The Efficacy of Cognitive-Behavioral Therapy and Psychodynamic Therapy in the Outpatient Treatment of Major Depression: A Randomized Clinical Trialby Ellen Driessen, Henricus L. Van, Frank J. Don, Jaap Peen, Simone Kool, Dieuwertje Westra, Mariëlle Hendriksen, Robert A. Schoevers, Pim Cuijpers, Jos W.R. Twisk, and Jack J.M. Dekker,American Journal of Psychiatry. 2013 170:1041-1050.
Objective: The efficacy of psychodynamic therapies for depression remains open to debate because of a paucity of high-quality studies. The authors compared the efficacy of psychodynamic therapy with that of cognitive-behavioral therapy [CBT], hypothesizing nonsignificant differences and the non-inferiority of psychodynamic therapy relative to CBT.Method: A total of 341 adults who met DSM-IV criteria for a major depressive episode and had Hamilton Depression Rating Scale [HAM-D] scores > 14 were randomly assigned to 16 sessions of individual manualized CBT or short-term psychodynamic supportive therapy. Severely depressed patients [HAM-D score > 24] also received antidepressant medication according to protocol. The primary out-come measure was post-treatment remission rate [HAM-D score < 7]. Secondary outcome measures included mean post-treatment HAM-D score and patient-rated depression score and 1-year follow-up outcomes. Data were analyzed with generalized estimating equations and mixed-model analyses using intent-to-treat samples. Non-inferiority margins were pre-specified as an odds ratio of 0.49 for remission rates and a Cohen’s d value of 0.30 for continuous outcome measures.Results: No statistically significant treatment differences were found for any of the outcome measures.The average post-treatment remission rate was 22.7%. Non-inferiority was shown for post-treatment HAM-D and patient-rated depression scores but could not be demonstrated for post-treatment remission rates or any of the follow-up measures.Conclusions: The findings extend the evidence base of psychodynamic therapy for depression but also indicate that time-limited treatment is insufficient for a substantial number of patients encountered in psychiatric outpatient clinics.
This study actually points out the difficulty of psychotherapy research. These patients had been somewhat refractory, they were chronically ill, and we know nothing of their motivation. They were selected by symptom [depression] and the therapy choice was random, not tailored to the patient. It was short [16 weeks]. The population was ‘take-all-comers.’ The results reflect all of those things. CBT and Dynamic Psychotherapy were "non-inferior" to each other sure enough, but that meant that the outcome wasn’t very good for either. If there are things to say from the results, it’s that psychotherapy isn’t for everyone; that assignment by symptom isn’t optimal; and that the venerated place of CBT may well have been an artifact of the times. Oh yeah, there’s an accompanying full text editorial by Michael Thase online [Comparative Effectiveness of Psychodynamic Psychotherapy and Cognitive-Behavioral Therapy: It’s About Time, and What’s Next?]. No comment.
I was on my own as a practitioner, but after retirement I volunteered in a child and adolescent clinic for four years with people of other disciplines, all of whom had been "trained in CBT." We had a lot of fun, because they were an unusually talented lot. Their version of CBT meant doing the same thing I did. We laughed about that some. Adolf Meyers would have approved. I was better at hearing the patients’ back stories, but they weren’t half bad. They tended to lean on learning theory and give "homework," but it wasn’t often. The experience reinforced what I always thought – that good psychotherapists are "naturals" who pick up on any and everything useful that comes their way, particularly the lessons the patients teach us, and incorporate it into their maturing approach.
Psychotherapy has helped me immensely. While attending the University of Texas, at Austin; there was free counseling available from interns, and there were a lot of psychiatrists and psychologists around town who worked on a sliding scale. One semester of group therapy helped me realize how normal a lot of my issues were so I stopped feeling like I didn’t belong on campus.
A psychiatrist I worked closely with on really hard childhood issues teared up while I was telling her about something that happened when I was eleven. I knew that that was going to be our last session because that was a no-no; but in that moment, I was a child and she was an empathetic adult, and then I was an adult seeing that event as an empathetic adult. What happened to me was sad. That recognition was profound for me, and that doctor with a tear in her eye set me on the path to having compassion for myself. It took about five years more for me to identify and override all the “tapes” in my head from parenting units in my childhood. It was rewarding and consuming at times, but priceless.
It didn’t take me too long to realize that all the interns embraced a certain school. I took the best, and left the rest. I even had a breakthrough with lay-counseling— re-evaluative counseling. Which is not to say that I haven’t seen some psychiatrists once, or didn’t rather I hadn’t met a few, but those came after the bio-bio-bio craze.
The last time I did talk therapy with a psychologist— I think we had three sessions— I could tell he was into CBT. If there is a rational way to view the imminent threat of total global thermo-nuclear war, then someone’s holding that one close to their chest. The V.A. psychiatrist who told me “we can’t help you” in reference to my service-connected trauma gave me my second greatest moment in psychiatry. They can’t. How wonderful it was to hear that acknowledged. It sure beat changing the subject, or insisting that the childhood I’ve gotten over is what I need to focus on.
I would like to see counselors, from time to time, like some of the counselors I saw in the eighties— like YOU. Helping people with psychological and social problems with person-centered appropriate counseling, would free the mental health system up enough to focus and spend more time and try more approaches with people who have problems with being floridly psychotic from time to time, and are incapable of taking care of themselves most of the time.
Psychiatry hasn’t lost its mission— it’s lost the plot by sticking with a single story.
I had read in a study somewhere that 11% of psychiatrists still offer exclusively psychotherapy. I can’t find the reference I had for that, but the director of the NIMH quoted it:
http://www.nimh.nih.gov/about/director/2011/psychiatry-where-are-we-going.shtml
I have never met a psychiatrist who didn’t claim they were offering psychotherapy with psychopharmacology. I’m not sure of the quality of the service on that one, but It always seemed strange when I asked “what type of psychiatrits are you?” I always got those two answers.
Actually I think the source cited from the AMA’s physican masterfile. The AMA actually rents out the data to researchers and companies, so it’s possible to get an exact number of who does what/where, and their prescribing habits.
http://www.ama-assn.org/ama/pub/about-ama/physician-data-resources/physician-masterfile.page?
I would be curious to see a study that reviewed the AMA’s masterfile to see how psychiatrists are employed and who offers what.
I feel like it is often said that 20%ish of people recover from depression without treatment. Anyone have some research accessible to verify? When randomly assigned a treatment, these patients were not likely to do any better. I do appreciate comparative therapy studies and am glad this one happened I’m not going to complain that they didn’t include a third arm of no treatment or something non-professional like aerobic exercise, as that would increase the expense and burden of the study, when comparison studies are badly needed. I just think this tells us at best, we need to do more research in identifying what kind of treatments would be most likely helpful particular people (if any), and at the worse end, that 4 months of therapy (something that is actually quite expensive on the open market), does help remit depression symptoms better than not being in therapy.
One of the best, most compassionate and empathetic articles I have ever read about help, therapy and validation of female domestic violence victims and survivors is by Dr. Frank Ochberg, Psychiatrist, Trauma Expert and Creator of the web site, Gift From Within as well as many books and articles on trauma. As Dr. Ochberg points out, much more than just regular “therapy” is needed here and “prozac won’t change the truth.” Here is the article:
http://giftfromwithin.org/html/spousal.html
It is very sad that most psychiatrists refuse to acknowledge the trauma for mainly women and children from domestic violence as also pointed out by Dr. Judith Herman, author of the classic, Trauma and Recovery, and creator of the Complex PTSD diagnosis for such repetitive trauma injuries to replace the insult borderline stigma for such victims of her time; Dr. Carole Warshaw, Psychiatrist and Domestic Violence Expert, exposes that abused women and children are routinely misdiagnosed with bipolar, ADHD and paranoia for their abuse related trauma symptoms today because psychiatrists/doctors fail to ask about or acknowledge domestic violence against them. This results in so called treatment that not only does not help the abused/traumatized women and children, but actively harms them while aiding and abetting the abusers in the courts, custody battles, stealing all the assets and all too often even murder of the victims. Why has psychiatry failed to act when well known batterers of women and/or children were also known to be very dangerous to their victims well before they murdered them? This is very ironic when psychiatry claims to force commitment and drugging on those who are a danger to themselves and others since such abusers do kill themselves along with their families all too frequently. Of course, many psychopaths murder their wives for money and freedom to prey on the next victim as with Scott Peterson whose story is told in the book, Erased, about all the men who get away with murdering their wives with impunity.
Thus, I think common sense must prevail at all times rather than so called evidence based therapies like CBT. CBT would have us believe the victims of abuse just need to have their faulty thinking corrected and all will be well with the family, which is just what the abusers believe while gas lighting their victims to believe it too.
But, as one psychiatrist working on the DSM claimed, he never saw such domestic violence among his clients despite the glaring world statistics that prove the opposite.
Thanks for that link, Florence.
Wiley,
Thanks for your note. I should have pointed out that the great web site, Gift From Within created by trauma expert, Dr. Frank Ochberg, I cited above includes help for all types of traumatic experiences including war, accidents, stressful occupations, abuse of all kinds and many, many others and a wide variety of trauma treatments, books and other resources.
http://www.giftfromwithin.org/