“My first therapy session is scheduled for next week. My therapist has said that cognitive behavior therapy is best for me, because of my depression. But a friend told me that this therapy is brief and only focused on symptoms. She said that long-term psychodynamic therapies are better, because they do not only focus on the symptoms but also on the deeper causes of why I am depressed. Is that true?”
What we know about brief therapies
There is a great deal of evidence that brief psychotherapies — including cognitive behavior therapy, but also interpersonal psychotherapy and behavioral activation — are effective in reducing depressive symptoms. Such therapies often consist of between 6 and 24 sessions. They also have significant effects on quality of life, social functioning, social support, self-esteem, anxiety, and several other outcomes.
These therapies typically focus on current problems and try to change how patients think or act, so that they can handle problems better. Learning about depression, and learning skills to cope with problems, is a key element of most brief therapies.
Whether these therapies also affect the “deeper causes” of mental health problems is not known — because the causes of depression itself are not known. Many risk factors have been identified, but it is still unclear how they lead to depression, and why one person becomes depressed while another in comparable circumstances does not.
What long-term therapies aim to do
Longer-term therapies, including psychodynamic and psychoanalytic therapies, have a different focus. They seek to understand how unconscious feelings, conflicts, early relationships, and habitual ways of relating influence current emotions and behavior.
There are also brief psychodynamic therapies that use these techniques to help people with depression or other mental health problems, and there is quite a lot of evidence that they are effective. Most research suggests that brief psychodynamic therapies have effects comparable to those of other brief therapies, including cognitive behavior therapy.
Although brief and long-term therapies can have a different focus, their results can actually be quite similar. For common mental disorders such as depression, the evidence base for short-term treatments is much larger.
The evidence gap for long-term therapies
Unfortunately, there is very little controlled research on the effects of long-term therapies for most mental health problems. This means that it is not known whether long-term therapies are effective for depression or related problems, and there is too little research to show whether they produce better outcomes than brief therapies. It is simply not known.
Long-term therapies are also very difficult to examine. To do good outcome studies, patients need to be randomized to a treatment or a control condition. Patients who want an intensive therapy, such as psychoanalysis, usually do not want to be randomized to a control group — and if they agree to it, they are probably not that motivated to undergo psychoanalysis in the first place. A further problem is that it is very difficult to follow patients for several years, during which their lives change because of the life events that happen to everyone.
Because long-term therapies are so hard to study, we cannot say that they work — but we also cannot say that they do not.
The exceptions that have been studied
Some longer-term therapies have been examined in well-designed outcome studies — for example, dialectical behavior therapy and schema therapy for borderline personality disorder. These therapies easily have more than 100 sessions and last more than a year. In these studies, patients are compared with the “usual care” they would otherwise receive, and overall these therapies have small but clinically highly relevant effects. Unfortunately, such studies have hardly been done for depression or other common mental health problems.
What this means in practice
For patients with depression, it is therefore usually recommended to start with a brief therapy. Cognitive behavior therapy is a good choice, because there is a large body of research showing that it works.
However, brief therapies do not work for everyone. It is quite possible that someone is not recovered after two or three brief therapies, or after adding antidepressants to the treatment. In such situations, it can certainly be worthwhile to consider a therapist who specializes in longer-term therapies. There is no evidence that these therapies work — but by that point the briefer therapies have not worked either, and many patients are understandably willing to try anything that might help them.
- For why CBT is often recommended first, see Is cognitive behavior therapy the best treatment for everyone?
- For what to do when a treatment does not help, see What can I do if therapy does not seem to work?
- For whether differences between therapies are real, see Are all psychotherapies equally effective?
Pim Cuijpers is professor emeritus of clinical psychology and scientific director of Metapsy. He has been involved in more than 1,100 scientific studies, mostly on psychological treatments of mental health problems. This is one of a series of evidence summaries in which Prof. Cuijpers tries to answer questions from patients and clinicians, based on what is known in science about treatments. The knowledge is mostly drawn from collective work of the Metapsy collaboration of at least 15 years. Do you have other questions you would like Prof. Cuijpers to discuss? Feel free to contact us.
Literature
- Cuijpers P, Karyotaki E, Ciharova M, et al. (2021). The effects of psychotherapies for depression on response, remission, reliable change, and deterioration: A meta-analysis. Acta Psychiatrica Scandinavica, 144(3), 288–299.
- Cuijpers P, Quero S, Noma H, Ciharova M, Miguel C, Karyotaki E, Cipriani A, Cristea I, Furukawa TA. (2021). Psychotherapies for depression: a network meta-analysis covering efficacy, acceptability and long-term outcomes of all main treatment types. World Psychiatry, 20, 283–293.
- Wienicke FJ, Beutel ME, Zwerenz R, Brähler E, Fonagy P, Luyten P, … Driessen E. (2023). Efficacy and moderators of short-term psychodynamic psychotherapy for depression: A systematic review and meta-analysis of individual participant data. Clinical Psychology Review, 101, 102269.
- Driessen E, Dekker JJM, Peen J, Van HL, Maina G, Rosso G, Rigardetto S, Cuniberti F, Vitriol VG, Florenzano RU, Andreoli A, Burnand Y, López-Rodríguez J, Villamil-Salcedo V, Twisk JWR, Cuijpers P. (2020). The efficacy of adding short-term psychodynamic psychotherapy to antidepressants in the treatment of depression: a systematic review and meta-analysis of individual participant data. Clinical Psychology Review, 80, 101886.
