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Key Words ing brain metabolism predicted both clinical course and
Psychotherapy · Depression · Positron relevant psychotherapeutic process during short-term
emission tomography psy-chodynamic psychotherapy for depression.
© 2014 S. Karger AG, Basel
Abstract
Background: Psychodynamic psychotherapy has been used Introduction
to treat depression for more than a century. However, not all
patients respond equally well, and there are few reliable pre- A cornerstone of treatment for major depressive dis-
18 order, psychodynamic psychotherapy has been continu-
dictors of treatment outcome. Methods: We used resting F-
18 ously practiced since the late 19th century. An outgrowth
fluorodeoxyglucose positron emission tomography ( FDG-
of Freudian analysis, modern psychodynamic psycho-
PET) scans immediately before and after a structured, open
therapy focuses on how past experience, including sig-
trial of brief psychodynamic psychotherapy (n = 16) in
conjunction with therapy process ratings and clinical out-come
nificant relationships, influences character and current
measures to identify neural correlates of treatment re-sponse.
relational styles. Psychodynamic treatment can generate
Results: Pretreatment glucose metabolism within the right insights that change affect and behavior. Meta-analyses of
posterior insula correlated with depression severi-ty. both long- and short-term psychodynamic therapies in-
Reductions in depression scores correlated with a pre- to dicate their overall effectiveness for depression and re-
posttreatment reduction in right insular metabolism, which in lated psychiatric disorders [1, 2]. However, as with other
turn correlated with higher objective measures of patient
insight obtained from videotaped therapy sessions. Pre-
treatment metabolism in the right precuneus was signifi-cantly K.C.E. and M.F. contributed equally to this paper. This study
higher in patients who completed treatment and cor-related was pre-sented in part at the Society for Biological Psychiatry
with psychological mindedness. Conclusions: Rest- Annual Meeting, San Francisco, Calif., 2013.
treatments for depression, discontinuation rates for psy- Psychotherapy Treatment and Process Measurement
chodynamic psychotherapy are high, and reasons for Please refer to online supplementary material Supplemental Methods
(for all online suppl. material, see www.karger.com/
ear-ly termination are difficult to predict [3, 4]. doi/10.1159/000364906) for a detailed description of the psycho-therapy
Although understudied relative to other interventions intervention and process measurement. Briefly, all partici-pants received
[5], psychodynamically oriented therapies have been pre- 16 sessions of weekly, individual psychotherapy using the Core
liminarily associated with synaptic and metabolic changes Conflictual Relationship Theme (CCRT) manual [7], ad-ministered by 1
in limbic, midbrain, and prefrontal regions [6]. However, of 4 trained study therapists. The CCRT approach is based on the
supportive-expressive model of psychodynamic psy-chotherapy.
heterogeneity of treatment (even within-study) and lack of
Treatment focused on eliciting ‘relationship episodes’ characteristic of a
discrimination between responders and nonresponders problematic, recurring interpersonal pattern (weeks 1–4); achieving
limit previous studies in the field. The present investiga- insight by working through the patient’s his-tory and his/her interactions
tion used resting 18F-fluorodeoxyglucose positron emis- with the therapist (weeks 5–12), and consolidating gains (weeks 13–16).
Participants were maintained on stable, adequate doses of antidepressant
sion tomography (18FDG-PET) to study individuals with medication. Each session was videotaped, and 2 sessions per patient
incompletely treated major depressive disorder before and were rated for psycho-therapy process using the Psychotherapy Process
after a 16-week trial of adjunctive psychodynamic Q-Set (PQS) [8].
psychotherapy. We deployed a manualized treatment and Clinical Measures
obtained measurements of psychotherapy process by rat- Patients were evaluated using the Hamilton Depression Rat-
ing videotaped sessions using a validated metric. These ing Scale (HamD-17) [9] at the pretreatment visit, after therapy
methods ensured that treatment was standardized and re- sessions 1, 2, 4, 10, and 16, and at a 3-month follow-up visit. At
producible and provided the opportunity to explore neu-ral pretreatment, patients also completed the Psychological Mind-
correlates of the psychotherapy process. We also com- edness Scale [10], which measures capacity for self-examination
pared pretreatment scans between individuals who com- and personal insight. Immediately following therapy sessions at
weeks 2, 4, 6, 8, 10, 12, 14, and 16, the patient and therapist
pleted versus discontinued treatment and evaluated inde-pendently completed the Working Alliance Inventory-Short
ongoing therapeutic alliance and depression scores to ex- Ver-sion, Revised [11], which assesses agreement on the tasks
plore predictive markers of treatment outcome. and goals of therapy and development of an affective bond.
PET Scans
Please refer to online supplementary material Supplemental
Materials and Methods Methods for a detailed description of PET image acquisition, pre-
18
processing, and analysis. Briefly, resting FDG scans (Siemens
Patients HR+) were acquired prior to the first therapy session and again
Study procedures were Institutional Review Board approved within 7 days of completing treatment. Following image process-ing,
and participants provided written informed consent. All proce- voxel-wise tests identified clusters where pretreatment region-al
dures took place at a single academic medical center in Boston, cerebral metabolic rate of glucose uptake (rCMRglu) co-varied
Mass. Inclusion and exclusion criteria are summarized in table 1. significantly with depression severity (HamD-17). Follow-up tests
Patients were paid for their participation in the imaging part of determined whether metabolic changes after treatment correlated
the study. with change in HamD-17, as well as with specific PQS measures.
item 32, ‘Patient achieves a new understanding or in- right precuneus, rCMRglu was positively correlated with the
sight’ (ρ = –0.92; p = 0.0004; online suppl. fig. S2B). Psychological Mindedness Scale score (fig. 1c). The in-verse
Pa-tients with greater reductions in insular metabolism contrast of noncompleters versus completers failed to identify
were given higher insight ratings. significant differences in pretreatment rCMRglu.
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