Efficacité des psychothérapies psychanalytiques longues dans le traitement des troubles mentaux complexes

Long-term psychodynamic psychotherapy in complex mental disorders: update of a meta-analysis

Par Falk Leichsenring (1), Sven Rabung (2)   

    (1) Department of Psychosomatics and Psychotherapy, University of Giessen

    (2) Department of Medical Psychology, University Medical Centre Hamburg-Eppendorf, Germany

Pour citer cet article :

Falk Leichsenring, Sven Rabung, (2011). Long-term psychodynamic psychotherapy in complex mental disorders: update of a meta-analysis. British Journal of Psychiatry, Volume 199, Issue 1, July 2011, pp. 15-22.

Abstract

Background : Dose–effect relationship data suggest that short-term psychotherapy is insufficient for many patients with chronic distress or personality disorders (complex mental disorders).

Aims : To examine the comparative efficacy of long-term psychodynamic psychotherapy (LTPP) in complex mental disorders.

Method : We conducted a meta-analysis of controlled trials of LTPP fulfilling the following inclusion criteria: therapy lasting for at least a year or 50 sessions; active comparison conditions; prospective design; reliable and valid outcome measures; treatments terminated. Ten studies with 971 patients were included.

Results : Between-group effect sizes in favour of LTPP compared with less intensive (lower dose) forms of psychotherapy ranged between 0.44 and 0.68.

Conclusions : Results suggest that LTPP is superior to less intensive forms of psychotherapy in complex mental disorders. Further research on long-term psychotherapy is needed, not only for psychodynamic psychotherapy, but also for other therapies.

(…)

Discussion

A considerable proportion of patients with chronic mental disorders or personality disorders do not benefit sufficiently from short-term psychotherapy. 1,3 Long-term psychotherapy, however, is associated with higher direct costs than short-term psychotherapy. For this reason it is important to know whether the effects of long-term psychotherapy exceed those of short-term treatments. In this meta-analysis, LTPP was superior to less intensive methods of psychotherapy in complex mental disorders. Furthermore, we found positive correlations between outcome and duration or dosage of therapy. Both of these results are consistent with data on dose–effect relations. 1

One limitation of this meta-analysis may be seen in the scarcity of controlled studies. Further studies of LTPP are required to confirm the results and allow for more refined analyses. With a small number of studies it is of particular importance to test for publication bias. For that purpose, we applied several measures. Fail-safe number analysis indicated that for overall outcome, 66 studies would need to be added to this meta-analysis in order to change the results of the meta-analysis from significant to non-significant. Furthermore, we found no significant correlation between outcome and sample size nor with standard error of effect sizes. We also found no significant correlation between outcome and the methodological quality of the studies as assessed using the scale proposed by Jadad et al. 43 However, the size of some correlations may indicate a systematic relationship, in that studies of higher quality tended to yield larger between-group effect sizes in favour of LTPP. Another limitation can be seen in the small number of studies that reported follow-up assessments. It is of interest to know whether the between-group effect sizes in favour of LTPP are stable beyond the end of treatment. The results of our previous meta-analysis suggest that the effects of LTPP even increase after the end of treatment. 16 When follow-up data from the studies included are available, this question can be addressed directly. As another limitation, not all studies reported ITT analyses. In this meta-analysis, however, we could show that adjusting for missing ITT data did not substantially change the results. Nonetheless, future studies should include ITT analyses whenever possible.

Duration of therapy

There is no generally accepted standard duration for LTPP. We included studies that lasted for at least a year or in which at least 50 sessions were applied. In some studies treatment lasted for a year or more but comprised fewer than 50 sessions; for this reason, some of these studies were included in previous meta-analyses as short-term. This was true, for example, for the study by Svartberg et al in which 40 sessions were applied. 27,51 Apparently, the inclusion of studies depends on the question of research addressed and the specific definition that is used in a meta-analysis. The correlations between dosage and outcome in the LTPP studies reported above suggest that the inclusion of studies in which LTPP lasted for fewer than 50 sessions reduced the treatment effects of LTPP. However, including only studies that fulfilled both the dosage and the duration criteria would have further reduced the already small number of studies. Future meta-analyses of LTPP or of long-term psychotherapy in general should include studies that fulfil both the dosage and the duration criteria. Furthermore, a differentiation between long-term, medium-term and short-term therapy might be useful.

Critical discussion of results

This meta-analysis took several points of critique put forward against our 2008 meta-analysis into account, such as lack of between-group effect sizes or of ITT analyses, possible publication bias or inclusion of inactive control conditions. 17,58 According to the results presented here we did not find cogent indication for any systematic bias. The methodological quality both of our meta-analyses and of the studies included is comparable to that of many studies of CBT. 59

Some controlled studies did not meet the inclusion criteria because the majority of patients had not completed their treatment when the effect sizes were assessed. This was true, for example, for the studies by Brockmann et al, Doering et al, Giesen-Bloo et al and Puschner et al. 15,60–62 In the study by Giesen-Bloo, for example, 19 of 42 patients treated with LTPP (45%) were still in treatment when outcome was assessed, and only 2 patients had completed LTPP; in the comparison group 27 of 44 patients (61%) were still in treatment, and only 6 patients had completed the treatment. 15 Data from ongoing treatments do not provide reliable estimates for treatment outcome at termination or follow-up, for example if patients had received only half of the ‘dose’ of treatment when outcome was assessed. By analogy, if one runner enters a 100 m race and a second enters a 10 000 m race, the time taken after 100 m will not be representative of the short-distance speed of the second runner. The runners will adapt their speed to the short or long distance they are going to face. This is true for patients in psychotherapy as well. 49 Psychotherapy is not a drug that works equally under different conditions, but a psychosocial process.

We compared the effects of LTPP with a group of mixed psychotherapeutic treatments. The control conditions consisted of specific forms of psychotherapy, including established forms such as CBT or DBT, as well as several TAU conditions. Including TAU can be assumed to reduce the mean effect size of the control group; on the other hand, the control conditions included not only short-term psychotherapy but also long-term psychotherapy applied as long as LTPP in the respective studies (e.g. DBT, CBT), in turn increasing the mean effect of the control condition. It is noteworthy that it was on average that duration and the number of treatment sessions applied was higher in the LTPP conditions. Thus, we used the alternative treatments as an unspecific (mixed) control group including both TAU and specific forms of alternative psychotherapy. Consequently, we do not claim that LTPP is superior to any specific form of psychotherapy in complex mental disorders that is carried out equally intensively, rather that it is superior to less intensive forms of psychotherapeutic interventions in general. We expect this to be true for other more intensive approaches of formal psychotherapy as well, for example that higher-dose CBT is superior to lower-dose CBT in borderline personality disorder. For psychodynamic psychotherapy this should also be true. With regard to the hierarchy of evidence, our comparison of LTPP with a mixed control group including TAU and specific psychotherapy is stricter than a comparison with a waiting-list group, placebo therapy or pure TAU, but less strict (and specific) than a comparison with specific or established forms of psychotherapy only. 63,64

Future research

Without doubt comparisons of LTPP with specific therapies are desirable, both short-term and long-term. At present, however, not enough studies are available. For CBT or DBT more comparative studies exist. Thus, it would be interesting to compare long-term CBT or DBT with short-term CBT or DBT in specific mental disorders. For some mental disorders for which response rates are not satisfactory, such as social anxiety disorder, experts in the field propose increasing treatment duration. 65

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