Randomised controlled trials in psychiatryBMJ 2000; 320 doi: https://doi.org/10.1136/bmj.320.7228.186 (Published 15 January 2000) Cite this as: BMJ 2000;320:186
Trials show that psychotherapy is effective for wide range of psychological conditions
- Helen Barker (), specialist registrar in psychotherapy
EDITOR—In his article on randomised controlled trials in psychiatry Andrews concludes that dynamic psychotherapy is not efficacious and that drugs and cognitive behaviour therapy are more beneficial.1 In fact, results from randomised controlled trials show that psychotherapy is an effective treatment for a wide range of psychological conditions.2 Furthermore, the results of a recent randomised controlled trial of brief psychodynamic-interpersonal therapy shows that this may be a cost effective intervention for patients who have not responded to conventional psychiatric treatment.3 In previous research this therapy was shown to be superior to supportive listening alone,4 in contrast to Andrews' claim that no trial has “been shown to be superior to talking to a mature and kindly adviser.”
In general, the debate about the evidence base for psychotherapy has moved on from questioning its overall effectiveness and is now considering more specific issues such as appropriate dosages, optimal delivery, and cost effectiveness. I agree with Andrews that what people think about a treatment can be as important as the evidence of its efficacy. If psychiatry is to accept and implement evidence based practice then the available evidence must be presented objectively.
Scarcity of evidence is not necessarily evidence against long term psychodynamic psychotherapy
- Jane Milton (), consultant psychiatrist,
- Philip Richardson, consultant clinical psychologist,
- Robert Hale, consultant psychiatrist
EDITOR—Andrews makes the misleading and unreferenced statement in his article on randomised controlled trials in psychiatry that “long term psychodynamic psychotherapy … has not been shown to be superior to talking to a mature and kindly adviser.”1 To apply randomised controlled trials to long term psychotherapeutic approaches is notoriously difficult, and we know of no trial that has done this using treatment by non-expert therapists as a control condition. An evidence based review of psychotherapy services in England does not support Andrews' views on dynamic psychotherapy and warns against regarding scarcity of evidence as evidence against.2 Most randomised controlled trials in psychotherapy study short term treatments (12-20 sessions) and usually show no or marginal differences in efficacy between cognitive and dynamic treatments. Effect sizes are generally small albeit clinically significant; follow up is short. With these brief interventions any coherent, skilfully applied therapy will apparently have moderate, though not necessarily enduring, effects. Reviews habitually exclude all but studies of atypical, highly homogeneous patient populations.
The small amount of psychoanalytic psychotherapy available in the NHS is mostly used to treat patients referred to tertiary centres who have moderate to severe persisting disturbance—a diagnostically heterogeneous group of patients who have frequently not responded to short term cognitive treatments. Andrews' pessimistic views on dynamic psychotherapy are out of date, as several excellent randomised controlled trials are in progress or recently published showing the advantage of psychodynamic psychotherapy over other approaches for severe disorders. Bateman and Fonagy, for example, have shown the value of a psychoanalytic approach based in day hospitals for patients with severe personality disorder.3 Sandahl et al have shown the superiority of psychodynamic group psychotherapy over cognitive behavioural therapy in reducing alcohol intake in patients dependent on alcohol, as judged by abstinence at 15 months of follow up.4 These studies and others show change not just in wellbeing and in interpersonal relationships but in reduced use of health and social services.
In practice, cognitive behavioural therapy may not be acceptable to patients. The London depression intervention study compared three treatments for severe depression: systemic or dynamic couple therapy, drug treatment, and cognitive therapy.5 Most patients allocated to the cognitive therapy found the treatment unacceptable and dropped out. The final comparison favoured couple therapy over drug treatment overall, even after two years. These results challenge the idea that an evidence based approach to the treatment of depression can rely exclusively on drug treatments and cognitive behavioural therapy.