In Reply: Psychodynamic therapy of depression

1. The title is rhetorical. Moderators and mediators of psychotherapy outcomes are poorly understood. In the absence of such mechanistic knowledge, any ranking of therapeutic brands must be tentative and qualified. 2. Please see Leichsenring et al. (2021) for their full arguments and associated references. 3. Indeed, the guidelines note each of the epistemological criticisms forwarded by Leichsenring and Steinert in their argument that CBT is not a gold standard for psychotherapy (in contrast to Leichsenring and Steiner, we lay the criticisms at the door of the literature rather than this particular brand).

emphasize that LTPP was not superior to CBT. This is true, but this implies that no differences in efficacy were found between LTPP and CBT. As a limitation, however, the statistical power was not high enough to detect small differences. In addition, we cited a study which found no differences in efficacy between LTPP and CBT in patients with chronic depression, with LTPP using more sessions (see online supplement #3), and another study in which LTPP combined with treatment as usual (TAU) was not superior to TAU alone in treatment-resistant depression at the end of treatment but at 24-, 30-and 42-month follow-ups with regard to partial remission (for reference, see online supplement #4). Chronic or treatment-resistant depression can be regarded as the more severe and difficult-to-treat condition compared to acute depression. Thus, if LTPP is efficacious in chronic and treatmentresistant depression, there is no reason to assume that it is not also efficacious in acute depression. As correctly cited by Murray et al. (2022), in another study, LTPP was not superior to STPP in the short term (online supplement reference #5). However, LTPP was superior in the 36-month follow-up with regard to the reduction of depressive symptoms (beck depression inventory, hamiltin depression rating scale). Regarding recovery, it is true that in this study LTPP was not superior to STPP, neither in the short-term nor in the long-term outcome.
In addition, the argument put forward by Murray et al. (2022) regarding the evidence for long-term psychodynamic therapy is based on a very limited view concerning the nature of depression. Depression is a notably heterogeneous condition. Many patients with depression present with personality issues such as borderline personality disorder (BPD). In fact, studies have shown that depression is not only a central feature of BPD, but that the nature of depressive experiences is qualitatively different in patients with BPD compared to depressed patients without substantial BPD features, with greater feelings of emptiness, self-harm and risk for suicidality (for a review, see supplement reference #6) A recent Cochrane meta-analysis found that mentalizationbased treatment (MBT), a type of LTPP for BPD, was superior to TAU in reducing self-harm, suicidality and depression with moderate to large effects at long-term (>12 months) follow-up (for reference, see online supplement #7). Similarly, a recent meta-analysis found that MBT was associated with large effect sizes (standardized mean difference = 1.03) in reducing suicidality in BPD (see online supplement reference #8). Although we agree that more research on LTPP for depression is required, the absence of a consideration of the effectiveness of different types of LTPP (and other long-term treatments) for patients with more complex presentations is a notable limitation, particularly given that many patients in routine care present with complex depression for which brief psychotherapy is not sufficiently efficacious (see online supplement reference #9). In the context of complex presentations of depression, Malhi et al. (2021) also cited a meta-analysis reporting that PDT and dialectical behavior therapy, but not CBT, are superior to controls in patients with BPD. In spite of this, Malhi et al. (2021: 96) argued that for psychodynamic therapies '... there are no RCTs ... to suggest that they may be of some help'. Yet, as noted, meta-analyses provide evidence that PDT is efficacious in complex presentations of depression (Leichsenring et al., 2021).
We agree that for LTPP of depression, further studies are required.
3. In our comment (Leichsenring et al., 2021), we criticized that the guidelines incorrectly stated that regression is promoted in PDT. We stated that neither treatment manuals of STPP for depression nor manuals for the long-term treatment of complex presentations of depression (e.g. with comorbid BPD) promote regression; by contrast, regression is explicitly restricted in these manuals (e.g. Leichsenring and Steinert, 2018 We thank Murray et al. for discussing critical aspects of the treatment of depression.

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