Finally moving beyond the horse race: CBT and psychodynamic therapy equally effective for depression

What is already known on this topic?

The efficacy of cognitive behavioural therapy (CBT) in the treatment of major depression has been relatively well established, with comparable efficacy to pharmacological therapy at treatment termination and potentially superior outcomes in the long run.¹ The empirical status of brief psychodynamic treatment (BPT) for depression is less well established, which hampers decision-making for policy-makers, clinicians and patients.²

What does this paper add?

• This study is by far the largest existing randomised trial to compare the efficacy of CBT and BPT.

• Findings further enhance the evidence base for BPT in depression, with no significant differences observed on any of the outcome measures at treatment termination and at 1-year follow-up.

• Remission rates for CBT and BPT were somewhat lower compared to some other studies, which may be explained by the sample's ethnic heterogeneity, low socioeconomic status and high Axis I comorbidity. Yet these features are often typical of depressed patients seen in routine clinical practice, so perhaps they allow for a reasonably accurate estimate of treatment effects.

Limitations

• Outcome measurement was limited to severity of depression, and it is not clear whether the findings generalise to other clinically relevant outcomes such as interpersonal functioning and quality of life.

• Treatment adherence was not systematically assessed and differences in adherence between CBT and BPT may have influenced the results.

• Many patients seem to have received a limited number of sessions (less than 11 on average), which might be a suboptimal dose and which might provide a further explanation for the relatively low remission rates.

What next in research?

Studies investigating the impact of CBT and BPT should address the influence of patient preference and patient-to-treatment and therapist match, and should move away from an exclusive focus on comparative efficacy research to a focus on the mechanisms of change across treatment modalities that could assist in developing more effective, integrative treatments.² Research on the efficacy of longer term depression treatment should be prioritised, particularly as studies suggest that sustained changes in depression may be achieved only with 40 sessions or more.³ Findings concerning the relatively high dropout rates and additional treatment seeking in both brief CBT and BPT, including in the present study,³ provide further support for this assumption as they may indicate problems with the acceptability and limited treatment effects of brief psychotherapy for depression for many patients.

Could these results change your practices and why?

Results of this study have further reinforced our policy to offer brief CBT, BPT or medication, depending on the patient's preference, as a first-line treatment for depression, particularly in moderately depressed patients, as these treatments seem to lead to equivalent outcomes. Yet for many depressed patients, this may be insufficient and longer term psychotherapy, such as maintenance/continuation CBT, longer term psychodynamic treatment and combined psychotherapy/pharmacotherapy, may be indicated.^{1 3}