Effectiveness of Long-term Psychodynamic Psychotherapy · Effectiveness of Long-term Psychodynamic...

REVIEW

Effectiveness of Long-term PsychodynamicPsychotherapyA Meta-analysis

Context The place of long-term psychodynamic psychotherapy (LTPP) within psychiatry is controversial. Convincing outcome research for LTPP has been lacking.

Objective To examine the effects of LTPP, especially in complex mental disorders,ie, patients with personality disorders, chronic mental disorders, multiple mental disorders, and complex depressive and anxiety disorders (ie, associated with chronic courseand/or multiple mental disorders), by performing a meta-analysis.

Data Sources Studies of LTPP published between January 1, 1960, and May 31,2008, were identified by a computerized search using MEDLlNE, PsyciNFO, and Current Contents, supplemented by contact with experts in the field.

Study Selection Only studies that used individual psychodynamic psychotherapylasting for at least a year, or 50 sessions; had a prospective design; and reported reliable outcome measures were included. Randomized controlled trials (RCTs) and observational studies were considered. Twenty-three studies involving a total of 1053patients were included (11 RCTs and 12 observational studies).

Data Extraction Information on study characteristics and treatment outcome wasextracted by 2 independent raters. Effect sizes were calculated for overall effectiveness, target problems, general psychiatric symptoms, personality functioning, and social functioning. To examine the stability of outcome, effect sizes were calculated separately for end-of-therapy and follow-up assessment.

Results According to comparative analyses of controlled trials, LTPP showed significantly higher outcomes in overall effectiveness, target problems, and personality functioning than shorter forms of psychotherapy. With regard to overall effectiveness, abetween-group effect size of 1.8 (95% confidence interval [Cll. 0.7-3.4) indicated thatafter treatment with LTPP patients with complex mental disorders on average werebetter off than 96% of the patients in the comparison groups (P= .002). According tosubgroup analyses, LTPP yielded significant, large, and stable within-group effect sizesacross various and particularly complex mental disorders (range, 0.78-1.98).

Conclusions There is evidence that LTPP is an effective treatment for complex mental disorders. Further research should address the outcome of LTPP in specific mentaldisorders and should include cost-effectiveness analyses,lAMA. 2008;300(13):1551-1565 wwwjama.com

Falk Leichsenring, DSc

Sven Rabung, PhD

THE PLACE OF PS.'YCHOANALYTIC

and psychodynamic treatments within psychiatry iscontroversiaL 1.2 Although

some evidence supports the efficacyof short-term psychodynamic psychotherapy (STP?) for specific disorders,)·i convincing research on theoutcome of long-term psychodynam ic psycho thera py (LTPP) hasbeen lacking.I.2.~ Evidence suggeststhat short-term psychotherapy is sufllciently effective for most indivi.duals experiencing acute distress." Evidence, however, also indicates thatshort-term treatments are insufficientror a considerable proportion ofpatients with complex mental disorders, ie, patients with multiple orchronic mental disorders or personality disorders9 ' 11 Some studies suggest that long-term psychotherapymay be helpful ror these groups ofpatients9.lo.12.lfi This is true not only

of psychodynamic therapy but alsoof psychotherapeutic approachesthat are usually short-term, suchas cognitive-behavioral therapy(CBT).15.IO

Evidence-based trea tmen ts fo rthese patient groups are particularlyimportant. Personality disorders, forexample, are quite common in both

For editorial comment see p 1587.

general and clinical populations.They show a high comorbidity with awide range of Axis I psychiatric disorders and are significantly associated with functional impairments. 17. IY

Furthermore, a high proportion ofpatients in clinical populations expe-

Author Affiliations: Department of Psychosomabcs andPsychotherapy, University of Giessen, Giessen (DrLeichsenring); and Department of Medical Psychology, University Medical Center HamburgEppendorf, Hamburg (Dr Rabung), Germany.Corresponding Author: Faik Leichsenring, DSc,Department of Psychosomatics and Psychotherapy,University of Giessen, Ludwigstrasse 76, 35392Giessen Germany ([email protected]).

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LONG-TERM PSYCHODYNAMIC PSYCHOTHERAPY

rience not just a single but rathermultiple mental disorders 20

.l1 Pa

tients with multiple mental disordersreport significantly greater deficits insocial and occupational functioning. 20.11

Although some studies suggest thatLTPP may be helpful for these patientgroups, strong evidence-based support for LTPP has been lacking. Nometa-analysis addressing the outcomeqf LTPP has yet been published, although preliminary data have been reported by LambY This article reportsthe first meta-analysis to our knowledge on the outcome of LTPP.

Experts continue to discuss whichtype of research design-randomizedcontrolled trials (RCTs) vs elTectiveness or observational studiesprovides the best evidence that atreatment "vorks.13·2~ Randomizedcontrolled trials are carried outunder controlled experimental conditions. As such, their strength lies inthe control of factors influencingoutcome external to the treatmentsin question; they thus ensure highinternal validity of the study. However, their clinical representativeness(external validity) can be limited bystrict experimental con trol. l

" In contrast, effectiveness studies are carriedout under the conditions of clinicalpractice. Consequently, they ensureclinically representative results (ie,high external validity).29 However,they cannot control for factors influencing outcome apart from the treatment to the same degree as RCTs, ie,threats to internal validity. Takingthese issues into account, this metaanalysis sought to include studieswith high internal validity (RCTs)and studies with high clinical representativeness (effectiveness studies)provided that they fulfilled predefined inclusion criteria. Includingboth types of studies allowed themeta-analysis to test for the effect ofthe research design on outcome andthe gcneralizability of results.

This meta-analysis of LTPP addresses the following research questions:

1. Is LTPP superior to other (shorter)psychotherapeutic treatments, particularly with regard to complex mental disorders, ie, personality disorders, chronicmental disorders (defined as lasting atleast a year), multiple mental disorders, or complex depression and anxiety disorders?

2. How effective is LTPP with regard to overall outcome, target problems, general psychiatric symptoms,personality functioning, and socialfunctioning in patients with various, especially complex mental disorders?

3. \Vhat patient, treatment, or research factors conLribute Significantlyto the outcome of LTPP (eg, age, sex,diagnostic subgroups, use of therapymanuals, therapist experience, treatment duration, or concomitant psychotropic medication)?

METHODS

The procedures carried out in this metaanalysis are consistent with recentguidelines for the reporting of metaanalysesJo.J '

Definition of LTPP

Psychodynamic psychotherapies operate on an interpretive-supportivecontinuum. An emphasis is placedon more interpretive or supportiveinterventions depending on the patient's needs.~.Jl Gunderson and GabbardH'pfi~51 defined LTPP as "a therapythat involves careful attention to thetherapist-patient interaction, withthoughtfully timed interpretation oftransference and resistance embeddedin a sophisticated appreciation of thetherapist's con tribution to the twoperson field." There is no generally accepted "standard" duration for LTPP.LamV2compiled more than 20 definitions given by experts in the field. Theyranged from a minimum of 3 monthsto a maxi.mum of 20 years. In this metaanalysis, we included studies that examined psychodynamic psychotherapy lasung for at least a year, or 50sessions. This criterion is consistentwith the definition given by CritsChristoph and Barber. 13

(r45li)

Inclusion Criteriaand Selection of StudiesWe applied the following inclusioncriteria: (1) studies of individual psychodynamic therapy meeting the definiti.on given by Gunderson and Gabbard above H; (2) psychodynamictherapy lasting for at least a year, or atleast 50 sessions; (3) prospectivestudies of LTPP including before-andafter or follow-up assessments; (4)use of reliable outcome measures; (5)a clearly described sample of patientswith mental disorders; (6) adultpatients (2: 18 years); (7) sufficientdata to allow determination of effectsizes; (8) concomitant (eg, psychopharmacological) treatments wereadmissible, but studies involving concomitant treatment were evaluatedseparately in order to compare theresults of the combined treatment vsLTPP alone; and (9) both RCTs andobservational studies fulfilling the criteria listed above. These criteria areconsistent with recent meta-analysesof psycho therapy. 5.\ 0

We collected studies of LTPP thatwere published between 1960 andMay 2008 based on a computerizedsearch of MEDLINE, PsyciNFO, andCurrent Contents. The followingsearch terms were used: (pSyc1lOdynamic or dynamic or psychoanalytic*or trans[erenceJocusecl or self psychology or psychology of self) and(therapy or psychotherapy or treatment) and (suldy or studies or trial"')and (outcome or result* or effect* orchange*) and (psych* or mental*). Inaddition, manual searches of articlesand textbooks were performed, andwe communicated with authors andexperts in the field. A flow chartshowing the process of study selection is given in FIGURE 1.

Data Extraction

The 2 authors independently extracted the follOWing information fromthe articles: author names, publication year, psychiatric disorder treatedwith LTPP, age and sex of patients, dumUon ofLTPP, number ofsessions, typeof comparison group, sample size in

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each group, use of treatment manuals(yes/no), general clinical experience oftherapists (years), specific experiencewith the patient group under study(years), specific training of therapists(yes/no), study design (RCT vs observational), duration of follow-up period, and use of psychotropic medication. Disagreements were resolved byconsensus. The raters were not blindedwith regard to treatment condition, because evidence suggests that blindingis unnecessary for meta-analyses. 34

Effect sizes were independently assessed by the 2 raters. Interrater reliability was assessed for the outcome domains in question, ie, overall outcome,target problems, general psychiatricsymptoms, personali ty functioning,and social functioning. For all areas,interrater reliability was satisfactory(12::0.80).

Assessment of Effect Sizesand Statistical Analysis

In addition to overall outcome, weassessed effect sizes separately for target problems, general psychiatricsymptoms, personality functioning,and social functioning. This procedure was analogous to those in othermeta-analyses of psychodynamictherapy."'» As outcome measures oftarget problems, we included patientratings of target problems)(, and measures referring to the symptoms specific to the patient group under study(eg, a measure of impulsivity for studies examining borderline personalitydisorder). For general psychiatricsymptoms, both broad measures ofpsychiatric symptoms such as theSymptom Checklist-90 (SCL-90)37and specific measures that do not specifically refer to the disorder understudy were included, eg, an anxietyinventory applied to patients withpersonality disorders. For the assessment of personality functioning, measures of personality characteristics(eg, self-report inventories such as theDefense Style Questionnaire) wereincluded. )'<.39 Social functioning wasassessed using the Social AdjustmentScale40 and similar measures.

Whenever a study reported multiple measurements for 1 of the areasof functioning (eg, target problems), weassessed the effect size for each measure separately and calculated the meaneffect size of these measures to assessthe overall outcome in the respectivearea of functioning. Overall outcomewas assessed by averaging the effectsizes of target problems, general psychiatric symptoms, and personality andsocial functioning. If a study involvedmore than I form ofLTPP, each formwas entered separately into this metaanalysis. As a measure of betweengroup effect size, we used the point biserial correlation rr as suggested byCohen and Rosenthal.4!.42 The point biserial correlation also allows us to testfor differences between LTPP and otherronns of psychotherapy.

As a measure of within-group effectsize, the d statistic was calculated foreach measure by subtracting the posttreatment mean from the pretreatment mean and dividing the difference by the pretreatment standarddeviation of the measure.42.4] If therewas more than 1 treatment group, wecalculated a pooled baseline standarddeviation as suggested by Hedgesand Rosenthal.4!.4] To correct for biaswhen sample sizes were small, we calculated the Hedges d statistic, anunbiased measure or effect size insmall samples (formula 1O).44(I'SI) Thewithin-group effect size d givest.he difference in t.he magnitude ofchange from pret.reat.ment t.o post.treatment in units of standard deviations. A value or 0.80 is regarded as alarge effect. 42.4>

If the dat.a necessary t.o calculat.eeffect sizes were not published in an article, we asked t.he st.udy authors forthese data. If necessary, signs were reversed so that a posit.ive effect size always indicated improvement. To examine t.he stabilit.y of psychot.herapeut.iceffects, we assessed effect sizes separately for assessments at the t.ermination of therapy and follow-up. If several follow-up assessment.s wereperformed, we included only t.he I wit.hthe longest follm.v-up period t.o study

Figure 1. Selection of Trials

4014 Potentially relevant articles

3963 Excluded based on reviewof titles and abstracts

~I 22 Excluded

29 Articles met inclusion criteria

29 Articles (23 sludies) were includedin meta-analysis

6 Articles reported complementaryresults from the same study

See the "Methods" section for study exclusioncriteria.

long-t.erm stability of treatment effects. If data pertaining t.o complet.ersand intent-to-treat samples were reported, t.he latter were included.

Tests for heterogeneity were carriedout. using t.he Q statistic."' In case ofsignificant. heterogeneity, randomeffect. models were applied.4!>47 Toassess the degree of heterogeneity, wecalculated the 12 index.4~ For controlof publication bias, file-drawer analyses were performecl.47"f~I.5oTo test. fordifferences between RCTs and observational studies, point biserial correlat.ions bet.ween type of study and outcome were calculat.ed. Only if nosigniricant. differences exist, it isappropriate to combine outcomedata from RCTs and observationalstudies.

To compare the effect.s of LTPPwith t.hose of other psychotherapymet.hods, we performed comparativeanalyses for the subsample of st.udieswit.h a control group design. To analyze the effect.s of LTPP in complexmental disorders, subgroup analyseswere carried out. for personality disorders, chronic mental disorders,mult.iple ment.al disorders, andcomplex depression and anxietydisorders (t.he latter being characterized by the chronic course and/orcooccurrence with multiple ment.al

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disorders). For sensitivity analyses,additional subgroup analyses werecarried out. Correlation analyseswere performed to test the impact ofpredictor or moderator variables onoutcome (eg, concomitant psychotropic medication, use of treatmentmanuals). Statistical analyses wereconducted using SPSS 15.0 51 andMetavVin 2.0. 52 Two-tailed tests ofsignificance were carried out for allanalyses. The significance level wasdefined to be P=.05 if not otherwisestated.

Assessment of Study Quality

According to the inclusion criteriadescribed above, only prospectivestudies of LTPP were included inwhich reliable outcome measureswere used, the patient sample wasclearly described, and data to calculate effect sizes were reported. Inaddition, the quality of studies wasassessed by use of the scale proposedby Jadad et al. 53 This scale takes intoaccount if a study was described asrandomized, if a study was describedas double blind, and if withdrawalsand dropouts were described. Inpsychotherapy research, however,double-blind studies cannot be realized because the pa tients know orcan easily find out which treatmentthey receive. Thus, all studies of psychotherapy would have to be given ascore of 0 points on this item of theJadae! scale. Instead of blindingtherapists and patients, the respective requirement in psychotherapyresearch is that in case of observerrated outcome measures the ratingswere carried out by raters blind tothe treatment condition. Additionally, the patient perspective is of particular importance in psychotherapy.For this reason, outcome is oftenassessed by self-report instruments.We therefore decided to give a scoreof 1 point on this item if outcomewas assessed by blinded raters or byreliable self-report instruments. Withthis modification, the 3 items of theJadad scale were independently ratedby the 2 authors for all studies

included. A satisfactory interraterreliability was achieved for thetotal score of the scale (r=0.84,P< .001).

RESULTSIncluded Studies

Twenty-three studies met the inclusion criteria (Figure 1).11.11.39.54.79For 8 of the studies, we receivedadditional information from theauthors. 14 .59 ,05.M.7.l.75,n.79 The studiesare described in TABLE 1. Five studiesinvolved more than 1 LTPP treatmentcondition. 55.till ./i1.'5.'" Each LTPP conclition applied in these studies wasentered separately into this metaanalysis.

For 5 studies, some control conclitions had to be excluded from thismeta-analysis. ti5 .M .7l-75 The observational study comparison groups ofthe study by Rudolf et aF4 were notincluded because 1 comparisongroup did not clearly represent LTPPor STPP due to variability in treatment duration (5 to 200 sessions),and the other condition representedinpatient treatment (Table 1). Thecomparison group of the study byHuber and Klug('S was not includedbecause not enough data were available. The low-dose therapy controlgroup of the Sandell et aI's study wasnot included, because data to calculate elTect sizes were not publishedfor this condition. The data of theshort-term psychotherapy groups ofthe Knekt et al"" study were notincluded as control groups becauseassessments were made at predefinedtime points that did not representend of therapy for the short-termtreatment group. Of the 4 forms ofpsychodynamic therapy studied byPiper et al,73 only the individuallong-term and short-term conditionswere included, The group treatmentswere not included due to our inclusion criterion of individual therapy.In all, 8 cont.rolled studies providedt.he dat.a necessary for comparativeanalyses of LTPP with other forms ofpsyc hath e ra py. 12, 14.54,5",0 I,n. 77.7~

Table 1 and FIGURE 2 indicate 11

studies with 13 LTPP conditions asbeing RCTS; however, only 8 of these11 provided dat.a for other forms ofpsychotherapy.

The results of t.he studies by Bondand Perry,3Y,51i Clarkin et al,14,57 Knektet al,lin,67 and Monsen et aF1.72 were reported in 2 journal articles each. Bateman and Fonagyl2,13 present.ed the dataof an 18-month follow-up in a separate article, and H,~glend et a162 ,63 presented the data of the I-year and3-yearfollow-up in separat.e articles, We included t.he data from both articles in ouranalysis for all of these studies.

For 3 studies/0.n .7Y we received addit.ional information about treatmentduration from the aut.hors. In t.hese 3studies, t.reatment duration was longerthan a year.

In the study by Wilczek et al,'9 notall of the patients under study met. thecriteria for an Axis I or Axis II diagnosis, To include only individuals withmental disorders, we included onlythe data from those patients diagnosed with a "character pat.hology" at.intake, according to the KarolinskaPsychodynamic Profile as reported byWilczek et. al.'Y'pI1(6)

In all, 11 RCTs* and 12 observational studies"! were included in thismeta-analysis. To make the procedures applied in t.his meta-analysis astransparent as possible, we includedthe out.come measures used in eachstudy and indicat.ed for which outcome area each measure was included(Table 1). For reasons of space limitations, however, we do not give a reference for each instrument. The readeris referred to the original studies forthis informat.ion.

The 23 studies included 1053 patients treated with LTPP. For comparative treatments, the number was 257.The 23 included studies cover a widerange of mental disorders (Table 1).

We evaluated the effects or LTPPseparately for patients with personality disorders, chronic mental disorders (defined as mental disorders

"References 12, 14, 54, 59, 61,62,65,66,73,77,78tReferences 39,55,57,60,68-71,74-76,79.

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Table 1. Studies of Long-term Psychodynamic Psychotherapy

LTPP Group Comparison Group Outcome Measures

Duration of Duration ofTreatment Treatment

Mental No. of (Follow-up No. of (Follow-upSources Disorder Patientsb Interval) Patients Interval) RCT Test Domains

Bachar et ai,s, Eating disorders 17 40 Sessions; 17CT 12 moCT Yes OSM-SS Target probiems1999 12mo 10 Controll 6mo EAT 26 Target problems

nutritional Nutritional SCL-90 Symptomscounseling counseling Selves Q Personality

Barber et al,55 Avoidant and 24 Avoidant 52 Sessions No WISPI Target problems1997 obsessive- personality BAI Symptoms

compulsive disorder BOI Symptomspersonality HARS Symptomsdisorders HRSD Symptoms

liP Social functioning% Oiagnosisd

14 Obsessive- 52 Sessions No WISPI Target problemscompulsive BAI Symptomspersonality BDI Symptomsdisorder HARS Symptoms

HRSO SymptomsliP Social functioning% Oiagnosisd

Bateman and Borderline 19 18mo 19 Psyclliatric 11.6d Yes BOI SymptomsFonagy, personality TAU Inpatient SCL-90-R Symptoms1999,'2 disorder Inpatient treatment liP Social functioning2001 ,3a treatment + (90% of STAI-state Symptoms

Partial pa~ents) + STAI-trait PersonalityIlospitaliza- 6mo Partialtion hospitaliza-

tion(72%of patients)

Bond and Cilronic 53 Mecian, 110 No SCL-90 SymptomsPerry, depression, Sessions; HRSO Symptoms2004,"" anxiety, and Median, 3.0 y; GAF Social functioning20065o,a personality Mean, 3.32 y DSQ Personality

disordersClarkin et al,57 Borderline 23 12mo No Parasuicide Target problems

2001 a personality Service utilization Social functioningdisorders

Clarkin et ai, ,., Borderline 30 12mo 170BT 12 mo DBT Yes Aggression scale Target problems2007; personality 220ST 12moOST Anger scale Target problemsLevy et al,5Il disorders Barrett scale Target problems2006a BOI Symptoms

BSI SymptomsGAF Social functioningSAS Social functioningRF PersonalityCoherence PersonalityResolution Personality

Dare et ai,"" Anorexia 21 Mean, 24.9 22 CAT 7moCAT Yes BMI Target problems2001 nervosa Sessions; 22 FT 12 moFT ABW% Target problems

12mo 19 Routine 12moTAU Morgan Russel Target problemstreatment

19TAUGrande et al,e", Depressive 32 Analytic Mean, 310 2nd LTPP No SCL-90-R Symptoms

2006 and anxiety psycho- Sessions; condition liP Social functioningdisorderse therapy Mean, 44.2 mo

(12mo)

27 PSYCllO- Mean, 71.1 1stLTPP Nodynamic Sessions; conditionfocal Mean, 24.2 motherapy (12mo)

Gregory et al,61 Borderline 15 12-18mo 15TAU 12-18mo Yes BEST Target problems2008 personality BOI Symptoms

disorders DES SymptomsSPS Social functioning% Parasuicide,

alcollol mis-use, institu-tional cared

(continUed)

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Table 1. Studies of Long-term Psychodynamic Psychotherapy (cant)

LTPP Group Comparison Group Outcome Measures


Mental No. of (Follow-up No. of (Follow-upSources Disorder Patientsb Interval) Patients Interval) RCT Test Domains

H0glend et al,6' Depressive, 52 Transfer- 33 Sessions: 2nd LTPP Yes PFS Target problems2006, anxiety and ence 12 mo condition SCL-90-R Symptoms200863 personality interpreta- (12 mo. 24 mol liP Social functioning

disorderse tion GAF Social functioning

48 No transfer- 33 Sessions: 1st LTPP Yes PFS Target problemsence 12 mo condition SCL-90-R Symptomsinterpreta- (12mo, 24 mol liP Sociai functioningtion GAF Social functioning

Huber and Depressive 35 229 Sessions; 8 PFTc 60.6 Sessions Yes BDI Target problemsKlug.G5 disorders Mean. 48.8 mo 19.4 mo SCL-90-R Symptoms2006 liP Social functioning

Knekt et al,,,,67 Depressive or 128 235 Sessions; 101 STPpc 20STPP Yes BDI Target problems2008 anxiety :536 mo 97 SFTc sessions HRSD Target problems

disorders 5-6mo HARS Target problems:512 SFT SCL-Ai1xiety Target problems

sessions SCL-90-GSI Symptoms:58 mo WAI Social functioning

SAS-W Social functioningPPFS Social functioningNSLD Social functioning

Korner et ai, ,-a Borderline 29 12 mo 31 TAU 12 mo No DSM-III-R Score Target problems2006 personality GAF Social functioning

disorder

Leicllsenring Depressive, 36 Mean, 253 No GAF Target problemset al,69 anXiety, sessions: SCL-90-R Symptoms2005 and Mean. 37.4 mo FLZ Personality

personality (12 mo) liP Social functioningdisorderse

Lubarsky Heterogeneous 17 >50 Sessions No GAF Social functioninget al,7O disorders HSRS Social functioning2001

Monsen Personality 23 Mean, 25.4 mo No Affect Target problemset al.",72 disorders (60mo) MMPI Target problems1995 [D+Pt+Si] Symptoms

[F + pa + sc] Personality

Piper et al. 73 Heterogeneous 30 Mean, 76 27 Individuai Mean, 22 Yes TSP Target problems1984 disorders sessions: STPP sessions TSPI Target problems

30% (6mo) (6mo) TSIA Target problemsPersonality TSIAi Target probiemsdisorders TST Target problems

TSTI Target problemsCornell SymptomsDA SymptomsCAn PersonalityIBSP Social functioningIBSD Social functioningSSIAM Social functioning

Rudolf et ai,'" Depressive, 44 Mean, 265 56 PFTc 5-200 PFT No PSKB-SE 1 Symptoms1994 anxiety. sessions 164 POlc sessions. PSKB-SE2 Personality

and 2.6mo, POIpersonalitydisorderse

Sandell et al/5 Heterogeneous 24 PSYCllO- Mean. 642 27 Low-dose No SCL-90-R Symptoms2000 disorders analysis sessions: therapiesc sacs Personality

Mean, 54 mo SAS Social functioning(12 mo. 24 rno)

129 LTPP 43 mo LTPP 27 Low-dose No SCL-90-R Symptoms(12 mo, 24 mol therapiesc sacs Personali ty

SAS Social functioning

Stevenson Borderline 30 12 mo No DSM-f11 Score Target problemsand personality Cornell SymptomsMeares,'" disorders Behavior Social functioning1992

(continued)

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Table 1. Studies of Long-term Psychodynamic Psychotherapy (cont)

LTPPGroup Comparison Group Outcome Measures


Mental No. of (Follow-up No. of (Follow-upSources Disorder Patientsb Interval) Patients Interval) RCT

Svartberg, et ClusterC 25 40 sessions: 25CT 18.3mo Yesai," 2004 personality Mean, 16.9 mo (6,12,24 mol

disorders (6,12,24 mol

Vinnars et ai,'· Personality 80 Manualized 2:12 mo 2nd LTPP Yes2005a disorders pSyCl1Ody- (12 mo, 36 mol condition

namictherapy

Test

MillonSCL-90-RliP

OSM-IV scoreSCL-90-TGAFChange in

diagnosisd

Domains

Target problemsSymptomsSocial functioning


Wilczel< et al!92004

Heterogeneousdisorders

Only "characterpathology"patientsincluded

76 CommunitydeliveredpSyCl10dynamictherapy

36

2:12 mo(12 mo, 36 mol

Mean, 159sessions

(6mo)

1st LTPPcondition

Yes

No

OSM-IV scoreSCL-90-TGAFChange in

diagnosisd

KAPPCPRS-S-AdGAFd


Target problems

Abbreviations: ABW. average body weight; BAl. Beck Anxiety Inventory; BDI. Beck Depression InventQly; BEST. Borderline Evaluation of severity Over lime; BMI. body mass index;BSI, Brief Symptom Inventory; CAT, cognitive-analytic therapy; CAD. Cattel's H Scale; CPR-S-A. Self-Rating Scale for Affective Syndromes; CT. cognitive therapy; DA.Depression-Anxiety Subscale of Psychiatric Status Schedule: DBT. dialectic behavioral therapy: DES. Dissociative Experiences Scale; D+Pt+Si. subjecfive discomfort. anxiety,social introversion subscales of MMPI: DSM-III-R. Diagnostic and Statisllcat Manual of Mental Disorders (Third EdITion Revised); DSM-SS. DSM Symptomatology Scale for Anorexiaand BUlimia; DSQ, Defense Style Questionnaire; DST. dynamic supportive treatment: EAT, Eating Atlitudes Test FLZ. Life Satisfaction Questionnaire: F+pa+sc. F. projection. withdrawal subscales of MMPI; FT, family therapy: GAF, Global Assessment of Funclioning SCale: HAAS, Hamilton Allloety Rating SCale: HRSD. Hamilton Rating Scale for Depression;HSRS, Health Sickness Rating Scale; 1880, Interpersonal Behavior Scale (discrepancy between present and ideal functioning); IBSP, International Beha\;or SCale (present iunctioning): liP. Inventory of Interpersonal Problems: KAPP, Karolinska Psychodynamic Profile: LTPP, long-ternl psycllodynamic psychotherapy: MMPI, Minnesota Multiphasic Personality:Inventory: NSLD. number of sick-leave days, PFS, Psychodynamic Functioning Scales; PFT. Psychodynamic Focal Therapy; PCI, psychodynamically oriented inpatient treatment;PPFS. Perceived Psychological Functioning Scale; PSKB·SE. psychological and social-communicative state-self-report (Psychischer und Sozialkommunikativer BeiundSelbsteinschatzung); RCT. randomized controlled trial; RF. reflexive Function; SAS, Social Adjustment Scale: SAS-W, Wort< Subscale of the Social Adjustment Scale: SCL·90-R.Symptom Check List-90 revised; SFT, solution- focused therapy, sacs, Sense of Coherence Scale; SPS, Social Provisions Scale: SSIAM. Structured and Scaled Interview toAssess Maladjustment; STAt. State-Tratt AnXiety InventQly: STPP. short-term psychodynamic psychotherapy; TAU. treatment as usual: TSIA and TSIAI. severity for all target objectives and most important objective. TSP & TSPI. severity for all target objectives and most important objective. TST & TSTf. severity for all target objectives and most importantobjective: WAI, Work Ability Index. WISPI. Wisconsin Personality Disorders Inventory; % o;agnosis. percentage of patients fulfilling criteria for diagnosis.

aLTPP combined with psychotropic medication in some patients of the sample.b Intenlion to treat samples.CData of tllese comparison groups were not included in tllis meta-analysis,dThese outcome measures were not included (no cfata to calculate effect size d for the respective treatmenl or patient group),epredominant diagnoses in sample.

lasting 2:1 year), multiple mentaldisorders (defined as 2 or more diagnoses of mental disorders), and complex depressive or anxiety disorders.

Treatment manuals aT manual-likeguidelines were applied in 12 studies, t

The mean (SD) number of sessionscarried out in the 23 studies ofLTPP was151.38 (154.98) and a median 01'73.50.The duration of therapy was 94.81(58.79) weeks and a median of 69,00,

For LTPP the mean (SD) length offollow-up period after treatment was93.23 (64,93) weeks,

In 16 of the 23 studies, olltcomedata for LTPP alone without anyconcomitan t psychotropic medica-

:t:References 12. 14.54.55,57.59,61,62,68.76-78,

tion were reported,§ In 7 studies, somepatients received concomitant psychotropic medication as needed (ie, because of higher symptom severity orother clinical factors). 12.14,30 .57.61.61>.7H

Tests for Heterogeneity

To test for heterogeneity of the effectsof LTPP, we used the Q statistic+l.52 Toassess the degree of heterogeneity, wecalculated the 12 index,4H For some outcome analyses, Q yielded a significantresult. In the total sample of 23 studies, [or example, this was true [or overall outcome at the postlest assessment(Q=53.71; P=.002; 12 =49%), In the 8comparative studies o[ LTPP, how-

§References 54.55,59,60.62,65,68-71.73-77.79.

ever, Q was significant for only 2 variables, both [or follow-up data for whichonly 2 studies allowed the calculationof the respective effect sizes (targetproblems: Q=11.92; P=.OOI; 11=92%;social functioning: Q=4.53; P=.03;F= 78%). In the comparative studies,the 12index [or overall outcome was OOAl,for target problems, 45%; [or symptoms, 46%; for personality [unctioning, 60%; and social functioning, 51%at the time of posttest indicating low tomedium heterogeneity.Ho For [ollowup, the number o[ studies providingdata was too limited to calculate reasonable 12 statistics. To take heterogeneity between studies into account, weused the random-effects modelthroughout.

©2008 American Medical Association. All rights reserved. (Reprinted) JAMA. OCiuber I, 200S-Vol 3110. No. 13 1557



Tests for Publication BiasTo reduce the me-drawer effect, wetried to identify unpublished studiesvia the Internet and by contactingresearchers. Only 1 additional LTPPstudy was identified, but it was notincluded because long-term grouptherapy was appliedH' To test for publication bias, we calculated the Spearman rank correlation between effectsize and sample size across studies. Asignificant correlation may indicate apublication bias in which studies withlarger effect sizes in 1 direction aremore likely to be publishecl.H2 Due tothe small number of studies providingfollow-up data, we assessed the corre-

lations for only the posttreatmenteffect sizes. All correlations were nonsignificant (P> .30).

As another test for publication bias,we assessed the fail-safe number according to Rosenthal for the posttreatment effect sizes.-tY A fail-safe numberis the number of nonsignificant, unpublished, or missing studies thatwould need to be added to a metaanalysis in order to change the resultsof the meta-analysis from significanceto nonsignificance. In the total sampleof studies examining LTPP alone, thefail-safe numbers were 921 for overalloutcome, 535 for target problems, 623for general symptoms, and 358 for so-

cial functioning. Due to the smallernumber of studies providing data forou tcome measures of personality functioning, the fail-safe number was 42 forpersonality functioning. Even this number is almost twice the number of studies we included. We therefore failed tofind any indication of publication biasin this meta-analysis.

Correlation of Quality RatingsWith Outcome

To examine the relationship betweenstudy quality and outcome ofLTPP, thewithin-group effect sizes for overall outcome, target problems, general symptoms, personality functioning, and so-

Figure 2. Effects of Long-term Psychodynamic Psychotherapy on Overall Outcome

Sample Effect Size Indicates IndicatesSource Size, No. (95% Gil deterioration improvement

Randomized Controlled Trials

Bachar et al .... 1999 17 0.89 (0.18 to 1.59) ---.---Baleman and Fonagy." 1999 19 1.45 (0.73 10 2.16) --.--C1arl<in et al, loj 2006 30 0.89 (0.3610 1.42) ---.--Dare el al.'" 2001 20 0.88 (0.23 10 1.53) ---.---Gregory el al."' 2008 15 1.02 (0.26 10 1.78) ---.---Hoglend el al.'" 2006 (1) 52 0.96 (0.5610 1.37) •Hoglend el al.'" 2006 (2) 48 096 (0.54 to 1.38) -.-Huber and l\lug,65 2006 35 1.74 (1.19 to 2.29) -.-Knel<1 al al,e.. 2008 128 1.07 (0.81 10 1.33) -.-Piper et al,73 1984 20 0.56 (-0.08 10 1.19) ----.---Svartberg al al." 2004 25 0.65 (0.0810 1.22) ---------Vinnars a1 31.;e 2005 (1) 80 0.78 (0.46 10 1. 10) -.-Vinnars al al." 2005 (2) 76 0.69 (0.36 10 1.0'1) ---Subtotal 565 0.94 (0.82 10 1.06) •

Observational Studies

Barberal ai," 1997 (1) 13 0.99(0.18tol.81) .-----Barber et ai," 1997 (2) 14 1.14(0.34to 1.94) .----Bond and Perry,J9 2004 41 0.56(0.1210 1.01) --11--

Clarkin et a1. 5';' 2001 23 0.34(-0.24 100.93)

Grande et al.co 2006 (1) 32 1.36 (0.82 to 1.91) -.-Grande et al.'" 2006 (2) 27 0.78 (0.23 10 1.34) ---Korner et al.ae 2006 29 1.39 (0.82 to 1.96) --.--Leichsenring at aI." 2005 36 1.62 (1.09 to 2.15) -.-Lubarsky et al.;o 2001 17 0.96 (0.25 to 1.67) ---------Monsen el al,71 1995 23 1.38 (0.73 to 2.02) --.--Rudolf el ai," 1994 44 0.61 (0.1910 1.04) --II--

Sandell et ali' 2000 (1) 24 1.04 (0.44 to 1.65) --.--Sandell et alis 2000 (2) 99 0.46(0.18100.74) -.-Stevenson and Meares,';'';; 1992 30 1.34 (0.78 to 1.90) --.--Wilczek et al,70 2004 36 1.26 (0.75 to 1.(6) -.-Subtotal 488 0.99 (0.86 to 112) •Total 1053 0.96 (0.87 10 1.05) • ,

-0.5 0 05 1.0 1.5 2.0 2.5

Hedges d (95% CI)

Overall outcome was assessed by averaging the effect sizes of target problems, generai psychiatric symptoms, and personality and social functioning. Effect sizes areHedges d (ie, Within-group effect sizes). measured at the beginning and end of therapy. Error bars represent 95% confidence intervals (Cis). Studies are stratified intorandomized controlled triais (RCTs) vs observational studies (with or without controi groups).

1558 JAMA. Ocwber I. 20L18-Vol 300, No. 13 (Reprinted) ©2008 American Medical Association. All rights reserved.

Downloaded from www.jama.Gom at University of Arizona on November 9, 2008


cial functioning were correlated withthe total score of the ]adad scale. Dueto the small number of studies providing follow-up data, correlations wereonly calculated for posttreatment effectsizes. For this purpose, the averagescore of the 2 raters was used. All correlations were nonsignificant (P> .28).

Comparison of RCTsWith Observational Studies

A forest plot listing the within-group,ie, pretreatment-posttreatment, effectsizes of LTPP on overall outcome foreach of the 23 studies is presented inFigure 2. Data are presen ted separately for RCTs and observational studies. Considering each LTPP conditionincluded in the 23 studies resulted ina total of 13 effect sizes for randomized trials and 15 effect sizes for observational studies.

To test for differences between RCTsand effectiveness (observational) studies, we calculated point biserial correlations in the total sample of 23 studies between the within-group effect size ofLTPP at posttest and the type of studydesign (RCT, 1; observational studies, 0).According to the results, all correlations with outcome measures were nonsignificant (P> .36). Observational studies, therefore, did not provide effect sizessignificantly different from those ofRCTs. There were also no significant differences between the effect sizes of 16controlled and 7 uncontrolled studieswhen the 5 studies including observational control groups55.no.li,u4.75(Table 1)were included (P> .22).

In view of these findings, data fromRCTs and observational studies werecombined in the further analyses ofeffect sizes of LTPP (see total score inFigure 2).

Effects of LTPP vs Thoseof Other Psychotherapy Methods

Eight controlled studies provided thedata necessary for comparative analyses of LTPP with other forms ofpsychotherapy.12.14.54.54.nl.hK.7J.77 These

studies included the treatment of personali ty, eating, and heterogeneousdisorders (Table 1). The psycho thera-

peutic treatments applied in the comparison groups included CBT,cognitive-analytic therapy, dialecticalbehavioral therapy, family therapy,supportive therapy, short-term psychodynamic therapy, and psychiatrictreatment as usual (Table I). For thesample of comparative studies, wetested for a correlation between psychotropic medication (0/1) and outcome. Due to the small number ofstudies providing data for follow-upassessments, tests of significance werecarried out only for the posttherapydata, not for the follow-up data. Noneof the correlations were significant(P> .13). For this reason, we includedstudies of both LTPP alone andLTPP combined with psychotropicmedication in the comparative analyses of LTPP vs other methods ofpsychotherapy.

In the 8 studies included, the mean(SD) duration of LTPP was 53.41(30.92) weeks and a median of 52weeks. The mean number ofLTPP sessions ,vas 102.57 (135.58), and a median of 49 sessions. In the comparisongroups, the mean treatment durationwas 39.02 (22.77) weeks, and a median of 52 weeks; the mean number ofsessions was 32.58 (27.65), and a median of 22 sessions. Comparing thewithin-group effects ofLTPP with thoseof the comparison groups will yield information about the possible additional benefit ofLTPP. Due to the smallnumber of studies providing data forfollow-up assessments, tests of significance were canied out only for the posttherapy data, not for the follow-up data.

We calculated point biserial correlations (1'1') between the within-groupelTectsizes and type of treatment (LTPPvs other psychotherapies, I/O) as a measure of between-group effect size as described in the methods section.41 .42 AccOl'ding to Cohen,42(rK1) a point biserialcorrelation of 0.371 constitutes a largeeffect size. The point biserial correlation was also used to test for significance of ditTerences between LTPP andother methods of psychotherapy. As afirst step, we compared LTPP with otherforms of psychotherapy applied in the

comparison groups across the variousmental disorders treated in the 8 studies listed above. This comparison included 8 treatment conditions ofLTPPand 12 treatment conditions of otherpsychotherapeutic methods. According to the results, the point biserial correlation between the within-group effectsize and treatment condition was significant for overall outcome (1'1'=0.60;95°;':, Cl, 0.25-0.81; P= .005, n=20), target problems (1'1'=0.49; 95°!c, CI, 0.080.76; P= .04, n= 18), and personalityfunctioning (1'1'=0.76; 95% CI, 0.330.93; P= .02, n=9). Thus, LTPP yieldedsignificantly larger pretreatmentposttreatment effect sizes in overall effectiveness (0.96 vs 0.47), targetproblems (1.16 vs 0.(1), and personalityfunctioning (0.90 vs 0.19) than didother forms of psychotherapy appliedin the comparison groups. The between-group effect sizes of 1'1'=0.60,0.49, and 0.76, respectively, clearly exceed the value of 0.371 and are therefore considered large effects.'12 For social functioning, the between-groupeffect size was large as well (1'1'=0.39;95% CI, -0.13 to 0.74; P=.19, n=13),but not significant due to the smallnumber of studies reporting this outcome (symptoms: 1'1'=0.29; 95'iG CI-0.22 to 0.68; P=.30, n=14).

In the second step of the comparative analysis, we focused on thosestudies including complex mental disorders that we defined as personalitydisorders, chronic mental disorders, ormultiple mental disorders. For thispurpose, 1 study had to be excludedfrom analysis because the patientsample was not described as havingany of these conditions./} In order toachieve a sufficient sample size, we didnot conduct separate analyses forchronic mental disorders, multiplemental disorders, personality disorders, or complex depression and anxiety disorders. We instead lumpedthese studies together as studiesincluding "complex mental disorders."In these studies, the point biserial correlation between treatment condition(LTPP vs other psychotherapies) andwithin-group effect sizes was again

©2008 Amcrican Mcdical Association. All rights rcscrvcd. (Reprinted) JAMA, OCiuber 1. 2008-Vol 300, No. 13 1559



Table 2. Effect Sizes (d) of Long-term Psychodynamic Psychotherapy Alone Across VariousMental Disorders

Abbreviations: CI, confidence interval: d, Hedges d: blank cell indicates that no tests of significance were performeddue to the small number of studies providing data

aBecause some studies included more than 1 form of long-term psychodynamic psychotherapy, the number of treatment conditions in some cases differs from the number of studies.

IIReferences 54,55,59,60,62,65,68-71,73-77,79.

off than 96% of the patients in thecomparison groups.

'II References 54, 55, 59, 60, 62, 65, 68-71,73-77,79.

Therapy Duration and Effect Sizes

In the studies of LTPP alone, thenumber of sessions correlated significantly with the outcome fortarget problems (Spearman 1',=0.62,P= .03, n= 12) and general psychiatricsymptoms (r,=O.54, P=.04, n=15),at posttest time points. The correlations with overall outcome (r,=0.29,P=.25, n=l7), changes in personality(1',=0.43, P=.40, 11=6), and socialfunctioning (1',=O.ll, P=.73, n=12)were not significant. The duration oftherapy (weeks) did not show significant correlations with outcome ofLTPP alone (P> .07). Again, no correlations were calculated for follow-updata due to the small number of studies providing such data.

Effects for LTPP Alone AcrossVarious Mental Disorders

As a first step, we assessed the outcome of LTPP alone by evaluating theeffect sizes across the various mentaldisorders treated in the respective studies of LTPP alone.9l Four of these 16studies included 2 treatment conditions of LTPP.55.nll,f>2.75 Thus, 1.6 studies and 20 tTeatment conditions ofLTPPencompassing 641 patients were evalu'Hed. The within-group effect sizes ofLTPP are presented in TABLE 2. According to the results, LTPP yielded significant pretreatment-posttreatmenteffect sizes that were stable at follow-up for all outcome areas. With theexception of personality functioning(0.78), all effect sizes including thoseat follow-up were more than 0.80 indicating large effects. For overall outcome, we compared the posttreatment effect sizes of LTPP alone withthose at follow-up. The effect sizes significantly increased at follow-upCt=3.76, P=.007).

LTPP alone in those studies. To avoidbias when estimating the effects ofLTPPin specific groups of patients, we decided to include only studies of LTPPalone without concomitant psychotropic medication.

.003

.005

.001

<.001

<.001

<.001

<.001

<.001

<.001

P Value(2-Tailed Test)

Comparison of LTPP Aloneand LTPP Combined WithPsychotropic Medication

1n 7 of the total sample of 23 studies,some patients received concomitantpsychotropic medication as needed (ie,patients were not randomly assigned tomedication but received medication because of higher symptom severity orother clinical factors). Therefore, weagain compared the effect sizes ofLTPPalone (16 studies) II and LTPP combined with psychotropic medication (7studies) 12,14J9.57,(il,6f>.7~by calculating the

point biserial correlation between effectsize and treatment condition (LTPPalone vs LTPP combined with psychotropic medication, Oil). For target problems, the correlation was significant(r,,=-0.45; 95 0ft, cr, -0.11 to -0.69;P=.05). This means that LTPP combined with psychotropic medicationyielded significantly smaller pretreatment-posttreatment effect sizes than

significant for overall outcome(r,,=0.68; 95% CI, 0.35-0.86; P=.002,n= 18), target problems (1',,=0.69; 95%CI, 0.34-0.87; P=.003, n=16), andpersonality functioning (1',,=0.96; 95%Cl, 0.84-0.99; P< .001, n= 7). Thebetween-group effect sizes were alsolarge, but not significant for generalpsychiatric symptoms (1',,=0.40; 95%cr, -0.14 to 0.76; P= .20, n = 12) andsocial functioning (1',,=0.45; 95% Cl,-0.11 to 0.79; P=.17, n=l1). Thebetween-group effect sizes of r,,=0.68,0.69, and 0.96 are equivalent to Cohend=1.8 (95% Cl, 0.7-3.4),1.9 (95% cr,0.7-3.5), and 6.9 (95% cr, 3.0-14.6),respectively.-f2(r221 In complex mentaldisorders, therefore, the differences ineffect size between LTPP and otherforms of psychotherapy for overalloutcome, target problems, and personality functioning were between 1.8and 6.9 standard deviations. Effectsizes can be transformed into percentiles. 42 .M3 For example, a betweengroup effect size of 1.8 (95% cr, 0.73.4), as identified in overall outcome,indicates that after treatment withLTPP patients on average were better

No. ofTreatment

Conditions· d (95% CI)

Overall effectiveness pretllerapy 20 1.03 (0.84 to 1.22)vs posttllerapy

Overall effectiveness pretherapy 8 1.25 (1.00 to 1.49)vs follow-up

Target problems pretllerapy 14 1.54 (1 .20 to 1.87)vs posttherapy

Target problems pretherapy 6 198 (137 to 2.59)vs follow-up

Psychiatric symptoms pretherapy 17 0.91 (0.72 to 1.11)vs posttherapy

Psychiatric symptoms pretherapy 6 1.06 (0.64 to 1.47)vs follow-up

Personality functioning pretherapy 7 0.78 (0.30 to 1.26)vs posttllerapy

Personality functioning 3 1.02 (-0.99 to 3.03)pretherapy vs follow-up

Social functioning pretherapy 14 0.81 (0.60 to 1.03)vs posttherapy

Social functioning pretherapy 7 0.91 (0.49 to 1.34)vs follow-up

1560 JAMA, OC1Qber 1. 2008-V,,1 300, No. 13 (Reprinted) ©2008 American Medical Association. All rights reserved.



Table 3. Effect Sizes (d) of tong-term Psychodynamic Psychotherapy Alone in Patients WithPersonality Disorders and Chronic Mental Disorders

Abbreviations: CI. confidence interval; d. Hedges d; blank cell indicates 1I1at no tests of significance were performeddue to the small number of sfudies providing data.

aBecause some studies included more than 1 form of long-term psychodynamic psycllofherapy. fhe number of treatment conditions in some cases diHers from 1I1e number of studies.

studies in which at least 50% of thepatient sample had 2 or more diagnoses of mental disorders. Thisgroup of studies overlaps in part withthe studies of personality disorders,chronic mental disorders, anddepressive and anxiety disordersbecause these mental disorders areusually highly comorbid. '7 ' 21 Thiscondition was true for 8 studies oflTPP alone.55.oo.62.65.6~.71.H/7Three of

points (Table 3). All effect sizes including those at follow-up were again morethan 0.80 indicating large effects in alloutcome areas.

.02

.004

007

.002

.004

<.001

<.001

<.001

P Value(2-Tailed Test)

0.88 (0.40 to 1.37)

1.79 (-)

2.45 (-)

d (95% CI)

1.23 (-0.06 to 2.52)

0.87 (0.18 to 1.56)

1,05 (0,69 to 1.41)

1.32 (0.63 to 2.01)

1.36 (0.21 to 2.51)

1.70 (0.40 to 3.00)

1.05 (0.61 to 1.48)

0.82 (0.39 to 1.25)

1.04 (-)

1.13 (-)

1.58 (0.80 to 2.35)

0.95(-)

1.65 (-5.90 to 9.19)

0.89 (0.49 to 1.29)

0.92 (-1.81 to 3.65)

1.21 (-1,62 to 4.03)

1.16 (0.82 to 1.50)

5

8

3

6

3

3

4

2

2

9

5

2

5

6

6

No. ofTreatment

Conditions a

Psychiatric symptoms pretherapyvsfollow-up

Personality functioning pretherapyvs posttherapy

Psyclliatric symptoms pretherapyvs posttherapy

Social functioning pretherapyvs posttllerapy

Psyclliatric symptoms pretherapyvs posttherapy

Personality functioning pretherapyvs follow-up

Target problems pretherapyvs follow-up

Social functioning pretherapyvs posttherapy

Psychiatric symptoms pretllerapyvs follow-up

Personality functioning pretherapyvs posttherapy

Social functioning pretherapyvs follow-up

Target problems pretllerapyvs posttllerapy

Overall effectiveness pretherapyvs follow-up

Personality fUllctioning pretherapyvs follow-up

Social functioning pretllerapyvs follow-up

Overall effectiveness pretherapyvs follow-up

Target problems pretllerapyvs posttherapy

Target problems pretherapyvs follow-up

Patients witll cllronic mental disordersOverall effectiveness pretherapy

vs posttherapy

Patients with personality disordersOverall effectiveness pretherapy

vs posttllerapy

Effect Sizes for LTPP Alonein Patients With MultipleMental Disorders

To assess the outcome of lTPP alonein patients with multiple mental disorders, we separately evaluated those

#References 12. 14. 55. 57, 61,68,71,76-78.

Effect Sizes for LTPP Alonein Patients With PersonalityDisordersTen studies included treatments of personality disorders by lTPP (Table 1).#Five studies examined the effects oflTPP alone.55.oH.71,76./7 One study in-cluded 2 different groups of personality disorders (avoidant and obsessivecompulsive personality disorder)tTeated with lTPP.55 Thus, 5 studies and6 treatment conditions oflTPP encompassing 134 patients were evaluatedwith regard to the treatment of personality disorders. According to the results, lTPP alone yielded significanteffect sizes for overall outcome, targetproblems, general psychiatric symptoms, and social functioning at posttest time points (TABLE 3). All theseeffect sizes were more than 0.80 inclicating large effects. large effect sizeswere also observed for personality functioning at posttest and for all outcomeareas at follow-up. Due to the smallnumber of studies, however, we performed no tests of significance for thesefindings (Table 3). Also in the following analyses, no tests of significancewere performed for follow-up data because of small sample size.

Effect Sizes for LTPP Alonein Patients With ChronicMental Disorders

[n 7 studies, patients with chronic mental disorders (defined as mental disorders lasting 2:: 1 year) were treated wi thlTPP alone.54.5~.no.o5M.H,75This sub-

sample of studies overlaps in part withthe studies of multiple mental disorders and depressive and anxiety disorders described below. Two studies inc1uded2 different treatment conditionsoflTPP."o.75 Thus, the data from 7 studies including 9 lTPP treatment conclitions including 334 patients were entered in our meta-analysis. Accordingto the results, lTPP alone yielded signilkant and large effect sizes for overall outcome, general psychiatric symptoms, personality functioning, andsocial functioning at posttest time

©2008 Amcrican Mcdical Association. All rights rcscrvcd. (Reprinted) JAMA, October 1. 2008-VoI31111. No. 13 1561



Target problems pretherapy 8 1.62 (1.07 to 2.18) <.001vs posttllerapy

Overall effectiveness pretherapy 7 1.28 (1.01 10 1.54) <.001vs follow-up

Table 4. Effect Sizes (d) of Long-term Psychodynamic Psychotherapy Alone in Patients WithMultiple Mental Disorders or Mainly Complex Depressive and Anxiety Disorders

Patients with mUltiple mental disordersOverall effectiveness pretherapy 11 1.09 (0.83 to 1.36) <.001

vs posttllerapy

these studies included patients withmultiple mental disorders. In addition, the patients in 71 % of these studies had chronic mental disorders. Thus,the depressive and anxiety disorder subsample ofstudies included patients withchronic and/or multiple mental disorders (complex mental disorders). Because 2 studies included 2 differenttreatment conditions ofLTPP,6o.62 ailSstudies and 7 LTPP treatment conditions including 274 patients were included in our meta-analysis. According to the results, LTPP alone yieldedsignificant and large effect sizes in overall outcome, general psychiatric symptoms, and social functioning at posttest. All effect sizes, including those atfollow-up, were more than 0.80 indicating large effects in all outcome areas(Table 4).

P Value(2-Tailed Test)d (95% CI)

Effect Sizes for LTPP Alonein Patients With ComplexDepressive and Anxiety Disorders

In 5 studies ofLTPP alone, the majority of patients had complex depressiveand anxiety disorders.60.(i2.1i4.tw./4 All of

functioning. All effect sizes includingthose at follow-up were more than0.80 (TABLE 4).

No. ofTreatment

Conditions a

these studies included 2 differenttreatment conditions of LTPP thatwere evaluated separately.55.()O.tilThus, 8 studies including 11 LTPPtreatment conditions including 349patients were included in our metaanalysis. According to the results,LTPP yielded significant before-aftereffect sizes for all outcome domainswith the exception of personality

Target problems pretherapy 5 1.84 (1.22 to 2.45) .002vs follow-up

Psyclliatric symptoms pretherapy 11 0.98 (0.76 to 1.21) <.001vs posttherapy

Psychiatric symptoms pretherapy 5 1.18 (0.81 to 1.55) .001vsfollow-up

Personality functioning pretherapy 3 0.96 (-0.52 to 2.44)vs posttherapy

Personality functioning pretherapy 2 1.43 (-3.32 to 6.18)vs follow-up

Social functioning pretherapy 9 0.94 (0.70 to 1.17) <.001vs posttllerapy

Social functioning pretllerapy 6 1.01 (0.57 to 1.45) .002vs follow-up

Patients with complex depressiveand anxiety disorders

Overall effectiveness 7 1.13(0.74t01.51) <.001pretllerapy vs posttherapy

Overall effectiveness 5 1.30 (0.91 to 1.68) .001pretherapy vs follow-up

Target problems pretherapy 4 1.82 (0.87 to 2.77)vs posttherapy

Target problems pretllerapy 3 1.94 (1.01 to 2.88)vs follow-up

Psychiatric symptoms 7 1.02 (0.70 to 1.34) <.001pretherapy vs postlherapy

Correlation of OutcomeWith Specific Patientand Therapist Variables

We examined the effect of the following variables on posttreatment outcome of LTPP (sensitivity analyses):age, sex, diagnost.ic group (personality disorders, chronic or multiple mental disorders, and depressive and anxiety disorders), general and specificclinical experience of t.herapists (years),use of t.reatment manuals (O/l.), andspecific training in t.he applied t.reatment. model (0/1). The impact of 10variables on 10 out.come variables (5 before-after and5 before follow-up variables) was test.ed. In order t.o prot.ect.against t.ype 1 error inflation, we adjust.ed for multiple t.est.ing (0.05/100).All correlat.ions wit.h the outcome ofLTPP were nonsignificant. (P> .04).

Psyclliatric symptoms 3 1.32 (0.63 to 2.01)pretherapy vs follow-up

Personality functioning 2 0.9! (-6.00 to 7.94)pretherapy vs postlherapy

Personality functioning 1.79 (-)pretherapy vs follow-up

Social functioning pretllerapy 6 1.02 (0.73 to 1.31) <.001vs postlherapy

Social functioning pretherapy 5 0.99 (0.44 to 1.54) .009vs follow-up

Abbreviations: CI. confidence interval; d. Hedges d: Blank cell indicates that no tests were performed due to the smallnumber of studies providing data.

aBecause some studies included more lIlan 1 torm of long-term psychodynamic psychotherapy. the number of treatment conditions in some cases differs from tile number of studies.

COMMENT

A considerable proportion of pat.ientswith chronic ment.al disorders or personality disorders do not. benefit sufficiently from short-term psychotherapy9.lll However, long-termpsychotherapy is associat.ed wit.h higherdirect cost.s t.han short-term psychotherapy. For this reason, it is import.ant t.o know whet.her the benefit.s ofLTPP exceed t.hose of short-term treat.-

1562 JAMA, OClober 1. 20LlS-V,,1 300, Nu. 13 (Reprinted) ©2008 American Medical Association. All rights reserved.



ments. In this meta-analysis, LTPP wassignificantly superior to shorter-termmethods of psychotherapy with regard to overall outcome, target problems, and personali ty functioning.Long-term psychodynamic psychotherapy yielded large and stable effectsizes in the treatment of patients withpersonality disorders, multiple mental disorders, and chronic mental disorders. The effect sizes for overall outcome increased significantly betweenend of therapy and follow-up.

One limitation of this meta-analysismay be seen in tbe limited number ofstudies. The results presented in thismeta-analysis, however, were robust.According to the results of sensitivityanalyses, they were independent. of age,sex, patient subgroups, experience oftherapists or use of treatment manuals. We also did not find indications forpublication bias. We performed failsafe number analyses and found that,except for personality functioning, morethan 300 studies would need to beadded to change the results of the metaanalysis from significance to nonsignificance.

Some of the studies included werecarried out in the 1980s and somemethodological shortcomings can beexpected (eg, problems of randomization, allocation concealment, or observer bias). There was some variancebetween the included studies with regard to methodological quality as assessed by the scale proposed by Jadadet al. 53 That scale, however, did notshow significant correlations with effectsizes of LTPP. This was also true forstudy design (RCTs vs observationalstudies). The latter result suggests thatthe outcome data of the RCTs included in this met.a-analysis are representative for clinical practice. On theother hand, the results also show thatthe data of the observational studies didnot systematically overestimate or underestimate the effects of LTPP.~4 Future studies addressing this questionshould include more specific comparisons of RCTs and observational studies using comparable treatments and diagnostic groups.

Several studies did not meet our inclusion criteria because the majority ofpatients had not completed their treatment at the time points when effect sizeswere assessed by the authors of theoriginal studies. This was true, for example, for the studies by Brockmann etal,"5 Puschner et al/ fi and Giesen-Blooet al.H

? In the study by Giesen-Bloo, forexample, 19 of 42 patients (45%) werestill in treatment (LTPP) when outcome was assessed, and only 2 patients had completed LTPP. In the comparison group 27 of 44 patients (61%)were still in treatment, and only 6 patients had completed the treatment.Data from ongoing treatments do notprovide valid estimates for treatmentoutcome at termination or follow-up,eg, if patients received only half of the"dose" of treatment when outcome isassessed.

Whether the effects of psychotherapy improve with longer treatments remains an interesting question. In this meta-analysis, the numberofLTPP sessions was Significantly correlated with improvements in both target problems and general psychiatricsymptoms. These results are consistent with previous findings 9 . lo However, no such correlations were foundfor the duration of LTPP. The numberof sessions and duration of LTPP appear to be different parameters thatfunction differently with regard to thepsychotherapeutic process and outcome.

Future research on LTPP, as well ason other approaches when applied aslong-term treatment (eg, CBT or interpersonal therapy) should focus on complex mental disorders, such as "doubledepression" (ie, major depressive disorder plus dysthymic disorder). Thesestudies should compare not only the effects of short-term and long-term psychotherapy but also direct and indirect costs. Some cost-effectivenessstudies suggest that LTPP may be a costefficient treatment.KH

-90

Author Contributions: Drs Leichsenring and Rabunghad full access to all of the data in the study and takeresponsibility for the integrity of the data and the accuracy of the data analysis.Study concept and design: Leichsenring, Rabung.

Acquisition of data: Leichsenring, Rabung.Analysis and interpretation of data: Leichsenring,Rabung.Drafting of the manuscript: Leichsenring, Rabung.Critical revision of the manuscript for important intellectual content: Leichsenring, Rabung.Statistical analysis: Leichsenring, Rabung.Administrative, technical, or material support:Leichsenring, Rabung.Financial Disclosures: None reported.Additional Contributions: We thank Jacques Barber,PhD (Department of Psychiatry, University of Pennsylvania), John Clarkin, PhD (Weill Medical Collegeof Cornell University, New York), Louis Diguer, PhD(Department of Psychology, University of Laval,Quebec), Ivan Eisler, PhD (Institute of Psychiatry, King'sCollege London, England), Dorothea Huber, MD, PhD(Department of Psychosomatic Medicine, TechnicalUniversity Munich, Germany), Paul Knekt, PhD (National Public Health Institute, Helsinki, Finland), William Lamb, PhD (University of California at Berkeley),William Piper, PhD (Department of Psychiatry, University of British Columbia, Vancouver), Sydney Pulver,MD (Department of Psychiatry, University of Pennsylvania), Frank Petrak, DSc (Department of Psychosomatic Medicine, University of Bochum, Germany),Rolf Sandell, PhD (Department of the BehaviouralSciences, Linkbping University, Stockholm, Sweden),Martin Svartberg. MD, PhD (Department of Psychiatry, Mount Sinai Hospital, Toronto), and AlexanderWilczek, MD, PhD (Department of Clinical Neuroscience, Karolinska Institute, Stockholm, Sweden) for information about their studies. None of these individuals received compensation for their support.

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