Annotated Bibliography

de Maat S, de Jonghe F, Schoevers R, Dekker J. The effectiveness of long-term psychoanalytic therapy:

a systematic review of empirical studies. Harvard Review of Psychiatry 2009; Vol. 17(1): 1-23.

[PubMed]

This study aimed to evaluate the effectiveness of psychoanalytic treatment on individuals with

enduring mental health issues using randomised controlled trials and utilising surveys of long

term psychotherapy treatments ranging from weekly sessions over one up to six years. The

data that was collected was then analysed with effect sizes for each study extracted and used

to calculate a percentage success rate. For participants with moderate pathology, a clear

reduction in symptoms was recorded both immediately after therapeutic intervention and

also after follow up. With regards to participants with severe pathology, distinct changes in

personality were noted again both immediately after the course of psychoanalytic therapy

and also after follow up. This large scale systematic study provided strong evidence for there

being much value to psychoanalysis as a therapeutic pathway, where there is often heavy

criticism on the approach for being pseudoscientific. The extraction of data empirically rather

than qualitative reports of individual examples of success demonstrate clear patterns to

suggest that at the very least, psychoanalytic therapy proves to be more successful in

improving and alleviating the symptoms of individuals with varying pathologies than no

treatment at all.

Fonagy P, Kachele H, Krause R, et al. An open door review of outcome studies in psychoanalysis.

London: International Psychoanalytical Association, 1999.

Fonagy, et al (1999) presented and reviewed a vast array of studies aiming to test the

effectiveness of psychoanalytic therapy and collated them in this paper. During this thorough

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 evaluation of numerous significant studies into psychoanalytic treatment, Fonagy identifies

and acknowledges weaknesses in much of the methodology implemented by the various

studies, with a particular theme being that there may be expectation bias present in many

studies due to the selection of participants from primary care settings leading to the inability

to mask the treatment type. Fonagy does however acknowledge that the vast array of

evidence of individuals seeing long term change to their symptoms and/or personality in

essence speaks for itself. All this should be caveated with the knowledge that, in fact, Fonagy

is indeed a psychoanalyst himself and while attempts throughout this review to remain

unbiased are clearly demonstratable, the reader should consider the question of the

motivation for conducting such an extensive review and the potential for the outcome of the

review being skewed from the beginning in favour of collating data and studies which have

clear evidence in favour of psychoanalysis despite their potential methodological weaknesses.

There is the potential that studies which fail to as strongly advocate for psychoanalysis as an

effective form of treatment may have been omitted from the review.

Fonagy, P, Rost, F, Carlyle, S et al. Pragmatic randomized controlled trial of long-term psychoanalytic

psychotherapy for treatment-resistant depression: the Tavistock Adult Depression Study (TADS).

World Psychiatry; Vol. 14(3): 2015.

A study conducted by Fonagy et al. (2015) set out to test the effectiveness of long term

psychoanalytic therapy (LTTP) on individuals deemed to be demonstrating cases of treatment-

resistant depression, the criteria for which was to have been unsuccessfully treated with two

previous forms of treatment conditions. 129 patients, randomly selected from primary care

settings were allocated to one of the two study groups with one group being delivered regular

once weekly 60 minute sessions of individual psychotherapy, whilst the other received varying

other treatment plans that met the treatment-as-usual standard of the UK National

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 Guidelines. The LTTP took place over 18 months with assessments at 6 monthly intervals and

also at point of follow up which occurred at 42 months. The primary outcome measure was

the 17-item version of the Hamilton Depression Rating Scale (HDRS-17) and secondary

outcome measures included self reporting by the patiets. The study found that complete

remission with regards to the participants depression was low in both the LTTP and the control

group and partial remission after the completion of the study was marginally higher in LTTP

than the control group (32.1% vs. 23.9% = p0.37). The most significant differences, however,

became apparent during the follow up months during which both observed scores on the

HDRS-17 and self reports showed a drastic decline in depression as well as improvements on

social adjustment, suggesting that LTPP, when implemented over time and a patient’s

progress observed with a comprehensive follow up can be very useful in alleviating treatment-

resistant depression.

Fonagy acknowledges various methodological flaws in this study, most notably that due to the

nature of the selection of participants from the primary care setting, the researchers were

unable to mask the treatment allocation from the patients which may have resulted in an

expectation bias. The study, does however have a high ecological validity due to the sample

being relatively unselected and combined with the extensive follow up assessments.

Paris, J. Is Psychoanalysis Still Relevant to Psychiatry? The Canadian Journal of Psychiatry / La Revue

Canadienne de Psychiatrie 2017; Vol. 62(5) 308-312.

In this paper, Paris (2017) discussed the relevance of psychoanalysis to modern psychiatry,

evaluating various studies, included that conducted by Peter Forangy. Paris argues that these

studies must be challenged due to a variety of limitations. Firstly, Paris highlights that studies

such as Forangy et el. (2015) lack the necessary comparison to control trials with ““A limited

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 number of mainly pre/post studies, presenting mostly completers analyses, provide empirical

evidence for pre/post changes in psychoanalysis patients with complex mental disorders” but

a lack of control treatments for comparison being a serious limitation to being able to

effectively analyse the results. Paris also notes that Forangy’s own therapy is not in fact a

demonstration of classical psychoanalysis but rather a “mentalization based treatment,”

which includes a combination of psychodyamic and cognitive-behavioral interventions and

cannot therefore be used in evidence for the support of classical psychoanalysis and its

effectiveness. Finally, Paris stresses the challenge of studying psychoanalysis and its true

efficacy as a therapeutic treatment due to its lengthy, time consuming and expensive nature.

In some cases of patients who seek psychoanalysis, treatment may be ongoing over years,

decades and in some cases indefinite. Paris highlights the difficulty of such longitude study as

well as many modern practitioners choosing to opt for training in shorter scale, finite

approaches to treatment such as cognitive behavioural therapy (CBT) which are considered to

be more accessible and feasible for patients to complete.

Poulsen, S, Lunn S, Daniel, S, et al. A Randomized Controlled Trial of Psychoanalytic Psychotherapy or

Cognitive-Behavioral Therapy for Bulimia Nervosa. Am J Psychiatry 2014; Vol. 171(1) 109–116.

A study conducted by Poulsen et al. (2014) offered a more direct comparison of psychoanalytic

therapy with that of another form of therapy, in this case cognitive behavioural therapy, with

the study turning the lens to a specific condition – Bulimia Nervosa. Already differing from de

Maat’s (2009) previous study which assessed individuals with varying conditions, Poulsen was

able to establish a comparison of the effects of the two types of treatment on the same

condition. This is an important distinction as different conditions may be more effectively

treated by different forms of therapy and so would be better studied individually.

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 In a randomised controlled trial of 70 patients all diagnosed with bulimia nervosa received

either two years of weekly psychoanalytic psychotherapy or 20 sessions of CBT over a period

of 5 months. The progress was measured by the Eating Disorder Examination interview which

was conducted blind at numerous point throughout the process of the study and finally at

completion of both courses of treatment. In both courses of treatment, it is important to note,

that significant improvement in the condition was observed with binge eating and purging

reducing. The patients who completed the psychoanalytic psychotherapy saw a reduction in

binge eating and purging by 15% after follow up of the two year treatment. In the case of CBT,

however, a reduction of these behaviour by 44% was observed after only 5 months of

treatment. The conclusion to be drawn here is clear – while both treatments were successful

in alleviating some of the symptoms of the eating disorder bulimia nervosa, CBT when

compared with psychoanalysis seems to have higher success rates and taken significantly less

time to achieve these.

It would be important to conduct or indeed analyse further studies which compare the success

rates of the treatment of patients with different types of psychotherapies and distinguish

them by the condition (or conditions) the patient is diagnosed with. Obtaining more extensive

results for specific the response to treatment in specific disorders would enable researchers

to better understand when it would be most appropriate to offer psychoanalysis as a

treatment or indeed identify when another form of psychotherapy may be more effective,

faster or longer lasting.

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