BURNAND Y., ANDREOLI A., KOLATTE E., VENTURINI A. ROSSET N.
Leichsenring F, Rabung S
Gabbard GO, Gunderson JG, Fonagy P.
Kernberg OF.
Fonagy P, Roth A, Higgitt A.
Leichsenring F, Rabung S, Leibing E.
Lenzenweger MF, Lane MC, Loranger AW, Kessler RC.
Dekker JJ, Koelen JA, Van HL, Schoevers RA, Peen J, Hendriksen M, Kool S, Van Aalst G, De Jonghe F.Psychodynamic psychotherapy and clomipramine in the treatment of major depression
Effectiveness of Long-term Psychodynamic Psychotherapy. A Meta-analysis
The place of psychoanalytic treatments within psychiatry.
Psychoanalytic contributions to psychiatry.
Psychodynamic therapies, evidence-based practice and clinical wisdom
The Efficacy of Short-term Psychodynamic Psychotherapy in Specific Psychiatric Disorders. A Meta-analysis
DSM-IV personality disorders in the National Comorbidity Survey Replication.
Speed of action: the relative efficacy of short psychodynamic supportive psychotherapy and pharmacotherapy in the first 8 weeks of a treatment algorithm for depression..
Psychiatr. Serv.
JAMA
Arch Gen Psychiatry
Arch Gen Psychiatry
Bull Menninger Clin
Arch Gen Psychiatry
Biol Psychiatry
J Affect Disord 2002
2008
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resumé fr: Objectifs : Les auteurs ont comparé une combinaison de traitement par la clomipramine (Anafranil) et de psychothérapie psychodynamique associée à la clomipramine dans un essai contrôlé randomisé par mi des patients souffrant de dépression majeure.
Méthode : Soixante quatorze patients de 20 à 65 ans qui bénéficiaient de 10 semaines de traitement ambulatoire intensif pour dépression majeure ont été étudiés. Les troubles bipolaires, les symptomes psychotiques, les addicitons sévères, les troubles organiques, une intolérance antérieure à la clomipramine, et le retard mental étaient des critères d’exclusion.
Résultats : une amélioration marquée a été notée dans les deux groupes de traitement. Le traitement combiné était associé avec moins d’échec de traitement, une meilleure adaptation à 10 semaines, un meilleur fonctionnement global et une réduction du taux d’hospitalisation à l’issue du traitement. Une réduction du coût de 3 311 $ par patient dans le groupe de traiement combiné, associée avec un taux de réhospitalisation réduit et moins de journées de perte de travail, était supérieure au coût lié à la psychothérapie.
Conclusions : la mise en oeuvre d’une psychothérapie psychodynamique complémentaire chez des patients souffrant de dépression majeure qui reçoivent un trairement antidépresseur est efficace en terme de coût.
CONTEXTE : La place de la psychothérapie psychodynamique longue (LTPP) dans la psychiatrie est controversée. La recherche de la preuve de résultats des LTPP a manqué.
OBJECTIF : Examiner les effets des LTPP, particulièrement dans les troubles mentaux complexes, c-a-d patients présentant des troubles de la personnalité, des troubles mentaux chroniques, des troubles mentaux multiples, et des troubles complexes dépressifs et anxieux (c-a-d, associés à un cours chronique et/ou à des troubles mentaux multiples), en réalisant une méta-analyse.
SOURCES DES DONNÉES : Les études de LTPP publiées entre le 1 janvier 1960 et le 31 mai 2008, ont été identifiées par une recherche automatisée utilisant MEDLINE, PsycINFO, et les Current Contents, complétée par un contact avec les experts du domaine.
SÉLECTION DES ÉTUDES : Seules les études qui ont utilisé la psychothérapie psychodynamique individuelle durant pendant au moins une année, ou 50 séances ; prospectives ; et dans lesquelles des mesures fiables de résultats étaient incluses. Les études contrôlées randomisées (RCTs) et les études observationnelles ont été considérées. Vingt-trois études impliquant un total de 1053 patients ont été incluses (11 RCTs et 12 études observationnelles).
EXTRACTION DEs DONNÉES : L'information sur les caractéristiques de l'étude et des résultats du traitement a été extraite par 2 cotateurs indépendants. Les tailles d'effet ont été calculées pour l'efficacité globale, les problèmes cibles, les symptômes psychiatriques généraux, le fonctionnement de la personnalité fonctionnant, et le fonctionnement social. Pour examiner la stabilité des résultats, les tailles d'effet ont été calculées séparément pour l'évaluation à la fin de la thérapie et l'évaluation de suivi.
RÉSULTATS : Selon les analyses comparatives des essais contrôlés, les LTPP ont montré des résultats sensiblement plus élevés dans l'efficacité globale, des problèmes cibles, et le fonctionnement de la personnalité que des formes plus courtes de psychothérapie. En ce qui concerne l'efficacité globale, une taille d'effet Inter-groupe de 1.8 (intervalle de confiance
de 95% [CI], 0.7-3.4) a indiqué qu'après traitement avec LTPP les patients présentant des troubles mentaux complexes allaient en moyenne mieux que 96% des patients inclus dans les groupes de comparaison (P = 002). Selon des analyses de sous-groupe, les LTPP a montré des tailles d'effet significatives, importantes, et stables dans des groupes divers et en particulier les troubles mentaux complexes (allant de 0.78 à 1.98).
CONCLUSIONS : Il est démontré que les LTPP constituent un traitement efficace pour les troubles mentaux complexes. La recherche ultérieure devrait aborder les résultats des LTPP dans des troubles mentaux spécifiques et devrait inclure des analyses coût-efficacité.
Les traitements psychoanalytiques peuvent être nécessaires quand d'autres traitements sont inefficaces. Un cadre de travail empiriquement fondé pour l'usage de ces traitements implique des sources d'évidence émanant à la fois d’études d'efficacité potentielle et d’études d'efficacité en conditions naturelles.
La preuve préliminaire suggère que la psychanalyse semble être utile de façon consistante pour les patients présentant des troubles plus légers et quelque peu utile pour ceux qui présentent des perturbations plus graves.
Un plus grand nombre d'études contrôlées sont nécessaire pour confirmer ces impressions. Une étude de processus et de résultats multisites est proposée.
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resumeang: OBJECTIVE: The authors compared a combination of clomipramine and psychodynamic psychotherapy with clomipramine alone in a randomized controlled trial among patients with major depression. METHODS: Seventy-four patients between the ages of 20 and 65 years who were assigned to ten weeks of acute outpatient treatment for major depression were studied. Bipolar disorder, psychotic symptoms, severe substance dependence, organic disorder, past intolerance to clomipramine, and mental retardation were exclusion criteria. RESULTS: Marked improvement was noted in both treatment groups. Combined treatment was associated with less treatment failure and better work adjustment at ten weeks and with better global functioning and lower hospitalization rates at discharge. A cost savings of $2,311 per patient in the combined treatment group, associated with lower rates of hospitalization and fewer lost work days, exceeded the expenditures related to providing psychotherapy. CONCLUSIONS: Provision of supplemental psychodynamic psychotherapy to patients with major depression who are receiving antidepressant medication is cost-effective.
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 course and/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 MEDLINE, PsycINFO, and Current Contents, supplemented by contact with experts in the field.
STUDY SELECTION: Only studies that used individual psychodynamic psychotherapy lasting 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 1053 patients were included (11 RCTs and 12 observational studies).
DATA EXTRACTION: Information on study characteristics and treatment outcome was extracted 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, 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 (P = .002). According to subgroup analyses, LTPP yielded significant, large, and stable within-group effect sizes across 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 mental disorders and should include cost-effectiveness analyses.
Psychoanalytic treatments may be necessary when other treatments are ineffective. An empirically grounded framework for the use of these treatments involves sources of evidence from both efficacy and effectiveness studies. Preliminary evidence suggests that psychoanalysis appears to be consistently helpful to patients with milder disorders and somewhat helpful to those with more severe disturbances. A greater number of controlled studies are necessary to confirm these impressions. A multisite process and outcome study is proposed.
THE TIGHTLY argued essay in this month's issue of the ARCHIVES1 by 3 outstanding psychoanalytic researchers and highly respected contributors to both psychoanalytic and psychiatric literature is a welcome wake-up call to the psychoanalytic profession, as well as an expression of a realistic concern for the future of the psychoanalytic contributions to psychiatry. Its main recommendation, that the psychoanalytic profession carry out research on the efficacy and effectiveness of psychoanalytically based treatments, is eminently reasonable and convincing. The restriction of the essay's focus, however, underestimates other actual and potential contributions of psychoanalysis to the field of psychiatry, as well as the constraints to some of the authors' recommendations. This commentary explores some of these broader issues and may modulate their proposals, while reflecting an essential agreement with them.
The affirmation that the growing importance of the neurosciences has helped make the role of psychoanalytic treatment within psychiatry more controversial is open to question. The ascendance of psychopharmacological treatments as a practical consequence of the rapid progress in the neurosciences has greatly enriched our therapeutic armamentarium, but there is abundant evidence that psychosocial modalities of treatment also have an important role, for example, in the treatment of schizophrenia, the depressions, and, particularly, the personality disorders. At the same time, the discovery of the complexity of neurobiological systems—so that, for example, the study of the neuroscience of affects requires the simultaneous consideration of neurobiological structures, neurotransmitter systems, and behavior2—also points to the need to study the psychological structuring of affect, such as the relationships among attachment, chronic stress, and the responses of the hypothalamic-pituitary-adrenal axis. The psychoanalytic studies of normal and pathological attachment and their relationship to psychopathological characteristics may complement significantly the understanding of affect systems from a neurobiological perspective. Other areas where, as Kandel3 suggests, biology and psychoanalysis could join include the nature of unconscious mental processes, psychological causality and its relation to psychopathological characteristics, the relation between preconscious and unconscious processes and the prefrontal cortex, sexual orientation, structural changes in the brain in relation to psychotherapy, and psychopharmacological treatment as an adjunct to psychoanalysis.
This article is based on an exhaustive review of the psychotherapy outcomes literature, undertaken originally at the instigation of the UK Department of Health by Roth and Fonagy (Department of Health, 1995). We have recently updated this review (Fonagy, Target, Cottrell, Phillips, & Kurtz, 2002; Roth & Fonagy, 2004) and extended it to identify all studies of psychoanalytic psychotherapy.
The usual methods for identifying studies were employed (Fonagy, Target, et al., 2002; Roth & Fonagy, in press).
The key questions that should be asked of this literature given the current state of research in this area (also see Westen, Morrison, & Thompson-Brenner, 2004) are:
- Are there any disorders for which short-term psychodynamic psychotherapy (STPP) can be considered evidence-based,
- Are there any disorders for which STPP is uniquely effective as either the only evidence-based treatment or as a treatment that is more effective than alternatives, and
- Is there any evidence base for long-term psychodynamic psychotherapy (LTPP) either in terms of achieving effects not normally associated with short-term treatment or addressing problems that have not been addressed by STPP? In this context, short-term therapy is conceived of as a treatment of around 20 sessions delivered usually once weekly.
BACKGROUND: The efficacy of psychodynamic therapy is controversial. Previous meta-analyses have reported discrepant results.
OBJECTIVE: To test the efficacy of short-term psychodynamic psychotherapy (STPP) in specific psychiatric disorders by performing a meta-analysis of more recent studies. We assessed outcomes in target problems, general psychiatric symptoms, and social functioning.
DESIGN: We identified studies of STPP published between January 1, 1970, and September 30, 2004, by means of a computerized search using MEDLINE, PsychINFO, and Current Contents. Rigorous inclusion criteria, included randomized controlled trials, use of treatment manuals and insurance of treatment integrity, therapists experienced or specifically trained in STPP, treatment of patients with specific psychiatric disorders, reliable and valid diagnostic measures, and data necessary to calculate effect sizes. Studies of interpersonal therapy were excluded. Seventeen studies fulfilled the inclusion criteria. The information was extracted by 3 raters. Effect sizes were calculated for target problems, general psychiatric symptoms, and social functioning using the data published in the original studies. To examine the stability of outcome, we assessed effect sizes separately for end of therapy and follow-up assessment. The effect sizes of STPP were compared with those of waiting-list control patients, treatments as usual, and other forms of psychotherapy.
RESULTS: Short-term psychodynamic psychotherapy yielded significant and large pretreatment-posttreatment effect sizes for target problems (1.39), general psychiatric symptoms (0.90), and social functioning (0.80). These effect sizes were stable and tended to increase at follow-up (1.57, 0.95, and 1.19, respectively). The effect sizes of STPP significantly exceeded those of waiting-list controls and treatments as usual. No differences were found between STPP and other forms of psychotherapy. CONCLUSIONS: Short-term psychodynamic psychotherapy proved to be an effective treatment in psychiatric disorders. However, further research of STPP in specific psychiatric disorders is needed, including a study of the active ingredients of STPP. Effectiveness studies should be included.
BACKGROUND: The population prevalence of DSM-IV personality disorders (PDs) remains largely unknown. Data are reported here on the prevalence and correlates of clinician-diagnosed Clusters A, B, and C DSM-IV PDs in the general population of the United States.
METHODS: Personality disorder screening questions from the International Personality Disorder Examination (IPDE) were administered in Part II (n = 5692) of the National Comorbidity Survey Replication (NCS-R). A probability sub-sample was then interviewed with the IPDE and used to link screening question responses with IPDE clinical diagnoses. The method of Multiple Imputation (MI) was then implemented to estimate prevalence and correlates of PDs in the full sample.
RESULTS: The MI prevalence estimates were 5.7% Cluster A, 1.5% Cluster B, 6.0% Cluster C, and 9.1% any PD. All three PD clusters were significantly comorbid with a wide range of DSM-IV Axis I disorders. Significant associations of PDs with functional impairment were largely accounted for by Axis I comorbidity.
CONCLUSIONS: Strong Axis I comorbidity raises questions about the somewhat arbitrary separation of PDs from Axis I disorders in the DSM nomenclature. The impairment findings suggest that the main public health significance of PDs lies in their effects on Axis I disorders rather than in their effects on functioning.
OBJECTIVE: To examine the efficacy and speed of action of short-term psychodynamic supportive psychotherapy (SPSP) in comparison to pharmacotherapy (PhT) in the acute treatment of depression. METHOD: This study reported on the first 8 weeks of a treatment algorithm for depression. 70 patients with a depressive episode according to DSM-IV were randomized to PhT, 71 patients were randomized to SPSP. The acceptability of the psychotherapy was greater than pharmacotherapy. RESULTS: At the end of the first 8 weeks of treatment, attrition rates were similar in both conditions. PhT-patients were better off at 4 weeks according to two of the four measures The superiority of PhT was clearer on the self-report than on the independent measure. CONCLUSIONS: There are signs that the benefits of PhT over SPSP--where detected--are short-lived and cover mostly the first month of treatment. The progression of these patients through the rest of their treatments, and afterwards, will be reported in further contributions. |
