Psychodynamic Treatment

of Depression
Patrick Luyten, PhDa,b,* , Sidney J. Blatt, PhDc

KEYWORDS
• Depression • Mood disorder • Psychoanalytic
• Psychodynamic • Treatment • Efficacy • Effectiveness

Key Points: SUMMARY OF KEY FINDINGS CONCERNING PSYCHODYNAMIC TREATMENT OF DEPRESSION

X Psychodynamic treatments for depression are readily accepted by many depressed patients as
a viable treatment
X Brief psychodynamic treatment
● Is superior to control conditions, is equally effective as other active psychological treatments,
and treatment effects are often maintained in the long run
● Is as effective as pharmacotherapy in the acute treatment of mild to moderate depression, and
either alone or in combination with medication is associated with better long-term outcome
compared with pharmacotherapy alone
X Longer-term psychoanalytic treatment and psychoanalysis
● May be indicated in patients with complex, chronic psychological disorders characterized by
mood problems, often with comorbid anxiety and personality problems.
● May be more effective in the long run compared with brief treatment for depression, although
more research is needed in this context.
X Evidence suggests that psychoanalytic treatment is also effective in children and adolescents

Over the last 2 decades, there has been a remarkable increase in research into
psychodynamic treatments (PT) for depression.1– 4 This article reviews the key
theoretical assumptions of PT for depression and summarizes findings concerning

The authors have nothing to disclose.

a
Department of Psychology, University of Leuven, Tiensestraat 102 PO Box 3722, 3000 Leuven,
Belgium
b
Research Department of Clinical, Educational and Health Psychology, University College,
London, UK
c
Departments of Psychiatry and Psychology, Yale University, New Haven, CT, USA
* Corresponding author. Department of Psychology, University of Leuven, Tiensestraat 102 PO
Box 3722, 3000 Leuven, Belgium.
E-mail address: patrick.luyten@psy.kuleuven.be

Psychiatr Clin N Am 35 (2012) 111–129

doi:10.1016/j.psc.2012.01.001 psych.theclinics.com
0193-953X/12/$ – see front matter © 2012 Elsevier Inc. All rights reserved.
112 Luyten & Blatt

the efficacy and effectiveness of these interventions alone and in combination with
pharmacotherapy in adults, children, and adolescents. Issues of suitability and
acceptability are also discussed as well insights into the mutative factors in these
treatments. We close this article with a summary and implications for future research
and treatment guidelines.

SPECIFICITY OF THE PSYCHODYNAMIC APPROACH: COMMON AND SPECIFIC

FACTORS IN PSYCHODYNAMIC TREATMENTS OF DEPRESSION

Meta-analyses have identified very few, if any, differences in the efficacy of bona fide
psychotherapies for a number of conditions, including depression.5,6 This may be
because the effects of these treatments are only in part related to specific techniques.
Other factors may account for a larger portion of the variance in treatment outcome;
it has been estimated that only 15% is predicted by specific techniques, 30% by
common factors (eg, providing support), 15% by expectancy and placebo effects,
and 35% to 40% by extratherapeutic effects (eg, spontaneous remission, positive
events or changes).7 Moreover, it has been difficult to find differences among
treatments because most studies have focused on symptom remission in brief,
highly structured, and manualized interventions. Furthermore, most randomized,
controlled trials (RCTs) have only had power to investigate noninferiority com-
pared with other active treatments and thus may be unable to detect meaningful
differences between treatments. Research focusing on outcomes broader than
symptom remission, as well as long-term effects, may be more promising as
discussed below.

Psychodynamic Specific Features

Notwithstanding the many common features of treatments for depression (such as
provision of hope, support, and a theoretical framework concerning the origins of
and potential cure for the disorder), studies do show important differences
between psychodynamic and other treatments. For instance, relative to cognitive–
behavioral therapists, psychodynamic therapists tend to have a stronger empha-
sis on8:
1. Affect and emotional expression
2. Exploration of patients’ tendency to avoid topics (ie, defenses)
3. Identification of recurring patterns in behavior, feelings, experiences, and relationships
4. The past and its influence on the present
5. Interpersonal experiences
6. The therapeutic relationship
7. Exploration of wishes, dreams, and fantasies.

These findings are largely congruent with work done in the United Kingdom in the
context of the Improving Access to Psychological Therapies initiative. This demon-
strates that although psychodynamic competencies overlap to some extent with
those of other treatments (such as the ability to engage the client and establish a
positive therapeutic alliance), there are a number of competencies specific to
psychodynamic therapy (such as the ability to work with transference and counter-
transference and to recognize and work with defenses).9 The focus on competencies
has also led to the development of dynamic interpersonal therapy, a promising novel
psychodynamic treatment for depression that integrates features of a number of
current empirically supported PT of depression. Dynamic interpersonal therapy is
currently being evaluated in an RCT.2
 Psychodynamic Treatment of Depression 113

Aside from these specific techniques and competencies, a number of general

assumptions, rooted in psychodynamic theory,10 further define the specificity of the
psychodynamic approach to the treatment of depression.

Psychodynamic Approaches Focus on the Patient’s Internal World

First, perhaps more so than any other treatment, PT focus on the patient’s internal
world, that is, representations or cognitive affective schemas of self and others that
influence our perceptions, thoughts, feelings and actions, including an emphasis on
the role of unconscious motivation and intentionality. The emphasis in psychody-
namic approaches to depression is on how (unconscious) motivational factors lead
the patient to (mis)perceive and (mis)interpret external reality and experiences and to
create, unwillingly, problems that maintain depressive symptoms, particularly in
interpersonal relationships. For instance, highly dependent individuals may uncon-
sciously avoid any manifest expression of aggression in close relationships for fear of
abandonment, although they may feel very frustrated and dissatisfied. Likewise,
because of their high standards and competitiveness, highly self-critical individuals
may unconsciously and unwittingly elicit criticism and dislike by others, reinforcing
their belief that that nobody really likes or loves them.11 Of course, these tendencies
are likely to be influenced by social– environmental factors (eg, growing up in a family
characterized by low parental warmth or working in a competitive work environment)
and by biological factors, some of which are discussed below.
Yet, psychoanalytic approaches to depression emphasize the need to understand
the subjective experience of the disorder. As we discuss in more detail below, a focus
on the phenomenology of depression has not only allowed researchers from different
theoretical strands to delineate different types of depressive experiences. This has
also facilitated research into neurobiological and social factors related to depres-
sion12–14 and led to an awareness of the role of distortions in mentalization, that is, the
ability to reflect on the self and others in terms of mental states, both as a cause and
a consequence of depression. These distortions may not only influence the course
but also the treatment of this disorder.2,13

Psychodynamic Approaches Take a Developmental Perspective

Second, psychodynamic approaches have always emphasized the importance of a
developmental perspective in conceptualizing and treating depression, and recent
research has provided dramatic support for these assumptions. For instance, the
emphasis in contemporary models of depression concerning the impact of early
adversity on the programming of the main human stress system and the existence of
critical time windows in development, when biological/psychological systems are
especially sensitive to environmental experiences, are congruent with assumptions
about the role of early developmental factors in the causation of depression.15–17
Psychoanalytic treatment approaches more specifically emphasize the role of insight
into the past in changing attitudes and feelings in the present, offering the possibility
of a “new beginning.”18 Moreover, even in brief PT of depression that focus less on
the past, developmental antecedents of behavior, thoughts, feelings, and attitudes
are always taken into account.2

Psychodynamic Approaches are Person Centered

Finally, psychodynamic approaches of depression are more person than disorder
centered. The view, supported by empirical research,19,20 is that depression is not
categorically distinct from subclinical depression and from normality and that
114 Luyten & Blatt

depression is not a discrete disorder, distinct from other Axis I and Axis II disorders.
Depression is first and foremost considered to be a basic affect that signals a
discrepancy between a wished-for state and an actual state of the self; it is not
necessarily considered something pathologic. It is seen as a primordial, probably for
evolutionary reasons prewired, signal affect or a basic “building block” of the
individual’s internal affective world. From a psychoanalytic perspective, both normal
and disrupted development involve ongoing attempts by the individual, throughout
the life span, to find an optimal balance between biological givens and the demands
of the environment.11 Depression is, thus, not conceptualized in terms of a static end
state, but as reflecting continuing attempts of the individual, however maladaptive, to
find a (better) balance between endowment and experience.21 Together with anxiety
and aggression, depression is seen as a basic emotional response of the individual,
in particular to feelings of loss of a wished-for state. Depression, anxiety, and
aggression are, thus, inextricably linked. This also explains the high comorbidity of
depression and anxiety and the largely artificial distinction between these 2 disorders
in psychiatric classification.22 Viewing depression as a basic affect suggests there is
no qualitative but only quantitative distinction between normal and “pathological”
mood, with depression situated on a continuum ranging from mild dysphoria to
clinical depression, a view supported by taxometric studies.23
Person- and disorder-centered approaches should be seen as complementary.
Studies clearly show that most patients seek help from psychoanalytically trained
therapists primarily for (chronic) mood problems, often in combination with anxiety
and personality problems.24,25 In response, a substantial empirical tradition
focusing on depression and its treatment has emerged within the psychoanalytic
tradition.

THEORETICAL PERSPECTIVES
Historical Developments
Freud aptly described depression as a psychic wound or hemorrhage (“innere
Verblutung”), a kind of “hole in the psyche” (“ein Loch im psychischen”) that drains all
energy of the individual.26 From a psychoanalytic perspective, the core features of
depression indeed refer to a problem related to desire, that is, the relationship of the
individual to his wishes, ideals, and ambitions27,28 or “wished-for state.”29 The
depressed patient’s complaints can be seen as indicative of a continuous and often
very painful confrontation resulting from the gap between his ideals and ambitions, his
wished-for state of the self and the actual state of the self. This may lead to feelings
of helpless or hopelessness,30 possibly explaining the typical feelings of anhormia
(lack of drive) and anhedonia observed in depressed individuals. Yet, this state is also
often accompanied by anxiety (anxious or agitated depression), and aggression
toward the self or others. In Kleinian31 and attachment-based32 approaches, aggres-
sion toward the self and others (eg, because of self-criticism or disappointment) is
seen as playing a prominent role in depression. Moreover, feelings of pain and
exhaustion also typically color the clinical picture, as is also expressed in the high
co-occurrence and comorbidity between depression, pain, and fatigue syndromes.33
By contrast, in (hypo)manic states, which are almost the opposite of depression in
terms of symptoms, the individual appears to be at one with his ego ideal.34 Although
these observations are still relevant clinically, traditional psychoanalytic theories of
depression were often overspecified, lacked theoretical precision, and were too broad
to be empirically tested.
 Psychodynamic Treatment of Depression 115

Fig. 1. Treatment focus: dysfunctional transactional styles associated with personality-re-

lated vulnerability for depression.

Personality and the Dynamics of Depression

In the early 1970s, Blatt35 provided a view of depression that has been the basis for
almost 40 years of empirical research and most contemporary psychodynamic ap-
proaches to depression.11,14,20,36,37 Congruent with earlier psychoanalytic theorizing, he
argued that in the phenomenologic experience of depression, 2 central issues can be
identified: one relating to loneliness, feelings of neglect, and abandonment, the other to
self-worth, responsibility, and guilt. As a result of this distinction, investigators from both
the psychodynamic and cognitive– behavioral tradition have focused on 2 independent
personality dimensions in depression,35,38,39 an interpersonal dimension, reflecting high
levels of dependency, and a self-critical dimension that involves extensive preoccupation
with self-definition and autonomy. Beck,38 from a cognitive-behavioral perspective,
similarly distinguished sociotropy and autonomy, personality dimensions that, in the
extreme, confer vulnerability for depression.
Considerable evidence indicates that the dependency and self-critical personality
dimensions are associated with differences in the onset, course, and clinical expres-
sion of depression,14,20,35 basic personality style,11 relational and attachment
style,21,40 and current and early life experiences.41,42 Perhaps most importantly, as
discussed in the final section of this article, these 2 dimensions are also related to
treatment response across different therapeutic modalities.43
Evidence also indicates that high levels of dependency and self-criticism are
associated both with increased stress sensitivity and the generation of stress,
particularly through so-called dysfunctional interpersonal transactional styles,20,44,45
which often are the central focus in PT of depression (Fig. 1). These findings are
particularly relevant given that stress and adversity play a major role in the causation
of depression.46,47
Individuals with high levels of dependency or self-criticism tend to behave in ways
that elicit particular responses from others. These reactions often confirm the
116 Luyten & Blatt

individual’s fear of rejection and abandonment or of disapproval, thereby creating a

vicious cycle. For example, high levels of dependency have been associated with
annoyance and resentment in others, eventually leading to rejection and abandon-
ment, thereby confirming fears associated with high levels of dependency. Similarly,
high levels of self-criticism are associated with ambivalence toward others because of
fear of criticism and disapproval. Accordingly, others perceive these individuals as
cold, competitive, and distant, confirming the highly self-critical individual’s belief that
others do not like and disapprove of them.

Attachment, Mentalization, and the Neurobiology of Depression

Attachment
Blatt’s and Beck’s models are conceptually and empirically linked to attachment
theory,20 fostering dialogue between psychoanalytic, developmental psychopathol-
ogy, and neuroscience approaches to depression.13,48 Contemporary research
suggests that 2 dimensions, avoidance and anxiety, underlie attachment styles49,50
and that these are conceptually related to Blatt’s concepts of self-definition and
relatedness, respectively. The attachment avoidance dimension refers to “discomfort
with closeness and with discomfort depending on others”49 and is typically associ-
ated with the use of attachment deactivation strategies. In times of distress,
automatic unconscious strategies are activated that involve denying attachment
needs and asserting one’s own autonomy, independence, and strength. The attach-
ment anxiety dimension, in contrast, involves “fear of rejection and abandonment.”49
In times of stress, the attachment system becomes hyperactivated leading to frantic
attempts to find security, support, and relief, often expressed in demanding or clingy
behavior.
Evidence from various strands of research support the key role of attachment in
depression.13 Vulnerability to depression is related to both attachment hyperactiva-
tion and deactivation strategies.51,52 Insecure attachment has been shown to be
prospectively related to recurrent depression and is associated with more depressive
episodes and residual symptoms, longer use of antidepressants, greater impairments
in social functioning,53 and suicide.54 As noted, early adversity, and disruptive
attachment experiences in particular, play a central role in the causation of depres-
sion.46 This may explain, at least in part, the role of increased responsivity to both
daily and major life stressors in the causation and course of depression.46,55
Furthermore, both animal56 –58 and human59 – 61 research suggests that the neuro-
peptide oxytocin (and potentially also vasopressin), which is involved in neural
systems underlying attachment,56,62 plays a key role in stress regulation. This
hormone is involved in affiliative behavior (eg, pair bonding, maternal care, and sexual
behavior), social memory, and social support63 and has stress-reducing and anx-
iolytic effects,56 again indicating the close relationship between attachment history,
depression, and anxiety.48
The emphasis on attachment in depression is further reinforced by findings on the
role of impairments in social cognition, and mentalizing in particular, in depression.2,64

Mentalization
Mentalizing refers to the imaginative mental activity involving interpretation of the self
and others in terms of mental states, such as feelings, desires, wishes, and goals. It
enables us to navigate the social world and is typically acquired in the context of
(early) attachment relationships. Impairments in mentalizing have been associated
with depression, and they may, in part, underlie the interpersonal problems typically
associated with this disorder (for a detailed review, see Luyten and coworkers13).
 Psychodynamic Treatment of Depression 117

As well as having a causative role, it is likely that impairments in mentalizing also

result from depression. Depressed mood impairs the capacity of an individual to
reflect on both the self and others, and when he or she does mentalize, it is likely to
be distorted. As a result, modes of thinking that antedate full mentalizing re-emerge
that help understand the phenomenologic experience of depression. For example, in
the psychic equivalence mode, psychological and physical pain and emotional and
physical exhaustion are equated, possibly explaining the high comorbidity of pain,
fatigue, and depression.65,66 Psychological experiences are felt as too real; psycho-
logical pain means bodily pain, and criticism by others is felt as a physical attack on
the integrity of the self. Findings on the common neural circuits underlying psycho-
logical and physical pain show that these experiences are closely intertwined;
rejection literally hurts.67 In the pretend mode, thoughts and feelings are severed from
reality, which is typically expressed in overly detailed, highly cognitive, or affectively
overwhelming narratives, often characterized by rumination, self-blame, or the
relentless blaming of others. In the teleological mode, only observable behavior or
material causes can be real. The patient can only feel loved if there is also a physical
expression of love, which may lead to frantic attempts to elicit care and love from
attachment figures, including the therapist (eg, demanding longer or more sessions or
asking to be hugged or touched, which may lead to boundary violations). In this mode,
suicidal thoughts and gestures often lead others, including professionals, to similarly
revert to a teleological mode in an attempt to demonstrate love, care, and concern.
EFFICACY AND EFFECTIVENESS OF PSYCHODYNAMIC THERAPY FOR DEPRESSION

Over the last decades, a range of brief and long-term psychodynamically based
treatments for depression have been empirically evaluated in children, adolescents,
and adults. Although some of these treatments have been based on generic
psychodynamic treatment principles,68 –73 others have been more explicitly rooted in
extant psychodynamic findings concerning depression.2,74 These treatments differ to
the extent that they emphasize supportive and expressive techniques (although they
all include elements of both) and whether their primary focus is interpersonal or
intrapsychic. Despite these differences, as noted, these treatments have in common
a focus on recurring patterns in feelings and relationships with the aim to increase the
patient’s insight into these patterns, so that he or she can change them.8 Several
recent reviews and meta-analyses have addressed their efficacy and effective-
ness.4,75,76 Below we critically review the findings.

Efficacy and Effectiveness of Psychodynamic Treatment Alone

A recent meta-analysis of 23 studies with a total of 1365 patients found that brief
psychoanalytic therapy (BPT) for depression was associated with large symptom
reductions (Cohen’s d ⫽ 1.34) that were maintained at 1-year follow-up.4 BPT was found
superior to control conditions (d ⫽ 0.69). After treatment, BPT was slightly less effective
than other psychotherapies (d ⫽ 0.30), yet these differences disappeared at 3- and
12-month follow-up (d ⫽ 0.05 and d ⫽ 0.29, respectively). Moreover, individual BPT (d ⫽
1.43) was more effective compared with group BPT (d ⫽ 0.83) and was as effective as
other individual psychotherapies after treatment (d ⫽ 0.19) and at 3- and 12-month
follow-up (d ⫽ 0.05 and d ⫽ 0.31, respectively; all nonsignificant). These results are
surprisingly good, given that in early trials, BPT was often included as a control condition.
The use of BPT as a control may also explain, in part, why some previous reviews
found BPT to be inferior to other therapies, including cognitive behavioral treatment
(CBT). In the meta-analysis by Gloaguen and colleagues,77 for example, Wampold
and coworkers5 found that once non– bona fide therapies were removed, superiority
118 Luyten & Blatt

of CBT over other therapies could no longer be demonstrated. A recent meta-analysis

of RCTs comparing the efficacy of BPT to CBT in major depressive disorder, similarly
found no differences in changes in depressive and general psychiatric symptoms nor
social functioning.78

Specific types of depression and BPT

Reviews and meta-analyses focusing on specific types of depression and related
conditions similarly support the efficacy and effectiveness of BPT. Abbass and
colleagues79 recently presented a meta-analysis of BPT in patients with depression
and comorbid personality disorder, showing moderate to large effect sizes that were
maintained at treatment follow-up. These findings are important, as estimates of
comorbidity between major depression and personality disorder typically range
between 35% and 65%.80 Maina and colleagues81 compared the efficacy of BPT,
brief supportive therapy (ST), and a wait-list condition (WL) in the treatment of minor
depressive disorder. Both BPT and ST were superior to the WL at treatment
termination, and BPT was superior to ST at 6-month follow-up. In one RCT focusing
on pathologic grief, it was found that group BPT was superior to a WL control group.82
In a second RCT of this group, there was a patient–treatment interaction; patients with
high quality of object relationships showed greater improvement with regard to grief
symptoms in insight-oriented BPT, whereas those with low-level object relations
showed greater gains in supportive BPT.83 These findings are congruent with those
from studies showing that patients with lower levels of personality organization may
benefit more from treatments with a greater emphasis on supportive interventions.84
Yet, for general symptoms, insight-oriented BPT was superior regardless of level of
object relations.
Although BPT is highly effective for a considerable subgroup of patients suffering
from depressive disorders, a substantial proportion do not improve, as is the case
with other brief treatment.85 Recent studies suggest that only about 50% of
depressed patients show a response to brief treatment and that relapse figures can
be as high as 75%.19,20,85,86 A recent follow-up study found that 42% of patients
treated with BPT for depression had a recurrence within a 5-year time span, which is
similar to findings in follow-up studies of other brief psychological treatments, such as
CBT.87

Long-term perspective in depression treatment

Current treatment guidelines, therefore, emphasize the role of a long-term perspec-
tive in the management of depression, stressing continuation and maintenance
treatment, with a focus on relapse prevention.85 In this context, studies concerning
longer-term psychoanalytic treatment (LTPT) are highly relevant, as LTPT focuses on
patients suffering from chronic mood problems, which often result from a combina-
tion of depression, anxiety, and significant personality and relational problems.
Studies by Knekt and colleagues88,89 are particularly pertinent in this context. They
conducted an RCT comparing BPT, LTPT, and solution-focused therapy in 326
patients with depressive and anxiety disorders. During the first year, BPT was
superior to LTPT, during the second year there were no differences between these
treatments, and at 3-year follow-up LTPT outperformed both BPT and solution-focused
therapy, with no differences between the latter 2 treatments. These findings are
consistent with the assumption that LTPT is characterized by a slower rate of change
compared with brief treatment (probably because it focuses less on symptomatic
improvement), but is associated with more lasting, and perhaps broader, changes. In the
 Psychodynamic Treatment of Depression 119

next section, we discuss evidence suggesting that LTPT may be associated with greater
changes in underlying vulnerabilities than BPT.
More generally, recent meta-analyses have found evidence for the efficacy and
effectiveness of LTPT for patients with so-called “complex” disorders, often
including previously unsuccessfully treated (chronic) depressed patients with
considerable personality comorbidity.25,90 Similarly, there is some evidence for
the effectiveness of psychoanalysis in the treatment of this group.89 (de Maat S,
De Jonghe F, de Kraker R, et al. The effectiveness of psychoanalysis: a
comparison between psychoanalysis (PA) and long-term psychoanalytic psycho-
therapy (LTPP). Manuscript submitted for publication, 2010.) Importantly, both
LTPT and psychoanalysis have been associated with continuing improvement
after treatment termination, suggesting that they are associated with changes in
vulnerability to depression.91

Summary: BPT and LTPT for depression treatment

Overall, findings suggest that BPT should be included in guidelines as a first-line
treatment for patients suffering from depressive disorders.75 LTPT and perhaps
psychoanalysis should be considered for patients suffering from complex conditions
characterized by (chronic) mood and personality problems. None of the meta-
analyses reviewed found differences in effect sizes between controlled trials and
naturalistic studies, suggesting that PT for depression can be translated to routine
clinical practice without loss of its effects. Future research should concentrate on the
cost effectiveness of both BPT and LTPT. A recent review of 8 studies showed that
BPT was consistently associated with a significant decrease compared with control
conditions in health care costs as expressed in lower physician and hospital costs,
reduced medication usage and disability claims, and increases in the proportion of
patients returning to work. (Abbass A, Driessen E, Town J. Cost-effectiveness of
intensive short-term dynamic psychotherapy. Manuscript submitted for publication,
2011.) More studies focusing on the cost effectiveness of BPT and LTPT in the
treatment of depression are needed.

Psychodynamic Psychotherapy and Pharmacotherapy

The evidence base of research comparing the efficacy and effectiveness of PT,
pharmacotherapy, and their combination is still relatively limited. Yet, studies in this
area seem to be consistent with meta-analyses suggesting few differences in the
effects of bona fide psychotherapeutic treatments and pharmacotherapy in the acute
treatment of depression and that psychotherapy and combined treatment are
associated with better (long-term) outcome.6,92
A mega-analysis of 3 RCTs found that BPT was as effective as pharmacotherapy
in terms of symptom reduction based on the Hamilton Rating Scale, but patients and
therapists considered the effects of BPT to be superior compared with pharmaco-
therapy.74 Because this conclusion is based on studies investigating psychodynamic-
supportive psychotherapy, results may not generalize to other brief PT. Salminen and
colleagues93 compared a more expressive variant of BPT and fluoxetine in a trial of 51
patients with major depression and found no differences in terms of symptoms and
functional ability. BPT was not manualized in this study, so it is possible that therapists
differed considerably in their adherence to the therapeutic model. Moreover, follow-up
analyses showed that patients with high levels of immature defense styles benefited more
from BPT than fluoxetine, suggesting that BPT may be superior to pharmacotherapy
when addressing depression in patients with fewer psychologic resources and more
severe character pathology.94 One study found that pharmacotherapy was associated
120 Luyten & Blatt

with a more rapid response compared with BPT, but this difference largely disappeared
after 8 weeks.95
In a small trial (n ⫽ 35), Maina and colleagues96 found that the combination of BPT
with pharmacotherapy was superior to the combination of pharmacotherapy with ST.
In another study, Maina and collaborators97 followed up patients that had remission
after a trial with either a combination of BPT and medication or medication alone.
Remission rates in both conditions were identical (64.1% vs 61.4%, respectively). All
patients subsequently received a 6-month continuation treatment with medication
alone. At the 48-month follow-up, patients who received the combined treatment,
however, showed significantly lower recurrence rates than patients in the medication-
alone condition (27.5% vs 46.9%, respectively).
A mega-analysis of 3 RCTs of brief psychodynamic-supportive treatment found that
combined treatment was more efficacious than pharmacotherapy alone.74 Interestingly,
again, rates of change were somewhat slower in BPT compared with pharmacotherapy.
Finally, Burnand and colleagues98 found that combined treatment was associated with
fewer treatment failures, better work adjustment, better global functioning, and lower
hospitalization rates. The costs of psychotherapy were offset by fewer hospitalizations
and lost work days in patients receiving the combined treatment.
Although more research is needed, current evidence suggests that BPT is as
effective as pharmacotherapy for mild to moderate depression and that combined
treatment is more effective and cost effective. Studies show similar findings in
patients with comorbid anxiety and depression.99,100 Moreover, there are also
indications that combined treatment is more acceptable to patients than mono-
therapy.101 More long-term follow-up studies are needed. A recent follow-up study,
for instance, found no differences in recurrence of depression at 5-year follow-up
between BPT alone and combined treatment.87

Psychodynamic Therapy in Children and Adolescents

There has been less research on the effectiveness of psychodynamic therapy for
children and adolescents than there has been for adults. A recent review, however,
provides evidence for both BPT and LTPT in the treatment of young people suffering
from various emotional disorders, including depression.102 Yet, only 2 naturalistic
studies73,103 and 1 randomized trial104 have specifically targeted children and
adolescents with depression as the primary problem. Although this is in line with the
more person-centered rather than disorder-focused approach, and children and
adolescents do tend to present with a variety of emotional and behavioral problems,
more studies of PT that specifically focus on depression are needed. In a study by
Trowell and coworkers,104 depressed adolescents improved more slowly with BPT
but made more sustained changes compared with those receiving family therapy.
This finding parallels the research focusing on adults with depression who had been
treated with PT; results showed slower rates of change but maintenance of effects
and even posttreatment improvement. More research in this area is needed. Several
ongoing trials, including a trial comparing BPT and CBT in the treatment of adolescent
depression,3 promise to fill this critical gap in our knowledge.
PROCESS AND OUTCOME OF PSYCHODYNAMIC TREATMENT

Little is known about the mutative factors in the range of evidence-based

treatments for depression, including PT. Several studies, however, have begun to
elucidate those ingredients that promote change. Hilsenroth and colleagues,105
for instance, using the Comparative Psychotherapy Rating Scale, found a strong
association between psychodynamic–interpersonal technique and change in depressive
 Psychodynamic Treatment of Depression 121

symptoms (r⫽.57, P⬍.01) in patients treated with BPT. Conversely, studies have found
that the extent to which psychodynamic techniques were used in other treatments was
correlated with good outcome (for an overview, see Shedler106). Yet, much more research
is needed in this context, particularly as patient, therapist, and alliance factors (and their
interactions) may explain more variance in outcome than specific techniques, particularly
in brief treatments.

Self-Critical Perfectionism
Blatt and colleagues,43 for instance, found that self-critical perfectionism, a person-
ality dimension that, as noted, is related to the onset and course of depression,
negatively predicted treatment outcome in CBT, Interpersonal Psychotherapy (IPT),
and pharmacotherapy in the National Institute of Mental Health Treatment of
Depression Collaborative Research Program (TDCRP). Pretreatment levels of self-
critical perfectionism were also associated with lower enhanced adaptive capacities,
that is, the capacity to manage life stress, at 18-month follow-up, which may explain
in part the negative effect of self-critical perfectionism on long-term outcome in this
study. Importantly, further analyses showed that pretreatment self-critical perfectionism
significantly interfered with therapeutic outcome in the TDCRP by disrupting the devel-
opment of the therapeutic alliance as well as patients’ general social relationships, which
left them more vulnerable to stressful life events. Decreases in self-critical perfectionism
were significantly associated with a decline in symptoms of depression, which provides
further evidence for the role of patient factors in the treatment of depression. More
specifically, in the TDCRP, the strength of the therapeutic alliance was significantly
associated with changes in self-critical perfectionism, which, in turn, significantly influ-
enced the reduction of depressive symptoms.107 These findings suggest that the lack of
sustained therapeutic gain in the TDCRP may have been the consequence of the failure
to address the personality factors involved in vulnerability for depression in all treatment
conditions, which then, in turn, negatively affected the therapeutic alliance and, ultimately,
treatment outcome. Yet, compared with medication, the 2 psychotherapies (ie, CBT and
IPT) led to significantly greater enhanced adaptive capacities and a significantly greater
reduction of stress reactivity,108 which may provide a partial explanation for the superi-
ority of psychotherapy compared with medication in the prevention of relapse of
depression.
The negative impact of self-critical perfectionism on outcome in brief treatments
has now been replicated in a number of studies.13,43 The typically externally imposed
time-limited treatment may interfere with the strong need for autonomy and control
associated with self-critical perfectionism.109 Patients with these features may also
have more difficulty accepting an interpersonal focus,110 and they may be unable to
form a positive therapeutic alliance in such a short timeframe.43 More generally, in
some patients, brief treatments (including BPT), may be associated with relatively
high relapse rates because they do not lead to changes in vulnerability factors for
depression but only result in a deactivation of maladaptive representations of self and
others that are relatively easily re-activated when confronted with stress and
adversity.91 By contrast, LTPT and PA are typically associated with more profound
changes as expressed in106,111:
1. Increased capacity for self-analysis
2. Ability to experiment with new behaviors, particularly in interpersonal relationships
3. Finding pleasure in new challenges
4. Greater tolerance for negative affect
5. Greater insight into how the past may determine the present
122 Luyten & Blatt

6. Use of self-calming and self-supportive strategies, among which is the use of the
representation of the therapist as a supportive good internal object.
Yet, more research that specifically focuses on depression is needed, and studies are
needed that investigate whether such changes are causally related to sustained
symptom reduction in both brief and long-term treatments.

ACCEPTABILITY AND SUITABILITY OF PSYCHODYNAMIC TREATMENT

BPT is readily accepted by many depressed patients.2 Patients often prefer combi-
nation treatment over medication alone101 and BPT over pharmacotherapy.112
Similarly, a study in Germany suggests that LTPT and PA are well accepted by many
(chronic) depressed patients and even preferred by at least a substantial subgroup of
depressed patients over cognitive behavioral treatment.113 Yet, cultural factors are
likely to determine patient preference.
As for suitability for PT, clinical decision making is seriously hampered by our lack
of understanding of therapeutic mechanisms. Clinical lore emphasizes the impor-
tance of psychological mindedness, a wish to target the treatment beyond symptom
reduction and an openness to consider the antecedents and particularly the relational
contexts of current problems.114 Yet, whether these features are associated with better
treatment outcome remains to be investigated, particularly given the broadening scope of
PT to more characterologically disturbed patients. Interestingly, in a study by Van and
colleagues,112 there were no differences in outcome after BPT for depression between
randomized and by-preference patients. These findings contrast somewhat with findings
by Watzke and colleagues115 that provides some validation for clinical judgment in
relation to suitability for psychodynamic psychotherapy. This study also highlights the
potential negative effects of unselected assignment to PT and possible iatrogenic factors,
at least of PT as practiced in routine clinical care.114 Basically, Watzke and colleagues115
found that patients whom clinicians considered suited for PT had better outcome
compared with patients who were randomly assigned to PT. No such effect was found for
CBT, with patients whom clinicians originally considered to be suited for PT showing
similar improvement when they were randomly assigned to CBT compared with patients
that initially were considered more suited for CBT. These findings suggest potential
limitations in terms of suitability of patients for PT. Yet, they may also suggest limitations
of the particular psychoanalytic treatment model that was investigated in this study. More
systematic treatment delivery and the ongoing monitoring of intermediate treatment
outcomes may lead to improved outcome also in patients that are often considered to be
less suited for PT. Moreover, whether these results generalize to depressed patients and
all types of PT is unknown. A recent trial in Germany is currently exploring whether
randomization versus preference for PT is related to outcome in the long-term psychody-
namic treatment of depression.113

SUMMARY

Findings reviewed in this article show that PT should be included in treatment

guidelines for depression. BPT in particular has been found to be superior to control
conditions, equally effective as other active psychological treatments, with treatment
effects that are often maintained in the long run, conferring resistance to relapse.
Moreover, BPT is as effective as pharmacotherapy in the acute treatment of mild to
moderate depression, and, either as monotherapy or combined with medication, BPT
is associated with better long-term outcome compared with pharmacotherapy alone.
PT is accepted by many depressed patients as a viable and preferred treatment.
Furthermore, LTPT and PA have shown promise in treating patients with complex
 Psychodynamic Treatment of Depression 123

psychological disorders characterized by mood problems, often with comorbid

personality problems. Finally, although studies suggest that effects of PT may be
achieved somewhat slower compared with other forms of psychotherapy116 as well
as medication95 in the acute treatment of depression, LTPT appears to be more
clinically effective and perhaps more cost effective in the long run, particularly for
chronically depressed patients.
As noted, these conclusions need to be interpreted within the context of important
limitations. Compared with other treatments, the evidence base for PT in depression
remains relatively small, despite a respectable research tradition supporting psy-
chodynamic assumptions with regard to the causation of depression.64 Moreover,
and perhaps most importantly, although more studies now include longer follow-up
assessments, our knowledge about the long-term effects of so-called evidence-
based treatments of depression remains sketchy at best. In this context, the growing
evidence for the efficacy and effectiveness of LTPT is promising.
Overall, it is clear that the future of the treatment of depression may lie in a
combined disorder- and person-centered, tailored-made approach, which takes into
account, particularly in chronic depression, the broader interpersonal context and life
history of the individual. It is clear that psychodynamic therapies have an important
role to play in this respect.
ACKNOWLEDGMENTS

The authors wish to thank David L. Mintz and Allan Abbass for constructive
comments on an earlier version of this paper and Rose Palmer for her editorial
assistance.
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