Further Evidence for Short-Term Psychodynamic Therapy in Major Depressive Disorder

Dear Editor:

The Canadian Network for Mood and Anxiety Treatments (CANMAT) guidelines recommend short-term psychodynamic therapy (STPP) as a second-line treatment for the acute treatment of depression “due to an absence of replication of specific models.”^1(p8)

We would like to point out that the committee has not taken into account that for de Jonghe et al.’s model of STPP, ² 2 randomised controlled trials (RCTs) provide evidence for efficacy in the (acute) treatment of depression. ^3,4 In the first RCT, STPP was as efficacious as the combination of pharmacotherapy and STPP with no differences between treatment conditions in the intention to treat sample in any outcome measure at any time of measurement. ³ With samples of 106 and 85 patients per group, sample size can be regarded as adequate. This study is a proof of the efficacy for STPP, since STPP fared as well as an efficacious treatment—the combined treatment was at least as efficacious as pharmacotherapy alone, for which efficacy has been established, ⁵ as the success rates yielded by the combined treatment in the 2004 study ³ are descriptively higher than those of pharmacotherapy alone in an earlier study by de Jonghe et al. ⁶ For further comparisons, see also the recovery rates for pharmacotherapy listed by Craighead et al.^7(p387) Adding STPP to pharmacotherapy ³ did not reduce efficacy but rather increased it.

In the second RCT of the de Jonghe model, STPP was as efficacious as CBT. ⁴ This led Thase to the following conclusion: “On the basis of these findings, there is no reason to believe that psychodynamic psychotherapy is a less effective treatment of major depressive disorder than CBT.”^8(p954)

With 2 RCTs demonstrating efficacy, STPP following de Jonghe et al.’s model fulfils the criteria used by CANMAT ¹ (Table 1, p. 3) for level 1 evidence. This model can also be regarded as ‘efficacious’ according to the criteria for empirically supported psychotherapies. ^9,10

Furthermore, in another large RCT just published, STPP using Luborsky’s model ¹¹ proved to be as efficacious as CBT in the treatment of depression. ¹² According to the criteria used by CANMAT (Table 1, p. 3), a treatment may be considered first line if level 2 evidence (1 or more RCTs with adequate sample size) is available and clinical support exists. ¹ As this is the case for Luborsky’s model of STPP, it can be considered another first-line treatment for acute depression.

In light of the above-mentioned findings, we ask the CANMAT committee to correct their grading of STPP and recommend the STPP models by de Jonghe et al. and Luborsky et al. as first-line treatments for acute depression.

To rule out the possibility of biases in favor of any kind of therapy, a committee developing treatment guidelines ideally consists of proponents of all kinds of treatments involved (a form of adversarial collaboration ¹³ ). This is the case, for example, in Germany with regard to the treatment guidelines for depression and the evaluation of psychotherapy. ^14,15 We wonder whether this was the case in the CANMAT committee.

Falk Leichsenring, DSc Christiane Steinert, PhD Department of Psychosomatics and Psychotherapy, Justus-Liebig-University Giessen, Giessen, Germany