Emotional ups and downs are a normal part of life, but when the lows last for long periods of time, affect the capacity to function, cause an inability to experience pleasure, and lead to intense self-deprecating and even suicidal thoughts, a person may be thought to be experiencing clinical depression.

While, many people recover from clinical depression, according to Keller ¹ , a third of all people who have depression experience it for longer than two years. Furthermore, over three-quarters of all patients who recover from one episode, go on to have at least one or more subsequent depressive episodes.

A combination of psychotherapy and medication are usually recommended by health care professionals to assist in alleviating depression. Studies ^2,3,4,5 such as the ones listed below this article have revealed that cognitive behavioural therapies, as well as short term psychodynamic therapies, are equally effective for acute depression, but the effects of these treatments have been limited for chronic depression.

Considering the high rates of relapse, the consequent suicidality amongst those who relapse and the burden that depression places on patients, family, friends, co-workers and other health care services, it is important to continue research into establishing which treatments produce the greatest effects on patient’s mental health and whether these effects are sustained.

Encouragingly, the Canadian Journal of Psychiatry6 has reported a first-of-a-kind comparison of the effectiveness of long-term cognitive-behavioural therapy (CBT) and long-term psychoanalytic therapy (PAT) of chronically depressed patients and the effects of preferential or randomized allocation.

A total of 252 adults, aged 21-60 years, diagnosed with major depression, dysthymia, or double depression, for at least 24 months, were included. Outcomes were measured by depression self-rating scales and scales administered by independent, treatment-blinded clinicians . An independent data management centre analyzed the treatment effects and differences.

Several important findings were made. These include that…

• Psychoanalytic and cognitive behavioural therapies achieved similar outcomes
• Long-term therapy produced a continuous improvement over the three-year period studied
• Greater effects were noted than in previously reported studies
• Remission rates were lower than in previously reported studies
• If given the choice, participants tended to opt for psychoanalytical treatment
• No difference was noted between the randomly assigned and self-selecting group.

The results support what clinicians have long since argued, i.e. that chronically depressed patients require longer-term interventions. Unfortunately, few insurance companies reimburse for long-term treatment. This reflects the convergence of multiple factors including economic pressures and a climate that has supported a controversial and misguided narrative that argues against considering evidence derived from sources other than randomised and controlled trials (RCTs). Several consequences follow, including damaging the reputations of some treatments (such as psychoanalytical therapy, which RCTs are poorly suited to) by unfairly declaring them as not evidence-based.

INVESTIGATING FALSE CLAIMS OF EVIDENCE-BASED PSYCHOTHERAPY, by V Joly

THE SCIENTIFIC STANDING OF PSYCHOANALYSIS, by M Solms

The research reported here bucks this trend. We as clinicians and other proponents of mental health are obliged to draw attention to these findings since, as important as these are, they imply higher treatment costs and hence are unlikely to be driven by straight forward economics. That is not to say that more effective treatments for depression don’t produce economic benefits, they do.

What is Cognitive-behavioural therapy?

Cognitive-behavioural therapists conceptualise chronic depression as originating from irrational thinking and deeply ingrained maladaptive behaviour patterns. Cognitive Behavioural Therapy for depression includes interventions such as problem analysis; goal setting; psychoeducation; behavioural activation; increasing pleasant activities; cognitive interventions to restructure basic assumptions and schemata; social skill training, problem-solving, stress management techniques; maintenance and relapse prevention strategies. 6

What is Psychoanalytical therapy?

Psychoanalytically oriented therapists broadly conceptualise chronic depression as arising from problematic internal relating to representations of the self, relationships and aspects of reality within the mind at an unconscious level. Furthermore, this way of looking at depression considers that chronically depressed patients experience a breakdown of mentalising capacity, as well as a loss of basic feelings of self-agency and trust in helpful others. Modifying these relations and representations takes time and an intensive working through within the relationship to the psychotherapist. This is done through considering dreams, current inner and external relationships and fantasies leading into psychic retreat. Furthermore, this worked through in the ‘here and now’ of what is called the transference relationship. The transference relationship occurs when the therapist receives, understands and digests the unconscious thoughts and feelings that the patient unconsciously locates within the therapist instead of themselves (usually because it is too painful for the patient to experience these within the self, which is connected to problematic self-relating). The therapist then feeds the projected aspects of the patient’s self back in an understanding and empathic way that can allow the patient to become conscious of them and begin to relate to the self and others differently. This takes a longer time and might be one reason why several studies reported that psychoanalytic treatments have a delayed therapeutic effect. 6

Michelle Scott is a counselling psychologist currently working at a student counselling centre at Wits University in Johannesburg. She is involved in psychotherapy for students as well as supervision for intern psychologists. She also consults with adults and adolescents for psychotherapy in part-time private practice in Dunkeld.

Vincenzo Sinisi is a psychoanalyst, clinical psychologist and group-analyst in full private practice in Cape Town.

References

1 Keller M.B. (2001). Long-term treatment of recurrent and chronic depression. Journal of Clinical Psychiatry, 62 (24) 3–5

2 Gibbons, M.B.C., Gallop, R. & Thompson, D., et al. (2016). Comparing effectiveness of cognitive therapy and dynamic psychotherapy for major depressive disorder in a community mental health setting: a randomized clinical noninferiority trial. JAMA Psychiatry, 73 (9) 904-911.

3 Driessen E, Cuijpers P, de Maat SC, et al. (2010). The efficacy of short-term psychodynamic psychotherapy for depression: A meta-analysis. Clinical Psychology Review, 30 (1) 25-36.

4 Steinert, C., Hofmann, M., Kruse, J., et al. (2014). Relapse rates after psychotherapy for depression-stable long-term effects? A meta-analysis. Journal of Affective Disorders, 168, 107-118.

5 Cuipers, P., Huibers M.J.H., & Furukawa, T.A. (2017). The need for research on treatments of chronic depression. JAMA Psychiatry, 74(3):242-243.

6 Leuzinger-Bohleber M, Hautzinger M, Fiedler G, Keller W, Bahrke U, Kallenbach L, Kaufhold J, Ernst M, Negele A, Schoett M, Küchenhoff H, Günther F, Rüger B, Beutel M. Outcome of psychoanalytic and cognitive-behavioural long-term-therapy with chronically depressed patients. A controlled trial with preferential and randomized allocation. The Canadian Journal of Psychiatry, vol. 64, 1: pp. 47-58. November 1, 2018

Emotional ups and downs are a normal part of life, but when the lows last for long periods of time, affect the capacity to function, cause an inability to experience pleasure, and lead to intense self-deprecating and even suicidal thoughts, a person may be thought to be experiencing clinical depression.

While, many people recover from clinical depression, according to Keller ¹ , a third of all people who have depression experience it for longer than two years. Furthermore, over three-quarters of all patients who recover from one episode, go on to have at least one or more subsequent depressive episodes.

A combination of psychotherapy and medication are usually recommended by health care professionals to assist in alleviating depression. Studies ^2,3,4,5 such as the ones listed below this article have revealed that cognitive behavioural therapies, as well as short term psychodynamic therapies, are equally effective for acute depression, but the effects of these treatments have been limited for chronic depression.

Considering the high rates of relapse, the consequent suicidality amongst those who relapse and the burden that depression places on patients, family, friends, co-workers and other health care services, it is important to continue research into establishing which treatments produce the greatest effects on patient’s mental health and whether these effects are sustained.

Encouragingly, the Canadian Journal of Psychiatry6 has reported a first-of-a-kind comparison of the effectiveness of long-term cognitive-behavioural therapy (CBT) and long-term psychoanalytic therapy (PAT) of chronically depressed patients and the effects of preferential or randomized allocation.

A total of 252 adults, aged 21-60 years, diagnosed with major depression, dysthymia, or double depression, for at least 24 months, were included. Outcomes were measured by depression self-rating scales and scales administered by independent, treatment-blinded clinicians . An independent data management centre analyzed the treatment effects and differences.

Several important findings were made. These include that…

• Psychoanalytic and cognitive behavioural therapies achieved similar outcomes
• Long-term therapy produced a continuous improvement over the three-year period studied
• Greater effects were noted than in previously reported studies
• Remission rates were lower than in previously reported studies
• If given the choice, participants tended to opt for psychoanalytical treatment
• No difference was noted between the randomly assigned and self-selecting group.

The results support what clinicians have long since argued, i.e. that chronically depressed patients require longer-term interventions. Unfortunately, few insurance companies reimburse for long-term treatment. This reflects the convergence of multiple factors including economic pressures and a climate that has supported a controversial and misguided narrative that argues against considering evidence derived from sources other than randomised and controlled trials (RCTs). Several consequences follow, including damaging the reputations of some treatments (such as psychoanalytical therapy, which RCTs are poorly suited to) by unfairly declaring them as not evidence-based.

INVESTIGATING FALSE CLAIMS OF EVIDENCE-BASED PSYCHOTHERAPY, by V Joly

THE SCIENTIFIC STANDING OF PSYCHOANALYSIS, by M Solms

The research reported here bucks this trend. We as clinicians and other proponents of mental health are obliged to draw attention to these findings since, as important as these are, they imply higher treatment costs and hence are unlikely to be driven by straight forward economics. That is not to say that more effective treatments for depression don’t produce economic benefits, they do.

What is Cognitive-behavioural therapy?

Cognitive-behavioural therapists conceptualise chronic depression as originating from irrational thinking and deeply ingrained maladaptive behaviour patterns. Cognitive Behavioural Therapy for depression includes interventions such as problem analysis; goal setting; psychoeducation; behavioural activation; increasing pleasant activities; cognitive interventions to restructure basic assumptions and schemata; social skill training, problem-solving, stress management techniques; maintenance and relapse prevention strategies. 6

What is Psychoanalytical therapy?

Psychoanalytically oriented therapists broadly conceptualise chronic depression as arising from problematic internal relating to representations of the self, relationships and aspects of reality within the mind at an unconscious level. Furthermore, this way of looking at depression considers that chronically depressed patients experience a breakdown of mentalising capacity, as well as a loss of basic feelings of self-agency and trust in helpful others. Modifying these relations and representations takes time and an intensive working through within the relationship to the psychotherapist. This is done through considering dreams, current inner and external relationships and fantasies leading into psychic retreat. Furthermore, this worked through in the ‘here and now’ of what is called the transference relationship. The transference relationship occurs when the therapist receives, understands and digests the unconscious thoughts and feelings that the patient unconsciously locates within the therapist instead of themselves (usually because it is too painful for the patient to experience these within the self, which is connected to problematic self-relating). The therapist then feeds the projected aspects of the patient’s self back in an understanding and empathic way that can allow the patient to become conscious of them and begin to relate to the self and others differently. This takes a longer time and might be one reason why several studies reported that psychoanalytic treatments have a delayed therapeutic effect. 6

Michelle Scott is a counselling psychologist currently working at a student counselling centre at Wits University in Johannesburg. She is involved in psychotherapy for students as well as supervision for intern psychologists. She also consults with adults and adolescents for psychotherapy in part-time private practice in Dunkeld.

Vincenzo Sinisi is a psychoanalyst, clinical psychologist and group-analyst in full private practice in Cape Town.

References

1 Keller M.B. (2001). Long-term treatment of recurrent and chronic depression. Journal of Clinical Psychiatry, 62 (24) 3–5

2 Gibbons, M.B.C., Gallop, R. & Thompson, D., et al. (2016). Comparing effectiveness of cognitive therapy and dynamic psychotherapy for major depressive disorder in a community mental health setting: a randomized clinical noninferiority trial. JAMA Psychiatry, 73 (9) 904-911.

3 Driessen E, Cuijpers P, de Maat SC, et al. (2010). The efficacy of short-term psychodynamic psychotherapy for depression: A meta-analysis. Clinical Psychology Review, 30 (1) 25-36.

4 Steinert, C., Hofmann, M., Kruse, J., et al. (2014). Relapse rates after psychotherapy for depression-stable long-term effects? A meta-analysis. Journal of Affective Disorders, 168, 107-118.

5 Cuipers, P., Huibers M.J.H., & Furukawa, T.A. (2017). The need for research on treatments of chronic depression. JAMA Psychiatry, 74(3):242-243.

6 Leuzinger-Bohleber M, Hautzinger M, Fiedler G, Keller W, Bahrke U, Kallenbach L, Kaufhold J, Ernst M, Negele A, Schoett M, Küchenhoff H, Günther F, Rüger B, Beutel M. Outcome of psychoanalytic and cognitive-behavioural long-term-therapy with chronically depressed patients. A controlled trial with preferential and randomized allocation. The Canadian Journal of Psychiatry, vol. 64, 1: pp. 47-58. November 1, 2018