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Articles   |    
The Efficacy of Cognitive-Behavioral Therapy and Psychodynamic Therapy in the Outpatient Treatment of Major Depression: A Randomized Clinical Trial
Ellen Driessen, Ph.D.; Henricus L. Van, M.D., Ph.D.; Frank J. Don, M.Sc.; Jaap Peen, Ph.D.; Simone Kool, M.D., Ph.D.; Dieuwertje Westra, M.Sc.; Mariëlle Hendriksen, M.Sc.; Robert A. Schoevers, M.D., Ph.D.; Pim Cuijpers, Ph.D.; Jos W.R. Twisk, Ph.D.; Jack J.M. Dekker, Ph.D.
Am J Psychiatry 2013;170:1041-1050. doi:10.1176/appi.ajp.2013.12070899
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Preliminary results presented at the annual meeting of the Dutch Association of Psychiatry, Amsterdam, March 31, 2011, and the annual meeting of the Society for Psychotherapy Research, Bern, Switzerland, June 30, 2011.

Dr. Van and Ms. Hendriksen have received training fees from RINO, Amsterdam, and VU University, Amsterdam, and Dr. Van is president of the Dutch Association of Psychoanalytic Psychotherapy. Mr. Don has served on the board of the mood disorders section of the Dutch Association of Cognitive and Behavior Therapy, and he receives royalties from Springer Media. Dr. Dekker receives royalties from Springer Media. All other authors report no financial relationships with commercial interests.

Supported by an unrestricted research grant from Wyeth Pharmaceuticals, the Netherlands; by research logistics grants and other research grants from Arkin Mental Health Care, Amsterdam (to Drs. Driessen, Van, Peen, Kool, Schoevers, and Dekker and Mr. Don, Ms. Westra, and Ms. Hendriksen); by a research grant from ProPersona Mental Health Care (to Mr. Don); and by research grants from the Faculty of Psychology and Education, Department of Clinical Psychology, VU University, Amsterdam (to Drs. Driessen and Cuijpers). The authors thank all of the patients, therapists, supervisors, and research assistants who participated in this study. The authors also thank W. van den Brink, M.D., Ph.D. (Amsterdam Institute for Addiction Research, Academic Medical Center, University of Amsterdam) and S.D. Hollon, Ph.D. (Vanderbilt University, Nashville) for their editorial assistance.

Current Controlled Trials identifier: ISRCTN31263312 (http://www.controlled-trials.com).

From Arkin Mental Health Care, Amsterdam; the Departments of Clinical Psychology and Health Sciences, VU University, Amsterdam; EMGO Institute for Health and Care Research, VU University and VU University Medical Center, Amsterdam; ProPersona Mental Health, Ede, the Netherlands; Department of Psychiatry, University Medical Center Groningen, the Netherlands; and the Department of Epidemiology and Biostatistics, VU University Medical Center, Amsterdam.

Address correspondence to Dr. Driessen (e.driessen@vu.nl).

Copyright © 2013 by the American Psychiatric Association

Received July 11, 2012; Revised October 24, 2012; Revised March 21, 2013; Accepted April 15, 2013.

Abstract

Objective  The efficacy of psychodynamic therapies for depression remains open to debate because of a paucity of high-quality studies. The authors compared the efficacy of psychodynamic therapy with that of cognitive-behavioral therapy (CBT), hypothesizing nonsignificant differences and the noninferiority of psychodynamic therapy relative to CBT.

Method  A total of 341 adults who met DSM-IV criteria for a major depressive episode and had Hamilton Depression Rating Scale (HAM-D) scores ≥14 were randomly assigned to 16 sessions of individual manualized CBT or short-term psychodynamic supportive therapy. Severely depressed patients (HAM-D score >24) also received antidepressant medication according to protocol. The primary outcome measure was posttreatment remission rate (HAM-D score ≤7). Secondary outcome measures included mean posttreatment HAM-D score and patient-rated depression score and 1-year follow-up outcomes. Data were analyzed with generalized estimating equations and mixed-model analyses using intent-to-treat samples. Noninferiority margins were prespecified as an odds ratio of 0.49 for remission rates and a Cohen’s d value of 0.30 for continuous outcome measures.

Results  No statistically significant treatment differences were found for any of the outcome measures. The average posttreatment remission rate was 22.7%. Noninferiority was shown for posttreatment HAM-D and patient-rated depression scores but could not be demonstrated for posttreatment remission rates or any of the follow-up measures.

Conclusions  The findings extend the evidence base of psychodynamic therapy for depression but also indicate that time-limited treatment is insufficient for a substantial number of patients encountered in psychiatric outpatient clinics.

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FIGURE 1. CONSORT Diagram of Participants in a Study of the Efficacy of Psychodynamic Therapy Relative to Cognitive-Behavioral Therapya

a CBT=cognitive-behavioral therapy; HAM-D=Hamilton Depression Rating Scale; MINI-Plus=Mini-International Neuropsychiatric Interview–Plus.

FIGURE 2. Observer-Rated and Patient-Rated Mean Depression Scores During Treatmenta

a CBT=cognitive-behavioral therapy; HAM-D=Hamilton Depression Rating Scale; IDS-SR=Inventory of Depressive Symptomatology–Self Report.

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TABLE 1.Baseline Demographic and Clinical Characteristics of Participants in a Study of the Efficacy of Psychodynamic Therapy Relative to Cognitive-Behavioral Therapya
Table Footer Note

a CBT=cognitive-behavioral therapy; HAM-D=Hamilton Depression Rating Scale.

Table Footer Note

b Comorbid axis I disorders were assessed by the psychotherapists during treatment without the use of a structured interview, and comorbidity rates may therefore be underestimated.

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TABLE 2.Treatment Effects at Different Assessment Points According to the Basic Model of Analysis and When Corrected for Different Sets of Covariatesa
Table Footer Note

a HAM-D=Hamilton Depression Rating Scale; IDS-SR=Inventory of Depressive Symptomatology–Self Report. Model 1 is the basic model including a main effect for treatment and time and a time-by-treatment interaction; model 2 is the basic model with clinic and number of patients with baseline HAM-D scores >24 added as covariates; model 3 is the basic model with demographic characteristics (as listed in Table 1) added as covariates; model 4 is the basic model with depression characteristics (as listed in Table 1) added as covariates; model 5 is the basic model with therapist gender and profession added as covariates; and model 6 is the basic model with HAM-D assessors' hypotheses regarding treatment outcomes added as a covariate.

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TABLE 3.Follow-Up Outcomes According to the Basic Model of Analysis and When Corrected for Different Sets of Covariatesa
Table Footer Note

a HAM-D=Hamilton Depression Rating Scale; IDS-SR=Inventory of Depressive Symptomatology–Self Report. Model 1 is the basic model including a treatment and time main effect and a time-by-treatment interaction; model 2 is the basic model with clinic and number of patients with baseline HAM-D scores >24 added as covariates; model 3 is the basic model with demographic characteristics (as listed in Table 1) added as covariates; model 4 is the basic model with depression characteristics (as listed in Table 1) added as covariates; model 5 is the basic model with therapist gender and profession added as covariates; model 6 is the basic model with HAM-D assessors' hypotheses regarding treatment outcomes added as a covariate; and model 7 is the basic model with patient-reported treatments in the follow-up period added as a covariate.

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