What works for whom when treating major depression with psychotherapy? 1

To the Editor

The aim of this article is to respond systematically to queries (Leichsenring et al., 2021) about the positioning of psychodynamic psychotherapy (PP) in the 2020 RANZCP clinical practice guidelines for mood disorders (Malhi et al., 2021). Each query is paraphrased and addressed below. ²

1. When discussing PP, the guidelines state ‘… not all depressive presentations benefit from this therapeutic approach’, and ‘robust replications are required’. The same could be said of all psychological interventions.

Response: We agree that these statements are not specific to PP. However, readers are left in no doubt that short-term PP (STPP – 25–30 sessions) has strong evidentiary support for treating major depression. The guidelines position STPP as one of six evidence-based psychotherapies. All of these have been shown more effective than control in at least 10 randomized controlled trials (RCTs), with benefits maintained over time (p. 44). At no point do the guidelines assert that cognitive behavioural therapy (CBT) is more effective than other psychological treatments for depression. ³ The decision to prioritize CBT and interpersonal therapy (IPT) was pragmatic, ‘… because they have been subjected to more investigation across sites, are more commonly taught in training programs and are familiar to current practitioner networks’ (p. 44).

• 2. The guidelines incorrectly assert, ‘there is no evidence to support long-term psychodynamic therapy’ (LTPP, 100–150 sessions), since there is evidence that LTPP is effective in complex presentations.

Response: This assertion was in Box 14, reviewing psychological treatments for acute major depression. To our knowledge, there is no evidence for LTPP (cf. STPP) for acute major depression. For example, across 14 reviewed investigations of PP for major depression (Leichsenring and Steinert, 2018), all tested STPP. Only one of these studies additionally investigated LTPP, finding that M = 232 sessions was significantly superior to M = 18.5 sessions of STPP for anxiety symptoms, but not for either depression symptoms or remission rates. Leichsenring and colleagues directed us to one interesting study comparing CBT (M = 45 sessions) with LTPP (M = 88) and psychoanalytic therapy (M = 234, 2–3 sessions per week) for the treatment of depressive symptoms in major depression (albeit not assessed by structured interview). Post-treatment, no significant differences between therapies were found. However, at 3-year follow-up, one comparison was significant: improvement of depressive symptoms, and remission from depression were significantly greater for psychoanalysis (patient lying on a couch, therapy duration M = 39 months, i.e. continuous across the follow-up period) compared to CBT (but LTPP was not superior to CBT). The guidelines (Box 12) note that many questions in this area await systematic investigation using such long-term follow-ups.

• 3. The guidelines cite a systematic review concluding that PP and dialectical behavior therapy but not CBT are superior to control.

Response: The cited review is for the treatment of borderline personality disorder, not the treatment of major depression. The authors (a) did not select studies based on an inclusion criterion of a depression diagnosis and (b) do not report depression outcomes separately (collapsing these data into what they call ‘general psychopathology’).

• 4. The guidelines incorrectly state that regression is promoted in PPs.

Response: At the risk of being pedantic, we wonder whether regression is considered a tool in some variants of PP? For example, it has been suggested that transitory regression may occur in the context of ‘working through’ trauma and that managing distress related to regression is an area of expertise within PP. We commend the efforts of a burgeoning group of PP advocates (including Leichsenring et al.) who are developing manualized versions of their treatments, which will help clarify questions about active ingredients and therapeutic mechanisms.

Concluding Remarks: The guidelines explicitly encouraged clinicians to remain open and skeptical about the evidence base for psychological treatments (p. 43), and we thank our colleagues for joining the discussion. We are particularly grateful to Leichsenring (personal communication, February 2022) for explaining how psychotherapy services are managed in Germany. Here, the state licenses practitioners to work in PP and psychoanalytic modalities and the German model includes independent review of psychotherapy treatment plans, through which therapists can request funding from statutory insurance companies for CBT (stepped increments of 24-60-80 sessions), psychodynamic (24-80-100), and psychoanalytic (160-240-300) treatment. Only if independent reviewers consider the planned, time-limited treatment to be efficacious and economic for this particular patient are costs reimbursed. In light of this, we welcome further discussion about quality assurance mechanisms for psychotherapy delivery in the Antipodean context.