We welcome the revised Canadian Network for Mood and Anxiety Treatments (CANMAT) guidelines for psychological treatments in depression. We understand that the updated guidelines are based on a thorough literature search focusing on systematic reviews and meta-analyses, and thus we seek to highlight the omission of key findings from 2 recent meta-analyses of short-term psychodynamic psychotherapy (STPP) for depression.1,2
First, while the guideline authors identified the meta-analysis of 54 STPP studies (33 randomised controlled trials [RCTs]) for depression2 as evidence of effectiveness of this approach, it would have been informative to note that analyses adequately powered to detect clinically significant differences found no such differences between STPP delivered in individual format and other psychotherapies at posttreatment or at follow-up for depression. Moderator analyses clearly showed that the observation of nonequivalence between STPP versus other psychotherapies at posttreatment was explained by the inclusion of 2 STPP studies applying group format. Adjustment for publication bias also indicated no difference between STPP and other psychotherapies even when individual and group were combined. If the complete meta-analytic results are taken into consideration, it appears that the authors’ conclusion that “STPP compared to other types of psychotherapy resulted in slightly worse outcomes on some measures of depression at the end of treatment” might not be correct.
Since the methods for determining line of treatment used by CANMAT state, “A first line treatment recommendation indicates good-quality evidence (Level 1 or 2 Evidence),”3(p2) it would be helpful if the authors could clarify that these findings are consistent with the criteria for meta-analytic data used by CANMAT4(p3) for level 1 or 2 evidence.
While meta-analyses of STPP include different models, this is also the case for those cited as evidence5 for the effectiveness of other psychotherapies (e.g., cognitive behavioural therapies [CBTs]). CBT approaches employ broad definitions and include different treatment manuals but are equally considered a family of therapies that share common features.6 Furthermore, models of STPP for depression were recently shown to overlap to a high degree, having most treatment elements in common.7
Second, the guidelines address whether “co-occurring psychiatric conditions affect the efficacy of psychological treatments.” The authors determined that there is insufficient evidence on anxiety disorders and personality disorders. We noticed that select individual studies are subsequently discussed, and only statements about the likely effectiveness of CBTs are given. A new finding of potential significance that was overlooked by the authors, despite being derived from meta-analytic data, showed significant superiority of STPP over other psychotherapies in 5 studies, which reported anxiety measures in patients with depression; a significant small difference at posttreatment became a medium to large difference at follow-up. Similarly, data from another meta-analysis found that STPP is likely effective for depression and comorbid personality disorder.1 According to the dearth of alternative meta-analytic studies around treating comorbid psychiatric conditions, these findings warrant referencing. The guidelines could state that as an effective treatment for major depressive disorder, STPP may remain effective in comorbid personality disorders and can improve symptoms of anxiety to a greater extent than other psychotherapies for depression.
Joel M. Town, DClinPsy
PenCLAHRC, Plymouth University Peninsula Schools of Medicine and Dentistry, Plymouth, UK
Centre for Emotions and Health, Dalhousie University, Halifax, Nova Scotia
Allan Abbass, MD, FRCPC
Centre for Emotions and Health, Dalhousie University, Halifax, Nova Scotia
Ellen Driessen, PhD
Department of Clinical, Neuro, and Developmental Psychology, VU University Amsterdam, Amsterdam, The Netherlands EMGO Institute for Health and Care Research, VU University Amsterdam and VU University Medical Center, Amsterdam, The Netherlands
Patrick Luyten, PhD
Faculty of Psychology and Educational Sciences, University of Leuven, Leuven, Belgium
Research Department of Clinical, Educational, and Health Psychology, University College London, London, UK
Priyanthy Weerasekera, MD, MEd
Psychiatry and Behavioral Neurosciences, McMaster University, Hamilton, Ontario
Footnotes
Declaration of Conflicting Interests: The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding: The author(s) received no financial support for the research, authorship, and/or publication of this article.
Contributor Information
Joel M. Town, PenCLAHRC, Plymouth University Peninsula Schools of Medicine and Dentistry, Plymouth, UK; Centre for Emotions and Health, Dalhousie University, Halifax, Nova Scotia.
Allan Abbass, Centre for Emotions and Health, Dalhousie University, Halifax, Nova Scotia.
Ellen Driessen, Department of Clinical, Neuro, and Developmental Psychology, VU University Amsterdam, Amsterdam, The Netherlands EMGO Institute for Health and Care Research, VU University Amsterdam and VU University Medical Center, Amsterdam, The Netherlands.
Patrick Luyten, Faculty of Psychology and Educational Sciences, University of Leuven, Leuven, Belgium; Research Department of Clinical, Educational, and Health Psychology, University College London, London, UK.
Priyanthy Weerasekera, Psychiatry and Behavioral Neurosciences, McMaster University, Hamilton, Ontario.
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