Welcome to my blog, a place to explore and learn about the experience of running a psychiatric practice. I post about things that I find useful to know or think about. So, enjoy, and let me know what you think.

Monday, March 30, 2015

Analytic Evidence

One of my goals, or maybe wishes, in writing this blog, is to educate a wider audience about psychoanalysis. Let's face it, analysis is, at best, passe. Mostly it's dissed. After all, everyone "knows" there's no evidence that analysis works, but there's lots of evidence that CBT works, so why spend all that time and money in analysis when you could be in and out in 30 sessions?

Just see this article in the NY Times:

As Jeffrey A. Lieberman, chairman of psychiatry at the Columbia University College of Physicians and Surgeons, makes clear in his chatty, expert, sometimes scathing but ultimately upbeat account of the history of psychiatry, the evidence, quite simply, doesn’t exist.

Maybe analysis was cool back in the 50's and 60's, when everyone smoked during sessions, and the analyst had a beard and a deep-voiced German accent and was a blank screen who only made comments about oedipal conflict. It's fun to watch in Woody Allen movies, but really, it's just a silly, archaic modality that thinks penis envy is the cause of everyone's problems, and now functions only as a narcissistic indulgence for the wealthy.

I once mentioned to a colleague I had just met that at certain hospitals, psychiatrists are not permitted to wear white coats because it makes the patients anxious. His response was, "That's just analytic bullshit!" I guess to most people, analysis qualifies as its own special category of bullshit.

Well, there is evidence that analysis works. Not only that it works, but that it works better than meds or CBT. I highly encourage readers to watch a 35 minute video on YouTube entitled, The Case for Psychoanalysis, Version 4, by John Thor Cornelius, a psychiatrist and psychoanalyst from California, who took on the challenge of convincing residents at UC Davis, who had been taught otherwise, that there is evidence for the usefulness of psychoanalysis. Obviously, he's made 3 earlier versions of the video, and he updates as new evidence becomes available. But I'm going to use highlights of the video (with his permission), and include other evidence, in this post.

Cornelius looked at effect size in meta-analyses of meds, CBT, and psychoanalytic psychotherapy, which he uses as a stand-in for analysis. The difference between analysis and analytic psychotherapy is something I'll get to in another post. Maybe. There's a lot of literature on it. For now, it'll have to be an adequate place-holder, and obviously, for my purposes, this is one of the limitations of his presentation.

Just quickly, effect size is the difference between treatment groups, expressed in standard deviations. Roughly speaking, a large effect size is 0.8, medium is 0.5, and small is 0.2. So, for example, if the effect size of A v. B is 0.8, then A did 0.8 of a standard deviation better than B, and this is considered a large effect.

 First, Cornelius looked at effect sizes at the ends of studies:

Erick H Turner, MD, Annette M Matthews, MD, Eftihia Linardatos, BS, Robert A Tell, LCSW, and Robert Rosenthal, PhD. Selective Publication of Antidepressant Trials and Its Influence on Apparent Efficacy. NEJM 2008; 358:252-260 January 17, 2008.
Butler, AC, Chapman, JE, Forman EM, & Beck, AT. (2006). The empirical status of cognitive-behavioral therapy: A review of meta-analyses. Clinical Psychology Review, 26 (1), 17-31.
Abbass AA, Hancock JT, Henderson J, Kisely S, Short-term psychodynamic psychotherapies for common mental disorders. Cochrane Database Syst Rev. 2006;4:CD004687.
Maat S, De Jonghe F, Schoevers R, Dekker J. The effectiveness of long-term psychoanalytic therapy: a systematic review of empirical studies. Harv Rev Psychiatry. 2009;17(1):1-23.

You'll notice antidepressants aren't great, and CBT for chronic pain isn't either, but everything else does okay.

Then he looked at long-term follow-up, and this is what he found.

For antidepressants:

For Psychotherapy, there is evidence that its benefits endure and increase over time (Psychodynamic Psychotherapy Research: Evidence-Based Practice and Practice-Based Evidence (Current Clinical Psychiatry) [Kindle Edition]Raymond A. Levy (Editor), J. Stuart Ablon (Editor), Horst K├Ąchele (Editor)):

Leichsenring F, Rabung S. Effectiveness of long-term psychodynamic psychotherapy: a meta-analysis. J Am Med Assoc. 2008;300:1551-65.

MBT is Mentalization Based Treatment, an 18 month psychoanalytic partial hospitalization protocol for borderline personality disorder. 
Bateman A, Fonagy P. Randomized controlled trial of outpatient mentalization-based treatment versus structured clinical management for borderline personality disorder. Am J Psychiatry. 2009;165:556-9.

As for CBT, some of the results fall under Steps 2, 3, and 4 of the STAR-D trial, which had CBT arms. But here are some more results to consider:

40-50,000 patients per year for 5 years, $500 million dollars, and no effect of CBT. Those numbers big enough for you?

Next up, head to head comparison of psychoanalysis (PA), psychodynamic psychotherapy (PD), and CBT.

Comparison of cognitive-behaviour therapy with psychoanalytic and psychodynamic therapy for depressed patients – A three-year follow-up study (Z Psychosom Med Psychother 58/2012, 299–316), by Huber et al, is a prospective study of 100 patients diagnosed with unipolar depression and randomized into the three groups. I'm not including the studies this one follows-up on because this post is already too long.

"...mean duration of PA was 39 months (range 3–91) or 234 sessions (range 17–370), of PD was 34 months (range 3–108) or 88 sessions (range 12–313), and of CBT was 26 months (range 2–78) or 45 sessions (range 7–100); minimal values are due to the intent-to-treat approach."

PA was practiced at a frequency of 2-3 sessions per week, on the couch. PD was once a week, sitting up. And CBT was once a week.

There were 21 therapists, all past training, with mean duration of practice 15 years. 7 did CBT, and 14 did PA or PD, and there was no significant difference in respective training, expertise, and experience.

Raters were blind to treatment modality. They used a 3 year follow-up period to account for the naturally fluctuating course of depression. Treatment fidelity was also assessed.

"Outcome measures were the Beck Depression Inventory and Global Severity Index for measuring symptoms, the Inventory of Interpersonal Problems and the Social Support Questionnaire for measurement of social-interpersonal functioning, and the INTREX Introject Questionnaire for measuring personality structure."

I'm leaving out a lot of the methodological details, but I did want to give you the general sense that the study was conducted in a rigorous way. And these were the results:

"...at three-year follow-up, rate of remission from depressive symptoms was 83% in the PA group, 68% in the PD group, and 52% in the CBT group. When controlling age and gender, the odds of remission were significantly greater in the PA group as compared to the CBT group, with odds ratio (OR) = 4.79, 95% CI [1.29 to 17.74], and did not differ between the PD and CBT groups, with OR = 2.06, 95% CI [0.60 to 7.10]."

More generally, they found, "significant outcome differences between psychoanalytic therapy and cognitive-behaviour therapy in depressive and global psychiatric symptoms, partly social-inter- personal and personality structure at three-year follow-up. Psychodynamic therapy was superior to cognitive-behaviour therapy in the reduction of interpersonal problems."

In the discussion section, the authors were pretty good at describing the limitations of the study. They also addressed the question of a dose effect. We're talking 45 sessions of CBT vs. 88 sessions of PD vs. 234 sessions of PA. This is a fair question to ask, i.e., would 234 sessions of CBT have been as effective as the same 234 sessions of PA? However, the CBT lasted, on average, 26 months, while the PA lasted 39 months, only about a year longer than the CBT. At the rate of 1 session a week, or roughly 4 sessions a month, a CBT of 234 sessions would last for 58.5 months, or about 5 years, 2 years longer than the average psychoanalysis in the study lasted.

This was pretty farschlepped, but I hope you can see that there is some evidence that psychoanalysis is effective. Jeez, Dr. Lieberman, do your homework!


  1. Also plenty of evidence from manualized versions from Klerman and Weissman, Luborsky, Strupp, and Gunderson's GPM etc. along with more recent articles in Am J. Psychiatry are all psychoanalytically informed therapies. I don't think that gathering statistics that are comparable to drug trials are very useful for psychotherapy or for that matter drug trials either.

    The usual outcome measure checklists for drug trials are inadequate measures of change in psychotherapy unless symptoms alone are the largest symptoms. We do not currently have any adequate measures or even clinical approaches to the patients conscious state, except for psychoanalysis and psychodynamic but even them the data is not collected in a systematized manner. It is what I would expect for non-linear process.

    1. I forgot to mention that these were non-manualized treatments in the Huber study. It is very hard to systematize research in psychoanalysis or psychoanalytic psychotherapy. I think they did a pretty good job, given what they were trying to establish.

  2. Is there any research on either long-term dynamic therapy or 4-5 time-week psychoanalysis (2 times sounded more like intensive psychotherapy, but I'm no expert) AND medical outcomes.

    I ask, because I look at people with substance abuse, familial mental illness with poor caregiving, adverse childhood events, and untreated mood disorders who then develop heart disease, diabetes, liver disease (bonus if you're a baby boomer-your heart surgery might have led to your getting Hep C.) and a compromised immune system. That costs hundreds of thousands of dollars, maybe millions.

    At $200 a session, 5 days a week for 48 weeks a year (approximately) that comes out to $48,000/year. If you did analysis for 30 years that comes out to $1,440,000. That's probably less than the medical costs of some people--never mind the fact that they would be happier and more productive economically. If you counted the cost of treating their children's anxiety and depression it would probably represent a significant savings to the health system as a whole.

    1. I don't know the answer. I'll try to do some research. Excellent point.

  3. As you may know, Jonathan Shedler did a nice review of the evidence base for psychodynamic therapy in American Psychologist, Feb-Mar 2010:


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