Comparative effectiveness of psychodynamic psychotherapy and cognitive-behavioral therapy: it's about time, and what's next?

Since depression is one of the world’s greatest public health problems, conducting research to accurately weigh the benefits and risks of commonly used interventions should be asmuch a research priority as developing novel treatments or investigating mechanisms of disease pathophysiology. Psychotherapy is one of the most widely used classes of treatment, but unfortunately there is no commercial entity analogous to the pharmaceutical industry to support research and development of the current and next generations of interventions. The impact of this state of affairs is particularly evident with respect to the ability to conduct larger-scale studies of comparative treatment effectiveness, for which there are only a handful of relevant studies. Thus, although psychodynamic psychotherapy has been used to treat depressed outpatients for decades, the utility of this time-honored approach, asmeasured by the results of randomized controlled trials of treatment efficacy and effectiveness, has not been extensively studied. The study by Driessen et al. (1) in this issue of the Journal is therefore noteworthy because it provides some of the strongest evidence to date that short-term psychodynamic psychotherapy is an effective treatment for major depressive disorder. The study, in which 341 outpatients seeking treatment for major depressive disorder at three different psychiatric centers in Amsterdam were randomly assigned, is the largest randomized controlled trial of psychodynamic psychotherapy ever conducted. It is a relatively inclusive study conducted under real-world conditions. The study had two phases, a 16-session (22 weeks) acute phase contrasting psychodynamic psychotherapy against a standard comparator with established efficacy, cognitive-behavioral therapy (CBT), and a 1-year naturalistic follow-up. Severely depressed patients, who comprised about 40% of the sample, could receive concomitant antidepressant pharmacotherapy. The 93 therapists were practicing psychologists and psychiatrists with an average of $7 years posttraining experience. For the purposes of the study, they completed standardized training in one of the two modalities (presumably based on their interest) and subsequently were supervised by members of the respective national associations for psychodynamic psychotherapy and CBT. Outcomes were assessed by independent (albeit unblinded) evaluators using standard measures, including the Hamilton Depression Rating Scale (HAM-D). The primary outcome of interest was the posttreatment remission rate, defined as a final HAM-D score#7. Although the investigators included all randomly assigned patients in analyses of symptom When compared on a level playing field, the two forms of therapy may be comparably useful for treatment of depressed outpatients, both singly and in combination with antidepressants.