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This is a randomized controlled trial with blinded ratings of response will be used to evaluate whether Intensive Short-term Dynamic psychotherapy (ISTDP) is effective and whether it is efficacious compared to medical treatment as usual in patients not remitting with 1 or more trials of antidepressant.
Major depression is a common morbid condition resulting in chronicity, recurrent disability, loss of physical health and in many cases, death through suicide or medical conditions.The existing first line treatments include various psychotherapies and anti-depressant medication. The literature on anti-depressant medication has been fraught with controversy and difficulty over recent years. Many proponents argue that publication bias renders anti-depressant treatment of questionable value across the continuum of mild to severe depressed patients. Nonetheless, anti-depressant treatment is considered a bona fide first line agent. In some real world studies, however, anti-depressant medications have not fared well. Based on large scale studies including the STAR-D study, remission rates and recovery rates were disappointing in first line and second line anti-depressant trials. In the real world, a large portion of patients on anti-depressant medication stay on these medications long term and have mild to modest benefits.
There is a growing body of literature suggesting that a combination of psychotherapy and medication may be superior to medication alone. This is however somewhat controversial. Other studies suggest that the presence of personality factors and personality disorders render psychotherapy the treatment of choice in these cases. Indeed, personality factors and the process of anger turning inward toward oneself are common amongst chronically depressed patients (Gilbert) and can predict a negative outcome or limited outcome to pharmacotherapy and, indeed, first line psychotherapies.
Short Term Psychodynamic Psychotherapy (STPP) is a category of brief treatment that focuses on unconscious emotional processes that can impact on a person and produce or exacerbate major depression. One just published study of STPP found it to significantly enhance serotonin binding while Fluoxetine did not do so: this finding may explain the general finding of maintained gains in long-term follow-up after STPP in depression (Karlsson et al, 2009). Three studies have demonstrated direct treatment intervention outcome relationships between STPP and subsequent improvements in depressive symptoms (Barber et al., 1996; Gaston et al., 1998; Hilsenroth et al., 2003). A recent meta-analysis suggests that STPP treatment may be quite effective for depression but that further, high-quality, randomized control trials are required (Driessen et al, 2010).
One subtype of STPP is a method called Intensive Short Term Dynamic Psychotherapy (ISTDP). ISTDP has been studied in eighteen published clinical studies. It has been demonstrated efficacious in patients with personality disorders, panic disorder and somatoform disorders in randomized control trials. In a single case series of patients with treatment resistant depression, patients fared well with ISTDP with 8 of 10 achieving remission (Abbass, 2006). This published study was performed in conjunction with Mood Disorder Service here at Capital Health. These patients responded to a relatively short course of treatment with reduction and stoppage of the majority of medication. Four of five patients were able to return to work from disabilities which averaged two years.
This study will test the hypothesis that ISTDP yields a superior outcome compared to medical treatment as usual in treatment refractory depression.
Allocation: Randomized, Control: Active Control, Intervention Model: Parallel Assignment, Masking: Single Blind (Outcomes Assessor), Primary Purpose: Treatment
Intensive Short-term Dynamic Psychotherapy, Medical treatment as Usual
Capital District Health Authority
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Capital District Health Authority, Canada
Published on BioPortfolio: 2014-08-27T03:13:01-0400
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