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Depression Studies Pertinent to NICE Guidelines: Short-term
Psychodynamic Psychotherapies (STPP)
Allan Abbass, Professor of Psychiatry and Psychology, Dalhousie University, Canada
1-902-473-2514, [email protected]

Overview
STPP methods have been developed and researched over the past 40 years to shorten emotionally focused treatment of a broad range of conditions including depression, anxiety, somatic problems and personality disorders. These treatments are under 40 sessions of average and have now been studied with over 60 randomized controlled trials of variable quality and 5 meta-analyses that support the method as being effective compared to minimal treatment and wait list controls for a broad range of conditions as noted above. (Abbass AA, Hancock JT, Henderson J, et al. Short-term psychodynamic psychotherapies for common mental disorders. Cochrane Database of Systematic Reviews. 2006(4). Herein, I will provide references (and abstracts of more recent studies) to RCT and Non-RCT studies of STPP with depression. Because depression, and especially treatment resistant depression, is often mixed with personality disorder (PD), I will highlight the body of data showing the efficacy of this method in PD and some studies that examined the 2 conditions. This is critical to examine because we know that the majority of patients treated with front line treatment do not remit, thus treatment resistance of some degree is the norm. For any brief treatment to be effective and have a significant impact on the overall system, personality problems must thus be addressed. In summary, STPP is effective with lasting effects, likely cost effective, and preferred by patients over medication treatments. STPP is also effective with personality disorders even combined with depression suggesting they be considered a first line option in those cases to reduce the rate of non-response and perhaps prevent chronicity.
Randomized Controlled Trials of STPP for Depression

Research report Combining psychotherapy and antidepressants in the treatment of
Depression F. de Jonghe*, S. Kool, G. van Aalst, J. Dekker, J. Peen. Journal of Affective
Disorders 64 (2001) 217–229

Objective: To compare the efficacy of antidepressants with that of antidepressants plus
psychotherapy (‘‘combined therapy’’) in the treatment of depression. Method: 6 month
randomised clinical trial of antidepressants (N=84) and combined therapy (N=83) in
ambulatory patients with Major Depression and a 17-item HDRS baseline score of at
least 14 points. The antidepressant protocol provides for three successive steps in case of
intolerance or inefficacy: fluoxetine, amitriptyline and moclobemide. The combined
therapy condition consists, in addition to pharmacotherapy, of 16 sessions of Short
Psychodynamic Supportive Psychotherapy. Efficacy is assessed using the 17-item HDRS,
the CGI of Severity and of Improvement, the depression subscale of the SCL-90, and the
Quality of Life Depression Scale. The data analysis is conducted on three samples: the
intention-to-treat sample, the per protocol sample and the observed cases sample. Results:
After randomisation, 32% of the patients refused the proposed pharmacotherapy while
13% refused the proposed combined therapy. In 24 weeks, 40% of the patients who
started with the pharmacotherapy stopped medication; 22% of those receiving the
combined therapy did so. The difference in success rates is statistically significant,
favouring combined therapy, in 23%, 31% and 62% of the patients after 8, 16 and 24
weeks of treatment, respectively. At week 24, the mean success rate is 40.7% in the
pharmacotherapy group and 59.2% in the combined therapy group. Conclusion: Patients
found combined treatment significantly more acceptable, they were significantly less
likely to drop out of combined therapy and, ultimately, significantly more likely to
recover. Combined therapy is preferable to pharmacotherapy in the treatment of
ambulatory patients with major depression.

Psychotherapy alone and combined with pharmacotherapy in the treatment of
depression. de Jonghe F, Hendricksen M, van Aalst G, Kool S, Peen V, Van R, van den
Eijnden E, Dekker J. Br J Psychiatry. 2004 Jul;185:37-45
BACKGROUND: The relative efficacy of psychotherapy and combined therapy in the
treatment of depression is still a matter of debate. AIMS: To investigate whether
combined therapy has advantages over psychotherapy alone. METHOD: A 6-month
randomised clinical trial compared Short Psychodynamic Supportive Psychotherapy
(n=106) with combined therapy (n=85) in ambulatory patients with mild or moderate
major depressive disorder diagnosed using DSM-IV criteria. Antidepressants were
prescribed according to a protocol providing four successive steps in case of intolerance
or inefficacy: venlafaxine, selective serotonin reuptake inhibitor, nortriptyline and
nortriptyline plus lithium. Efficacy was assessed using the 17-item Hamilton Rating Scale
for Depression, the Clinical Global Impression of Severity and of Improvement, and the
depression sub-scale of the Symptom Checklist. RESULTS: The advantages of
combining antidepressants with psychotherapy were equivocal. Neither the treating
clinicians nor the independent observers were able to ascertain them, but the patients
experienced them clearly. CONCLUSIONS: The advantages of combining
antidepressants with psychotherapy are equivocal.
Combined Brief Dynamic Therapy and Pharmacotherapy in the Treatment of
Major Depressive Disorder: A Pilot Study
Giuseppe Maina Gianluca Rosso Chiara Crespi Filippo BogettoPsychother Psychosom
2007;76:298–305

Background: The relative efficacy of supplemental psychotherapy in the treatment of
depression is still a matter of debate. Moreover, the superiority of brief dynamic therapy
(BDT) over supportive psychotherapies is not well established. The aim of this study is to
compare the efficacy of BDT added to medication with that of brief supportive
psychotherapy (BSP) added to medication in the treatment of major depressive disorder.
Method: A 12-month randomized clinical trial compared BDT (n = 18) with BSP (n =
17) combined with antidepressants in outpatients with major depressive disorder. Both
psychotherapies were added during the first 6 months of the trial; all patients continued to
be treated with only pharmacotherapy (paroxetine or citalopram) in the following 6-
month continuation phase. Efficacy was assessed using the 17-item Hamilton Rating
Scale for Depression (HAM-D), the Hamilton Rating Scale for Anxiety and the Clinical
Global Impression (CGI). The data analysis was conducted on two samples: the per-
protocol (PP) sample and the observed-cases (OC) sample. Results: Thirty-two patients
completed the study. Although at the end of the combined therapies (T2) no differences
emerged between the two treatment approaches, the group of patients treated with BDT
showed a further clinical improvement at the end of the study (T3): a significant
reduction in symptomatology emerged on the HAM-D (PP sample: F = 75.154, p = 0.03;
OC sample: F = 67.149, p = 0.022) and on the CGI total scores (PP sample: F = 78.527, p
= 0.016; OC sample: F = 74.104, p = 0.007). The difference in remission rates on the
HAM-D (75 vs. 12.5% at T3) is statistically significant favoring BDT. Conclusions:
BDT combined with antidepressants is preferable to supportive psychotherapy combined
with medication in the treatment of outpatients with major depression.
Randomized controlled trial comparing brief dynamic and supportive therapy with
waiting list condition in minor depressive disorders. Maina G, Forner F, Bogetto F.
Psychother Psychosom. 2005;74(1):43-50.
BACKGROUND: Although many evidences suggest the presence of specific therapeutic
factors in brief dynamic therapy (BDT), few studies have investigated its efficacy in the
treatment of depressive disorders in comparison to other psychotherapies. The aim of this
study was to determine whether BDT is more effective than brief supportive
psychotherapy (BSP) and waiting list condition in the treatment of minor depressive
disorders. METHOD: Thirty patients with primary DSM-IV dysthymic disorder,
depressive disorder not otherwise specified or adjustment disorder with depressed mood
completed a randomized controlled trial with three treatment groups (BDT, BSP, waiting
list condition). A 6-month follow-up was performed for patients treated with both
psychotherapeutic approaches. Other psychiatric treatments were not permitted
throughout the treatment period and the 6-month follow-up. Symptoms were assessed at
baseline, at the end of treatment, and after 6 months of follow-up. RESULTS: Patients
treated with both psychotherapeutic approaches showed a significant improvement after
treatment in comparison to non-treated controls, but BDT was more effective at follow-
up evaluation. CONCLUSIONS: BDT is a promising treatment for minor depressive
disorders. This study also suggests that BDT is more effective than supportive
psychotherapy in improving the long-term outcome of depressive disorders.

Psychodynamic Psychotherapy and Clomipramine in the Treatment of Major
Depression Yvonne Burnand, Ph.D. Antonio Andreoli, M.D. Evelyne Kolatte, M.D.
Aurora Venturini, M.D. Nicole Rosset, Ph.D. (Psychiatric Services 53: 585–590, 2002)

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.
Comparative Effects of cognitive-behavioral and brief psychodynamic
psychotherapies for depressed family caregivers. Gallagher-Thompson, D., & Steffen,
A.M. (1994).Journal of Consulting and Clinical Psychology, 62(3), 543-549.
Clinically depressed family caregivers (N = 66) of frail, elderly relatives were randomly assigned to 20 sessions of either cognitive-behavioral (CB) or brief psychodynamic (PD) individual psychotherapy. At posttreatment, 71% of the caregivers were no longer clinically depressed according to research diagnostic criteria (RDC), with no differences found between the 2 outpatient treatments. The results suggested therapy specificity; there was an interaction between treatment modality and length of caregiving on symptom-oriented measures. Clients who had been caregivers for a shorter period showed improvement in the PD condition, whereas those who had been caregivers for at least 44 months improved with CB therapy. These findings suggest that patient-specific variables should be considered when choosing treatment for clinically depressed family caregivers.
Effects of treatment duration and severity of depression on the effectiveness of
cognitive-behavioral and psychodynamic-interpersonal psychotherapy. Shapiro,
D.A., Barkham, M., Rees, A., Hardy, G.E., Reynolds, S., & Startup, M. (1994) Journal of
Consulting and Clinical Psychology, 62(2), 522-534.
A total of 117 depressed clients, stratified for severity, completed 8 or 16 sessions of
manualized treatment, either cognitive-behavioral psychotherapy (CB) or
psychodynamic-interpersonal psychotherapy (PI). Each of 5 clinician-investigators
treated clients in all 4 treatment conditions. On most measures, CB and PI were equally
effective, irrespective of the severity of depression or the duration of treatment. However,
there was evidence of some advantage to CB on the Beck Depression Inventory (Beck,
Ward, Mendelson, Mock, & Erbaugh, 1961). There was no evidence that CB's effects
were more rapid than those of PI, nor did the effects of each treatment method vary
according to the severity of depression. There was no overall advantage to 16-session
treatment over 8-session treatment. However, those presenting with relatively severe
depression improved substantially more after 16 than after 8 sessions.


RCT’s of STPP for both Personality Disorder and Depression

Efficacy of combined therapy and pharmacotherapy for depressed patients with or
without personality disorders. Kool S, Dekker J, Duijsens IJ, de Jonghe F, Puite B.
Harv Rev Psychiatry. 2003 May-Jun;11(3):133-41.
In general, depressed patients with personality pathology--Axis II disorders--respond less well or less quickly to the various kinds of individual treatment that are available, whether pharmacotherapy, psychotherapy, or both combined. This article sets forth the results of a six-month, randomized clinical trial of antidepressants and combined therapy in ambulatory patients with major depression and a baseline score of at least 14 on the 17-item Hamilton Rating Scale for Depression (HAM-D-17). The presence or absence of Axis II pathology was determined on the basis of a self-report version of the International Personality Disorder Examination. The study's antidepressant protocol provided for three successive steps in case of intolerance or inefficacy: fluoxetine, amitriptyline, and moclobemide. In addition to pharmacotherapy, the combined-therapy condition included 16 sessions of Short Psychodynamic Supportive Psychotherapy. Efficacy of the therapy provided was assessed using the HAM-D-17 and also other instruments. According to the results in secondary analyses, it emerged that combined therapy was more effective than pharmacotherapy for depressed patients with personality disorders. Combined therapy was not more effective than pharmacotherapy alone for depressed patients without personality disorders. It is recommended that depressed patients with comorbid personality pathology should be treated with combined therapy, with the focus of psychotherapy being not on the patient's symptoms and complaints, but on all aspects of the patient's actual relationships. Impact of Cluster C Personality Disorders on Outcomes of Contrasting Brief
Psychotherapies for Depression Hardy, G.E., Barkham, M., Shapiro, D.A., Stiles, W.B.,
Rees, A., & Reynolds, S. Journal of Consulting and Clinical Psychology, 1995; 63 (6)
997-1004.
Twenty-seven of 114 depressed clients, stratified for severity of depression, obtained a Diagnostic and Statistical Manual of Mental Disorders (3rd ed.; DSM-III; American Psychiatric Association, 1980) diagnosis of Cluster C personality disorder--that is, avoidant, obsessive-compulsive or dependent personality disorder (PD clients)--whereas the remaining 87 did not (non-personality-disorder [NPD] clients). All clients completed either 8 or 16 sessions of cognitive-behavioral (CB) or psychodynamic-interpersonal (PI) psychotherapy. On most measures, PD clients began with more severe symptomatology than NPD clients. Among those who received PI therapy, PD clients maintained this difference posttreatment and at 1-year follow-up. Among those who received CB therapy, posttreatment differences between PD and NPD groups were not significant. Treatment length did not influence outcome for PD clients. PD clients whose depression was also relatively severe showed significantly less improvement after treatment than either PD clients with less severe depression or NPD clients. Non RCT studies of STPP for Depression
Short-term psychodynamic psychotherapy for depression: an examination
of statistical, clinically significant, and technique-specific change. J Nerv
Ment Dis. 2003 Jun;191(6):349-57. Hilsenroth MJ, Ackerman SJ, Blagys MD, Baity MR,
Mooney MA.
This study investigates the effectiveness of short-term psychodynamic psychotherapy
(STPP) for depression in a naturalistic setting utilizing a hybrid effectiveness/efficacy
treatment research model. Twenty-one patients were assessed pre- and post-treatment
through clinician ratings and patient self-report on scales representing specific DSM-IV
depressive, global symptomatology, relational, social, and occupational functioning.
Treatment credibility, fidelity, and satisfaction were examined, all of which were found
to be high. All areas of functioning assessed exhibited significant and positive changes.
These adaptive changes in functioning demonstrated large statistical effects. Likewise,
changes in depressive symptoms evaluated at the patient level utilizing clinical
significance methodology were found to be high. A significant direct process/outcome
link between STPP therapist techniques and changes in depressive symptoms was
observed. Alternative treatment interventions within STPP were evaluated in relation to
subsequent improvements in depression and were found to be nonsignificant. The present
results demonstrate that robust statistical and clinically significant improvement can
occur in a naturalistic/hybrid model of outpatient STPP for depression.
INTENSIVE SHORT-TERM DYNAMIC PSYCHOTHERAPY OF TREATMENT-
RESISTANT DEPRESSION:A PILOT STUDY Allan Abbass, M.D., F.R.C.P.C.
Depression and Anxiety 23:449–452, 2006.

This pilot study examined the effectiveness of Intensive Short-term Dynamic
Psychotherapy (ISTDP) in treatment-resistant depression (TRD). Ten patients
with TRD were provided a course of ISTDP. Clinician and patient symptom and
interpersonal measures were completed every 4 weeks, at termination, and in
follow-up. Medication, disability, and hospital costs were compared before and
after treatment. After an average of 13.6 sessions of therapy, all mean measures
reached the normal range, with effect sizes ranging from 0.87 to 3.3. Gains
were maintained in follow-up assessments. Treatment costs were offset by cost
reductions elsewhere in the system. This open study suggests that ISTDP may be
effective with this challenging patient group. A randomized, controlled trial and
qualitative research are warranted to evaluate this treatment further and to
examine its possible therapeutic elements.


RCT’s of STPP for Personality Disorders

TABLE From Evidence-based Psychodynamic Therapy with Personality Disorders
Stanley B. Messer and Allan A. Abbass In Press. J. Magnavita (Ed.). Evidence-based
Treatment of Personality Dysfunction: Principles, Methods and Processes. Washington, DC:
American Psychological Association Press.

Diagnosis
BSI, or GSI
Winston et al, 1991, 1994
Cluster A, B and C
Hardy et al, 1995
Cluster C,
0.58 1.13
Depression
Hellerstein et al, 1998
Cluster B and C
Munroe-Blum et, 1999
Borderline
Svartberg et al, 2004
Cluster C
Vinnars et al, 2005
Cluster A, B and C
Muran et al, 2005
Cluster C, NOS
Abbass et al, in press
Cluster A, B and C
Mean ES (SD)
0.80 (0.44)
0.89 (0.57)
1.63 (1.12)

Note many of these patients had PD with comorbid depression, dysthymic disorder or both.
Our article (Abbass, in press 2008) is an example and over ½ of patients had depression
and nearly ½ had dysthymic disorder (appended).

Abbass A., Sheldon A., Gyra J., Kalpin A. (in press). Intensive Short-term Dynamic
Psychotherapy for DSM IV personality disorders: A randomized controlled trial.
Journal of Nervous and Mental Disease.
Hardy, G. E., Barkham, M., Shapiro, D. A., Stiles, W. B., Rees, A., Reynolds, S. (1995). Impact
of Cluster C personality disorders on outcomes of contrasting brief psychotherapies for
depression. Journal of Consulting & Clinical Psychology, 63, 997-1004.
Hellerstein, D. J., Rosenthal, R. N., Pinsker, H., Samstag, L. W., Muran, J. C. & Winston, A.
(1998). A randomized prospective study comparing supportive and dynamic therapies. Journal
of Psychotherapy Practice and Research, 7, 261-271.
Munroe-Blum, H. & Marziali, E. (1995). A controlled trial of short-term group treatment for
borderline personality disorder. Journal of Personality Disorders, 9, 190-198.
Muran, J. C., Safran, J. D., Samstag, L. W. & Winston, A. (2005). Evaluating an alliance-focused treatment for personality disorders. Psychotherapy: Theory, Research, Practice, Training, 42, 532-545. Svartberg, M., Stiles, T. C. & Seltzer, M. H. (2004). Randomized, controlled trial of the effectiveness of short-term dynamic psychotherapy and cognitive therapy for Cluster C personality disorders. American Journal of Psychology, 161, 810-817. Vinnars, B., Barber, J. P., Noren, K., Gallop, R. & Weinryb, R. M. (2005). Manualized supportive-expressive psychotherapy versus nonmanualized community-delivered psychodynamic therapy for patients with personality disorders: Bridging efficacy and effectiveness. American Journal of Psychiatry, 162, 1933-1940. Winston, A., Pollack, J., McCullough, L., Flegenheimer, W., Kestenbaum, R., & Trujillo, M. (1991). Brief psychotherapy of personality disorders. Journal of Nervous and Mental Disease, 179(4), 188-193. Winston, A., Laikin, M., Pollack, J., Samstag, L. W., McCullough, L. & Muran, J. C. (February 1994). Short-term psychotherapy of personality disorders. American Journal of Psychiatry, 151, 190-194.
Other STPP Studies: Note some are old and did not have well defined or
current STPP methods.

1. Barkham M., Shapiro DA, Hardy GE, Rees A. Psychotherapy in two-plus-one
sessions: Outcomes of a randomized controlled trial of cognitive-behavioral and
psychodynamic-interpersonal therapy for subsyndromal depression. J Consult
Clin Psychol 1999. 67(2): 201-211.
2. Gallagher DE, Thompson LW. Treatment of major depressive disorder in older
adult outpatients with brief psychotherapies. Psychotherapy: Theory, Research
and Practice 1982;19(4): 482-490.
3. Thompson LW, Gallagher D, Steinmentz Breckenridge J. Comparative
effectiveness of psychotherapies for depressed elders. J Consult Clin Psychol,
1983; 55:385-390.
4. Hersen M, Bellack AS, Himmelhoch, JM, Thase, ME. Effects of social skill
training, amitriptyline, and psychotherapy in unipolar depressed women.
Behavior Therapy, 1984;15: 21-40.
5. Reynolds S, Stiles, WB, Barkham, M, Shapiro, DA, Hardy, G, Rees, A.
Acceleration of changes in session impact during contrasting time-limited
psychotherapies. Journal of Consulting and Clinical Psychology, 1996;64: 577-
586.
6. Shapiro DA, Rees A, Barkham M, Hardy G, Reynolds S, Startup M. Effects of
treatment duration and severity of depression on the maintenance of gains after
cognitive-behavioral and psychodynamic-interpersonal psychotherapy. J
Consult Clin Psychol 1995; 63(3): 378-387.
7. Shapiro DA, Firth J. Prescriptive v. explorative psychotherapy: Outcomes of the
Sheffield Psychotherapy Project. Brit J Psychiatry 1987;151: 790-799.

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