Long-term psychodynamic psychotherapy effective for complex mental disorders

Long term psychodynamic psychotherapy (LTPP) is an effective treatment for complex mental disorders. Long term meaning at least one year or 50 sessions. Complex mental disorders means personality disorders, chronic mental disorders (defined as lasting at least a year), multiple mental disorders (2 or more mental disorders), or complex depression and anxiety disorders.

In all, 11 Randomized Controlled Trials and 12 observational studies were included in this meta-analysis. The 23 studies included 1053 patients treated with LTPP.

The mean (SD) number of sessions carried out in the 23 studies of LTPP was
151.38 (154.98) and a median of 73.50. The duration of therapy was 94.81 (58.79) weeks and a median of 69.00. For LTPP the mean (SD) length of follow-up period after treatment was 93.23 (64.93) weeks.

The authors used a definition of psychodynamic psychotherapy from Gunderson and Gabbard: “A therapy that involves careful attention to the therapist-patient interaction, with carefully timed interpretation of transference and resistance embedded in a sophisticated appreciation of the
therapist’s contribution to the two-person field.”

Transference is defined as, “those perceptions of, and responses to, a person in the here and now that more appropriately reflect past feelings about,or responses to, important people earlier in one’s life, especially parents and siblings.” You can detect transference in everyday life by a strong reaction to a person or situation in which the intensity of the emotion is more than what would be attributable to the current situation may be a clue to the presence of transference.

Resistance is the “patient’s attempt to protect herself or himself by avoiding the anticipated emotional discomfort that accompanies the emergence of conflictual; dangerous; or painful experiences, feelings, thoughts, memories, needs, and desires.”

The authors of this meta-analysis tried to find evidence for publication bias, negative results not being submitted or published. They couldn’t find any, doing such intensive time and work consuming research will probably always be published one way or another.

Observational or randomized controlled trials did not significantly differ in outcome. LTPP was significantly more effective than the shorter-term methods of psychotherapy such as cognitive behavioral therapy. Some cost-effectiveness studies suggest that LTPP may be a cost efficient treatment.

With regard to overall effectiveness, a between-group effect size of 1.8 (95% confidence interval [CI], 0.7-3.4) indicated that after treatment with LTPP patients with complex mental disorders on average were better off than 96% of the patients in the comparison groups. Further research should address the outcome of LTPP in specific mental disorders and should include cost-effectiveness analyses.

We are talking about patients with severe and debilitating mental illness. This research included a mean follow-up duration of 93 weeks. This is in accordance with a previous post on this blog: Long-term psychodynamic psychotherapy better than short-term

Long-term psychodynamic psychotherapy is superior in the long term to short-term psychodynamic psychotherapy. Short-term produces benefits more quickly than long-term therapies. After 3 years of follow-up, however, the situation was reversed with a stronger treatment effect in the long-term psychodynamic treatment group both for patients with depressive and anxiety symptoms.

To my opinion is LTPP an effective treatment especially for complex psychiatric disorders such as personality disorders. It is ironic that fewer psychiatrists perform these kind of treatments, not only in the US but also in the Netherlands since more evidence is accumulating of it’s efficacy in severe mental disorders. Complex mental disorders and it’s treatment should be the focus of psychiatrist.

F. Leichsenring, S. Rabung (2008). Effectiveness of Long-term Psychodynamic Psychotherapy: A Meta-analysis JAMA: The Journal of the American Medical Association, 300 (13), 1551-1565 DOI: 10.1001/jama.300.13.1551