EMPIRICAL PAPER

The efficacy of long-term psychodynamic psychotherapy fluoxetine andtheir combination in the outpatient treatment of depression

ANDRE GOETTEMS BASTOS1 LUCIANO SANTOS PINTO GUIMARAES2 ampCLARISSA MARCELI TRENTINI1

1Department of Psychology Universidade Federal do Rio Grande do Sul Porto Alegre Brazil amp 2Epidemiology andBiostatistics Unit Hospital de Cliacutenicas de Porto Alegre Porto Alegre Brazil

(Received 22 June 2013 revised 7 May 2014 accepted 8 June 2014)

AbstractObjective There are few randomized controlled trials examining the efficacy of long-term psychodynamic psychotherapy(LTPP) in depression treatment LTPP was compared with fluoxetine treatment and their combination Methods 272depressed patients (aged 26ndash34 72 with a first episode of depression) were randomized to receive LTPP (one sessionweek) fluoxetine treatment (20ndash60 mgday) or their combination for 24 months Beck Depression Inventory (BDI) was theoutcome measure The psychotherapy was not manualized and the treatment took place under real-life conditions in anoutpatient psychiatric clinic Results Intention-to-treat analyses indicated that all the treatments were associated withsignificant reductions in the BDI scores (mean reduction of 1888 BDI points) Furthermore LTPP and combinationtherapy were more effective in reducing BDI scores than fluoxetine alone (2208 and 2204 vs 1253 BDI points)Conclusions LTPP pharmacological treatment with fluoxetine and their combination are effective in reducing symptomsof patients with moderate depression LTPP and combined treatment were more effective compared to fluoxetine aloneThese findings have implications for patients with depression who may benefit from long-term psychotherapy or combinedtreatment or for depressed patients who do not wish to take medications such as fluoxetine

Keywords long-term psychodynamic psychotherapy fluoxetine depression

Introduction

Depressive disorders are among the most commonmental disorders (World Health Organization[WHO] 2009) They are associated with functionaldisability and personal suffering for patients (Bastosamp Trentini 2013) as well as with a tremendousfinancial burden to society (WHO 2009) There areevidence-based treatments for depression such asmedications and psychotherapies (Greenberg ampGoldman 2009) Among them long-term psycho-dynamic psychotherapy (LTPP) may have a role toplay in depression treatment (Luyten amp Blatt 2012)

However there are not many prior studies compar-ing LTPP medication or their combination in depres-sion treatment A meta-analysis showed that LTPPtreatment resulted in large effect sizes (Cohenrsquos d 080)

for symptom reduction and improvement of socialfunctioning (Leichsenring amp Rabung 2008) Theseresults were based on seven studies and only four ofwhich were randomized clinical trials The smallnumber of studies keeps actual efficacy of LTPPfor depression treatment still under debate (BergerBrakemeier Klesse amp Schramm 2009 HuberHenrich Gastner amp Klug 2012)

Taylor (2008) pointed out that this debate does notoccur with short-term psychodynamic psychotherapy(STPP) which has consistently demonstrated itsefficacy in randomized controlled trials Some studieshave suggested that there are no significant differencesbetween STPP and other short-term treatments likecognitive psychotherapy (Barber Muran McCarthyamp Keefe 2013) However considering the LTPP-STPP comparison there is a group of evidences that

Correspondence concerning this article should be addressed to Andre Goettems Bastos Department of Psychology Universidade Federaldo Rio Grande do Sul Porto Alegre Brazil Email andregbastosgmailcom

Psychotherapy Research 2014httpdxdoiorg101080105033072014935519

copy 2014 Society for Psychotherapy Research

in the long run LTPP tends to be more efficient thanSTPP (Knekt Lindfors Harkanen et al 2008Taylor 2008) There is also accumulating evidenceto suggest that treatments for depression would haveto be longer in order to prevent relapse (eg Hollon ampPonniah 2010) Cohort and observational researchesalso suggest thatmore durable benefitsmay relate withlonger-term treatments (Beutel amp Rasting 2002Knekt Lindfors Laaksonen et al 2008 Leichsenr-ing Biskup Kreische amp Staats 2005 Leichsenring ampRabung 2011 Sandell et al 2000) These findingssuggest rising evidence about LTPP clinical import-ance and effectiveness in depression treatment

Huber et al (2012) compared psychoanalyticpsychodynamic and cognitive-behavioral therapiesfor depression treatment in a process-outcome studybased on a prospective quasi-experimental designwith a 1-year 2-year and 3-year follow-up Thestudy concluded that the three treatments were allvery effective in the treatment of depression Huberet al (2012) suggested that patients with depressivedisorder could be treated with long-term psycho-therapy in order to prevent relapses and chronicityHuber and Klug (2006) investigated the effects oflong-term psychotherapies in depressed patients Ina prospective quasi-experimental study 100 patientswere compared pre and post-treatment followed bya three-year follow-up They found significant out-come differences between psychodynamic therapyand cognitive-behavioral therapy and results pointedthat psychodynamic therapy showed significantlylonger-lasting effects

Knekt et al (2013) performed an RCT comparingLTPP and two short-term therapies They found outthat patients suffering from mood and anxiety dis-orders recovered faster in short-term treatments butin the long run LTPP achieved greater benefits for thepatients (after a 5-year follow-up patients in thisgroup showed fewer anxiety and depression symp-toms and their work ability improvement rate washigher) Leichsenring et al (2005) in other studypointed out that LTPP demonstrated significantand large effect sizes (all gt 080) In terms ofdepressive symptoms at 1-year follow-up the effectsize was 138

Luyten and Blatt (2012) in a literature reviewabout psychodynamic treatment of depression con-cluded that the treatment should be included intreatment guidelines for depression Their argumentis that LTPP appears to be more clinically effectiveand perhaps even more cost effective in the long runHowever they pointed out that compared withother treatments the evidence base for LTPP indepression remains relatively small but that thereexists promising growing evidence for its efficacy andeffectiveness and recommended that further studies

comparing LTPP and other treatments for depres-sion should be done Gibbons Crits-Christoph andHearon (2008) in a previous review reached verysimilar conclusions

The growing evidences reported in previous stud-ies about LTPPrsquos efficacy motivate more researchMain benefits of LTPP pointed by literature includebut are not limited to clinical recovering from moodand anxiety disorders (Knekt et al 2013) longer-lasting treatment effects (Huber amp Klug 2006) andconsequent prevention of relapse and chronicity(Hollon amp Ponniah 2010) Furthermore there arealso some evidences that LTPP can induce neuro-cognitive gain in depressed patients (eg BastosGuimaratildees amp Trentini 2013)

The aim of the present study was to compare LTPPto antidepressant medication (fluoxetine) and theircombination in terms of efficacy in the remission ofdepressive symptoms The main hypothesis of thestudy is that LTPPrsquos efficacy for depression treatmentis as good as a well-known medication (in this casefluoxetine) and possibly not as good as combinedtreatment in reducing depressive symptoms

Materials and Methods

Design

The study is a randomized controlled trial investigat-ing changes in symptoms of depressed patients andcomparing LTPP fluoxetine and combined treat-ment A nonintervention control group was notincluded because of ethical considerations It wouldnot be possible for depressed patients to stay withoutany treatment for 24 months Brazilian ethical guide-lines for research with humans prohibit inclusion ofcontrol group is such a situation The investigationwas carried out in accordance with the Declaration ofHelsinki and the informed consent of the participantswas obtained The local Ethics Committee approvedthe study design

Participants

The participants were adult patients treated in amental health clinic in the urban area of PortoAlegre Brazil Inclusion criteria were presence ofmajor depressive disorder or depressive disorder nototherwise specified according to the SCID I and IIcriteria of the DSM-IV-TR moderate depressivesymptoms (Beck Depression Inventory [BDI] scoresbetween 20 and 35) age between 26 and 34 and tohave signed informed consent to participate in theresearch

Exclusion criteria were DSM-IV-TR Axis I and IIcomorbidities risk of suicide use of other medications

2 A G Bastos et al

that may influence the mental functioning severesomatic diseases and contraindication to treatmentwith fluoxetine Patients were also excluded ifpregnant

Procedure

A clinical psychologist initially interviewed allpatients who underwent screening In case of dia-gnosis hypothesis of depressive disorder and absenceof clear exclusion criteria the patients were invitedfor baseline assessment a week later

During baseline diagnostic assessment for dia-gnosis purpose it was administered the StructuredClinical Interview for the DSM SCID-I and SCID-II(Del-Ben Rodrigues amp Zuardi 1996 Del-BenZuardi amp Rodrigues 1998 Del-Ben et al 2001)Subsequently the BDI was used for measuring theseverity of the depressive symptoms The inclusionand exclusion criteria were checked again the objec-tives of the research were explained and all theinformation about the participation in the projectwas provided Informed written consent was obtainedfrom each patient before randomization Patients thatmet the inclusion and exclusion criteria were thenrandomized to one of the treatments The treatmentsstarted in the following week BDI assessments wereconducted at baseline and at 6 12 18 and 24 monthsafter baseline All treatments lasted 24 monthsPatients who were absent for more than three con-secutive sessions during the period of psychotherapyor absent from a psychiatric consultation were with-drawn from the study

Interventions

Long-term psychodynamic psychotherapyThe psychodynamic psychotherapy was conductedindividually and in weekly sessions This model ofpsychotherapy acts in a supportive-interpretive con-tinuum depending on the therapeutic needs of thepatient (Gabbard 2004 Gunderson amp Gabbard1999) The construction of the relationship betweenpatient and therapist is emphasized

Shedler (2010) points out that the distinctivetechniques of the long-term psychodynamic psycho-therapy include the focus on the affect and expres-sion of emotion exploration of attempts to avoiddistressing thoughts and feelings identification ofpatterns and recurring themes discussions of pastexperiences focus on interpersonal relationshipsfocus on the therapy relationship and explorationof desires dreams and fantasies The LTPP variantused in this study was similar to the one proposed byGabbard (2004 2010) The psychotherapy was not

manualized and the treatment took place under real-life conditions

Psychotherapeutic technique adherence was veri-fied in order to control if the therapists were reallyusing psychodynamic and psychoanalytical techni-ques during sessions with their patients Independentspecialized judges reviewed transcribed psychother-apy sessions Preliminary results showed high judgersquosagreement (as calculated by Prevalence-Adjusted andBias-Adjusted Kappamdashas proposed by Byrt Bishopamp Carlin 1993) and the technique used was consid-ered psychoanalytic oriented Further informationabout technique adherence may be included andpublished in a future report

Fluoxetine For the present study fluoxetine waschosen for its excellent cost-effectiveness comparingto the costs of depression treatment (Salminenet al 2008) In Brazil fluoxetine is one of themost inexpensive antidepressants available Moreimportant the efficacy of fluoxetine in the clinicalteatment of depression has been shown (egHashemi et al 2012) Salminen et al (2008)stressed that fluoxetine is effective in the reductionof symptoms and functional improvement of patientswho suffer from depression

Fluoxetine was prescribed according to the officialguidelines of the Brazilian Ministry of Health (httpwww4anvisagovbrbasevisadocBMBM[34652-1-0]PDF) Patients received fluoxetine starting at 20mgday during 2 weeks Then if necessary a gradualincrease was determined reaching up to 60 mgday

At the first consultation patients received detailedexplanation about the delayed onset of therapeuticeffects and potential drug side effects The secondvisit to psychiatrist occurred 2 weeks later Twice amonth visits to psychiatric consultations were keptup until the dosage regulation had finished Afterthe patients were appointed to monthly visits wherethey received the medication and the psychiatristsverified the treatment adherence

Combination therapy The combination ther-apy consisted of both of the above-mentioned inter-ventions concurrently

Psychotherapists and psychiatrists The 24psychotherapists (16 female and 8 male) were clin-ical psychologists specialized in long-term psycho-dynamic psychotherapy The mean duration ofclinical experience was 11 years and mean age was35 years The psychotherapists were divided into twogroups of 90-minute collective supervision con-ducted by the same supervisor (twice a month basis)where reports of the consultations were debatedduring the study

Psychotherapy Research 3

Biological therapists were six expert physicianndashpsychiatrists (3 female and 3 male) The meanduration of clinical experience was 6 years and themean age was 31 years There were no significantstatistical differences for variables involving the psy-chotherapists psychiatrists and supervision groups inthe tests of variables between conditions

Outcome Instruments

The primary outcome measure was the Beck Depres-sion Inventory (BDImdashBeck amp Steer 1993) The BDIis adapted and validated in Portuguese (Cunha2001) The BDI is a self-report questionnaire toassess depression severity and it is widely used byclinicians and researchers (Dunn Sham amp Hand1993 Kendall amp Sheldrick 2000) It has excellentpsychometric characteristics (Beck Steer amp Brown1996) The Brazilian BDI consists of 21 itemsincluding symptoms and attitudes with intensityranging from zero to three The items refer todifferent symptoms of depression (eg sadnessfatigue and loss of appetite) The final add up resultsin a total score that can be classified as followsminimum (score 0ndash11) mild (score 12ndash19) moderate(score 20ndash35) and severe (score 36ndash63) It is importantto notice that Brazilian BDI version has differentscore range classifications compared to Beck andSteer (1993) original BDI Brazilian BDI cuttingpoints tend to be higher (Cunha 2001) Further-more the cut-off for clinical significance in theBrazilian BDI is lt11 points (Cunha 2001) while inthe American BDI the cut-off is usually set in lt9points (Elkin et al 1989)

Statistical Methods

BDI scores of the three groups were compared atpre-treatment and every six months during treat-ment (at four times 6 12 18 and 24 months) Forthis comparison a mixed model analysis was usedan extension of the model of repeated measuresanalysis of variance that allows the simultaneouscomparison of two factors the inter-subject factor(groups) and the intra-subject factor (time of thetreatment) on the dependent variables (Gueorguievaamp Krystal 2004) Interaction effects between thesetwo factors on the dependent variables were alsoinvestigated The mixed model was also used toevaluate possible differences between groups at thedifferent moments The level of significance adoptedwas p lt 05

Intragroup (within treatment) and between groups(between treatment) effect sizes were calculated Thewithin treatment effect sizes were corrected fordependence between treatment means using Morris

and DeShonrsquos (2002) Equation 8 Between-treat-ment effect sizes were calculated according toCohenrsquos original instructions (Cohen 1988) Thestatistical analyses were conducted with the softwareSPSS v18 (IBM Corporation)

Results

Patient Flow

Subjects were selected among 417 individuals whowere initially recruited and assessed Subjects whomet inclusion criteria and agreed to participate in thestudy (N = 272 [652]) were randomized to treat-ments LTPP (n = 90) FLU (n = 91) and COM(n = 91) Figure 1 shows the participantsrsquo flow

After the randomization 11 individuals of thepsychotherapy group 7 of the fluoxetine group and15 of the combination treatment group refused tocontinue in the study During the treatment themental state of three individuals became worst andthe psychotherapy needed to be replaced by othermethod of therapy Three other individuals left thestudy after two visits without justification

In the fluoxetine group the mental state of fourpatients became worst and they needed to behospitalized Eleven individuals missed psychiatricappointments and were withdrawn from the study

In the combination therapy group nine indivi-duals gave up after the first month and five quit inthe second month Two hundred and two patientsconcluded the study 67 in the fluoxetine group 73in the psychotherapy group and 62 in the combina-tion therapy group

Patient Characteristics

The basic characteristics of the three groups are inTable I There were no significant differences inrelation to age proportion of men and women levelof education marital status family income numberof previous depressive episodes and BDI initialscore between the three groups

Treatment Outcomes

The results of the mixed analysis of all groups areshown in the Table II The analysis of the mixedmodels of the BDI scores revealed that the patientsin general presented a significant decrease in theintensity of the depressive symptoms (F8479 =4596 p lt 001)

The patients initiated treatment with moderatedepressive symptoms and concluded treatment withsignificantly fewer symptoms in BDI Figure 2 linesrepresent BDI means of each group along time

4 A G Bastos et al

Results of investigating the percentage of clinicalcases (above clinical cut-off point) for each pointof evaluation separately showed some differencesbetween groups At treatment termination theintention-to-treat remission rates showed differentresults

The LTPP group started treatment with BDI meanscore of 2736 and ended with a mean score of 528achieving a 2208mean reduction in BDI points Thisgroup reached the cut-off point for clinical signific-ance in 18 months of treatment (in mean) The FLUgroup initiated the treatment mean score of 2669and ended with a 1416 mean Participants of FLUgroup achieved a 1253 total mean reduction in BDIpoints This group did not reach the cut-off point forclinical significance (in mean) The COM group inits turn started treatment with a mean of 2620points and in the last measurement the mean point

of BDI was 416 This group achieved a 2204 totalmean reduction in BDI points COM group reachedthe cut-off point mean for clinical significance in 18months of treatment It is important to noticehowever that COM group had a BDI mean of 1164points at the 12th month of treatment This can beconsidered an overlap in classification score (ie ascore which would place a given participant at theboundary between mild and minimum depressedlevel of functioning because the pooled standarddeviation for this group was 278)

In the LTPP group 74 of patients achieved cut-off point compared to 65 of COM group and 22of FLU group These differences are statisticallysignificant (p lt 001) Another noteworthy findingwas that the number of patients below cut-off pointin the COM group was significantly lower thanLTPP and FLU by the sixth month of treatment

Table I Sociodemographic clinical and cognitive characteristics of participants in the three treatment groups at baseline (n = 272)

Total LTPP FLU COM df F χ2 p

Gender ( malefemale) 3862 3961 3763 4060 2 208 035Marital status ( singlecohabiting) 6535 6238 6634 6832 2 142 055Level of education ( until high schoolupper) 3268 3169 3565 3070 2 106 061No previous episodes () 72 72 73 70 2 037 059Age (SD) 2961 (231) 2982 (243) 2947 (217) 2955 (233) 540 057BDI mean score at baseline (SD) 2687 (377) 2731 (416) 2671 (328) 2660 (387) 912 040

Between-group sociodemographic and clinical characteristics of participantsrsquo differences were determined by ANOVA (if the variable wascontinuous) or Chi-square (if the variable was dichotomous)

Figure 1 Participants flow diagram

Psychotherapy Research 5

Table II Basic intention-to-treat model with mean scores and standard errors of the BDI in different times in the three treatments attrition rates and within treatment effect sizes

Month

Time treatment Basal BDI 6 12 18 24 (final) Δ Attrition rate Pooled SD d Corrected d

LTPP (SE) 2736(044)

1974dagger

(051)1504dagger

(038)1043dagger

(049)528dagger

(042)2208 369

Effect sizes (95 CI) 185(plusmn036)

346(plusmn048)

426(plusmn056)

597(plusmn072)

450(plusmn054)

N 90 79 76 73 73 17 19Patients with scores abovethe clinical cut-off (n)

100(90)

96(76)

86dagger

(65)34dagger

(25)8dagger

(6)FLU (SE) 2669

(032)1834dagger

(064)1723(039)

1576(033)

1416dagger

(031)1253 265

Effect sizes (95 CI) 197(plusmn036)

313(plusmn045)

396(plusmn053)

472(plusmn061)

391(plusmn050)

N 91 84 79 72 67 24 26Patients with scores abovethe clinical cut-off (n)

100(91)

95(80)

88dagger (69)

71dagger

(51)68dagger

(47)COM (SE) 2620

(049)1646dagger

(063)1164dagger

(044)793dagger

(033)416dagger

(032)2204 278

Effect sizes (95 CI) 224(plusmn038)

409(plusmn054)

554(plusmn069)

676(plusmn083)

570(plusmn067)

N 91 76dagger 70 67 62 29 32Patients with scores abovethe clinical cut-off (n)

100(91)

85dagger

(65)46dagger

(32)12dagger

(8)3dagger

(2)

Note Underlined entries mean significant differences between treatments (p lt 05)daggerDenotes a significant difference within treatment (p lt 05)d was corrected for dependence between means within treatment using Morris and DeShonrsquos (2002) equation 8 ie d uses variants of M1ndashM2 (in this case Basal BDI ndash Final BDI of a giventreatment) as the numerator It scales a simple difference between means in SD units In other words d = 1 represents a 1 SD difference in the meansThe cut-off for clinical significance in the Brazilian BDI is lt11 points

6AGBastos

etal

and these numbers remained significantly lower untilthe end of the study It is also important to point outthat the LTPP group had significantly more patientsbelow cut-off point than the FLU group by the 18thmonth of treatment and this significant differenceremained until the end

Regarding the attrition rates (dropouts) observedin the groups it is important to note that there aresignificant differences between then (p lt 05) LTPP(19 n = 17) had the lower attrition rate followedby FLU (26 n = 24) and COM (32 n = 29)

The within treatment effect sizes were consideredvery large in the three treatment groups (corrected dsranging from 391 to 570) On the other handbetween treatments effect sizes varied Table IIIdisplays between treatments effect sizes at differenttimes of treatment

In the LTPP-FLU comparison effect sizes rangedfrom 028 to 284 all favoring LTPP The meaneffect size was 132 BDI mean scores differenceranged from 140 to minus888 BDI points in the LTPPgroup In the LTPP-COM comparison effect sizesranged from 036 to 100 all favoring COM Themean effect size was 069 Finally COM-FLUcomparison effect sizes ranged from 036 to 392all favoring COM The mean effect size was 221

Discussion

Several clinical studies about the treatment of depres-sion have been conducted to establish therapeuticefficacy in a series of populations (Roth amp Fonagy2005) In the present study the efficacy and clinicalsignificance of three different treatments were inves-tigated Results demonstrated significant decrease inBDI scores Within treatment BDI scores and effectsizes varied in each treatment There were also severaldifferences between treatments The following sub-headings address these issues point-by-point

Within Treatment Effect Sizes

Within treatment effect sizes were very large (cor-rected ds were 450 for LTPP 391 for FLU and570 for COM) These effect sizes are surprisinglyenormous if compared to what other studies report(eg Lambert amp Ogles 2004 Taylor 2008) Stillthe ldquoinflated appearancerdquo of within treatment effectsizes reported here does not mean that the effectsencountered are not real for this group of partici-pants However they are indeed much larger thanwhat previous researches about psychotherapy out-come used to report The at first glance unusualtreatment effects have to be addressed critically andinterpreted with prudence

A closer look at BDI standard deviations reportedin three previous studies already mentioned isimportant because standard deviations are the keyto understand the huge and unusual within treat-ment effect sizes found in the present researchCohenrsquos d is in units of standard deviation and thismay explain the idiosyncrasy of the within treatmenteffect sizes Variability of response within group (asreflected by standard deviation) is relatively lowwhen compared to previous studies For instanceKnekt Lindfors Laaksonen et al (2008) Huberet al (2012) and Buchheim et al (2012) researchesall had very large standard deviations in BDI meanresults (ranging from 82 to 99 BDI points) com-pared to BDI mean scores standard deviations of thepresent study (369 in LTPP 265 in FLU and 279in COM) This minimal BDI variability dilated thewithin treatment effect sizes and may have occurredbecause of the clinic homogeneity of the sampleTaking the LTPP within treatment effect size as anexample the effect size arithmetically indicates thatthe average treated patient in this particular groupdecreased 450 standard deviations from basal tofinal assessment COM and FLU within treatmenteffect sizes followed the same logic

Figure 2 Mean scores on the Beck Depression Inventory in the three treatment groups along 24 monthsNote Bars represent standard errors

Psychotherapy Research 7

Table II Basic intention-to-treat model with mean scores and standard errors of the BDI in different times in the three treatments attrition rates and within treatment effect sizes

Month

Time treatment Basal BDI 6 12 18 24 (final) Δ Attrition rate Pooled SD d Corrected d

LTPP (SE) 2736(044)

1974dagger

(051)1504dagger

(038)1043dagger

(049)528dagger

(042)2208 369

Effect sizes (95 CI) 185(plusmn036)

346(plusmn048)

426(plusmn056)

597(plusmn072)

450(plusmn054)

N 90 79 76 73 73 17 19Patients with scores abovethe clinical cut-off (n)

100(90)

96(76)

86dagger

(65)34dagger

(25)8dagger

(6)FLU (SE) 2669

(032)1834dagger

(064)1723(039)

1576(033)

1416dagger

(031)1253 265

Effect sizes (95 CI) 197(plusmn036)

313(plusmn045)

396(plusmn053)

472(plusmn061)

391(plusmn050)

N 91 84 79 72 67 24 26Patients with scores abovethe clinical cut-off (n)

100(91)

95(80)

88dagger (69)

71dagger

(51)68dagger

(47)COM (SE) 2620

(049)1646dagger

(063)1164dagger

(044)793dagger

(033)416dagger

(032)2204 278

Effect sizes (95 CI) 224(plusmn038)

409(plusmn054)

554(plusmn069)

676(plusmn083)

570(plusmn067)

N 91 76dagger 70 67 62 29 32Patients with scores abovethe clinical cut-off (n)

100(91)

85dagger

(65)46dagger

(32)12dagger

(8)3dagger

(2)

Note Underlined entries mean significant differences between treatments (p lt 05)daggerDenotes a significant difference within treatment (p lt 05)d was corrected for dependence between means within treatment using Morris and DeShonrsquos (2002) equation 8 ie d uses variants of M1ndashM2 (in this case Basal BDI ndash Final BDI of a giventreatment) as the numerator It scales a simple difference between means in SD units In other words d = 1 represents a 1 SD difference in the meansThe cut-off for clinical significance in the Brazilian BDI is lt11 points

6AGBastos

etal

and these numbers remained significantly lower untilthe end of the study It is also important to point outthat the LTPP group had significantly more patientsbelow cut-off point than the FLU group by the 18thmonth of treatment and this significant differenceremained until the end

Regarding the attrition rates (dropouts) observedin the groups it is important to note that there aresignificant differences between then (p lt 05) LTPP(19 n = 17) had the lower attrition rate followedby FLU (26 n = 24) and COM (32 n = 29)

The within treatment effect sizes were consideredvery large in the three treatment groups (corrected dsranging from 391 to 570) On the other handbetween treatments effect sizes varied Table IIIdisplays between treatments effect sizes at differenttimes of treatment

In the LTPP-FLU comparison effect sizes rangedfrom 028 to 284 all favoring LTPP The meaneffect size was 132 BDI mean scores differenceranged from 140 to minus888 BDI points in the LTPPgroup In the LTPP-COM comparison effect sizesranged from 036 to 100 all favoring COM Themean effect size was 069 Finally COM-FLUcomparison effect sizes ranged from 036 to 392all favoring COM The mean effect size was 221

Discussion

Several clinical studies about the treatment of depres-sion have been conducted to establish therapeuticefficacy in a series of populations (Roth amp Fonagy2005) In the present study the efficacy and clinicalsignificance of three different treatments were inves-tigated Results demonstrated significant decrease inBDI scores Within treatment BDI scores and effectsizes varied in each treatment There were also severaldifferences between treatments The following sub-headings address these issues point-by-point

Within Treatment Effect Sizes

Within treatment effect sizes were very large (cor-rected ds were 450 for LTPP 391 for FLU and570 for COM) These effect sizes are surprisinglyenormous if compared to what other studies report(eg Lambert amp Ogles 2004 Taylor 2008) Stillthe ldquoinflated appearancerdquo of within treatment effectsizes reported here does not mean that the effectsencountered are not real for this group of partici-pants However they are indeed much larger thanwhat previous researches about psychotherapy out-come used to report The at first glance unusualtreatment effects have to be addressed critically andinterpreted with prudence

A closer look at BDI standard deviations reportedin three previous studies already mentioned isimportant because standard deviations are the keyto understand the huge and unusual within treat-ment effect sizes found in the present researchCohenrsquos d is in units of standard deviation and thismay explain the idiosyncrasy of the within treatmenteffect sizes Variability of response within group (asreflected by standard deviation) is relatively lowwhen compared to previous studies For instanceKnekt Lindfors Laaksonen et al (2008) Huberet al (2012) and Buchheim et al (2012) researchesall had very large standard deviations in BDI meanresults (ranging from 82 to 99 BDI points) com-pared to BDI mean scores standard deviations of thepresent study (369 in LTPP 265 in FLU and 279in COM) This minimal BDI variability dilated thewithin treatment effect sizes and may have occurredbecause of the clinic homogeneity of the sampleTaking the LTPP within treatment effect size as anexample the effect size arithmetically indicates thatthe average treated patient in this particular groupdecreased 450 standard deviations from basal tofinal assessment COM and FLU within treatmenteffect sizes followed the same logic

Figure 2 Mean scores on the Beck Depression Inventory in the three treatment groups along 24 monthsNote Bars represent standard errors

Psychotherapy Research 7

and these numbers remained significantly lower untilthe end of the study It is also important to point outthat the LTPP group had significantly more patientsbelow cut-off point than the FLU group by the 18thmonth of treatment and this significant differenceremained until the end

Regarding the attrition rates (dropouts) observedin the groups it is important to note that there aresignificant differences between then (p lt 05) LTPP(19 n = 17) had the lower attrition rate followedby FLU (26 n = 24) and COM (32 n = 29)

The within treatment effect sizes were consideredvery large in the three treatment groups (corrected dsranging from 391 to 570) On the other handbetween treatments effect sizes varied Table IIIdisplays between treatments effect sizes at differenttimes of treatment

In the LTPP-FLU comparison effect sizes rangedfrom 028 to 284 all favoring LTPP The meaneffect size was 132 BDI mean scores differenceranged from 140 to minus888 BDI points in the LTPPgroup In the LTPP-COM comparison effect sizesranged from 036 to 100 all favoring COM Themean effect size was 069 Finally COM-FLUcomparison effect sizes ranged from 036 to 392all favoring COM The mean effect size was 221

Discussion

Several clinical studies about the treatment of depres-sion have been conducted to establish therapeuticefficacy in a series of populations (Roth amp Fonagy2005) In the present study the efficacy and clinicalsignificance of three different treatments were inves-tigated Results demonstrated significant decrease inBDI scores Within treatment BDI scores and effectsizes varied in each treatment There were also severaldifferences between treatments The following sub-headings address these issues point-by-point

Within Treatment Effect Sizes

Within treatment effect sizes were very large (cor-rected ds were 450 for LTPP 391 for FLU and570 for COM) These effect sizes are surprisinglyenormous if compared to what other studies report(eg Lambert amp Ogles 2004 Taylor 2008) Stillthe ldquoinflated appearancerdquo of within treatment effectsizes reported here does not mean that the effectsencountered are not real for this group of partici-pants However they are indeed much larger thanwhat previous researches about psychotherapy out-come used to report The at first glance unusualtreatment effects have to be addressed critically andinterpreted with prudence

A closer look at BDI standard deviations reportedin three previous studies already mentioned isimportant because standard deviations are the keyto understand the huge and unusual within treat-ment effect sizes found in the present researchCohenrsquos d is in units of standard deviation and thismay explain the idiosyncrasy of the within treatmenteffect sizes Variability of response within group (asreflected by standard deviation) is relatively lowwhen compared to previous studies For instanceKnekt Lindfors Laaksonen et al (2008) Huberet al (2012) and Buchheim et al (2012) researchesall had very large standard deviations in BDI meanresults (ranging from 82 to 99 BDI points) com-pared to BDI mean scores standard deviations of thepresent study (369 in LTPP 265 in FLU and 279in COM) This minimal BDI variability dilated thewithin treatment effect sizes and may have occurredbecause of the clinic homogeneity of the sampleTaking the LTPP within treatment effect size as anexample the effect size arithmetically indicates thatthe average treated patient in this particular groupdecreased 450 standard deviations from basal tofinal assessment COM and FLU within treatmenteffect sizes followed the same logic

Figure 2 Mean scores on the Beck Depression Inventory in the three treatment groups along 24 monthsNote Bars represent standard errors

Psychotherapy Research 7

Restricting discussion to research related to BDIas outcome measure for psychodynamic psychother-apy in general some studies do report very largewithin treatment effect sizes In a review about theempirical status of psychodynamic therapies Gib-bons et al (2008) found at least two studies report-ing ldquoextra largerdquo effect sizes using BDI as outcomemeasurement Hersen Bellack Himmelhoch andThase (1984) in a study comparing short-termpsychodynamic psychotherapy to medication founda 341 within treatment effect size in STPP More-over Kornblith Rehm OrsquoHara and Lamparski(1983) found a 357 within treatment effect sizein STPP

Large effect sizes were also found in two similarlongitudinal RCTs comparing LTPP to shorter-termtherapies Knekt Lindfors Laaksonen et al (2008)randomized 367 patients with anxiety or mood dis-orders to three different treatments (STPP LTPP orpsychoanalysis) and assessed participants severaltimes with a set of instruments LTPP group withmood disorders (n = 113) had a basal BDI mean of198 points and finished the study with a mean of 75points The pooled standard deviation was 851Thus within treatment effect size was 144 Huberet al (2012) compared psychoanalytic therapyLTPP and cognitive-behavioral therapy in the treat-ment of depression LTPP group (n = 31) initiatedtreatment with a BDI mean of 251 (SD = 87) andended with 83 (SD = 99) Effect size was 210

On the other side meta-analyses have reportedvery different effect sizes compared to what wasfound here Leichsenring and Rabung (2008 20092011) reported large within treatment effect sizes(range 097ndash194) in the treatment of ldquocomplexdepressive disordersrdquo with LTPP De Maat deJonghe Schoevers and Dekker (2009) examinedthe efficacy of LTPP for patients suffering from whatthe authors called ldquomixedmoderate pathologyrdquo andhad a pre to post-treatment effect size of 078 forldquogeneral symptom improvementrdquo

FLU treatment group in its turn presented differ-ent within treatment patterns of response The aver-age treated patient in this particular group decreased371 standard deviations from basal to final assess-ment Considering effect size this is a very highantidepressant response in comparison to previoustrials but it is important to consider that treatmentoutcome studies with fluoxetine usually show differ-ent results Shedler (2010) analyzed the US Food andDrug Administration databases and reported a 026within treatment effect size for fluoxetine This is asmall effect size Salminen et al (2008) compared theefficacy of STPP and fluoxetine in major depressivedisorder of mild to moderate intensity Fluoxetinepatients (n = 25) basal BDI was 248 and final BDImean after four months was 113 The within treat-ment effect size was a large 162Hashemi et al (2012)used the BDI in a clinical trial Participants were 120depressed patients taking nortriptyline or fluoxetineBefore intervention the mean BDI score was 3312 inthe fluoxetine group Six months later the BDI scorewas 1696 Effect size was 279 considered very largeIn the present study participants of FLU group had abasal BDI of 2669 and in the sixth month assess-ment BDI was 1834 with a 064 effect size

Finally within treatment effect size found in COMgroup indicated that the average treated patientdecreased 570 standard deviations from basal to finalassessment De Maat Dekker Schoevers van Aalstet al (2007) performed a mega-analysis comparingthe efficacy of STPP antidepressants and their com-bination in the treatment of depression Combinationtherapy yielded an effect size of 159 what is differentfrom what was found in the present research

Remission Rates

A large reduction in the number of patients withclinically elevated BDI scores occurred Reductionin LTPP group reached 74 of total cases Previousstudies using percentage as measurement of efficacy

Table III Between treatments effect sizes and BDI mean scores differences in different times

Month

Comparison 6 12 18 24 Mean effect size Mean BDI difference β

LTPPndashFLU (95 CI) 028 (plusmn026) 066 (plusmn032) 151 (plusmn037) 284 (plusmn082) 132 (plusmn044) 589

BDI difference 140 minus219 minus533 minus888 minus375

LTPPndashCOM (95 CI) 070 (plusmn032) 100 (plusmn035) 073 (plusmn034) 036 (plusmn034) 069 (plusmn033) 182

BDI difference 328 340 250 112 257

COMndashFLU (95 CI) 036 (plusmn031) 165 (plusmn037) 292 (plusmn048) 391 (plusmn059) 221 (plusmn043) 1121

BDI difference minus188 minus559 minus1569 minus1000 829

Note Underlined entries mean significant differences between treatments (p lt 005) Effect sizes are in Cohenrsquos d and followed Cohenrsquosinstructions for calculation (Cohen 1988)

8 A G Bastos et al

have reached similar results Berghout and Zevalkink(2009) evaluated the clinical significance of LTPP infour groups of about 60 patients in different phasesof treatment Compared to basal assessment theyfound significant decrease in the percentage ofclinical cases after treatment (87) Leichsenringet al (2005) reported that around 80 of thepatients receiving psychoanalytic treatments reachedclinically significant reduction of symptom by theend of treatment

In FLU group 22 of the participants reached theBDI cut-off point for clinical significance Resultsindicated that 78 still had elevated BDI scores bythe end of the study Taylor (2008) affirms that drugtreatments for depression are capable of producingaround 12ndash13 score improvement in the BDI Thismagnitude of improvement is very similar to thevalues found here (1253 points) It is important topoint out that a complete remission of depressivesymptoms with fluoxetine may not be realistic foroutpatient treatments of moderate depression Itcould be that some patients achieved significantsymptom change but at the end of treatment theyhad not completely recovered These particularcases are often referred to as ldquoimprovedrdquo instead ofldquorecoveredrdquo (Jacobsen amp Truax 1991)

In COM group 65 of the participants reachedthe BDI cut-off point for clinical significanceDe Jonghe et al (2004) examined whether associat-ing antidepressants to STPP would improve in theoutcome of mild to moderate depression treatmentTwo-hundred patients were treated and remissionrate was 81 De Maat Dekker Schovers and deJonghe (2007) conducted a meta-analysis comparingthe efficacy of short-term psychotherapies and com-bination therapy in the treatment of depressionResults regarding moderate depression showed a47 remission rate for combined treatment Com-bined treatment outperformed STPP in moderatechronic depression These results are in line with theones found by Friedman et al (2004) who reportedthat associating psychotherapy and antidepressantswas most clinically relevant among chronic orseverely depressed patients

Comparison between Treatments

Remission rates based on BDI were significantlybetter for LTPP and COM compared to FLU andrepresent different mean effect sizes between treat-ments LTPP-FLU mean effect size was large (132)There are no previous studies comparing directly theefficacy of LTPP and medication for moderatedepressed patients Salminen et al (2008) found aSTPP-fluoxetine small effect size of 012 Smalleffect sizes are normally found comparing STPP

with pharmacotherapy alone in the treatment ofdepression (de Maat Dekker Schoevers van Aalstet al 2007)

There were significant differences between LTPPand COM Mean effect size was moderate favoringCOM (069) Remission rates were significantlydifferent (66 in COM and 74 in LTPP) Thesenumbers might suggest that COM tends to promotemore intense therapeutic effects while LTPP effectstend to reach a wider number of patients Studiescomparing psychodynamic psychotherapy combinedwith medication and psychodynamic psychotherapyalone usually report that both seem to be equallyefficacious (de Maat Dekker Schoevers van Aalstet al 2007) This also suggests similar clinicalsignificance between LTPP and COM However inCOM group BDI mean achieved the cut-off forclinical significance faster than LTPP group (12 and18 months respectively) This result is in line withwhat was found by de Maat Dekker Schoevers vanAalst et al (2007) They reported that patientsdeclared they felt combined treatment superior topsychodynamic therapy alone (STPP) for fastersymptom reduction De Maat Schoevers et al(2007) in a mega-analysis comparing STPP med-ication and combination therapy found a small tomoderate effect size favoring combination therapyover STPP

COM-FLU comparison resulted in differencesfavoring COM Mean effect size was very large(221) Remission rates were significantly different(66 in COM and 22 in FLU) BDI mean scoresat final were different either (COM = 416 FLU =1416) All these findings are supported by previousstudies De Jonghe et al (2001) found significantlylarger remission rates for STPP combined withmedication (373) compared to medication alone(155) with a moderate effect size (057) Bur-nand Andreoli Kolatte Venturini and Rosset(2002) demonstrated that combination therapy wassuperior to medication alone in terms of clinicalsignificance but with a small effect size (036)Mostly comparisons between medication and com-bined treatment for depression report more pro-nounced differences in remission rates instead ofdifferences in effect size According to Greenbergand Goldman (2009) around 33 of depressedpatients achieve remission after treatment with anti-depressants while combined treatments reach higherremission rates (50ndash90)

Finally the number needed to treat (NNT)methodology also helps to compare the treatmentsfor discussion Using FLU as control (becausefluoxetine has been considered an efficacious treat-ment for depression for more than 30 years) changesthe results When LTPP is compared to control

Psychotherapy Research 9

(FLU) 51 of FLU subjects have the adverseoutcome 7 of LTPP subjects have the adverseoutcome the difference indicating the absolute riskreduction is 45 plusmn 11 (95 CI) the NNT is 3and the 95 confidence interval for this NNTranges from 18 to 30 This means that about onein every three moderately depressed patients willbenefit from LTPP When COM is compared tocontrol (FLU) the scenario shows that 52 of FLUsubjects have the adverse outcome 2 of COMsubjects have the adverse outcome the differenceindicating the absolute risk reduction is 49 plusmn 11(95 CI) and NNT is 3 (ranging from 18 to 30[95 CI]) NNT indicates that about one in everythree patients moderately depressed patients willbenefit from COM The 95 confidence intervalfor the COM group NNT ranges from 17 to 26Thus LTPP and COM showed very similar levels ofeffects when compared to a notorious treatment usedas control (FLU)

Attrition Rates

COM had larger attrition rate (32) compared toLTPP (19) and FLU (26) This has beenreported by previous studies (eg Greenberg ampGoldman 2009 Hawley Ho Zuroff amp Blatt2007) There are also evidences showing that ifpatients had opportunity to choose a treatmentmore patients indicate that they would choosepsychotherapy rather than drugs (Lin et al 2005van Schaik et al 2004) Indeed some researchersbelieve that if it there is any possibility to sparepatients from the risks of taking drugs that should bedone because there are strong evidences that psy-chotherapy has less chances to lead to relapse whenit is terminated and produces fewer side effects (egGreenberg amp Goldman 2009)

Limitations

The present research like many studies has somelimitations Individuals assessed here do not repres-ent all patients with depression that need treatmentTherefore results cannot be generalized The dilatedeffect sizes reported here may lead to an overestima-tion of treatment effect and were caused by groupaverages low variability This also posts a questionmark on the clinical significance utility of theinterpretation criteria of within treatment effect sizesIn longitudinal research designs that aim to increaseinternal validity using a very specific profile ofparticipants within treatment effect sizes may notbe as useful as it is in shorter-term treatments Theparticipantsrsquo homogeneity can also be interpreted asa limitation of the present study because it may

threaten external validity of the findings Further-more participants were mostly young adult womenand with good socioeconomic conditions and higheducational level According to Houle et al (2013)this profile of participants generally adapts moreeasily to psychotherapeutic context and this charac-teristic may help to understand low attrition ratesfound in LTPP group for example Patients withother features might not have adapted to a long-termpsychotherapy or to a longitudinal study

An additional limitation was the use of a singleendpoint measure assessing only the perspective ofthe patients in relation to their symptoms Futurestudies shall seek to approach different perspectives(such as the perspectives of the patientsrsquo relatives orfriends) different areas of symptoms (such as cog-nition) and different areas of functioning (such aswork and social life) Moreover there has not been afollow-up after the conclusion of treatments Thiscould contribute to obtain deeper and more com-prehensive notion of the changes in patients

The LTPP applied in the study although theoret-ically and technically well focused on collectivesupervisions was not strictly guided by a properpractical manual On the other hand fluoxetine wasgiven in accordance with government-manualizedguidelines This creates a validity problem interpret-ing results However the controversy betweenmanualized versus non-manualized treatments con-stitutes a research dilemma This occurs particularlyin long-term treatments where more general theor-etical guidelines may be of preferred use (KnektLindfors Harkanen et al 2008 Piper McCallumJoyce Azim amp Ogrodniczuk 1999)

Other limitations include the lack of a non-inter-vention control group (which was not included inthe research desing because of ethical questions) theintrinsic differences between treatments (biologicalvs face-to-face treatment amounts and so on) andthe expectancies of the providers and patients (whichwere not assessed and constitute an issue to beaddressed in future researches) At any rate theauthors have made a decision on the grounds oflimitations of space of not to itemizing all possiblelimitations of the present study except the onesespecially relevant Instead the authors rely onthe overall discussion contained in this paper andentrust the readersrsquo criticism

Strengths and Potential Implications

Main findings of the present study underline theefficacy of LTPP and combination treatment Theywere superior over the time in all aspects evaluatedhere when compared to the use of fluoxetine alone inthe treatment of patients with moderate depression

10 A G Bastos et al

The results found here also support the idea thatLTPP is an effective treatment for moderate depres-sion Hereupon it is necessary to point out that it isbeyond the scope of this study to provide definitivestatements regarding the benefits of the treatmentsdescribed here

The strengths of this manuscript include somefeatures First it has a sizable sample size in eachtreatment group and randomization of patientsSecond it monitored patients for a meaningfultime and had multicriteria of analysis for represent-ing outcome Third the clinical relevance of themain questions addressed (eg given the long-termtime course psychotherapy benefit more than biolo-gical treatment or not what is the additive clinicalvalue if any of combined treatment over a longit-udinal course and so forth)

All together it seems that LTPP may be a viableclinical option for some patients comparing toCOM Remission rates are quite similar and thereis no strong between treatments effect size favoringCOM and there are no significant differences inBDI scores

Finally it is important to consider that there arerelatively few randomized controlled trials (RCT) ofLTPP for depression The authors of the presentresearch are unaware of the existence of other RCTin which LTPP was both compared with a legitimatepsychopharmacological treatment and with com-bination therapy and likewise treatment outcomewas assessed in many meaningful intervals Therelative absence of RCTs with LTPP in the treat-ment of depression creates serious limitation inliterature which could lead to automatic exclusionof this therapy from clinical choices for depressiontreatment The present research and its findings shalloffer a partial but quite infrequent contribution topsychiatric and psychological fields It may provide aconceptual extension to what have been found byother researchers (eg Huber et al 2012 KnektLindfors Harkanen et al 2008) suggesting thatlong-term psychotherapy is clinically superior whenprovided over the same period of time as a knownSSRI treatment

References

Barber J Muran J McCarthy K amp Keefe R (2013) Researchon psychodynamic therapies In M J Lambert (Eds) Berginand Garfieldrsquos handbook of psychotherapy and behavior change(pp 443ndash494) New York NY John Wiley amp Sons

Bastos A Guimaratildees L amp Trentini C (2013) Neurocognitivechanges in depressed patients in psychodynamic psychother-apy therapy with fluoxetine and combination therapy Journalof Affective Disorders 151 1066ndash1075 doi101016jjad201308036

Bastos A amp Trentini C (2013) Psicoterapia psicodinacircmica etratamento bioloacutegico com fluoxetina Comparaccedilatildeo de respostacognitiva em paciente deprimidos [Psychodynamic

psychotherapy and biological treatment with fluoxetine Com-parison of cognitive response in depressed patients] PsicologiaTeoria e Pesquisa 29 437ndash446 doi101590S0102-37722013000400010

Beck A amp Steer R (1993) Beck Depression Inventory SanAntonio Psychological Corporation

Beck A Steer R amp Brown G (1996) Psychometric propertiesof the Beck Depression Inventory Twenty-five years of evalu-ation Clinical Psychologist Review 8 77ndash100 doi1010160272-7358(88)90050-5

Berger M Brakemeier E Klesse C amp Schramm E (2009)Affective disorders The significance of psychotherapeuticapproaches Nervenarzt 80 540ndash548 doi101007s00115-008-2624-x

Berghout C amp Zevalkink J (2009) Clinical significance of long-term psychoanalytic treatment Bulletin of the Menninger Clinic73(1) 7ndash33 doi101521bumc20097317

Beutel M amp Rasting M (2002) Long-term treatments from theperspectives of the former patients In M Leuzinger-Bohleberamp M Target (Eds) The outcomes of psychoanalytic treatment(pp 130ndash142) London Whurr

Buchheim A Viviani R Kessler H Kaumlchele H Cierpka MRoth G amp Taubner S (2012) Changes in prefrontal-limbicfunction in major depression after 15 months of long-termpsychotherapy PLoS ONE 7(3) 337ndash345 doi101371journalpone0033745

Burnand Y Andreoli A Kolatte E Venturini A amp RossetN (2002) Psychodynamic psychotherapy and clomipramine inthe treatment of major depression Psychiatric Services 53 585ndash590 doi101176appips535585

Byrt T Bishop J amp Carlin J (1993) Bias prevalence and kappaJournal of Clinical Epidemiology 46 423ndash429 doi1010160895-4356(93)90018-V

Cohen D (1988) Statistical power analysis for the behavioralsciences New York Academic Press

Cunha J (2001) Manual da versatildeo em portuguecircs das Escalas Beck[Manual of the Portuguese version of Beckrsquos Scales] SatildeoPaulo Casa do Psicoacutelogo

de Jonghe F Hendriksen M Aalst G Kool S Penn V VanR hellip Dekker J (2004) Psychotherapy alone and combinedwith psychopharmacotherapy in the treatment of depressionBritish Journal of Psychiatry 185 37ndash45 doi101192bjp185137

de Jonghe F Kool S Allst G Dekker J amp Peen J (2001)Combining psychotherapy and antidepressants in the treatmentof depression Journal of Affective Disorders 64 217ndash229doi101016S0165-0327(00)00259-7

Del-Ben C Rodrigues C amp Zuardi A (1996) Reliability ofthe Portuguese version of the structured clinical interview forDSM-III-R (SCD-I) in a Brazilian sample of psychiatric out-patients Brazilian Journal of Medical Research 29 1675ndash1682

Del-Ben C Vilela J Crippa J Hallak J Labate C amp ZuardiA (2001) Confiabilidade teste-reteste da Entrevista CliacutenicaEstruturada para o DSM-IV ndash Versatildeo cliacutenica (SCID-CV)traduzida para o portuguecircs [Test-retest reliability of thestructured clinical interview for DSM-IV - clinical version]Revista da Associaccedilatildeo Brasileira de Psiquiatria 23 156ndash159doi101590S1516-44462001000300008

Del-Ben C Zuardi A amp Rodrigues C (1998) Confiabilidadedo diagnoacutestico psiquiaacutetrico levantado sob supervisatildeo e dodiagnoacutestico obtido atraveacutes da entrevista cliacutenica estruturadapara o DSM-III-R (SCID) [Reliability of psychiatric diagnosisraised under supervision and diagnosis obtained through theStructured Clinical Interview for DSM-III-R (SCID)] Revistada Associaccedilatildeo Brasileira de Psiquiatria 20 140ndash145

de Maat S de Jonghe F Schoevers R amp Dekker J (2009)The effectiveness of long-term psychoanalytic therapy

Psychotherapy Research 11

A systematic review of empirical studies Harvard Review ofPsychiatry 17(1) 1ndash23 doi10108010673220902742476

de Maat S Dekker J Schoevers R amp de Jonghe F (2007)Relative efficacy of psychotherapy and combined therapy in thetreatment of depression A meta-analysis European Psychiatry22(1) 1ndash8 doi101016jeurpsy200610008

de Maat S Dekker J Schoevers R van Aalst G Gijsbers-vanWijk C Hendriksen M hellip de Jonghe F (2007) Shortpsychodynamic supportive psychotherapy antidepressants andtheir combination in the treatment of major depression Amega-analysis based on three randomized clinical trials Depres-sion and Anxiety 10 1ndash10

de Maat S Schoevers R de Jonghe F van Aalst GGijsbers-van Wijk C Hendriksen M hellip Dekker J (2007)Comparison of short psychodynamic supportive psychotherapypharmacotherapy and their combination on subdimensions ofthe HDRS and subscales of the SCL-90 A mega-analysis ofthree randomized controlled trials regarding depressed patientsIn S de Maat (Ed) On the effectiveness of psychoanalytic therapyShort if possible long if necessary (pp 109ndash124) AmsterdamRidderprint

Dunn G Sham P amp Hand D (1993) Statistics and nature ofdepression Psychological Medicine 23 871ndash889 doi101017S0033291700026350

Elkin I Shea M Watkins J Imber S Sotsky S Collins Jhellip Parloff M B (1989) National institute mental healthtreatment of depression collaborative program General effec-tiveness of treatments Archives of General Psychiatry 46 971ndash982 doi101001archpsyc198901810110013002

Friedman M Detweiler-Bedell J Leventhal H Horne RKeitner G amp Miller I (2004) Combined psychotherapy andpharmacotherapy for the treatment of major depressive dis-order Clinical Psychology Science and Practice 11(1) 47ndash68doi101093clipsybph052

Gabbard G (2004) Long-term psychodynamic psychotherapy Abasic text Arlington American Psychiatric

Gabbard G (2010) Long-term psychodynamic psychotherapy Abasic text 2nd ed Arlington American Psychiatric

Gibbons M Crits-Christoph P amp Hearon B (2008) Theempirical status of psychodynamic therapies Annual Review ofClinical Psychology 4 93ndash108 doi101146annurevclinpsy4022007141252

Greenberg R amp Goldman E (2009) Antidepressants psycho-therapy or their combination Weighing options for depressiontreatments Journal of Contemporary Psychotherapy 39 83ndash91doi101007s10879-008-9092-2

Gueorguieva R amp Krystal J (2004) More over ANOVAProgress in analyzing repeated-measures data and its reflectionin papers published in the archives of general psychiatryArchives in General Psychiatry 61 310ndash317 doi101001archpsyc613310

Gunderson J amp Gabbard G (1999) Making the case forpsychoanalytic therapies in the current psychiatric environ-ment Journal of the American Psychological Association 47679ndash704

Hashemi S Shirazi H Mohammadi A Zadeh-Bagheri GNoorian K amp Malekzadeh M (2012) Nortriptyline versusfluoxetine in the treatment of major depressive disorder A six-month double-blind clinical trial Clinical PharmacologyAdvances and Applications 4 1ndash6

Hawley L Ho M Zuroff D amp Blatt S (2007) Stressreactivity following brief treatment for depression Differentialeffects of psychotherapy and medication Journal of Consultingand Clinical Psychology 75 244ndash256 doi1010370022-006X752244

Hersen M Bellack A Himmelhoch J amp Thase M (1984)Effects of social skill training amitriptyline and psychotherapy

in unipolar depressed women Behavioral Therapy 15(1) 21ndash40 doi101016S0005-7894(84)80039-8

Hollon S amp Ponniah K (2010) A review of empiricallysupported psychological therapies for mood disorders in adultsDepression and Anxiety 27 891ndash932 doi101002da20741

Houle J Villaggi B Beaulieu M Lespeacuterance F RondeauG amp Lambert J (2013) Treatment preferences in patients withfirst episode depression Journal of Affective Disorders 147(1)94ndash100 doi101016jjad201210016

Huber D Henrich G Gastner J amp Klug G (2012) Must allhave prizes The Munich psychotherapy study In R Levy JAblon amp H Kaumlchele (Eds) Psychodynamic psychotherapyresearch Evidence-based practice and practice-based evidence(pp 51ndash70) London Humana Press

Huber D amp Klug G (2006) Munich psychotherapy study(MPS) In D Huber amp G Klug (Eds) The effectiveness ofpsychoanalytic long-term psychotherapy for depression Fromresearch to practice (pp 21ndash50) Ulm Ulmer Text Bank

Jacobsen N amp Truax P (1991) Clinical significance Astatistical approach to defining meaningful change in psycho-therapy research Journal of Consulting and Clinical Psychology59 12ndash19 doi1010370022-006X59112

Kendall P amp Sheldrick R (2000) Normative data for normativecomparisons Journal of Consultants Clinical Psychologists 68767ndash773 doi1010370022-006X685767

Knekt P Lindfors O Harkanaen T Vaumllikoski M Virtala ELaaksonen M hellip The Helsinki Psychotherapy Study Group(2008) Randomized trial on the effectiveness of long andshort-term psychodynamic psychotherapy and solution-focusedtherapy on psychiatric symptoms during a 3-year follow-upPsychological Medicine 38 689ndash703 doi101017S003329170700164X

Knekt P Lindfors O Laaksonen M Raitasalo R HaaramoP amp Jaumlrvikoski A (2008) Effectiveness of short-term and long-term psychotherapy on work ability and functional capacity ndash Arandomized clinical trial on depressive and anxiety disordersJournal of Affective Disorders 107 95ndash106 doi101016jjad200708005

Knekt P Lindfors O Sares-Jaumlske L Virtala E amp HaumlrkaumlnenT (2013) Randomized trial on the effectiveness of long- andshort-term psychotherapy on psychiatric symptoms and work-ing ability during a 5-year follow-up Nordic Journal of Psychi-atry 67(1) 59ndash68 doi103109080394882012680910

Kornblith S Rehm L OrsquoHara M amp Lamparski D (1983)The contribution of self-reinforcement training and behavioralassignments to the efficacy of self-control therapy for depres-sion Cognitive Therapy Research 7 499ndash527 doi101007BF01172888

Lambert M amp Ogles B (2004) The efficacy and effectivenessof psychotherapy In M Lambert (Ed) Bergin and Garfieldrsquoshandbook of psychotherapy and behavior change (pp 139ndash193)New York Wiley

Leichsenring F Biskup J Kreische R amp Staats H (2005) TheGoettingen study of psychoanalytic therapy First results Inter-national Journal of Psychoanalysis 86 433ndash455 doi101516XX6F-AU0W-KWM3-G6LU

Leichsenring F amp Rabung S (2008) Effectiveness of long-termpsychodynamic psychotherapy A meta-analysis Journal ofAmerican Medical Association 300 1551ndash1565 doi101001jama300131551

Leichsenring F amp Rabung S (2009) Analyzing effectiveness oflong-term psychodynamic psychotherapy reply Journal ofAmerican Medical Association 3001 932ndash933

Leichsenring F amp Rabung S (2011) Long-term psycho-dynamic psychotherapy in complex mental disorders Updateof a meta-analysis British Journal of Psychiatry 199 15ndash22doi101192bjpbp110082776

12 A G Bastos et al

Lin P Campbell D Chaney E Liu C Heagerty P FelkerB hellip Hedrick S C (2005) The influence of patientpreference on depression treatment in primary care Annals ofBehavioral Medicine 30 164ndash173 doi101207s15324796abm3002_9

Luyten P amp Blatt S (2012) Psychodynamic treatment ofdepression Psychiatr Clin North America 35(1) 111ndash129doi101016jpsc201201001

Morris S amp DeShon R (2002) Combining effect size estimatesin meta-analysis with repeated measures and independent-groupsdesigns Psychological Methods 7(1) 105ndash125 doi1010371082-989X71105

Piper W McCallum M Joyce A Azim H amp Ogrodniczuk J(1999) Follow-up findings for interpretive and supportive formsof psychotherapy and patients personality variables Journal ofConsultant Clinical Psychology 67 267ndash273 doi1010370022-006X672267

Roth A amp Fonagy P (2005) What works for whom A criticalreview of psychotherapy research New York The Guilford Press

Salminen J Karlsson H Hietala J Kajander J Aalto SMarkkula J hellip Toikka T (2008) Short-term psychodynamicpsychotherapy and fluoxetine in major depressive disorder Arandomized comparative study Psychotherapy and Psychoso-matics 77 351ndash357 doi101159000151388

Sandell R Blomberg J Lazar A Carlsson J Broberg J ampSchubert J (2000) Varieties of long-term outcome amongpatients in psychoanalysis and long-term psychotherapy Areview of findings in the Stockholm outcome of psychoanalysisand psychotherapy project (Stoppp) International Journal ofPsychoanalysis 81 921ndash942 doi1015160020757001600291

Shedler J (2010) The efficacy of psychodynamic psychotherapyAmerican Psychologist 65(2) 98ndash109 doi101037a0018378

Taylor D (2008) Psychoanalytic and psychodynamic therapiesfor depression the evidence base Advances in PsychiatricTreatment 14 401ndash413 doi101192aptbp107004382

van Schaik D Klijn A van Hout H van Marwijk HBeekman A de Haan M amp van Dick R (2004) Patientsrsquopreferences in the treatment of depressive disorder in primarycare General Hospital Psychiatry 26 184ndash189 doi101016jgenhosppsych200312001

World Health Organization (2009) The world health reportRetrieved November 27 2012 from httpwwwwhointwhr2009enindexhtml

Psychotherapy Research 13