Psychol Psychother 2017; 25:195-209. [DOI: 10.1002/cpp.2153] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2016] [Revised: 09/18/2017] [Accepted: 09/25/2017] [Indexed: 12/14/2022]
Affiliation(s)
- Felicitas Rost
- Research Department of Clinical, Educational and Health Psychology; University College London; London UK
- Tavistock and Portman NHS Foundation Trust; London UK
| | - Patrick Luyten
- Research Department of Clinical, Educational and Health Psychology; University College London; London UK
- University of Leuven; Leuven Belgium
| | - Peter Fonagy
- Research Department of Clinical, Educational and Health Psychology; University College London; London UK
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What we know, what we do not know, and where are we heading? Efficacy and acceptability of psychological interventions for depression. Epidemiol Psychiatr Sci 2016; 25:301-8. [PMID: 26411324 PMCID: PMC7137604 DOI: 10.1017/s2045796015000815] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
In the past several decades, increasing evidence supports the efficacy of psychotherapies for depression. The vast majority of findings from meta-analyses, randomized clinical trials (RCTs) and naturalistic studies have demonstrated that well-established psychotherapies (behavioural activation, problem-solving therapy, psychodynamic therapy, cognitive-behavioural therapy, interpersonal therapy and emotion-focused therapy) are superior to no-treatment and control conditions, and are in most cases equally effective in treating depression. However, despite this abundant support for psychotherapies, studies have also consistently shown high drop-out rates, high percentages of non-respondent patients who experience treatment failures, and mixed findings regarding the enduring effects of psychotherapy. Thus, there is a need to develop more personalised treatment models tailored to patients' needs. A new integrative sequential stepwise approach to the treatment of depression is suggested.
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Taylor D. Treatment manuals and the advancement of psychoanalytic knowledge: The Treatment Manual of the Tavistock Adult Depression Study. THE INTERNATIONAL JOURNAL OF PSYCHOANALYSIS 2016; 96:845-75. [PMID: 26173890 DOI: 10.1111/1745-8315.12360] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/18/2015] [Indexed: 11/28/2022]
Abstract
This paper has two aims: first, it seeks to understand the absence of treatment manuals in psychoanalysis. Secondly, it summarizes the treatment manual of the Tavistock Adult Depression Study, which describes the form of psychoanalytic psychotherapy whose effectiveness has been evaluated both in the Tavistock Adult Depression Study (TADS); and in the German Die Langzeittherapie bei chronischen Depressionen (LAC) Studie. Throughout the history of psychoanalysis, opinions about treatment manuals, empirical research and their antecedents have been deeply divided. After tracing the often polarized unfolding of these matters, the paper proposes that emotional and cognitive difficulties as well as scientific ones underpin their persistence. It is suggested that greater familiarity with them may lead to better combinations of outcome research and psychoanalysis: for example, the Tavistock manual seeks to match one account of the objects, aims, values, spirit and methods of psychoanalysis (as well as of connected forms of psychoanalytic psychotherapy); and also to meet what is required of treatment manuals by random allocation controlled trials. It has been a crucial element in the above studies of the outcome of long-term psychoanalytic psychotherapies with chronically depressed patients. After describing the Tavistock Manual, the paper concludes suggesting that, if appropriately constructed, treatment manuals can make a contribution to the advancement of specifically psychoanalytic knowledge.
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Affiliation(s)
- David Taylor
- Tavistock Adult Depression Study, Tavistock Clinic, London, NW3 5BA, UK.
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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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Leichsenring F, Schauenburg H. Empirically supported methods of short-term psychodynamic therapy in depression - towards an evidence-based unified protocol. J Affect Disord 2014; 169:128-43. [PMID: 25194781 DOI: 10.1016/j.jad.2014.08.007] [Citation(s) in RCA: 51] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2014] [Revised: 07/22/2014] [Accepted: 08/04/2014] [Indexed: 12/28/2022]
Abstract
CONTEXT There is evidence that psychotherapy is helpful in depressive disorders, with no significant differences between psychotherapies. For psychodynamic therapy (PDT) various models prove to be efficacious. Thus, the evidence for PDT is "scattered" between different forms of PDT, also implying problems in training of psychotherapy and in transferring research to clinical practice. A unified protocol based on empirically-supported methods of PDT in depression may contribute to solve these problems METHODS Systematic search for randomized controlled trials fulfilling the following criteria: (a) individual psychodynamic therapy (PDT) of depressive disorders, (b) treatment manuals or manual-like guidelines, (c) PDT proved to be efficacious compared to control conditions, (d) reliable measures for diagnosis and outcome, and (f) adult patients. FINDINGS Fourteen RCTs fulfilled the inclusion criteria. By a systematic review of the applied methods of PDT seven treatment components were identified. A high consistency between components was found. The components were conceptualized in the form of seven interrelated treatment modules. CONCLUSIONS A unified psychodynamic protocol for depression may enhance the empirical status of PDT, facilitate both the training in psychotherapy and the transfer of research to clinical practice and may have an impact on the health care system.
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Affiliation(s)
- Falk Leichsenring
- Clinic of Psychosomatics and Psychotherapy, University of Giessen, Ludwigstrasse 76, 35392 Giessen, Germany.
| | - Henning Schauenburg
- Clinic for General Internal Medicine and Psychosomatics, University of Heidelberg, Germany
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Brown KM, Tracy DK. Psychoanalytic Psychotherapy in Contemporary Mental Health Services: Current Evidence, Future Role and Challenges. BRITISH JOURNAL OF PSYCHOTHERAPY 2014. [DOI: 10.1111/bjp.12074] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
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Stein KF. A pressing question: is there a place for psychotherapy in PMHNP practice? J Am Psychiatr Nurses Assoc 2012; 18:324-5. [PMID: 23342398 DOI: 10.1177/1078390312469183] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Karen Farchaus Stein
- Karen Farchaus Stein, PhD, RN, FAAN, University of Rochester, Rochester, NY, USA
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