Long-term treatment outcomes of psychodynamic psychotherapy for major depressive disorder: a systematic review and meta-analysis

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Fu This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-9260871/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Objective : Major depressive disorder (MDD) is characterised by recurrent episodes, making sustained treatment benefits a clinical priority. We evaluated the long-term outcomes of psychodynamic psychotherapy (PDP) for MDD. Methods : A systematic review of randomised controlled trials (RCTs) was conducted in adults with MDD comparing PDP with treatment-as-usual (TAU) or other active treatments, with long-term follow-up at least 12 months after treatment completion. Outcomes included clinician-rated and self-rated depressive symptom severity and relapse rates. Random-effects pairwise meta-analyses were performed at 12 months used standardized mean differences (SMD) for symptom severity and risk ratios (RR) for relapse. Intention-to-treat analyses were primary, with completer analyses as sensitivity checks. Studies not eligible for pooling were synthesised narratively Results : Five RCTs (n = 624 randomised) met inclusion criteria, of which three RCTs (n = 338) contributed to the meta-analysis. Follow-up data at 12 months was available for 255 of 338 (75.44%) randomised participants. PDP was associated with greater improvement in clinician-rated depressive symptoms compared with TAU (SMD = −0.40, 95% CI [−0.72, −0.07]), but not self-rated symptoms (SMD = −0.32, 95% CI [−0.83, 0.19]). PDP was associated with a reduced risk of relapse at 12 months (RR = 0.78, 95% CI [0.68, 0.90]), corresponding with an number needed to treat of approximately 5-6. Limitations : The meta-analysis is based on a small number of RCTs with an attrition rate of approximately 25%. Concurrent antidepressant medication was high, making it difficult to attribute long term gains solely to the psychodynamic intervention. The number of treatment sessions varied across trials (12–88 sessions), which limits comparability between trials. Conclusion : Psychodynamic psychotherapy is associated with long-term benefits in MDD, particularly in clinician-rated outcomes and relapse prevention at 12 months, though effects on self-rated symptoms were less consistent. The discrepancy between clinician-rated and self-rated outcomes highlights the complexity of capturing internal change. Improvements in observable symptoms and functioning are more readily detected, whereas changes in internal experiences may be more slowly developing and less well captured by symptom-based self-report measures. Psychiatry major depressive disorder depression psychotherapy psychodynamic long term outcome Figures Figure 1 Figure 2 Figure 3 Introduction Major depressive disorder (MDD) is common and disabling, affecting over 280 million adults worldwide and having profound personal, social, and economic burdens (Gustavsson et al., 2011 ; Kessler et al., 2012 ; World Health Organization, 2023 ). Current first-line treatments include antidepressant medications and structured psychotherapies, such as cognitive behavioural therapy (CBT) and short-term psychodynamic psychotherapy (STPP) (NICE, 2022 ). CBT is a structured, time-limited psychotherapy that helps individuals identify and modify thoughts and behaviours that contribute to MDD, and STPP is a time-limited psychotherapy that explores unconscious process and relationship patterns in order to support an enduring change (Fonagy, 2015 ; Gunderson & Gabbard, 1999 ; Leichsenring & Rabung, 2008 ). Clinical efficacy for antidepressant medication is supported by small to moderate effect sizes (Cipriani et al., 2018 ), while CBT and short-term psychodynamic psychotherapy demonstrate moderate effects in the treatment of MDD (Driessen et al., 2017 ; Miggiels et al., 2025 ). However, relapse within the first year after treatment response is common, with pooled rates of approximately 30–40% within one year (Abu-Ashour et al., 2025 ; Steinert et al., 2014 ; Zhou et al., 2023 ), and substantially higher rates of relapse of around 56% when antidepressant medication is discontinued (Lewis et al., 2021 ). A large network meta-analysis by Cuijpers et al. ( 2021 ) (331 RCTs; >34,000 participants) reported that all psychotherapy modalities demonstrated greater efficacy than treatment-as-usual or waiting list at 12 months. However, Cuijpers et al. ( 2021 ) pooled across heterogeneous populations, pooled all available outcome measures across clinician-rated and self-rated scales, included short- to long-term follow-up periods from 6 to 18 months post-randomisation, which may have overlapped with treatment phases, and psychodynamic psychotherapy trials were underrepresented. Beyond 12 months, CBT has demonstrated sustained benefits (Bruijniks et al., 2024 ; Wiles et al., 2016 ). Long term follow-up studies of psychodynamic psychotherapy have generally examined long-term psychodynamic psychotherapy, which is commonly defined as an intervention extending over at least a year or 50 sessions with an emphasis on interpretations of transference and resistance within the therapeutic alliance (Gunderson & Gabbard, 1999 ; Leichsenring & Rabung, 2008 ). Ongoing benefits have been observed at 2–3 year follow ups, however assessments had also overlapped with ongoing treatments (Knekt et al., 2008 ; Steinert et al., 2014 ). In the present systematic review and meta-analysis, we sought to investigate the long-term treatment outcomes of psychodynamic psychotherapy by requiring at least 12 months follow-up after the end of treatment, beyond short- and medium-term efficacy. Our focus was in MDD adults in order we provide a more precise estimate of the durability of psychodynamic psychotherapy in a more homogeneous group. We distinguished between clinician-rated and self-rated depressive symptom scales and relapse rates to address methodological issues of pooled outcome measures. We expected that psychodynamic psychotherapy would be associated with an improvement in depressive symptoms severity and relapse rates at 12 months or more post-treatment as compared to usual treatments. Methods Protocol and Registration The systematic review and meta-analysis were conducted according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. A pre-specified protocol was registered on PROSPERO (International Prospective Register of Systematic Reviews; registration number: CRD420251000935). Selection Criteria Inclusion criteria of the present review specified that studies must include adults (aged 18 years or older) diagnosed with MDD according to the Diagnostic and Statistical Manual (DSM) -III/III-R/IV/5 or the International Classification of Diseases (ICD) -9/10 diagnostic criteria. No restrictions were placed on geographical location or treatment setting. For the Intervention, studies evaluating psychodynamic psychotherapy (PDP), defined either as short-term psychodynamic psychotherapy, intensive psychodynamic psychotherapy, or brief dynamic psychotherapy involving 12–24 sessions or as long-term psychodynamic psychotherapy or psychoanalytic therapy defined as treatment with a duration of ≥ 50 sessions, were included. Comparison conditions included other psychotherapeutic interventions such as CBT, supportive therapy, or non-psychotherapeutic controls such as treatment as usual, waiting list, or pharmacotherapy. Comparison conditions in which PDP was combined with another treatment, such as treatment as usual (TAU) or pharmacotherapy, were also included. Our primary outcome focused on depressive symptom severity measured ≥ 12 months post-treatment using standardized clinician-reported or self-reported scales. Our secondary outcome was relapse rates measured ≥ 12 months post-treatment and defined as the return of depressive symptoms following remission and assessed via clinical interviews such as structure clinical interview (SCID), clinician-rated scales, or predefined diagnostic thresholds. The study design included only randomised controlled trials (RCT) with a minimum follow-up of 12 months or more after treatment termination. The exclusion criteria included studies a) not reporting follow-up beyond 12 months or more, b) non-RCT designs, c) including bipolar or psychotic depression, and d) with non-adult population. Search Strategy We searched the electronic databases PubMed, Cochrane Central Register of Controlled Trials, and Embase and PsychINFO through OVID from the start to 26th February 2025. To extend our search, we also identified relevant literature through searching a meta-analytic database of randomised trials on psychotherapies for depression (Cuijpers & Karyotaki, 2019 ) and a meta-analytic paper (Steinert et al., 2014 ). The following terms were implemented in our search: ‘depressive disorder*’, ‘depress*’, ‘major depress* disorder*’, ‘affective disorder*’, and ‘mood disorder*’, as well as ‘psychodynamic psychotherapy’, ‘psychodynamic therapy’, ‘psychodynamic’, ‘psychoanaly*’, ‘psychoanalytic therapy’, ‘brief dynamic psychotherapy’, and ‘brief dynamic therapy’ (see Appendix 1 for details). We did not include search terms for ‘follow-up’ as this may have narrowed our search and possibly limited the number of relevant literatures identified. No language or publication date restrictions were applied in the searches. Data Extraction After completing a search for relevant literature, all results ( n = 1760) were independently screened by two reviewers based on their titles and abstracts according to the predefined selection criteria. Any disagreements were resolved through discussion. All potentially relevant articles were retrieved for full-text review ( n = 45 ) , which were independently screened by the same reviewers using the selection criteria. Uncertainties were discussed and resolved through consensus. In instances where consensus could not be reached, a third reviewer was consulted. We emailed the authors of papers ( n = 3) when the selection criteria were met, but data was missing from their paper. Included papers were checked by the two reviewers to confirm follow-up length of 12-months or more was post-treatment and not post-baseline (Fig. 1 ). Extracted data of the included studies involved author and year of the publication, sample size, treatment and control conditions, number of sessions, follow-up length and outcome measures, depression scores and relapse rate, and sample used for analysis (intention-to-treat versus completers at follow-ups). Statistical Analysis We assumed between-study heterogeneity due to differences in psychodynamic psychotherapy (PDP) formats, comparators, and populations, and therefore used random-effects models for all syntheses (inverse-variance weighting; REML as the heterogeneity estimator; Hartung–Knapp adjustments when k < 5). Because only two RCTs reported outcomes beyond 12 months, we restricted quantitative syntheses to the 12-month post-treatment follow-up and conducted three pairwise meta-analyses comparing PDP with TAU. The primary outcome was depressive symptom severity. Because several trials reported multiple measures on the same participants, we ran separate meta-analyses for self-reported and clinician-rated outcomes to avoid dependent effects (Scammacca et al., 2014 ). Continuous outcomes were summarised as standardised mean differences (Hedges’ g) with 95% CIs; dichotomous relapse outcomes were summarised as risk ratios (RRs) with 95% CIs, where RR < 1 favoured PDP. Heterogeneity was assessed using I², τ², and the Q test. Where possible we used intent-to-treat (ITT) data; when required, we reconstructed group means/SDs from reported SMDs and CIs or extracted values from published graphs (e.g., de Roten et al. ( 2017 )) and contacted authors for missing data (e.g., Koppers et al. ( 2011 )). Trials lacking analysable data or using psychoanalytic therapy as the comparator (Huber et al., 2013 ) were excluded from the relevant syntheses. For relapse, when not directly reported we derived rates from remission percentages at 12 months. Sensitivity analyses repeated the meta-analyses with completer samples to examine robustness to missing outcome data. Given the small number of studies per comparison, we did not conduct subgroup/meta-regression analyses and did not assess publication bias (< 10 studies) (Chandler et al., 2019 ). All analyses were performed in RevMan Web (Cochrane). Risk-of-bias assessment was conducted for each included RCT using the Cochrane Risk of Bias 2.0 tool (RoB-2) for each RCT and outcome (self-reported and clinician-rated symptom severity as well as relapse/remission rate). Published protocols (BMC Psychiatry protocols) and trial registries (e.g., ClinicalTrials.gov) were consulted to aid in bias judgments. Disagreements were resolved by discussion to consensus. Each study received an overall rating of “low risk,” “some concerns,” or “high risk.” Results Eligible studies From 1,760 records identified (1,740 database and 20 additional), 1,045 titles/abstracts were screened after de-duplication, after which 45 full texts were assessed, and five RCTs met inclusion criteria. Reasons for full-text exclusion: follow-up < 12 months post-treatment (n = 24), non-randomised design (n = 10), no depressive symptom severity measure (n = 1), protocol paper (n = 1), adolescent sample (n = 1), MDD was not specified as an inclusion criterion (n = 1), unavailable follow-up data (n = 1), and analyses combining treatment arms at follow-up (n = 1). Authors were contacted for missing data, and one study was excluded due to unavailable data and two did not respond (Fig. 1 ). The included studies (5 RCTs) consisted of a total of 624 participants randomised to interventions (315 PDP, 144 alternative treatment, 165 control conditions) (Table 1 ). Majority of participants were female (68.02%). Mean age ranged from 33 (Huber et al., 2013 ) to 44 years (Fonagy, 2015 ). Participants were recruited from clinical population (n = 3), community (n = 1), and clinical/community (n = 1). All studies specified a MDD diagnosis, though differed in whether MDD was with/without dysthymia, unipolar MDD, recurrent MDD, and treatment-resistant MDD. Mean baseline BDI scores ranged from 25.30 to 36.60, suggesting moderate to severe depression, and mean baseline HAMD scores ranged from 20.10 to 23.89, indicating moderate depression. Number of psychodynamic psychotherapy sessions ranged from 12 (de Roten et al., 2017 ) to 88 (Huber et al., 2013 ). Table 1 Characteristics of included studies Study MDD diagnosis Sample size; mean age (years), gender (% female) Recruitment method Treatment conditions Treatment concept No. of psycho-therapy sessions Comparison condition concept Follow-up length PT Depression outcome measures Definition of relapse De Roten, 2017 Unipolar major depressive episode (DSM-IV); MADRS > 18/semi-structured interview, DIGS 149 accepted randomisation, 105 assessed 12-months post-treatment, 43.2, 72.5% female Clinical (inpatients at UPH) ( 1 ) IBPP + TAU ( n = 76) ( 2 ) TAU ( n = 73) Manual of PD treatment of depression (Busch et al., 2004) and a manual on BPT (Despland et al., 2010) 12 sessions; Mean sessions (8.5) TAU, clinical management, supportive interventions, and ADM, following practical guidelines for the treatment of MDD (APA, 2010) 12-months MADRS QIDS-SR Remission defined as MADRS ≤ 7 Remission defined as QIDS-SR ≤ 5 Fonagy, 2015 Current depressive episode with minimum duration of two years and two failed treatments, one being ADM (DSM-IV); BDI-II ≥ 21 and HDRS ≥ 14/SCID-I 129 randomised, 97 assessed at 1- and 2-year post-treatment, 44.4, 66.4% female Clinical and community (GPs refer a potential participant) ( 1 ) LTPP + TAU ( n = 67) ( 2 ) TAU ( n = 62) Individual PAT, manual (Taylor, 2015) 60 sessions; Mean hours (41) TAU, including (e.g., ADM, self-help groups, psycho-therapeutic treatments) using NICE guidelines. LTPP not in guidelines. 1-and 2-years HDRS-17 BDI-II Remission defined as HDRS ≤ 8 Huber, 2013 Current moderate/ severe depressive episode/ double depression characterised by MDD and dysthymia (ICD-10 or DSM-IV); BDI ≥ 16/ IDCL 78 randomised, 66 received allocated intervention , 63 assessed at 1-year post-treatment, 54 at 2-year, and 55 at 3-year; 33, 63.6% female Clinical (an outpatient clinic) ( 1 ) PD ( n = 35) ( 2 ) PA ( n = 31) Classical (Freudian) and object-relational PA; treatments not formally manualised Mean sessions (1) 88 (2) 234 1, 2, and 3-year BDI Remission defined as a total score of < 10 on the BDI Koppers, 2011 Mild or moderate MDD with/without dysthymia (DSM-IV); HRSD 12–24/semi-structured interview (Huyser et al., 1996) 208 randomised, 140 completed treatment, 52 completed 5-years post-treatment, 71.2% female Clinical (two outpatient clinics) ( 1 ) Short supportive PDT ( n = 27) ( 2 ) Short supportive PDT + ADM ( n = 25) Manualised PDT (De Jonghe, 2005) 16 sessions 5 years Recurrence of MDE (CIDI) Town, 2020 Current depressive episode duration of 6 weeks or more, met TRD criteria, non-remitting following at least one trial of antidepressants (DSM-IV); HAM-D) ≥ 16/SCID and M.I.N.I plus 60 randomised, 29 assessed at 12-months post-treatment, 41.55, 63.3% female Community (an outpatient community mental health team) ( 1 ) ISTDP ( n = 30) ( 2 ) CMHT TAU ( n = 30) Individual, manual and published recommendations (Abbas, 2015; Davanloo, 2000) 20 sessions Mean sessions (16.1) Secondary care TAU, clinical management, ADM, according to clinical guidelines (Lam et al., 2009) and, for some, individual/group psychotherapy (not ISTDP) 1-year HAM-D PHQ-9 Remission defined as a HAM-D score of ≤ 7 Remission is scale sum of PHQ-9 ≤ 4 Abbreviations: ADM= Antidepressant medication, BDI= Beck Depression Inventory BPT= Brief psychodynamic therapy CIDI= Composite International diagnostic interview CMHT = Community mental health team DIGS= Diagnostic interview for genetic studies (Nurnberger et al., 1994), DSM= Diagnostic and Statistical Manual HAMD/HRSD= Hamilton Rating Scale for Depression GP= General Practitioners IBPP= Intensive brief psychodynamic psychotherapy ICD= International Classification of Diseases IDCL= International diagnostic checklist for ICD-10 and DSM-IV/5 ISTDP= Intensive Short-term Dynamic Psychotherapy LTPP= Long-term psychoanalytic psychotherapy MADRS= Montgomery-Asberg Depression Rating Scale MDD= Major depressive disorder MDE= Major depressive episode M.I.N.I= Mini-International Neuropsychiatric Interview NICE= National Institute for Health and Care Excellence PA= Psychoanalysis PAT= Psychoanalytic therapy PD= Psychodynamic PDT= Psychodynamic therapy PHQ-9 = Patient Health Questionnaire therapy PT= post-treatment QIDS-SR= Quick inventory of depressive symptomology SCID= Structured clinical interview for DSM-III-R/DSM-IV/DSM TAU= Treatment as usual TRD= Treatment resistant depression UPH= University Psychiatric Hospital. Four studies reported outcomes at follow-up intervals of 12-months post-treatment (Koppers et al., 2011 ; de Roten et al., 2017 ; Fonagy, 2015 ; Town et al., 2020 ) consisting of 416 participants at baseline and 294 participants (70.67%) having a 12-month follow-up. The studies eligible for the meta-analysis (3 RCTs; de Roten et al., 2017 ; Fonagy, 2015 ; Town et al., 2020 ) consisted of 338 participants, with 225 participants (75.74%) having a 12-month follow-up. Three of the five studies compared psychodynamic psychotherapy with treatment as usual (de Roten et al., 2017 ; Fonagy, 2015 ; Town et al., 2020 ), of which the psychodynamic psychotherapy condition was adjunctive to usual inpatient treatment in two of the studies (de Roten et al., 2017 ; Fonagy, 2015 ). Concurrent antidepressant medication in psychodynamic psychotherapy conditions was prominent in the three studies compared to one study, which had a wash-out period (Koppers et al., 2011 ) and one study stated in the selection criteria that concurrent treatment of antidepressants was excluded (Huber et al., 2013 ). Concurrent antidepressant use was high across the three trials where it was permitted alongside psychodynamic psychotherapy: 74.8% of participants were on antidepressants at baseline in de Roten et al. ( 2017 ) (71.4% in the IBPP arm, 81.4% in TAU); approximately 82% and 81% respectively in the LTPP and TAU arms before randomisation in Fonagy et al. (2015), rising to approximately 85% and 79% during the treatment period; and all 60 participants in Town et al. ( 2020 ) had prior antidepressant exposure by study inclusion criteria, with 73.3% of the ISTDP group and 96.4% of the CMHT group still receiving antidepressants during the follow-up period. Depressive symptom severity was measured by the self-rated scales, BDI, PHQ-9, and QIDS-SR, and clinician-rated scales, HAMD and MADRS. Remission status was based on HAMD (Fonagy, 2015 ) and recurrence of an major depressive episode was based on Composite International Diagnostic Interview (Koppers et al., 2011 ). Narrative Synthesis Koppers et al. ( 2011 ) investigated recurrence, defined as the onset of a new depressive episode following full recovery, in a 5-year follow-up period following two treatment arms: short supportive psychodynamic psychotherapy (SSPDP) alone and adjunctive antidepressant medication to SSPDP. At follow-up, the sample size was 52 participants, with no significant difference between the treatment groups in recurrence rates (37% SSPDP, 44% SSPDP + ADM). Risk factors for recurrence included younger age (57% < 40 years vs. 21% of those ≥ 40 years; OR = 0.87, p < .001) and female gender (70% women < 40 vs. 25% men < 40; OR = 1.05, p = .049). Huber et al. ( 2013 ) investigated two psychodynamic psychotherapies: psychodynamic psychotherapy (n = 88 sessions) and psychoanalysis (n = 234 sessions). Depressive symptoms were measured by self-rated BDI at post-treatment and 12-, 24-, and 36-month follow-up. Both treatment groups showed large within-group improvements (d > 2.0 at all time points), and between-group differences increased over time. At 12-month follow-up, the effect size for favoured psychoanalysis over PDP, showing a small effect (d = 0.3), which remained stable at 24 months (d = 0.3 (95% CI [-0.19, 0.79]) and increased at the 36-month follow-up (d = 0.7), showing a moderate-to-large advantage for psychoanalysis. Relapse rates were also lower in the psychoanalysis treatment group (8.6%) compared to the psychodynamic group (22.6%) at 3-year follow-up. There was risk of bias across all studies: four studies assessed as having an overall high risk of bias (de Roten et al., 2017 ; Huber et al., 2013 ; Koppers et al., 2011 ; Town et al., 2020 ) and one having some concerns of bias (Fonagy, 2015 ) (Table 2 ). Bias due to missing outcome data was judged as high in most studies, as the number of participants with missing outcome data was relatively high, which would be expected considering outcomes were assessed at longer-term follow-ups post-treatment. Across studies with self-rated measures, a judgement of ‘some concerns’ was made for bias in the outcome measurement because outcome assessors (participants) were aware of the intervention they received. This was not the case for clinician-administered measures in which studies reported that outcome assessors were blinded (Supplementary Materials). Table 2 Risk of Bias Study Outcome measures ROB arising from the randomisation process ROB due to deviations from the intended interventions ROB due to missing outcome data ROB in measurement of the outcome ROB in selection of the reported result Overall ROB De Roten 2017 SR Depression symptom severity Some concerns Low risk High risk Some concerns Low risk High risk CA Depression symptom severity Some concerns Low risk High risk Low risk Low risk High risk SR Remission/relapse rate Some concerns Low risk High risk Some concerns Low risk High risk CA Remission/relapse rate Some concerns Low risk High risk Low risk Low risk High risk Fonagy 2015 SR Depression symptom severity Some concerns Low risk Low risk Some concerns Low risk Some concerns CA Depression symptom severity Some concerns Low risk Low risk Low risk Low risk Some concerns CA Remission/relapse rate Some concerns Some concerns Low risk Low risk Low risk Some concerns Huber 2013 SR Depression symptom severity Some concerns High risk High risk Some concerns Some concerns High risk SR Remission/relapse rate Some concerns High risk High risk Some concerns Some concerns High risk Koppers 2011 CA Remission/Relapse rate Some concerns High risk High risk High risk Some concerns High risk Town 2020 SR Depression symptom severity Some concerns Low risk High risk Some concerns Low risk High risk CA Depression symptom severity Some concerns Low risk High risk Low risk Low risk High risk SR Remission/relapse rate Some concerns Low risk High risk Some concerns Low risk High risk CA Remission/relapse rate Some concerns Low risk High risk Low risk Low risk High risk SR: self-rated, CA: clinician-administered. Meta-analysis Four RCTs were included in the pairwise meta-analysis, in which the treatment arms were a psychodynamic psychotherapy intervention and an alternative treatment or control condition. One RCT was excluded as the treatment arms were both forms of psychodynamic therapies: psychodynamic psychotherapy and psychoanalysis (Huber et al., 2013 ). Further, in Fonagy ( 2015 ), at 24-months post-treatment, self-reported depressive symptoms (BDI) was lower in the psychodynamic psychotherapy group compared to the control group (d = -0.73 (95% CI [-1.09, -0.37])). Treatment effect was similar when depression symptom severity was measured at 24-months post-treatment based on clinician-rated HAMD (d = -0.68 (95% CI [-1.04, -0.33])), with both measures significantly in favour of psychodynamic psychotherapy. Self-Rated Depressive Symptoms Self-rated depressive symptom scales (BDI, PHQ-9, QIDS-SR) were assessed in 3 RCTs at 12-months post-treatment (de Roten et al., 2017 ; Fonagy, 2015 ; Town et al., 2020 ). Total pooled sample was 338 MDD participants (treatment arms: 173 psychodynamic psychotherapy, 165 control). In intention to treat analysis, pooled effect size was − 0.32 (95% CI [-0.83, 0.19]) (Fig. 2 ). Heterogeneity was low (Q = 2.31, p = 0.32, I 2 = 0%). Sensitivity analysis of completers showed a pooled effect size of d = -0.29 (95% CI [-0.71, 0.12]) (Supplementary Materials). Clinician-Rated Depressive Symptoms Clinician-rated depressive symptom scales ((HAMD, MADRS) were acquired in the 3 RCTs at 12-months post-treatment (de Roten et al., 2017 ; Fonagy, 2015 ; Town et al., 2020 ). In intention to treat analysis, there was a significant pooled effect size of -0.40 (95% CI [-0.72, -0.07]) (Fig. 2 ). Heterogeneity was low (Q = 0.94, p = 0.63, I 2 = 0%). Sensitivity analysis of completers showed a significant pooled effect size of -0.38 (95% CI -0.65, -0.12) (Supplementary Materials). Remission Rates Three studies were pooled for proportion of relapses at the 12-month follow-up, showing an event rate of 0.78 (95% CI [0.68, 0.90]) (Fig. 3 ). Heterogeneity was low ( Q = 0.44, p= .80, I 2 = 0%). Number needed to treat (NNT) was 5.45, indicating the number required to be treated with psychodynamic psychotherapy in order to achieve one less relapse as compared to the control condition. Sensitivity analysis of all completers resulted in a moderately large treatment effect of 0.77 (95% CI [0.68, 0.88]) (Supplementary Materials). Discussion The present systematic review and meta-analysis sought to evaluate the long-term outcomes of psychodynamic psychotherapy for major depressive disorder as measured by depressive symptom severity and rate of relapse at 12 months or longer after treatment. The meta-analysis revealed that psychodynamic psychotherapy was associated with significantly greater long-term improvements in depressive symptoms as compared to usual treatments as measured by blinded clinician-rated assessments. Moreover, psychodynamic psychotherapy was associated with a significantly reduced risk of relapse at 12 months compared with treatment as usual. However, self-rated depressive symptom outcomes were less consistent. The narrative synthesis further suggested that psychoanalysis may confer greater long-term benefits than psychodynamic psychotherapy. Previous meta-analyses which pooled post-treatment and short/medium follow-ups generally reported significant benefits of psychodynamic psychotherapy relative to control conditions (e.g., waitlist, care-as-usual) (Caselli et al., 2023 ; Driessen et al., 2010 ; Driessen et al., 2015 ). Effect sizes at post-treatment were typically larger (e.g., d ≈ 0.61–0.70). Meta-analyses of psychodynamic psychotherapy in common mental disorders have reported benefits as compared to treatment as usual (Abbass et al., 2014 ; Leichsenring et al., 2004 ). At the 12-month long term follow up, we found that improvements in depressive symptoms were maintained as measured by clinician-rated depressive symptoms and rates of relapse. However, Abbass et al. ( 2014 ) reported a non-significant effect at 9-month follow-up based on self-rated symptoms scales (d = − 1.00, 95% CI − 2.22 to 0.21). While we had focused on a more homogeneous MDD sample and a ≥ 12-month follow-up, we similarly did not find a significant effect in self-rated depressive symptom scales. The divergence between clinician- and self-rated outcomes may reflect both methodological and clinical factors. Clinician-rated scales are typically conducted by blinded assessors, thus less susceptible to expectancy and reporting biases (Cuijpers et al., 2010 ; Miguel et al., 2025 ). Clinician-administered scales show a significantly higher effect size compared to self-rated scales, although the difference is reduced when the clinician is blinded to treatment allocation (Cuijpers et al., 2010 ; Miguel et al., 2025 ). In clinical factors, self-rated symptoms scales contain more items related to cognitive and affective experiences (e.g. pessimism, worthlessness, shame), while clinician-rated scales include more somatic and observable domains (e.g. sleep, appetite, psychomotor change) (Beck et al., 1996 ; Hamilton, 1960 ). Somatic and observable domains may be more sensitive to treatment effects, while subjective experiences may persist and be readily reported by patients (Cuijpers et al., 2010 ; Miguel et al., 2025 ). In relapse prevention, our pooled risk ratio at 12 months (RR ≈ 0.78), implying about 22% relative risk reduction and an NNT of ~ 5–6, closely matches Steinert et al. ( 2014 ), who estimated an odds ratio of 0.51 (≈ 49% reduction) across psychotherapies over a mean 3.3 year follow-up, with an NNT of 5.55. However, heterogeneous modalities were pooled and did not include a specific psychodynamic psychotherapy subgroup analyses, leaving uncertainty about its unique contribution. Review of CBT from Chen et al. ( 2022 ) reported RR ≈ 0.61 at 12 months (31.6% vs 41.3% relapse), but definitions varied (DSM vs ICD vs scale cut-offs), follow-ups spanned 6–26 months, and multiple CBT formats (face-to-face, mindfulness-based cognitive therapy, internet-delivered) were pooled, with substantial heterogeneity (I² = 55%), potentially inflating durability estimates. Our psychodynamic psychotherapy-focused estimate shows comparable improvements in relapse rates at one year. Limitations include the number of trials as five RCTs met inclusion criteria, of which three contributed to the meta-analysis, substantially limiting statistical power and precluding subgroup or meta-regression analyses. Four of the five included studies were rated as having a high overall risk of bias, primarily due to missing outcome data at the 12-month follow up. Across the three trials that contributed to the pooled analyses (de Roten et al., 2017 ; Fonagy et al., 2015; Town et al., 2020 ), approximately 255 of 338 randomised participants (75%) provided follow-up outcome data, representing an attrition rate of approximately 25%. The remaining two studies (Huber et al., 2013 ; Koppers et al., 2011 ) were not pooled and had different follow-up timepoints (3-year and 5-year, respectively), precluding a meaningful aggregate attrition estimate across all five trials. Concurrent antidepressant use was high across the three trials where it was permitted alongside psychodynamic psychotherapy, making it difficult to attribute long-term gains solely to the psychodynamic intervention rather than to a synergistic or additive pharmacological effect. The trials differed in treatment intensity, ranging from 12 to 88 sessions, which complicates interpretation of efficacy and limits the generalisability of findings across settings. While clinician ratings were masked, self-rated outcomes were unblinded and vulnerable to response bias. Moreover, MDD is a heterogeneous syndrome in which patterns of brain structure have been associated with different symptom profiles and clinical outcomes (Fu et al., 2024 ), which could potentially impact on psychotherapy treatment outcomes. In summary, the present systematic review and meta-analysis evaluated the long-term effects of psychodynamic psychotherapy in MDD. By focusing on adults with MDD and requiring follow-up of at least 12 months post-treatment, we were able to examine the durability of therapeutic gains beyond short- and medium-term outcomes. A key methodological strength was the separation of clinician-rated from self-rated symptom scales, revealing that benefits were most consistent on blinded clinical assessments, while self-reports were less reliable in detecting sustained change. Psychodynamic psychotherapy was associated with improved rates of relapse at 12 months, with an estimated number needed to treat of 5–6. The present findings demonstrate that psychodynamic psychotherapy offers sustained symptom improvement and relapse prevention in MDD, supporting its role within stepped-care models and long-term clinical care planning. References Abbass AA, Kisely SR, Town JM, Leichsenring F, Driessen E, De Maat S, Gerber A, Dekker J, Rabung S, Rusalovska S (2014) Short-term psychodynamic psychotherapies for common mental disorders. Cochrane database of systematic reviews (7) Abu-Ashour W, Delaney S, Farrell A, Gamble J-M, Hawboldt J, Sale JE (2025) Incidence of Major Depressive Disorder Relapse and Effectiveness of Pharmacologic and Psychological Interventions in Primary Care: A Systematic Review and Meta-Analysis: Incidence de la rechute du trouble depressif majeur et efficacite des interventions pharmacologiques et psychologiques en soins primaires: revue systematique et meta-analyse. Can J Psychiatry, 07067437251322401 Beck AT, Steer RA, Ball R, Ranieri WF (1996) Comparison of Beck Depression Inventories-IA and-II in psychiatric outpatients. J Pers Assess 67(3):588–597 Bruijniks SJE, Hollon SD, Lemmens LHJM, Peeters FPML, Arntz A, Cuijpers P, Twisk J, Dingemanse P, Willems L, van Oppen P, van den Boogaard M, Spijker J, Huibers MJH (2024) Long-term outcomes of once weekly v. twice weekly sessions of cognitive behavioral therapy and interpersonal psychotherapy for depression. Psychol Med 54(3):517–526. https://doi.org/10.1017/S0033291723002143 Caselli I, Ielmini M, Bellini A, Zizolfi D, Callegari C (2023) Efficacy of short-term psychodynamic psychotherapy (STPP) in depressive disorders: a systematic review and meta-analysis. J Affect Disord 325:169–176 Chandler J, Cumpston M, Li T, Page MJ, Welch V (2019) Cochrane handbook for systematic reviews of interventions. Hoboken: Wiley 4(1002):14651858 Chen H, He Q, Wang M, Wang X, Pu C, Li S, Li M (2022) Effectiveness of CBT and its modifications for prevention of relapse/recurrence in depression: A systematic review and meta-analysis of randomized controlled trials. J Affect Disord 319:469–481 Cipriani A, Furukawa TA, Salanti G, Chaimani A, Atkinson LZ, Ogawa Y, Leucht S, Ruhe HG, Turner EH, Higgins JP (2018) Comparative efficacy and acceptability of 21 antidepressant drugs for the acute treatment of adults with major depressive disorder: a systematic review and network meta-analysis. Lancet 391(10128):1357–1366 Cuijpers P, Karyotaki E (2019) A meta-analytic database of randomised trials on psychotherapies for depression Cuijpers P, Li J, Hofmann SG, Andersson G (2010) Self-reported versus clinician-rated symptoms of depression as outcome measures in psychotherapy research on depression: a meta-analysis. Clin Psychol Rev 30(6):768–778 Cuijpers P, Quero S, Noma H, Ciharova M, Miguel C, Karyotaki E, Cipriani A, Cristea IA, 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(2):283–293 de Roten Y, Ambresin G, Herrera F, Fassassi S, Fournier N, Preisig M, Despland J-N (2017) Efficacy of an adjunctive brief psychodynamic psychotherapy to usual inpatient treatment of depression: Results of a randomized controlled trial. J Affect Cisorders 209:105–113 Driessen E, Cuijpers P, de Maat SC, Abbass AA, de Jonghe F, Dekker JJ (2010) The efficacy of short-term psychodynamic psychotherapy for depression: a meta-analysis. Clin Psychol Rev 30(1):25–36 Driessen E, Hegelmaier LM, Abbass AA, Barber JP, Dekker JJ, Van HL, Jansma EP, Cuijpers P (2015) The efficacy of short-term psychodynamic psychotherapy for depression: A meta-analysis update. Clin Psychol Rev 42:1–15 Driessen E, Van HL, Peen J, Don FJ, Twisk JW, Cuijpers P, Dekker JJ (2017) Cognitive-behavioral versus psychodynamic therapy for major depression: Secondary outcomes of a randomized clinical trial. J Consult Clin Psychol 85(7):653 Fonagy P (2015) The effectiveness of psychodynamic psychotherapies: An update. World Psychiatry 14(2):137–150 Fu CHY, Antoniades M, Erus G, Garcia JA, Fan Y, Arnone D, Arnott SR, Chen T, Choi KS, Fatt CC, Frey BN, Frokjaer VG, Ganz M, Godlewska BR, Hassel S, Ho K, McIntosh AM, Qin K, Rotzinger S, Sacchet MD, Savitz J, Shou H, Singh A, Stolicyn A, Strigo I, Strother SC, Tosun D, Victor TA, Wei D, Wise T, Zahn R, Anderson IM, Craighead WE, Deakin JFW, Dunlop BW, Elliott R, Gong Q, Gotlib IH, Harmer CJ, Kennedy SH, Knudsen GM, Mayberg HS, Paulus MP, Qiu J, Trivedi MH, Whalley HC, Yan CG, Young AH, Davatzikos C (2024) Neuroanatomical dimensions in medication-free individuals with major depressive disorder and treatment response to SSRI antidepressant medications or placebo. Nat Mental Health 2(2):164–176 Gunderson JG, Gabbard GO (1999) Making the case for psychoanalytic therapies in the current psychiatric environment. J Am Psychoanal Assoc 47(3):679–704 discussion 704 Gustavsson A, Svensson M, Jacobi F, Allgulander C, Alonso J, Beghi E, Dodel R, Ekman M, Faravelli C, Fratiglioni L (2011) Cost of disorders of the brain in Europe 2010. Eur Neuropsychopharmacol 21(10):718–779 Hamilton M (1960) A rating scale for depression. J Neurol Neurosurg Psychiatry 23(1):56 Huber D, Henrich G, Clarkin J, Klug G (2013) Psychoanalytic versus psychodynamic therapy for depression: A three-year follow-up study. Psychiatry: Interpers Biol Processes 76(2):132–149 Kessler RC, Petukhova M, Sampson NA, Zaslavsky AM, Wittchen HU (2012) Twelve-month and lifetime prevalence and lifetime morbid risk of anxiety and mood disorders in the United States. Int J Methods Psychiatr Res 21(3):169–184 Knekt P, Lindfors O, Härkänen T, Välikoski M, Virtala E, Laaksonen M, Marttunen M, Kaipainen M, Renlund C, Group HPS (2008) Randomized trial on the effectiveness of long-and short-term psychodynamic psychotherapy and solution-focused therapy on psychiatric symptoms during a 3-year follow-up. Psychol Med 38(5):689–703 Koppers D, Peen J, Niekerken S, Van R, Dekker J (2011) Prevalence and risk factors for recurrence of depression five years after short term psychodynamic therapy. J Affect Disord 134(1–3):468–472 Leichsenring F, Rabung S (2008) Effectiveness of long-term psychodynamic psychotherapy: A meta-analysis. JAMA 300(13):1551–1565 Leichsenring F, Rabung S, Leibing E (2004) The efficacy of short-term psychodynamic psychotherapy in specificpsychiatric disorders: a meta-analysis. Arch Gen Psychiatry 61(12):1208–1216 Lewis G, Marston L, Duffy L, Freemantle N, Gilbody S, Hunter R, Kendrick T, Kessler D, Mangin D, King M (2021) Maintenance or discontinuation of antidepressants in primary care. N Engl J Med 385(14):1257–1267 Miggiels M, Klooster T, Beekman P, Bremer A, Dekker S, Janssen J, C., van Dijk MK (2025) The D* Phase-study: Comparing short-term psychodynamic psychotherapy and cognitive behavioural therapy for major depressive disorder in a randomised controlled non-inferiority trial. J Affect Disord 371:344–351 Miguel C, Harrer M, Karyotaki E, Plessen CY, Ciharova M, Furukawa TA, Cristea IA, Cuijpers P (2025) Self-reports vs clinician ratings of efficacies of psychotherapies for depression: a meta-analysis of randomized trials. Epidemiol Psychiatric Sci 34:e15 NICE (2022) Depression in adults: treatment and management. NICE Guideline. https://www.nice.org.uk/guidance/ng222 Scammacca N, Roberts G, Stuebing KK (2014) Meta-analysis with complex research designs: Dealing with dependence from multiple measures and multiple group comparisons. Rev Educ Res 84(3):328–364 Steinert C, Hofmann M, Kruse J, Leichsenring F (2014) Relapse rates after psychotherapy for depression–stable long-term effects? A meta-analysis. J Affect Disord 168:107–118 Town JM, Abbass A, Stride C, Nunes A, Bernier D, Berrigan P (2020) Efficacy and cost-effectiveness of intensive short-term dynamic psychotherapy for treatment resistant depression: 18-Month follow-up of the Halifax depression trial. J Affect Disord 273:194–202 Wiles NJ, Thomas L, Turner N, Garfield K, Kounali D, Campbell J, Kessler D, Kuyken W, Lewis G, Morrison J (2016) Long-term effectiveness and cost-effectiveness of cognitive behavioural therapy as an adjunct to pharmacotherapy for treatment-resistant depression in primary care: follow-up of the CoBalT randomised controlled trial. Lancet Psychiatry 3(2):137–144 World Health Organization (2023) Depressive disorder (depression) . https://www.who.int/news-room/fact-sheets/detail/depression Zhou Y, Zhao D, Zhu X, Liu L, Meng M, Shao X, Zhu X, Xiang J, He J, Zhao Y (2023) Psychological interventions for the prevention of depression relapse: systematic review and network meta-analysis. Translational Psychiatry 13(1):300 Additional Declarations The authors declare no competing interests. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-9260871","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Systematic Review","associatedPublications":[],"authors":[{"id":614141540,"identity":"e31ba327-44f1-419b-8874-8d70dc128fef","order_by":0,"name":"Lingfeng Xue","email":"","orcid":"https://orcid.org/0000-0002-9922-5554","institution":"King's College London","correspondingAuthor":false,"prefix":"","firstName":"Lingfeng","middleName":"","lastName":"Xue","suffix":""},{"id":614141669,"identity":"30a4f5f8-5765-42fd-bc97-28f58f98e8e6","order_by":1,"name":"Tooba Farid","email":"","orcid":"","institution":"King's College London","correspondingAuthor":false,"prefix":"","firstName":"Tooba","middleName":"","lastName":"Farid","suffix":""},{"id":614141670,"identity":"904fbbbb-531f-455d-88fd-79f533dbd2f0","order_by":2,"name":"Kyra Moore","email":"","orcid":"","institution":"King's College London","correspondingAuthor":false,"prefix":"","firstName":"Kyra","middleName":"","lastName":"Moore","suffix":""},{"id":614141671,"identity":"cd48e968-b295-4aef-8a8c-28642afe8cfd","order_by":3,"name":"Cynthia H.Y. Fu","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA5ElEQVRIie3RMQuCQBTA8SeCNjyw8ab6Ck9cK79KcquG0BI0JDi4CK1CXyLwCwgOLn2AxkBoanNxaOiOagoux6D7T8fBj/eOA9DpfjQTCMBOzBogfl18yUglwcriIA8DCUiC3jDiFFHTxvECkIUd9QRTJ0GPVISdV0FaEBckKoOcwC3EuKWKEAvdFMkEX5BaLGYcAb1qANnJxVpJ/KGklsTkggSSKBdjp5t7QGoQ8eq5OTFe1NZa+XwnC6nD+3aCNm9Zv5nN91laMhWB8XMJfE8VvzJSDhFjqo8r+6ImOp1O9289AFZwO2LO3pfRAAAAAElFTkSuQmCC","orcid":"https://orcid.org/0000-0003-4313-3500","institution":"King's College London","correspondingAuthor":true,"prefix":"","firstName":"Cynthia","middleName":"H.Y.","lastName":"Fu","suffix":""}],"badges":[],"createdAt":"2026-03-29 20:25:21","currentVersionCode":1,"declarations":{"humanSubjects":false,"vertebrateSubjects":false,"conflictsOfInterestStatement":false,"humanSubjectEthicalGuidelines":false,"humanSubjectConsent":false,"humanSubjectClinicalTrial":false,"humanSubjectCaseReport":false,"vertebrateSubjectEthicalGuidelines":false},"doi":"10.21203/rs.3.rs-9260871/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-9260871/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":105883330,"identity":"67ee20c0-3093-4d27-84f0-516b95940326","added_by":"auto","created_at":"2026-04-01 07:07:43","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":49272,"visible":true,"origin":"","legend":"\u003cp\u003ePRISMA flowchart for inclusion of studies\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-9260871/v1/a5c11a75951540b94d32462c.png"},{"id":105905351,"identity":"34b69575-d53d-4da0-962f-227081f5eadb","added_by":"auto","created_at":"2026-04-01 10:11:55","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":245638,"visible":true,"origin":"","legend":"\u003cp\u003ePooled treatment effect on depression symptom severity of psychodynamic psychotherapy vs. control groups at 12-month post-treatment\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-9260871/v1/3664eade23aaaade3b224c5e.png"},{"id":105883331,"identity":"9c708361-90b7-453b-87ce-6f31de9d4771","added_by":"auto","created_at":"2026-04-01 07:07:43","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":215309,"visible":true,"origin":"","legend":"\u003cp\u003ePooled treatment effect on relapse rate\u003c/p\u003e","description":"","filename":"3.png","url":"https://assets-eu.researchsquare.com/files/rs-9260871/v1/3dadd6b44b325e4927744e7a.png"},{"id":106401635,"identity":"db15b1b1-7b6c-4da5-9180-6f51cb151148","added_by":"auto","created_at":"2026-04-08 09:08:29","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1258215,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-9260871/v1/3b486639-4cca-4a0e-83b1-ffb51f43e272.pdf"}],"financialInterests":"The authors declare no competing interests.","formattedTitle":"\u003cp\u003eLong-term treatment outcomes of psychodynamic psychotherapy for major depressive disorder: a systematic review and meta-analysis\u003c/p\u003e","fulltext":[{"header":"Introduction","content":"\u003cp\u003eMajor depressive disorder (MDD) is common and disabling, affecting over 280\u0026nbsp;million adults worldwide and having profound personal, social, and economic burdens (Gustavsson et al., \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e2011\u003c/span\u003e; Kessler et al., \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e2012\u003c/span\u003e; World Health Organization, \u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e2023\u003c/span\u003e). Current first-line treatments include antidepressant medications and structured psychotherapies, such as cognitive behavioural therapy (CBT) and short-term psychodynamic psychotherapy (STPP) (NICE, \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e2022\u003c/span\u003e). CBT is a structured, time-limited psychotherapy that helps individuals identify and modify thoughts and behaviours that contribute to MDD, and STPP is a time-limited psychotherapy that explores unconscious process and relationship patterns in order to support an enduring change (Fonagy, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e2015\u003c/span\u003e; Gunderson \u0026amp; Gabbard, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e1999\u003c/span\u003e; Leichsenring \u0026amp; Rabung, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e2008\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eClinical efficacy for antidepressant medication is supported by small to moderate effect sizes (Cipriani et al., \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e2018\u003c/span\u003e), while CBT and short-term psychodynamic psychotherapy demonstrate moderate effects in the treatment of MDD (Driessen et al., \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e2017\u003c/span\u003e; Miggiels et al., \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e2025\u003c/span\u003e). However, relapse within the first year after treatment response is common, with pooled rates of approximately 30\u0026ndash;40% within one year (Abu-Ashour et al., \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2025\u003c/span\u003e; Steinert et al., \u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e2014\u003c/span\u003e; Zhou et al., \u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e2023\u003c/span\u003e), and substantially higher rates of relapse of around 56% when antidepressant medication is discontinued (Lewis et al., \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e2021\u003c/span\u003e). A large network meta-analysis by Cuijpers et al. (\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e2021\u003c/span\u003e) (331 RCTs; \u0026gt;34,000 participants) reported that all psychotherapy modalities demonstrated greater efficacy than treatment-as-usual or waiting list at 12 months. However, Cuijpers et al. (\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e2021\u003c/span\u003e) pooled across heterogeneous populations, pooled all available outcome measures across clinician-rated and self-rated scales, included short- to long-term follow-up periods from 6 to 18 months post-randomisation, which may have overlapped with treatment phases, and psychodynamic psychotherapy trials were underrepresented.\u003c/p\u003e \u003cp\u003eBeyond 12 months, CBT has demonstrated sustained benefits (Bruijniks et al., \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e2024\u003c/span\u003e; Wiles et al., \u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e2016\u003c/span\u003e). Long term follow-up studies of psychodynamic psychotherapy have generally examined long-term psychodynamic psychotherapy, which is commonly defined as an intervention extending over at least a year or 50 sessions with an emphasis on interpretations of transference and resistance within the therapeutic alliance (Gunderson \u0026amp; Gabbard, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e1999\u003c/span\u003e; Leichsenring \u0026amp; Rabung, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e2008\u003c/span\u003e). Ongoing benefits have been observed at 2\u0026ndash;3 year follow ups, however assessments had also overlapped with ongoing treatments (Knekt et al., \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e2008\u003c/span\u003e; Steinert et al., \u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e2014\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eIn the present systematic review and meta-analysis, we sought to investigate the long-term treatment outcomes of psychodynamic psychotherapy by requiring at least 12 months follow-up after the end of treatment, beyond short- and medium-term efficacy. Our focus was in MDD adults in order we provide a more precise estimate of the durability of psychodynamic psychotherapy in a more homogeneous group. We distinguished between clinician-rated and self-rated depressive symptom scales and relapse rates to address methodological issues of pooled outcome measures. We expected that psychodynamic psychotherapy would be associated with an improvement in depressive symptoms severity and relapse rates at 12 months or more post-treatment as compared to usual treatments.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eProtocol and Registration\u003c/h2\u003e \u003cp\u003e The systematic review and meta-analysis were conducted according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. A pre-specified protocol was registered on PROSPERO (International Prospective Register of Systematic Reviews; registration number: CRD420251000935).\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eSelection Criteria\u003c/h3\u003e\n\u003cp\u003eInclusion criteria of the present review specified that studies must include adults (aged 18 years or older) diagnosed with MDD according to the Diagnostic and Statistical Manual (DSM) -III/III-R/IV/5 or the International Classification of Diseases (ICD) -9/10 diagnostic criteria. No restrictions were placed on geographical location or treatment setting. For the Intervention, studies evaluating psychodynamic psychotherapy (PDP), defined either as short-term psychodynamic psychotherapy, intensive psychodynamic psychotherapy, or brief dynamic psychotherapy involving 12\u0026ndash;24 sessions or as long-term psychodynamic psychotherapy or psychoanalytic therapy defined as treatment with a duration of \u0026ge;\u0026thinsp;50 sessions, were included. Comparison conditions included other psychotherapeutic interventions such as CBT, supportive therapy, or non-psychotherapeutic controls such as treatment as usual, waiting list, or pharmacotherapy. Comparison conditions in which PDP was combined with another treatment, such as treatment as usual (TAU) or pharmacotherapy, were also included.\u003c/p\u003e \u003cp\u003eOur primary outcome focused on depressive symptom severity measured\u0026thinsp;\u0026ge;\u0026thinsp;12 months post-treatment using standardized clinician-reported or self-reported scales. Our secondary outcome was relapse rates measured\u0026thinsp;\u0026ge;\u0026thinsp;12 months post-treatment and defined as the return of depressive symptoms following remission and assessed via clinical interviews such as structure clinical interview (SCID), clinician-rated scales, or predefined diagnostic thresholds. The study design included only randomised controlled trials (RCT) with a minimum follow-up of 12 months or more after treatment termination.\u003c/p\u003e \u003cp\u003eThe exclusion criteria included studies a) not reporting follow-up beyond 12 months or more, b) non-RCT designs, c) including bipolar or psychotic depression, and d) with non-adult population.\u003c/p\u003e\n\u003ch3\u003eSearch Strategy\u003c/h3\u003e\n\u003cp\u003eWe searched the electronic databases PubMed, Cochrane Central Register of Controlled Trials, and Embase and PsychINFO through OVID from the start to 26th February 2025. To extend our search, we also identified relevant literature through searching a meta-analytic database of randomised trials on psychotherapies for depression (Cuijpers \u0026amp; Karyotaki, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e2019\u003c/span\u003e) and a meta-analytic paper (Steinert et al., \u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e2014\u003c/span\u003e). The following terms were implemented in our search: \u0026lsquo;depressive disorder*\u0026rsquo;, \u0026lsquo;depress*\u0026rsquo;, \u0026lsquo;major depress* disorder*\u0026rsquo;, \u0026lsquo;affective disorder*\u0026rsquo;, and \u0026lsquo;mood disorder*\u0026rsquo;, as well as \u0026lsquo;psychodynamic psychotherapy\u0026rsquo;, \u0026lsquo;psychodynamic therapy\u0026rsquo;, \u0026lsquo;psychodynamic\u0026rsquo;, \u0026lsquo;psychoanaly*\u0026rsquo;, \u0026lsquo;psychoanalytic therapy\u0026rsquo;, \u0026lsquo;brief dynamic psychotherapy\u0026rsquo;, and \u0026lsquo;brief dynamic therapy\u0026rsquo; (see Appendix 1 for details). We did not include search terms for \u0026lsquo;follow-up\u0026rsquo; as this may have narrowed our search and possibly limited the number of relevant literatures identified. No language or publication date restrictions were applied in the searches.\u003c/p\u003e\n\u003ch3\u003eData Extraction\u003c/h3\u003e\n\u003cp\u003eAfter completing a search for relevant literature, all results (\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;1760) were independently screened by two reviewers based on their titles and abstracts according to the predefined selection criteria. Any disagreements were resolved through discussion. All potentially relevant articles were retrieved for full-text review (\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;45\u003cem\u003e)\u003c/em\u003e, which were independently screened by the same reviewers using the selection criteria. Uncertainties were discussed and resolved through consensus. In instances where consensus could not be reached, a third reviewer was consulted. We emailed the authors of papers (\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;3) when the selection criteria were met, but data was missing from their paper. Included papers were checked by the two reviewers to confirm follow-up length of 12-months or more was post-treatment and not post-baseline (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). Extracted data of the included studies involved author and year of the publication, sample size, treatment and control conditions, number of sessions, follow-up length and outcome measures, depression scores and relapse rate, and sample used for analysis (intention-to-treat versus completers at follow-ups).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003eStatistical Analysis\u003c/h2\u003e \u003cp\u003eWe assumed between-study heterogeneity due to differences in psychodynamic psychotherapy (PDP) formats, comparators, and populations, and therefore used random-effects models for all syntheses (inverse-variance weighting; REML as the heterogeneity estimator; Hartung\u0026ndash;Knapp adjustments when k\u0026thinsp;\u0026lt;\u0026thinsp;5). Because only two RCTs reported outcomes beyond 12 months, we restricted quantitative syntheses to the 12-month post-treatment follow-up and conducted three pairwise meta-analyses comparing PDP with TAU. The primary outcome was depressive symptom severity. Because several trials reported multiple measures on the same participants, we ran separate meta-analyses for self-reported and clinician-rated outcomes to avoid dependent effects (Scammacca et al., \u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e2014\u003c/span\u003e). Continuous outcomes were summarised as standardised mean differences (Hedges\u0026rsquo; g) with 95% CIs; dichotomous relapse outcomes were summarised as risk ratios (RRs) with 95% CIs, where RR\u0026thinsp;\u0026lt;\u0026thinsp;1 favoured PDP. Heterogeneity was assessed using I\u0026sup2;, τ\u0026sup2;, and the Q test. Where possible we used intent-to-treat (ITT) data; when required, we reconstructed group means/SDs from reported SMDs and CIs or extracted values from published graphs (e.g., de Roten et al. (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e2017\u003c/span\u003e)) and contacted authors for missing data (e.g., Koppers et al. (\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e2011\u003c/span\u003e)). Trials lacking analysable data or using psychoanalytic therapy as the comparator (Huber et al., \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e2013\u003c/span\u003e) were excluded from the relevant syntheses. For relapse, when not directly reported we derived rates from remission percentages at 12 months. Sensitivity analyses repeated the meta-analyses with completer samples to examine robustness to missing outcome data. Given the small number of studies per comparison, we did not conduct subgroup/meta-regression analyses and did not assess publication bias (\u0026lt;\u0026thinsp;10 studies) (Chandler et al., \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e2019\u003c/span\u003e). All analyses were performed in RevMan Web (Cochrane).\u003c/p\u003e \u003cp\u003eRisk-of-bias assessment was conducted for each included RCT using the Cochrane Risk of Bias 2.0 tool (RoB-2) for each RCT and outcome (self-reported and clinician-rated symptom severity as well as relapse/remission rate). Published protocols (BMC Psychiatry protocols) and trial registries (e.g., ClinicalTrials.gov) were consulted to aid in bias judgments. Disagreements were resolved by discussion to consensus. Each study received an overall rating of \u0026ldquo;low risk,\u0026rdquo; \u0026ldquo;some concerns,\u0026rdquo; or \u0026ldquo;high risk.\u0026rdquo;\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec9\" class=\"Section2\"\u003e \u003ch2\u003eEligible studies\u003c/h2\u003e \u003cp\u003eFrom 1,760 records identified (1,740 database and 20 additional), 1,045 titles/abstracts were screened after de-duplication, after which 45 full texts were assessed, and five RCTs met inclusion criteria. Reasons for full-text exclusion: follow-up \u0026lt;\u0026thinsp;12 months post-treatment (n\u0026thinsp;=\u0026thinsp;24), non-randomised design (n\u0026thinsp;=\u0026thinsp;10), no depressive symptom severity measure (n\u0026thinsp;=\u0026thinsp;1), protocol paper (n\u0026thinsp;=\u0026thinsp;1), adolescent sample (n\u0026thinsp;=\u0026thinsp;1), MDD was not specified as an inclusion criterion (n\u0026thinsp;=\u0026thinsp;1), unavailable follow-up data (n\u0026thinsp;=\u0026thinsp;1), and analyses combining treatment arms at follow-up (n\u0026thinsp;=\u0026thinsp;1). Authors were contacted for missing data, and one study was excluded due to unavailable data and two did not respond (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe included studies (5 RCTs) consisted of a total of 624 participants randomised to interventions (315 PDP, 144 alternative treatment, 165 control conditions) (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). Majority of participants were female (68.02%). Mean age ranged from 33 (Huber et al., \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e2013\u003c/span\u003e) to 44 years (Fonagy, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e2015\u003c/span\u003e). Participants were recruited from clinical population (n\u0026thinsp;=\u0026thinsp;3), community (n\u0026thinsp;=\u0026thinsp;1), and clinical/community (n\u0026thinsp;=\u0026thinsp;1). All studies specified a MDD diagnosis, though differed in whether MDD was with/without dysthymia, unipolar MDD, recurrent MDD, and treatment-resistant MDD. Mean baseline BDI scores ranged from 25.30 to 36.60, suggesting moderate to severe depression, and mean baseline HAMD scores ranged from 20.10 to 23.89, indicating moderate depression. Number of psychodynamic psychotherapy sessions ranged from 12 (de Roten et al., \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e2017\u003c/span\u003e) to 88 (Huber et al., \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e2013\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eCharacteristics of included studies\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"11\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c9\" colnum=\"9\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c10\" colnum=\"10\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c11\" colnum=\"11\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eStudy\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMDD diagnosis\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eSample size; mean age (years), gender (% female)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eRecruitment method\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eTreatment conditions\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eTreatment concept\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003eNo. of psycho-therapy sessions\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c8\"\u003e \u003cp\u003eComparison\u003c/p\u003e \u003cp\u003econdition\u003c/p\u003e \u003cp\u003econcept\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c9\"\u003e \u003cp\u003eFollow-up\u003c/p\u003e \u003cp\u003elength PT\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c10\"\u003e \u003cp\u003eDepression outcome measures\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c11\"\u003e \u003cp\u003eDefinition of relapse\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDe Roten, 2017\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eUnipolar major depressive episode (DSM-IV); MADRS\u0026thinsp;\u0026gt;\u0026thinsp;18/semi-structured interview, DIGS\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e149 accepted randomisation, 105 assessed 12-months post-treatment, 43.2, 72.5% female\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eClinical (inpatients at UPH)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e(\u003cem\u003e1\u003c/em\u003e) IBPP\u0026thinsp;+\u0026thinsp;TAU (\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;76)\u003c/p\u003e \u003cp\u003e(\u003cem\u003e2\u003c/em\u003e) TAU (\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;73)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eManual of PD treatment of depression (Busch et al., 2004) and a manual on BPT (Despland et al., 2010)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e12 sessions; Mean sessions (8.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eTAU, clinical management, supportive interventions, and ADM, following practical guidelines for the treatment of MDD (APA, 2010)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e12-months\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eMADRS\u003c/p\u003e \u003cp\u003eQIDS-SR\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003eRemission defined as MADRS\u0026thinsp;\u0026le;\u0026thinsp;7 Remission defined as QIDS-SR\u0026thinsp;\u0026le;\u0026thinsp;5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFonagy, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e2015\u003c/span\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCurrent depressive episode with minimum duration of two years and two failed treatments, one being ADM (DSM-IV); BDI-II\u0026thinsp;\u0026ge;\u0026thinsp;21 and HDRS\u0026thinsp;\u0026ge;\u0026thinsp;14/SCID-I\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e129 randomised, 97 assessed at 1- and 2-year post-treatment, 44.4, 66.4% female\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eClinical and community (GPs refer a potential participant)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e(\u003cem\u003e1\u003c/em\u003e) LTPP\u0026thinsp;+\u0026thinsp;TAU (\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;67)\u003c/p\u003e \u003cp\u003e(\u003cem\u003e2\u003c/em\u003e) TAU (\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;62)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eIndividual PAT, manual (Taylor, 2015)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e60 sessions; Mean hours (41)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eTAU, including (e.g., ADM, self-help groups, psycho-therapeutic treatments) using NICE guidelines. LTPP not in guidelines.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e1-and 2-years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eHDRS-17 BDI-II\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003eRemission defined as HDRS\u0026thinsp;\u0026le;\u0026thinsp;8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHuber, 2013\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCurrent moderate/ severe depressive episode/ double depression characterised by MDD and dysthymia (ICD-10 or DSM-IV); BDI\u0026thinsp;\u0026ge;\u0026thinsp;16/ IDCL\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e78 randomised, \u003cb\u003e66 received allocated intervention\u003c/b\u003e, 63 assessed at 1-year post-treatment, 54 at 2-year, and 55 at 3-year; 33, 63.6% female\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eClinical (an outpatient clinic)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e(\u003cem\u003e1\u003c/em\u003e) PD (\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;35)\u003c/p\u003e \u003cp\u003e(\u003cem\u003e2\u003c/em\u003e) PA (\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;31)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eClassical (Freudian) and object-relational PA; treatments not formally manualised\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eMean sessions\u003c/p\u003e \u003cp\u003e(1) 88\u003c/p\u003e \u003cp\u003e(2) 234\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e1, 2, and 3-year\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eBDI\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003eRemission defined as a total score of \u0026lt;\u0026thinsp;10 on the BDI\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eKoppers, 2011\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMild or moderate MDD with/without dysthymia (DSM-IV); HRSD 12\u0026ndash;24/semi-structured interview (Huyser et al., 1996)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e208 randomised, 140 completed treatment, 52 completed 5-years post-treatment, 71.2% female\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eClinical (two outpatient clinics)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e(\u003cem\u003e1\u003c/em\u003e) Short supportive PDT (\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;27)\u003c/p\u003e \u003cp\u003e(\u003cem\u003e2\u003c/em\u003e) Short supportive PDT\u0026thinsp;+\u0026thinsp;ADM (\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;25)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eManualised PDT (De Jonghe, 2005)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e16 sessions\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e5 years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003eRecurrence of MDE (CIDI)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTown, 2020\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCurrent depressive episode duration of 6 weeks or more, met TRD criteria, non-remitting following at least one trial of antidepressants (DSM-IV); HAM-D)\u0026thinsp;\u0026ge;\u0026thinsp;16/SCID and M.I.N.I plus\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e60 randomised, 29 assessed at 12-months post-treatment, 41.55, 63.3% female\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eCommunity (an outpatient community mental health team)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e(\u003cem\u003e1\u003c/em\u003e) ISTDP\u003c/p\u003e \u003cp\u003e(\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;30)\u003c/p\u003e \u003cp\u003e(\u003cem\u003e2\u003c/em\u003e) CMHT TAU (\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;30)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eIndividual, manual and published recommendations (Abbas, 2015; Davanloo, 2000)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e20 sessions Mean sessions (16.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eSecondary care TAU, clinical management, ADM, according to clinical guidelines (Lam et al., 2009) and, for some, individual/group psychotherapy (not ISTDP)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e1-year\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eHAM-D PHQ-9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003eRemission defined as a HAM-D score of \u0026le;\u0026thinsp;7 Remission is scale sum of PHQ-9\u0026thinsp;\u0026le;\u0026thinsp;4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"11\"\u003eAbbreviations: ADM= Antidepressant medication, BDI= Beck Depression Inventory BPT= Brief psychodynamic therapy CIDI= Composite International diagnostic interview CMHT\u0026thinsp;=\u0026thinsp;Community mental health team DIGS= Diagnostic interview for genetic studies (Nurnberger et al., 1994), DSM= Diagnostic and Statistical Manual HAMD/HRSD= Hamilton Rating Scale for Depression GP= General Practitioners IBPP= Intensive brief psychodynamic psychotherapy ICD= International Classification of Diseases IDCL= International diagnostic checklist for ICD-10 and DSM-IV/5 ISTDP= Intensive Short-term Dynamic Psychotherapy LTPP= Long-term psychoanalytic psychotherapy MADRS= Montgomery-Asberg Depression Rating Scale MDD= Major depressive disorder MDE= Major depressive episode M.I.N.I= Mini-International Neuropsychiatric Interview NICE= National Institute for Health and Care Excellence PA= Psychoanalysis PAT= Psychoanalytic therapy PD= Psychodynamic PDT= Psychodynamic therapy PHQ-9\u0026thinsp;=\u0026thinsp;Patient Health Questionnaire therapy PT= post-treatment QIDS-SR= Quick inventory of depressive symptomology SCID= Structured clinical interview for DSM-III-R/DSM-IV/DSM TAU= Treatment as usual TRD= Treatment resistant depression UPH= University Psychiatric Hospital.\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eFour studies reported outcomes at follow-up intervals of 12-months post-treatment (Koppers et al., \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e2011\u003c/span\u003e; de Roten et al., \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e2017\u003c/span\u003e; Fonagy, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e2015\u003c/span\u003e; Town et al., \u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e2020\u003c/span\u003e) consisting of 416 participants at baseline and 294 participants (70.67%) having a 12-month follow-up. The studies eligible for the meta-analysis (3 RCTs; de Roten et al., \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e2017\u003c/span\u003e; Fonagy, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e2015\u003c/span\u003e; Town et al., \u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e2020\u003c/span\u003e) consisted of 338 participants, with 225 participants (75.74%) having a 12-month follow-up.\u003c/p\u003e \u003cp\u003eThree of the five studies compared psychodynamic psychotherapy with treatment as usual (de Roten et al., \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e2017\u003c/span\u003e; Fonagy, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e2015\u003c/span\u003e; Town et al., \u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e2020\u003c/span\u003e), of which the psychodynamic psychotherapy condition was adjunctive to usual inpatient treatment in two of the studies (de Roten et al., \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e2017\u003c/span\u003e; Fonagy, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e2015\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eConcurrent antidepressant medication in psychodynamic psychotherapy conditions was prominent in the three studies compared to one study, which had a wash-out period (Koppers et al., \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e2011\u003c/span\u003e) and one study stated in the selection criteria that concurrent treatment of antidepressants was excluded (Huber et al., \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e2013\u003c/span\u003e). Concurrent antidepressant use was high across the three trials where it was permitted alongside psychodynamic psychotherapy: 74.8% of participants were on antidepressants at baseline in de Roten et al. (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e2017\u003c/span\u003e) (71.4% in the IBPP arm, 81.4% in TAU); approximately 82% and 81% respectively in the LTPP and TAU arms before randomisation in Fonagy et al. (2015), rising to approximately 85% and 79% during the treatment period; and all 60 participants in Town et al. (\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e2020\u003c/span\u003e) had prior antidepressant exposure by study inclusion criteria, with 73.3% of the ISTDP group and 96.4% of the CMHT group still receiving antidepressants during the follow-up period.\u003c/p\u003e \u003cp\u003eDepressive symptom severity was measured by the self-rated scales, BDI, PHQ-9, and QIDS-SR, and clinician-rated scales, HAMD and MADRS. Remission status was based on HAMD (Fonagy, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e2015\u003c/span\u003e) and recurrence of an major depressive episode was based on Composite International Diagnostic Interview (Koppers et al., \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e2011\u003c/span\u003e).\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eNarrative Synthesis\u003c/h3\u003e\n\u003cp\u003eKoppers et al. (\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e2011\u003c/span\u003e) investigated recurrence, defined as the onset of a new depressive episode following full recovery, in a 5-year follow-up period following two treatment arms: short supportive psychodynamic psychotherapy (SSPDP) alone and adjunctive antidepressant medication to SSPDP. At follow-up, the sample size was 52 participants, with no significant difference between the treatment groups in recurrence rates (37% SSPDP, 44% SSPDP\u0026thinsp;+\u0026thinsp;ADM). Risk factors for recurrence included younger age (57% \u0026lt; 40 years vs. 21% of those\u0026thinsp;\u0026ge;\u0026thinsp;40 years; OR\u0026thinsp;=\u0026thinsp;0.87, \u003cem\u003ep\u003c/em\u003e \u0026lt; .001) and female gender (70% women\u0026thinsp;\u0026lt;\u0026thinsp;40 vs. 25% men\u0026thinsp;\u0026lt;\u0026thinsp;40; OR\u0026thinsp;=\u0026thinsp;1.05, \u003cem\u003ep\u003c/em\u003e = .049).\u003c/p\u003e \u003cp\u003eHuber et al. (\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e2013\u003c/span\u003e) investigated two psychodynamic psychotherapies: psychodynamic psychotherapy (n\u0026thinsp;=\u0026thinsp;88 sessions) and psychoanalysis (n\u0026thinsp;=\u0026thinsp;234 sessions). Depressive symptoms were measured by self-rated BDI at post-treatment and 12-, 24-, and 36-month follow-up. Both treatment groups showed large within-group improvements (d\u0026thinsp;\u0026gt;\u0026thinsp;2.0 at all time points), and between-group differences increased over time. At 12-month follow-up, the effect size for favoured psychoanalysis over PDP, showing a small effect (d\u0026thinsp;=\u0026thinsp;0.3), which remained stable at 24 months (d\u0026thinsp;=\u0026thinsp;0.3 (95% CI [-0.19, 0.79]) and increased at the 36-month follow-up (d\u0026thinsp;=\u0026thinsp;0.7), showing a moderate-to-large advantage for psychoanalysis. Relapse rates were also lower in the psychoanalysis treatment group (8.6%) compared to the psychodynamic group (22.6%) at 3-year follow-up.\u003c/p\u003e \u003cp\u003eThere was risk of bias across all studies: four studies assessed as having an overall high risk of bias (de Roten et al., \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e2017\u003c/span\u003e; Huber et al., \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e2013\u003c/span\u003e; Koppers et al., \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e2011\u003c/span\u003e; Town et al., \u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e2020\u003c/span\u003e) and one having some concerns of bias (Fonagy, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e2015\u003c/span\u003e) (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). Bias due to missing outcome data was judged as high in most studies, as the number of participants with missing outcome data was relatively high, which would be expected considering outcomes were assessed at longer-term follow-ups post-treatment. Across studies with self-rated measures, a judgement of \u0026lsquo;some concerns\u0026rsquo; was made for bias in the outcome measurement because outcome assessors (participants) were aware of the intervention they received. This was not the case for clinician-administered measures in which studies reported that outcome assessors were blinded (Supplementary Materials).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eRisk of Bias\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"11\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c9\" colnum=\"9\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c10\" colnum=\"10\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c11\" colnum=\"11\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eStudy\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eOutcome measures\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eROB arising from the randomisation process\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eROB due to deviations from the intended interventions\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eROB due to missing outcome data\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c8\" namest=\"c7\"\u003e \u003cp\u003eROB in measurement of the outcome\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c10\" namest=\"c9\"\u003e \u003cp\u003eROB in selection of the reported result\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c11\"\u003e \u003cp\u003eOverall ROB\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"3\" rowspan=\"4\"\u003e \u003cp\u003eDe Roten 2017\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003eSR Depression symptom severity\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eSome concerns\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eLow risk\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eHigh risk\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eSome concerns\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c9\" namest=\"c8\"\u003e \u003cp\u003eLow risk\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c11\" namest=\"c10\"\u003e \u003cp\u003eHigh risk\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003eCA Depression symptom severity\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eSome concerns\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eLow risk\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eHigh risk\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eLow risk\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c9\" namest=\"c8\"\u003e \u003cp\u003eLow risk\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c11\" namest=\"c10\"\u003e \u003cp\u003eHigh risk\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003eSR Remission/relapse rate\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eSome concerns\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eLow risk\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eHigh risk\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eSome concerns\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c9\" namest=\"c8\"\u003e \u003cp\u003eLow risk\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c11\" namest=\"c10\"\u003e \u003cp\u003eHigh risk\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003eCA Remission/relapse rate\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eSome concerns\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eLow risk\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eHigh risk\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eLow risk\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c9\" namest=\"c8\"\u003e \u003cp\u003eLow risk\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c11\" namest=\"c10\"\u003e \u003cp\u003eHigh risk\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003eFonagy \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e2015\u003c/span\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003eSR Depression symptom severity\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eSome concerns\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eLow risk\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eLow risk\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eSome concerns\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c9\" namest=\"c8\"\u003e \u003cp\u003eLow risk\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c11\" namest=\"c10\"\u003e \u003cp\u003eSome concerns\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003eCA Depression symptom severity\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eSome concerns\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eLow risk\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eLow risk\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eLow risk\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c9\" namest=\"c8\"\u003e \u003cp\u003eLow risk\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c11\" namest=\"c10\"\u003e \u003cp\u003eSome concerns\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003eCA Remission/relapse rate\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eSome concerns\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eSome concerns\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eLow risk\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eLow risk\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c9\" namest=\"c8\"\u003e \u003cp\u003eLow risk\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c11\" namest=\"c10\"\u003e \u003cp\u003eSome concerns\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eHuber 2013\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003eSR Depression symptom severity\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eSome concerns\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eHigh risk\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eHigh risk\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eSome concerns\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c9\" namest=\"c8\"\u003e \u003cp\u003eSome concerns\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c11\" namest=\"c10\"\u003e \u003cp\u003eHigh risk\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003eSR Remission/relapse rate\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eSome concerns\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eHigh risk\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eHigh risk\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eSome concerns\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c9\" namest=\"c8\"\u003e \u003cp\u003eSome concerns\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c11\" namest=\"c10\"\u003e \u003cp\u003eHigh risk\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eKoppers 2011\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003eCA Remission/Relapse rate\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eSome concerns\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eHigh risk\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eHigh risk\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eHigh risk\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c9\" namest=\"c8\"\u003e \u003cp\u003eSome concerns\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c11\" namest=\"c10\"\u003e \u003cp\u003eHigh risk\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"3\" rowspan=\"4\"\u003e \u003cp\u003eTown 2020\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003eSR Depression symptom severity\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eSome concerns\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eLow risk\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eHigh risk\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eSome concerns\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c9\" namest=\"c8\"\u003e \u003cp\u003eLow risk\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c11\" namest=\"c10\"\u003e \u003cp\u003eHigh risk\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003eCA Depression symptom severity\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eSome concerns\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eLow risk\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eHigh risk\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eLow risk\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c9\" namest=\"c8\"\u003e \u003cp\u003eLow risk\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c11\" namest=\"c10\"\u003e \u003cp\u003eHigh risk\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003eSR Remission/relapse rate\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eSome concerns\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eLow risk\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eHigh risk\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eSome concerns\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c9\" namest=\"c8\"\u003e \u003cp\u003eLow risk\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c11\" namest=\"c10\"\u003e \u003cp\u003eHigh risk\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003eCA Remission/relapse rate\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eSome concerns\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eLow risk\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eHigh risk\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eLow risk\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c9\" namest=\"c8\"\u003e \u003cp\u003eLow risk\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c11\" namest=\"c10\"\u003e \u003cp\u003eHigh risk\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"11\"\u003eSR: self-rated, CA: clinician-administered.\u003c/td\u003e\u003c/tr\u003e\u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eMeta-analysis\u003c/h2\u003e \u003cp\u003eFour RCTs were included in the pairwise meta-analysis, in which the treatment arms were a psychodynamic psychotherapy intervention and an alternative treatment or control condition. One RCT was excluded as the treatment arms were both forms of psychodynamic therapies: psychodynamic psychotherapy and psychoanalysis (Huber et al., \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e2013\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eFurther, in Fonagy (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e2015\u003c/span\u003e), at 24-months post-treatment, self-reported depressive symptoms (BDI) was lower in the psychodynamic psychotherapy group compared to the control group (d = -0.73 (95% CI [-1.09, -0.37])). Treatment effect was similar when depression symptom severity was measured at 24-months post-treatment based on clinician-rated HAMD (d = -0.68 (95% CI [-1.04, -0.33])), with both measures significantly in favour of psychodynamic psychotherapy.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003eSelf-Rated Depressive Symptoms\u003c/h2\u003e \u003cp\u003eSelf-rated depressive symptom scales (BDI, PHQ-9, QIDS-SR) were assessed in 3 RCTs at 12-months post-treatment (de Roten et al., \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e2017\u003c/span\u003e; Fonagy, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e2015\u003c/span\u003e; Town et al., \u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e2020\u003c/span\u003e). Total pooled sample was 338 MDD participants (treatment arms: 173 psychodynamic psychotherapy, 165 control). In intention to treat analysis, pooled effect size was \u0026minus;\u0026thinsp;0.32 (95% CI [-0.83, 0.19]) (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). Heterogeneity was low (Q\u0026thinsp;=\u0026thinsp;2.31, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.32, I\u003csup\u003e2\u003c/sup\u003e\u0026thinsp;=\u0026thinsp;0%). Sensitivity analysis of completers showed a pooled effect size of d = -0.29 (95% CI [-0.71, 0.12]) (Supplementary Materials).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003eClinician-Rated Depressive Symptoms\u003c/h2\u003e \u003cp\u003eClinician-rated depressive symptom scales ((HAMD, MADRS) were acquired in the 3 RCTs at 12-months post-treatment (de Roten et al., \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e2017\u003c/span\u003e; Fonagy, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e2015\u003c/span\u003e; Town et al., \u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e2020\u003c/span\u003e). In intention to treat analysis, there was a significant pooled effect size of -0.40 (95% CI [-0.72, -0.07]) (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). Heterogeneity was low (Q\u0026thinsp;=\u0026thinsp;0.94, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.63, I\u003csup\u003e2\u003c/sup\u003e\u0026thinsp;=\u0026thinsp;0%). Sensitivity analysis of completers showed a significant pooled effect size of -0.38 (95% CI -0.65, -0.12) (Supplementary Materials).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003eRemission Rates\u003c/h2\u003e \u003cp\u003eThree studies were pooled for proportion of relapses at the 12-month follow-up, showing an event rate of 0.78 (95% CI [0.68, 0.90]) (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e). Heterogeneity was low (\u003cem\u003eQ\u0026thinsp;=\u003c/em\u003e\u0026thinsp;0.44, \u003cem\u003ep=\u003c/em\u003e .80, \u003cem\u003eI\u003c/em\u003e\u003csup\u003e2\u003c/sup\u003e\u0026thinsp;=\u0026thinsp;0%). Number needed to treat (NNT) was 5.45, indicating the number required to be treated with psychodynamic psychotherapy in order to achieve one less relapse as compared to the control condition. Sensitivity analysis of all completers resulted in a moderately large treatment effect of 0.77 (95% CI [0.68, 0.88]) (Supplementary Materials).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eThe present systematic review and meta-analysis sought to evaluate the long-term outcomes of psychodynamic psychotherapy for major depressive disorder as measured by depressive symptom severity and rate of relapse at 12 months or longer after treatment. The meta-analysis revealed that psychodynamic psychotherapy was associated with significantly greater long-term improvements in depressive symptoms as compared to usual treatments as measured by blinded clinician-rated assessments. Moreover, psychodynamic psychotherapy was associated with a significantly reduced risk of relapse at 12 months compared with treatment as usual. However, self-rated depressive symptom outcomes were less consistent. The narrative synthesis further suggested that psychoanalysis may confer greater long-term benefits than psychodynamic psychotherapy.\u003c/p\u003e \u003cp\u003ePrevious meta-analyses which pooled post-treatment and short/medium follow-ups generally reported significant benefits of psychodynamic psychotherapy relative to control conditions (e.g., waitlist, care-as-usual) (Caselli et al., \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e2023\u003c/span\u003e; Driessen et al., \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e2010\u003c/span\u003e; Driessen et al., \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e2015\u003c/span\u003e). Effect sizes at post-treatment were typically larger (e.g., d\u0026thinsp;\u0026asymp;\u0026thinsp;0.61\u0026ndash;0.70). Meta-analyses of psychodynamic psychotherapy in common mental disorders have reported benefits as compared to treatment as usual (Abbass et al., \u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e2014\u003c/span\u003e; Leichsenring et al., \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e2004\u003c/span\u003e). At the 12-month long term follow up, we found that improvements in depressive symptoms were maintained as measured by clinician-rated depressive symptoms and rates of relapse.\u003c/p\u003e \u003cp\u003eHowever, Abbass et al. (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e2014\u003c/span\u003e) reported a non-significant effect at 9-month follow-up based on self-rated symptoms scales (d\u0026thinsp;=\u0026thinsp;\u0026minus;\u0026thinsp;1.00, 95% CI\u0026thinsp;\u0026minus;\u0026thinsp;2.22 to 0.21). While we had focused on a more homogeneous MDD sample and a\u0026thinsp;\u0026ge;\u0026thinsp;12-month follow-up, we similarly did not find a significant effect in self-rated depressive symptom scales. The divergence between clinician- and self-rated outcomes may reflect both methodological and clinical factors. Clinician-rated scales are typically conducted by blinded assessors, thus less susceptible to expectancy and reporting biases (Cuijpers et al., \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e2010\u003c/span\u003e; Miguel et al., \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e2025\u003c/span\u003e). Clinician-administered scales show a significantly higher effect size compared to self-rated scales, although the difference is reduced when the clinician is blinded to treatment allocation (Cuijpers et al., \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e2010\u003c/span\u003e; Miguel et al., \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e2025\u003c/span\u003e). In clinical factors, self-rated symptoms scales contain more items related to cognitive and affective experiences (e.g. pessimism, worthlessness, shame), while clinician-rated scales include more somatic and observable domains (e.g. sleep, appetite, psychomotor change) (Beck et al., \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e1996\u003c/span\u003e; Hamilton, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e1960\u003c/span\u003e). Somatic and observable domains may be more sensitive to treatment effects, while subjective experiences may persist and be readily reported by patients (Cuijpers et al., \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e2010\u003c/span\u003e; Miguel et al., \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e2025\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eIn relapse prevention, our pooled risk ratio at 12 months (RR\u0026thinsp;\u0026asymp;\u0026thinsp;0.78), implying about 22% relative risk reduction and an NNT of ~\u0026thinsp;5\u0026ndash;6, closely matches Steinert et al. (\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e2014\u003c/span\u003e), who estimated an odds ratio of 0.51 (\u0026asymp;\u0026thinsp;49% reduction) across psychotherapies over a mean 3.3 year follow-up, with an NNT of 5.55. However, heterogeneous modalities were pooled and did not include a specific psychodynamic psychotherapy subgroup analyses, leaving uncertainty about its unique contribution. Review of CBT from Chen et al. (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e2022\u003c/span\u003e) reported RR\u0026thinsp;\u0026asymp;\u0026thinsp;0.61 at 12 months (31.6% vs 41.3% relapse), but definitions varied (DSM vs ICD vs scale cut-offs), follow-ups spanned 6\u0026ndash;26 months, and multiple CBT formats (face-to-face, mindfulness-based cognitive therapy, internet-delivered) were pooled, with substantial heterogeneity (I\u0026sup2; = 55%), potentially inflating durability estimates. Our psychodynamic psychotherapy-focused estimate shows comparable improvements in relapse rates at one year.\u003c/p\u003e \u003cp\u003eLimitations include the number of trials as five RCTs met inclusion criteria, of which three contributed to the meta-analysis, substantially limiting statistical power and precluding subgroup or meta-regression analyses. Four of the five included studies were rated as having a high overall risk of bias, primarily due to missing outcome data at the 12-month follow up. Across the three trials that contributed to the pooled analyses (de Roten et al., \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e2017\u003c/span\u003e; Fonagy et al., 2015; Town et al., \u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e2020\u003c/span\u003e), approximately 255 of 338 randomised participants (75%) provided follow-up outcome data, representing an attrition rate of approximately 25%. The remaining two studies (Huber et al., \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e2013\u003c/span\u003e; Koppers et al., \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e2011\u003c/span\u003e) were not pooled and had different follow-up timepoints (3-year and 5-year, respectively), precluding a meaningful aggregate attrition estimate across all five trials. Concurrent antidepressant use was high across the three trials where it was permitted alongside psychodynamic psychotherapy, making it difficult to attribute long-term gains solely to the psychodynamic intervention rather than to a synergistic or additive pharmacological effect. The trials differed in treatment intensity, ranging from 12 to 88 sessions, which complicates interpretation of efficacy and limits the generalisability of findings across settings. While clinician ratings were masked, self-rated outcomes were unblinded and vulnerable to response bias. Moreover, MDD is a heterogeneous syndrome in which patterns of brain structure have been associated with different symptom profiles and clinical outcomes (Fu et al., \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e2024\u003c/span\u003e), which could potentially impact on psychotherapy treatment outcomes.\u003c/p\u003e \u003cp\u003eIn summary, the present systematic review and meta-analysis evaluated the long-term effects of psychodynamic psychotherapy in MDD. By focusing on adults with MDD and requiring follow-up of at least 12 months post-treatment, we were able to examine the durability of therapeutic gains beyond short- and medium-term outcomes. A key methodological strength was the separation of clinician-rated from self-rated symptom scales, revealing that benefits were most consistent on blinded clinical assessments, while self-reports were less reliable in detecting sustained change. Psychodynamic psychotherapy was associated with improved rates of relapse at 12 months, with an estimated number needed to treat of 5\u0026ndash;6. The present findings demonstrate that psychodynamic psychotherapy offers sustained symptom improvement and relapse prevention in MDD, supporting its role within stepped-care models and long-term clinical care planning.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eAbbass AA, Kisely SR, Town JM, Leichsenring F, Driessen E, De Maat S, Gerber A, Dekker J, Rabung S, Rusalovska S (2014) Short-term psychodynamic psychotherapies for common mental disorders. \u003cem\u003eCochrane database of systematic reviews\u003c/em\u003e (7)\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAbu-Ashour W, Delaney S, Farrell A, Gamble J-M, Hawboldt J, Sale JE (2025) Incidence of Major Depressive Disorder Relapse and Effectiveness of Pharmacologic and Psychological Interventions in Primary Care: A Systematic Review and Meta-Analysis: Incidence de la rechute du trouble depressif majeur et efficacite des interventions pharmacologiques et psychologiques en soins primaires: revue systematique et meta-analyse. 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Lancet Psychiatry 3(2):137\u0026ndash;144\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWorld Health Organization (2023) \u003cem\u003eDepressive disorder (depression)\u003c/em\u003e. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.who.int/news-room/fact-sheets/detail/depression\u003c/span\u003e\u003cspan address=\"https://www.who.int/news-room/fact-sheets/detail/depression\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eZhou Y, Zhao D, Zhu X, Liu L, Meng M, Shao X, Zhu X, Xiang J, He J, Zhao Y (2023) Psychological interventions for the prevention of depression relapse: systematic review and network meta-analysis. Translational Psychiatry 13(1):300\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[{"identity":"32eabed1-0730-4867-a6a1-d00c07b27d71","identifier":"10.13039/100010827","name":"International Psychoanalytical Association","awardNumber":"158102845","order_by":0}],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":true,"highlight":"","institution":"King's College London","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"major depressive disorder, depression, psychotherapy, psychodynamic, long term, outcome","lastPublishedDoi":"10.21203/rs.3.rs-9260871/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-9260871/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eObjective\u003c/strong\u003e: Major depressive disorder (MDD) is characterised by recurrent episodes, making sustained treatment benefits a clinical priority. We evaluated the long-term outcomes of psychodynamic psychotherapy (PDP) for MDD.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods\u003c/strong\u003e: A systematic review of randomised controlled trials (RCTs) was conducted in adults with MDD comparing PDP with treatment-as-usual (TAU) or other active treatments, with long-term follow-up at least 12 months after treatment completion. Outcomes included clinician-rated and self-rated depressive symptom severity and relapse rates. Random-effects pairwise meta-analyses were performed at 12 months used standardized mean differences (SMD) for symptom severity and risk ratios (RR) for relapse. Intention-to-treat analyses were primary, with completer analyses as sensitivity checks. Studies not eligible for pooling were synthesised narratively\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults\u003c/strong\u003e: Five RCTs (n = 624 randomised) met inclusion criteria, of which three RCTs (n = 338) contributed to the meta-analysis. Follow-up data at 12 months was available for 255 of 338 (75.44%) randomised participants. PDP was associated with greater improvement in clinician-rated depressive symptoms compared with TAU (SMD = −0.40, 95% CI [−0.72, −0.07]), but not self-rated symptoms (SMD = −0.32, 95% CI [−0.83, 0.19]). PDP was associated with a reduced risk of relapse at 12 months (RR = 0.78, 95% CI [0.68, 0.90]), corresponding with an number needed to treat of approximately \u0026nbsp;5-6.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eLimitations\u003c/strong\u003e: The meta-analysis is based on a small number of RCTs with an attrition rate of approximately 25%. Concurrent antidepressant medication was high, making it difficult to attribute long term gains solely to the psychodynamic intervention. The number of treatment sessions varied across trials (12–88 sessions), which limits comparability between trials.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion\u003c/strong\u003e: Psychodynamic psychotherapy is associated with long-term benefits in MDD, \u0026nbsp;particularly in clinician-rated outcomes and relapse prevention at 12 months, though effects on self-rated symptoms were less consistent. The discrepancy between clinician-rated and self-rated outcomes highlights the complexity of capturing internal change. Improvements in observable symptoms and functioning are more readily detected, whereas changes in internal experiences may be more slowly developing and less well captured by symptom-based self-report measures.\u003c/p\u003e","manuscriptTitle":"Long-term treatment outcomes of psychodynamic psychotherapy for major depressive disorder: a systematic review and meta-analysis","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-04-01 07:07:33","doi":"10.21203/rs.3.rs-9260871/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"58317b81-88e7-493f-9a0a-7b5ac50af3f1","owner":[],"postedDate":"April 1st, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[{"id":65346624,"name":"Psychiatry"}],"tags":[],"updatedAt":"2026-04-01T07:07:34+00:00","versionOfRecord":[],"versionCreatedAt":"2026-04-01 07:07:33","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-9260871","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-9260871","identity":"rs-9260871","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}