Short-Term Psychodynamic Psychotherapy Plus Antidepressants For Patients With Depression

Severity and duration may be factors to consider when treating depression with antidepressants and possibly adding short-term psychodynamic psychotherapy (STPP) to treatment, most efficaciously for individuals with relatively high baseline measures of depressive symptoms and for those with episode durations lasting more than 2 years, according to systematic review findings published in Psychological Medicine.

Investigators aimed to evaluate the efficacy of combined treatment (antidepressants plus STPP) vs antidepressants (with or without brief supportive psychotherapy) on depressive symptoms in adults in acute-phase depression. The primary endpoint was posttreatment depression symptom level.

This systematic review and meta-analysis searched Embase.com, PsycINFO, PubMed, and the Cochrane Library databases (plus 2 gray-literature databases) from inception through December 2021. Randomly assigned clinical trials comparing combined treatment (antidepressants plus STPP) vs antidepressants in the acute phase treatment of depression in adults were included. Investigators used mixed-effects models and an exploratory machine learning technique. Sensitivity analyses were conducted using unstandardized 17-item Hamilton Depression Rating Scale (HAMD) scores as outcome.

Investigators identified 7 trials for review and analysis (n=238 combined treatment; n=244 antidepressants). Among patients with higher baseline levels of depression, combined treatment was more efficacious vs patients with lower baseline depression levels (B=−0.49; 95% CI, −0.61 to −0.37; P <.0001].

Investigators found combined treatment more efficacious among patients with a depressive episode duration greater than 2 years vs less than 1 year (B=−0.68; 95% CI, −1.31 to −0.05; P =.03) and with a depressive episode duration greater than 2 years vs 1 to 2 years (B=−0.86; 95% CI, −1.66 to −0.06; P =.04). They replicated effects in analysis controlling for risk for bias. Heterogeneity was low.

They found combined treatment more efficacious among patients without a comorbid anxiety disorder. The strength of evidence for anxiety disorder comorbidity as a moderator at follow-up was limited by lack of variability in 75% of the studies assessing this variable. They noted education associated with treatment efficacy in the mixed-effects models. Contrasts between education levels reached significance only in some analyses.

Review limitations include the observational design, limited number of study participants lacking statistical power to identify small moderator relationships or higher-order interactions, detection and attrition bias in some of the included studies, inability to assess publication bias, between-study differences in antidepressant type, STPP model used, and follow-up length, and unassessed variables in primary studies.

“The findings of this study suggest that adding STPP to antidepressants might be particularly efficacious for individuals with relatively high baseline HAMD scores, for individuals with episode durations of >2 years (at posttreatment), and for those without a comorbid anxiety disorder (at follow-up),” investigators concluded. They wrote “For individuals with relatively low baseline HAMD scores, for individuals with episode durations of ≤2 years, and for individuals with a comorbid anxiety disorder, adding STPP might not result in superior treatment effects.” Investigators asserted they were not implying that antidepressants only (or combined with BSP) should be considered first-line treatment since their study doesn’t address comparative efficacy of antidepressants vs other depression treatments.