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ON THE EFFECTIVENESS OF PSYCHOANALYTIC THERAPY Short if possible, long if necessary? The printing was financially supported by: JellinekMentrum Amsterdam Cover design: Annelies Frölke, Amsterdam Printed by: Ridderprint Offsetdrukkerij BV. ISBN: 978-90-5335-140-6 NUR: 770 © S.C.M. de Maat, Amsterdam, 2007 All rights reserved. No part of this publication may be reproduced or transmit- ted in any form or by any means, electronic or mechanical, including photo- copying, recording or any information storage and retrieval system, without written permission of the copyright owner. VRIJE UNIVERSITEIT THE EFFECTIVENESS OF PSYCHOANALYTIC THERAPY Short if possible, long if necessary? ACADEMISCH PROEFSCHRIFT ter verkrijging van de graad Doctor aan de Vrije Universiteit Amsterdam, op gezag van de rector magnificus prof.dr. L.M. Bouter, in het openbaar te verdedigen ten overstaan van de promotiecommissie van de faculteit der Psychologie en Pedagogiek op vrijdag 14 december 2007 om 10.45 uur, in de aula van de universiteit, De Boelelaan 1105 door Saskia Cornelia Maria de Maat geboren te Arnhem promotor: prof.dr. J.J.M. Dekker copromotoren: prof.dr. F.E.R.E.R. de Jonghe dr. R.A. Schoevers Beoordelingscommissie: prof.dr. A.T.F. Beekman prof.dr. P. Cuijpers prof.dr. J.A. Swinkels prof.dr. W. van Tilburg dr. M.H.M. de Wolf Als eine Spezialwissenschaft, ein Zweig der Psychologie, – Tiefenpsychologie oder Psychologie des Unbewussten, – ist sie ganz ungeeignet, eine eigene Weltanschauung zu bilden, sie muss die der Wissenschaft annehmen. (S. Freud, 1933) Contents Chapter 1 Introduction 9 Chapter 2 Relative efficacy of psychotherapy and pharmacotherapy in the treatment of depression: a meta-analysis 23 Chapter 3 Relative efficacy of psychotherapy and combined therapy in the treatment of depression: a meta-analysis 45 Chapter 4 Short-term Psychoanalytic Supportive Psychotherapy for depressed patients 63 Chapter 5 Support and personality change: A psychoanalytic view 75 Chapter 6 Short Psychodynamic Supportive Psychotherapy, anti- depressants, and their combination in the treatment of major depression: a mega-analysis based on three randomized clinical trials 93 Chapter 7 Comparison of Short Psychodynamic Supportive Psycho- therapy, pharmacotherapy and their combination on subdimensions of the HDRS and subscales of the SCL-90: a mega-analysis of three randomized controlled trials regarding depressed patients 109 Chapter 8 The effectiveness of long-term psychotherapy: methodological research issues 125 Chapter 9 The effectiveness of long-term psychoanalytic therapy: a sytematic review of empirical studies 137 Chapter 10 Costs and benefits of long-term psychoanalytic therapy: changes in health care use and work impairment 169 Chapter 11 General discussion 191 Summary 221 Samenvatting 229 Curriculum Vitae 241 List of publications 243 Dankwoord 245 7 CHAPTER 1 Introduction 1.1 Background Psychoanalytic therapies have existed for over a hundred years. From the very beginning, they have been contentious: applauded by some and reviled by others. The present situation is not essentially different. Gabbard (2004) indi- cates the continued popularity of psychoanalytic therapies and concludes: ‘The thirst to understand, to ‘know thyself’, persists despite managed care, the quick- fix mentality of our society and the remarkable progress in psychopharmacol- ogy.’ (p. 1). The popularity among clinicians and patients alike is underscored by studies of Wiener (1994) and Luborsky et al. (1993). They show that, at least in the United States, ‘psychoanalytic psychotherapy still seems to be the most fre- quent intervention practiced by the majority of psychiatrists’ (Wiener, 1994). Yet, criticisms too persist. Since we live in the era of evidence based medicine, they are concentrating on the argument that psychoanalytic therapies are not ‘scientifically proven’. The term ‘Evidence based medicine’ (EBM) was dubbed in the eighties of the last century, initially to indicate a new teaching method. Since then, many definitions have emerged, of which the following illustrates its most important aspects: ‘EBM is the conscious, explicit and expert use of the best available evidence to guide decisions regarding individual patients. EBM integrates the individual clinical expertise with the best available evi- dence of systematic research. The preferences, wishes and expectations of the patient play a central role in the decision making process.’(Offringa et al., 2000, p. 2-3). In the English language, the term ‘evidence’ is to be distinguished from ‘proof’, the latter meaning that there is little to no doubt about the truth of a conclusion, the first referring to an indication lending more or less strength to a judgement. In EBM the strength of scientific evidence is indicated by ‘levels of evidence’. The first level consists of a) a systematic review of Randomized Controlled Trials (RCTs) and b) a single high quality RCT. The second level consists of a) a systematic review of cohort studies and b) a single cohort- or patiënt-control study or a lower quality RCT. After these two, further levels are distinghuished, consisting of a systematic review of case-control studies, a single case-control study, case series and study expert’s opinions or generally accepted therapeutic methods (Center of Evidence Based Medicine Oxford, Levels of evidence, 2001). RCTs derive their name from their most important characteristic, the rand- omization of patients. This study design is also called the ‘confirmatory-deduc- tive methodology’ and is applied in ‘efficacy research’. RCTs strive for maxi- mum internal validity, so that it can be assumed, beyond reasonable doubt, that differences found between treatment and control groups (the dependent 9 variable) are explained by the therapeutic intervention (the independent vari- able). Cohort studies follow well-defined groups of people over a certain period of time in order to observe whether certain ‘outcomes’ occur. Relations between ‘determinants’ and outcomes are scrutinized. If the determinant is an inter- vention, this design is also called a quasi-experimental study: ‘experiments that lack random assignment (…) but that otherwise have similar purposes and structural attributes to randomized experiments.’ (Shadish et al., 2002). Quasi- experimental studies may or may not include comparison groups. The advantages of randomization are obvious and justify the high ranking of RCTs within the hierarchy of empirical evidence. However, RCTs too have been criticized. Leichsenring (2005) states: ‘The exclusive position of RCTs as method for demonstrating that a treatment works has been recently queried (Seligman, 1995, Roth and Parry, 1997, Beutler, 1998, Henry, 1998, Persons and Silberschatz, 1998, Fonagy, 1999, Leichsenring, 2004, Westen et al., 2004). The main argument is that it is questionable whether the results of RCTs are representative of clinical practice.’ In RCTs, many patients are excluded, or they refuse participation or drop out. The manuals and protocols applied, the many assessments, and so on, poorly connect to daily patient care. In short, this criticism applies to the external validity of RCTs, i.e., on the generalizability of their results to daily practice. Cohort studies can be and have been criticized as well. Although their exter- nal validity is often higher than that of RCTs, their internal validity is evidently weaker. Many feel that cohort studies tend to overestimate the effects of treat- ments, as there is no correction for potential confounders. First, it cannot be ruled out that the changes found in a cohort might be effectuated over time and not (just) by the treatment. Second, the comparability of the treated and the untreated group, or of two treated groups, may be doubted as they lack rand- omization. Therefore, the conclusive power of cohort studies is still a matter of debate. Contrary to what many people think, psychoanalytic therapies have been investigated intensively. In fact, a review of Beutler and Crago (1991) found that of the forty major international psychotherapy research programs at that time, eighteen were mainly psychoanalytic in orientation. Doidge (1997) con- cludes his review of the empirical evidence for psychoanalytic psychothera- pies with the statement that: ‘(…) the psychoanalytic therapies (…) not only have been, but continue to be, among the most intensively studied treatments.’ Briefer forms of psychoanalytic therapies have been investigated by means of RCTs, of which many reviews and meta-analyses provide the integrated results (Crits-Christoph, 1992, Leichsenring, 2005, Leichsenring, 2001, Anderson and Lambert, 1995, Leichsenring, 2003, Doidge, 1997). The findings lead to the conclusion that there is strong evidence that short-term psychoanalytic therapies perform equal to other short-term psychotherapies in a variety of disorders. Because of serious practical and ethical problems, longer psycho- analytic therapy has been investigated mainly in cohort studies. This means that the best available evidence for long-term psychoanalytic therapy consists of the second strongest possible level of evidence. Several reviews have been 10 performed to summarize the evidence for long-term psychoanalytic therapy (Bachrach et al., 1991: Doidge, 1997: Fonagy, 1999; Leichsenring, 2005), showing that there is evidence for the effectiveness of long-term psychoanalytic therapy. However, despite the evidence, a striking discrepancy between the endur- ing ‘belief’ in the effectiveness of psychoanalytic