Psychotherapy 2014, Vol. 51, No. 1, 138 –147

© 2013 American Psychological Association 0033-3204/14/$12.00 DOI: 10.1037/a0034178

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Psychoanalytic Psychotherapy for Children and Adolescents With Severe Depressive Psychopathology: Preliminary Results of an Effectiveness Trial Katharina Weitkamp

Judith K. Daniels

University Medical Centre Hamburg-Eppendorf

Universitätsmedizin Charité Berlin

Helmut Hofmann and Helene Timmermann

Georg Romer and Silke Wiegand-Grefe

Hamburg, Germany

University Medical Centre Hamburg-Eppendorf

This waitlist-controlled field study aimed to evaluate the effectiveness of psychoanalytic short- and long-term psychotherapy for children and adolescents by using a prospective design. The presented analyses focus on the self- and parent-reported levels of depression and the therapists’ ratings of the patients’ level of functioning. Thirty-five children and adolescents (aged 4 –21 years) and their parents who entered psychoanalytic therapy in private practices in northern Germany participated in this ongoing study. At the time of data analysis, the wait-list control group comprised 17 patients. Data were collected from therapists, parents, and from the patients themselves. Questionnaires were administered at the beginning and the end of treatment, as well as up to 5 points in time during therapy. Follow-up took place at 6 and 12 months after therapy. Depression levels were measured with the self- and parent-reported screening questionnaire Child Depression Inventory, and quality of life with the KIDSCREEN. Patients received, on average, 97 sessions of therapy (range: 25–205). Overall, patients showed pronounced impairments at the commencement of outpatient therapy. At the end of therapy, there was a significant reduction in depression in the treatment group (parent report: d ⫽ 0.88, p ⬍ .001; patient report d ⫽ 0.68, p ⱕ .003). The wait-list control group, which received minimal treatment, displayed a slight, but not statistically significant, symptom improvement in the patient report (d ⫽ 0.07, p ⱕ .503), but a significant improvement in the parent report (d ⫽ 0.49, p ⱕ .008). The results suggest that psychoanalytic therapy is successful in alleviating depressive pathology and improving quality of life for a significant number of depressed children and adolescents. Keywords: psychoanalytic psychotherapy, adolescents, children, depression, effectiveness

above the cutoff on the Center for Epidemiological Studies Depression Scale for Children as well as a high impact score on the Strengths and Difficulties Questionnaire (point prevalence; Bettge et al., 2008). A recent international review found an average prevalence rate of 4.4% for depressive disorders in children and adolescents following 10th revision of the International Statistical Classification of Diseases and Related Health Problems or Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, criteria (ranging from 1.1% to 18.0%, 3- to 12-month prevalence; Ihle & Esser, 2002). This is alarming not only in view of the distress and burden for the children and families but also in view of the levels of high comorbidity and the negative effect on functioning and day-to-day lives of children and adolescents (Bettge et al., 2008). Moreover, ⬍50% of a sample suffering from a severe depressive episode received any kind of treatment for their disorder by the age of 18 (Kessler, Avenevoli, & Merikangas, 2001). Comparable rates have been reported in the German Bella study, in which the parents of only 38% of the depressed children and adolescents saw a need for treatment or initiated a health service contact for their child (Ravens-Sieberer et al., 2008). German health insurance companies reimburse the costs for psychotherapy treatment from three different approaches: cognitive behavior, psychoanalytic, or depth-oriented therapy. In Germany, 48.7% of the child and adolescent psychotherapists have a

Depressive symptoms are widely prevalent in children and adolescents. In a representative sample, 10% to 15% of 7- to 17-year-old children and adolescents reported clinically significant levels of depressive pathology, defined as a combination of scores

This article was published Online First December 30, 2013. Katharina Weitkamp, Department of Child and Adolescent Psychiatry, Psychotherapy, and Psychosomatics, University Medical Centre HamburgEppendorf, Hamburg, Germany; Judith K. Daniels, Department of Psychiatry, Universitätsmedizin Charité Berlin, Berlin, Germany; Helmut Hofmann and Helene Timmermann, Hamburg, Germany; and Georg Romer and Silke Wiegand-Grefe, Department of Child and Adolescent Psychiatry, Psychotherapy, and Psychosomatics, University Medical Centre Hamburg-Eppendorf. Georg Romer is now at Department of Child and Adolescent Psychiatry, Psychosomatics and Psychotherapy, University Hospital Münster, Münster, Germany. The Vereinigung analytischer Kinder- und Jugendlichen-Psychotherapeuten (VaKJP) funded the study but had no influence on either study design or administration. The authors thank the patients, their families, and the therapists for their contribution to this study. Correspondence concerning this article should be addressed to Katharina Weitkamp, Klinik für Kinder- und Jugendpsychiatrie, -Psychotherapie und—Psychosomatik, Universitätsklinikum Hamburg-Eppendorf, Martinistrasse 52, 20246 Hamburg, Germany. E-mail: [email protected] 138

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PSYCHOANALYTIC PSYCHOTHERAPY FOR DEPRESSIVE CHILDREN

psychoanalytic training background (Bundesregister der Kassenärztlichen Bundesvereinigung, 2011). Although psychoanalytic psychotherapy is a prevalent treatment method, it has not been sufficiently evaluated yet. A number of studies have been carried out, but they varied in study quality, with many limitations due to the retrospective nature of some studies, the lack of control groups, or small sample sizes (Midgley & Kennedy, 2011). In a recent overview of meta-analyses and reviews on child and adolescent psychotherapy, small to medium effect sizes were established for the treatment of depressive disorders with either cognitivebehavior therapy (CBT) or interpersonal therapy (Bachmann, Bachmann, Rief, & Mattejat, 2008). A first methodologically sound study on the efficacy of psychoanalytic therapy for youth patients with depression compared 25 sessions of psychoanalytic psychotherapy with a wait-list control group (Horn et al., 2005). The primary outcome criterion was a global impairment scale (Impairment Severity Scale for Children and Adolescents; Fahrig, Kronmüller, Hartmann, & Rudolf, 1996; Stefini et al., 2008). Impairment was significantly reduced with a large effect size of d ⫽ 1.33. Twenty percent of the patients in the intervention group showed a clinically significant change, compared with no patient in the wait-list control group. Although helpful for some of the depressed patients, the authors concluded that a number of their patients needed longer or more intense treatment. Another randomized controlled trial compared focused psychoanalytic psychotherapy and systems integrative family therapy for childhood depression in 9- to 15-year-olds (Trowell et al., 2007). The psychoanalytic psychotherapy group received 16 to 30 sessions (M ⫽ 24.7) plus parent sessions over a 9-month period. At the end of the treatment, 74.3% of patients in the psychoanalytic psychotherapy group were no longer clinically depressed. Six months after treatment had ended, 100% of cases were no longer clinically depressed (compared with 75.7% at the end of therapy and 81% at 6-month follow-up in the systemic family therapy group). This study provided evidence for the efficacy of focused short-term psychoanalytic treatment under controlled conditions. The aim of the current study is to further our understanding of the evidence base for psychoanalytic treatments of child and adolescent depression. There is an increasing interest as to what extent the efficacy of psychotherapy may be translated into clinical effectiveness in routine practice, which can be addressed by a naturalistic study design such as this one. Hence, previous results from controlled trials by Horn et al. (2005) and Trowell et al. (2007) will be replicated and findings will be extended to the naturalistic setting with the effectiveness trial presented here. First, in contrast to the Horn et al. (2005) and Trowell et al. (2007) studies, the current study has been designed as a naturalistic study with naturally occurring therapy duration, as psychoanalytic therapy in Germany is usually longer in duration, with a maximum of 180 sessions for adolescents and 150 sessions for children reimbursed by the German health insurance companies. Second, the primary outcome criterion should be disorderspecific, as required by the German research advisory board of psychotherapy, which sets the standards for evidence-based psychotherapy research in Germany (Wissenschaftlicher Beirat Psychotherapie, 2007). In this case, it follows that a depression scale is used as the primary outcome measure filled out by both

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patients and parents. Third, the naturalistic design also entails a broader age range than the Trowell study.

Method Procedure The study was approved by the ethics committee of the University Medical Centre Eppendorf. The study was designed as a partly controlled, multiperspective effectiveness study in a naturalistic setting: while the first 25 sessions were controlled by a wait-list design, the evaluation of the long-term treatment was implemented as a time-series study. The therapists were contacted via the therapist association Vereinigung analytischer Kinder- und Jugendlichenpsychotherapie and they agreed to participate. They received financial compensation of 30€ per completed documentation of an intervention patient and 20€ per wait-list patient for their time and effort. The 26 participating therapists (21 female, 81%) all had a university degree (social pedagogy, education science, or psychology) and had certified degrees in psychoanalytical child and adolescent psychotherapy from the Michael-Balint-Institut in Hamburg, Germany, or another comparable board-certified institution. The therapists had, on average, 12 years (SD ⫽ 6.15) of work experience. All therapists received supervision as needed and met in so-called intervision groups on a monthly basis. Intervision groups are supervision groups consisting of small groups of therapists who supervise each other on a peer level. All patients received individual psychoanalytic psychotherapy, which was predominantly child-focused, complemented by parent sessions usually in a ratio of 4:1. The interventions were based on the observations of Anna Freud (1949/1980, 1965/1980) and the theory of object-relations as set out by Winnicott (1958/1988). Specific to the treatment of youth depression is the necessary balance between nurturing interventions supporting regression and a more confronting and active work concerning the subconscious conflict. The therapist takes on the role of a reliable object (Winnicott, 1958/1988), which creates a safe space for negative emotions and impulses to be “contained” within the therapeutic relationship (Bion, 1963). This means, for instance, that the therapist will not reply to the (verbal) aggression of the patient with a similar aggressive attack. The therapist will try to understand the patients’ reaction and then communicate his interpretation of the situation in a way that is acceptable to the patient. This allows the patient to have the correcting experience that neither the therapist nor the therapeutic relationship is threatened by his or her negative, aggressive feelings or impulses. As an example, a therapist might reply with a soft word to a “fatal” attack by a boy who experienced a humiliating situation at school earlier that day, “It has been a terrible day for you at school. You get really angry and it felt like you were being destroyed.” Another fundamental goal in the treatment of neurotic depression is the mitigation of a perfectionist, punishing superego. In the process, relieving and conciliatory interventions and interpretations are offered to the patient to attenuate the self-devaluation and the powerful defenses against aggressive impulses (Adler-Corman et al., 2013). A therapist might witness the patient being overcritical of herself/himself and may comment to the patient, “Oh, this looks like you are very strict with yourself.” If the depression appears to be based on early and

WEITKAMP ET AL.

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repeated traumatization, the therapeutic work focuses rather on early dissociative mechanisms, projective identifications, and the internalization of archaic object representations. The therapeutic work with parents of depressed children often focuses on unresolved experiences of loss, separation, or trauma. In the wait-list control group, 83% of the patients received a limited number of bridging sessions by the therapist to stabilize and support the patient and the family during the waiting period. These sessions focused on current problems rather than on underlying conflicts. Accordingly, the therapists were more engaging, encouraging, and supportive in this phase than during the actual therapy phase. As the goal of the study was to evaluate psychoanalytic psychotherapies as they are delivered in a naturalistic setting, no therapy manual was imposed on the therapists, but four of the therapists wrote a field manual mirroring their work with the children and adolescents (Baumeister-Duru, Hofmann, Timmermann, & Wulf, in press). Adherence to this code of practice was checked with a retrospective treatment fidelity checklist (Weitkamp et al., 2011) filled out by the therapists at the end of treatment for each patient. The participants were not recruited actively but presented themselves at the participating private practices during the study interval. Exclusion criteria were child’s age ⬍4 or ⬎21 years, having acute suicidal tendencies or current psychotic presentation based on the clinical judgment of the ther-

apists, or insufficient command of the German language. At the beginning of outpatient therapy, both patients and parents were asked to participate in this study by the therapist. Families then received a letter informing them of the study and the intended use of the collected data and they signed an informed consent. The families received questionnaires and instructions via mail. A prepaid self-addressed envelope was included to facilitate participants’ cooperation. Families who failed to return the questionnaires received two reminder letters after 2 and 4 weeks with backup questionnaires attached (see also flowchart in Figure 1). Assessments took place at the beginning and end of each individual therapy. Additional assessments were carried out after 50, 70, 120, and 150 sessions for children and after 50, 90, 140, and 180 sessions for adolescents. Follow-up assessments were carried out 6 and 12 months after the end of therapy. At each time point, the patient, the parents, and the therapists were asked by post to evaluate the patient’s functioning and the therapy process using standardized questionnaires. To establish the patient diagnoses at the beginning of treatment and 1 year after the end of treatment, patients aged 11 years and older and parents were invited to the research location and interviewed by a trained psychologist using the Kiddie Schedule for Affective Disorders and Schizophrenia– Present Episode (K-SADS-P; Chambers et al., 1985; Delmo, Weiffenbach, Gabriel, Stadler, & Poustka, 2001). Patients came to the research location and received a refund for their travel expenses.

Registered patients Sept. 2007 till June 2010: 393

♦ Refused to participate: 103 ♦ Other/unknown reasons: 56

Excluded (n=26) ♦ Did not meet inclusion criteria: 11 ♦ Impairment too severe: 15

Informed consent: 208 *plus 29; continued wait-list inclusion 07/10 till 10/12 ♦ Did not start treatment: 6

Baseline assessment: 231

Intervention group: 154 Depressive patients: 50

Post assessment: Attended: 32 In ongoing treatment: 3 ♦ Lost to post assessment: 15

♦ ♦

Both wait-list and study participants: 23 Depressive patients: 3

♦ ♦

Post assessment: Attended: 3 Lost to post assessment: 0

Wait-list control group: 54 Depressive patients: 21

♦ ♦

Figure 1. Flowchart of the total sample.

Post assessment: Attended: 14 Lost to post assessment: 7

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PSYCHOANALYTIC PSYCHOTHERAPY FOR DEPRESSIVE CHILDREN

Measures were collected at the same time but independently by therapists and patients. Between September 2007 and June 2010, 393 families with a child or adolescent aged between 4 and 21 years and diagnosed with a psychiatric disorder enrolled in psychotherapeutic treatment and were approached for participation. Recruitment of intervention patients ended in June 2010. The wait-list control group was formed by quasi-randomization, depending on the therapist’s availability. Thus, naturally occurring waiting periods were used. The wait-list interval was 3 months long. As naturally occurring waiting times were rather rare during the recruitment phase, inclusion of wait-list patients was extended, and wait-list controls are still being enrolled in the study. Between July 2010 and October 2012, a further 29 wait-list controls were included in the study. Thus, 54 wait-list patients, 123 intervention patients, and 23 patients, who were both in the wait-list and in the intervention arm of the study, form the complete sample of the effectiveness trial (see flow diagram in Figure 1). For nonparticipants, therapists filled out a completely anonymous sheet with basic data to enable comparison of this group with participants. Study participants and nonparticipants did not differ significantly on relevant characteristics, such as age, gender, type of psychiatric disorder, global level of impairment, or therapistrated family functioning. Of the 175 nonparticipants, 8 families met exclusion criteria (acute psychosis, suicidal, language problems), 26 patients were regarded as too severely impaired or were not asked for participation for other reasons, and 141 families refused to participate.

Participants For the current analyses, only those children and adolescents (aged 4 –21 years) were selected who showed clinical levels of depressive pathology rated either by the parents or the adolescent on the Child Depression Inventory (CDI cutoff ⱖ18; StiensmeierPelster, 2011). According to this definition, of the total sample of 177 patients, 53 intervention patients were identified as suffering from severe depressive symptoms. In terms of parent and child agreement on the severity of the depressive pathology, 28% of the cases were rated above the cutoff by both the patient and their parent, 40% were considered to be above the cutoff only from the parent’s perspective, and 32% were considered to be above the cutoff only from the patient’s perspective. In the wait-list control group, 24% of the cases were rated above the cutoff by both the patient and their parent, 57% were considered to be above the cutoff only from the parent’s perspective, and 19% were considered to be above the cutoff only from the patient’s perspective. Bivariate correlation between parent and child ratings was r ⫽ .29, p ⱕ .088. The remaining patients suffered from anxiety, externalizing disorder, or other disorders, and their data will be published elsewhere. For the current analyses, the patient sample of the completer group consisted of 35 children and adolescents (66% of the total number who were identified as suffering from severe depressive symptoms). Up to now, three patients are still in treatment (6%). Six patients (11%) discontinued their treatment. Another eight patients (15%) terminated their participation in the study, although they continued their treatment; one patient was excluded from analysis due to too many missing values (2%). Regarding the 35

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intervention patients, data were collected from 25 parents and 21 patients themselves. Thus, data from both perspectives were available for a subsample of 12 (34%) intervention patients. For the other 23 patients (66%), data was available from either the parent or the patient. Consequently, results of the different perspectives overlap to a certain degree but not completely. In the wait-list control group, 17 of the 21 families (81%) completed the questionnaires at both measurement points. For those 17 wait-list patients, data from 13 patients and 15 parents could be collected. Data from both perspectives were thus available only for a subsample of 11 (65%) wait-list patients. Wait-list group and intervention group did not differ significantly (between p ⱖ .137 and p ⱖ .696) on any of the reported descriptives. All participants were diagnosed with a mental disorder. Diagnosis was established either by K-SADS interview conducted by a trained psychologist or by therapist diagnosis. The wait-list group was only diagnosed by the attending therapists. For better comparability of both groups, therapist diagnoses are listed in Table 1. Eight of the 35 intervention families (23%) did not agree to participate in the diagnostic interview because of inability to schedule an interview after repeated attempts. These families reported that such an additional meeting was too much effort or they gave other personal reasons for not attending. However, therapist diagnoses were available for all patients. K-SADS diagnoses for the available patients of the intervention group were as follows: of the 27 (77%) patients in the intervention group who participated in the diagnostic interview, 11 patients had an affective disorder (41%). A further 11 children and adolescents suffered from an anxiety disorder (41%), 12 from a posttraumatic stress disorder (44%), and 10 from a disruptive disorder (37%). Four patients suffered from other disorders (15%), such as eating disorders, enuresis, encopresis, or tics. Nineteen participants were diagnosed with more than one disorder (70% comorbidity). Consequently, the majority of the sample scoring above the cutoff on the CDI from parent or patient report was not formally diagnosed with an affective disorder by an independent clinician.

Instruments The instruments for the current analyses were taken from a broader assessment battery, which was compiled for the evaluation

Table 1 General Characteristics of the Sample Characteristic

Wait-list control (n ⫽ 17)

Therapy (n ⫽ 35)

Age Gender (female) Parents living apart Functioning (CGAS) Affective disorder (K-SADS diagnosis) Affective disorder (therapist diagnosis) Comorbidity (ⱖ2 diagnoses) Patient report available Parent report available Both patient and parent report available

12.88 (3.08) 53% 36% 52.33 (10.73) — 31% 88% 76% 88% 65%

13.46 (3.80) 77% 53% 54.67 (10.20) 37% 30% 76% 60% 74% 34%

Note.

CGAS ⫽ Child Global Assessment Scale.

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WEITKAMP ET AL.

study (Wiegand-Grefe, Weitkamp, Timmermann, & Romer, 2011). The findings of those instruments are reported here. Depression. The Child Depression Inventory (CDI; Kovacs, 1992; German version: Stiensmeier-Pelster, Schürmann, & Duda, 2000) is a screening instrument that consists of 26 items comprising a variety of depressive symptoms and concomitants in childhood and adolescence. The self-report version is validated for children and adolescents aged 8 to 17 years. The German parent report form was developed parallel to the self-report version (Weitkamp, Romer, Rosenthal, Wiegand-Grefe, & Daniels, 2012). Each item has three response options, which range from 0 ⫽ symptom not present to 2 ⫽ symptom is very much present. The items are summed up to a total score (0 –52), with higher values representing a higher number and more severe depressive symptoms. For the German version, the suggested cutoff is ⱖ18 (Stiensmeier-Pelster et al., 2000). The German version has shown good reliability (Cronbach’s alpha ⫽ .83; Stiensmeier-Pelster et al., 2000) and sufficient inter-rater agreement between parents and children (mother– child: r ⫽ .54ⴱⴱ, father– child: r ⫽ .62ⴱⴱ; Weitkamp et al., 2012). In the current sample, reliability was high with ␣ ⫽ .88 for the parent version and ␣ ⫽ .87 for the self-report version. Health-related quality of life. The German KIDSCREEN-27 was used to assess health-related quality of life (QoL) (The KIDSCREEN Group Europe, 2006). This instrument consists of 27 items and was developed to measure the following five dimensions of QoL in children and adolescents: physical well-being, psychological well-being, autonomy and parent relation, social support and peers, and school environment. Parallel parent and child self-rating versions are available. Each item is scored on a 5-point Likert scale, with high values representing a high QoL. The items of the KIDSCREEN fulfill the assumptions of the Rasch model and can be translated into T-values (The KIDSCREEN Group Europe, 2006). T values ⬎45 define the normative range of QoL. Reliability has been shown to be good (Cronbach’s alpha: ␣ ⫽ .78 to ␣ ⫽ .83), and agreement between youth and parent proxy report was satisfactory. Intraclass correlations (ICC) were between .44 and .61 in parent– child dyads (The KIDSCREEN Group Europe, 2006), and ICC for father– child dyad and mother– child dyad were .61 and .67, respectively (Weitkamp, Daniels, Rosenthal, Romer, & Wiegand-Grefe, 2013). Psychiatric diagnosis. It was established in a twofold way. First, the K-SADS-P (Chambers et al., 1985; Delmo et al., 2001) was used. The K-SADS is a semistructured interview guideline covering 10th revision of the International Statistical Classification of Diseases and Related Health Problems and Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, diagnoses of child and adolescent psychiatric disorders. The interview needs to be carried out by a trained expert and takes about 1.5 hr to complete. In the present study, the K-SADS interview was carried out by four psychologists (two MSc, two BSc) who had undergone K-SADS training. Second, the therapists providing the treatment noted the psychiatric diagnoses based on their clinical interviews at the beginning of treatment based on the initial assessment before treatment. Treatment fidelity. The treatment fidelity checklist (Weitkamp et al., 2011) was developed for this study based on a fidelity checklist for psychodynamic treatment of attention-deficit hyperactivity disorder (Leuzinger-Bohleber, Läzer, & al., 2009). The

checklist comprises 19 items with two subscales. Each item is scored on a 5-point Likert scale ranging from 1 ⫽ never to 5 ⫽ very often. There are nine items on behavioral techniques like teaching specific coping techniques or practicing target behavior (present sample: Cronbach’s alpha ⫽ .82), and 10 items on psychodynamic techniques like linking current feelings to experiences in the past (present sample: Cronbach’s alpha ⫽ .86). The item means are the scale scores (range: 1–5). The ratings were made by the therapist at the end of treatment.

Analysis The primary outcome was the depressive pathology as rated by patients and/or parents. Secondary outcome criteria were the therapist-rated level of functioning and QoL rated by patients and/or parents. To analyze the change in depressive symptoms, QoL, and level of functioning over time, analyses of variance (ANOVAs) with repeated measures were calculated with the General Linear Model, for the wait-list and the therapy interval separately. To analyze the group ⫻ time interaction, additional twoway ANOVAs were calculated. For these analyses, the patients who were both in the intervention group and in the control group were considered as intervention patients. Effect sizes d were calculated following the method reported by Durlak (2009). Although the intervention group did not differ significantly from the control group before the treatment (e.g., patient report CDI: p ⬎ .060), we chose to provide “adjusted” effect sizes (Durlak, 2009)1 to ensure comparability. To this end, pre-effect sizes were subtracted from the post-effect sizes. Violation of necessary assumptions was checked before the ANOVAs. As the sample size is still small, all results need to be seen as preliminary and should be interpreted with caution. Level of significance was set to the conventional ␣ ⫽ .05. Effect sizes were interpreted following established conventions (Cohen, 1988). Thus, an effect size of d ⱖ .02 is considered to be a small effect, d ⱖ .05 a moderate effect, and d ⱖ .08 a large effect. Data analyses were carried out with SPSS 18.0.

Results General characteristics of the sample are shown in Table 1. Fourteen percent of the patients received short-term therapy (up to 25 sessions) and 86% engaged in long-term therapy (⬎25 sessions). On average, patients had 96.86 sessions of therapy (range: 25–205; SD ⫽ 52.95) over 24.47 months (SD ⫽ 12.86). On the fidelity checklist, the therapists retrospectively reported that they never or rarely used behavioral techniques (behavioral subscale: M ⫽ 1.46, SD ⫽ 0.38) and sometimes or often used psychody1 The effect sizes between the intervention and the control group were calculated by subtracting the intervention mean from the control mean for pre- and post values independently. Cohen’s d was calculated with the N⫺2 N⫺3 Min ⫺ Mco x where x following formula: d ⫽ Sample SD pooled N ⫺ 2.25 N 2 2 关共SDin兲 ⫹共SDco兲 兴 . N equals the total sample sample SD pooled ⫽ 2 size; M refers to the mean, the subscripts in and co refer to the intervention and the control group, respectively. SD is the standard deviation (Durlak, 2009, p. 928).





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PSYCHOANALYTIC PSYCHOTHERAPY FOR DEPRESSIVE CHILDREN

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25 20.38

20 15

17.46 16.69

CDI

namic techniques (psychodynamic subscale: M ⫽ 3.74, SD ⫽ 0.51). A paired t test between the behavioral and dynamic subscales yielded a significant difference with a large effect (t ⫽ 15.110; p ⬍ .001; d ⫽ 4.36). Half of the patients met with the therapist twice a week, the other half once a week. The wait-list interval was, on average, 3.38 months (SD ⫽ 1.31). Eighty-three percent of the patients in the wait-list control group received bridging sessions by the therapist, to stabilize and support the patient and the family, when necessary. The number of bridging sessions ranged from 1 to 8 (M ⫽ 3.5, SD ⫽ 2.89). Thus, the comparison group needs to be regarded as a minimal treatment rather than a no-treatment comparator.

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14.62

10 5 0 t0

t1

tE

Measurement points

Depressive Pathology

Wait-list control (n=13) Therapy (n=21)

During the course of therapy, a significant reduction in depressive symptoms with a large effect size was reported by both parents and patients (F ⫽ 11.545, p ⱕ .003, d ⫽ 0.81; parent rating: F ⫽ 20.536, p ⬍ .001, d ⫽ 1.09). For the wait-list control group, slight reductions were reported in both parent report and self-report. However, these changes in depressive pathology were not significant for the patient self-rating (F ⫽ 0.480, p ⱕ .502, d ⫽ 0.10), but were significant for the parent rating (F ⫽ 9.687, p ⱕ .008, d ⫽ 0.64). Additionally, two-way ANOVAs with the factor “time” (pre- vs. postmeasurement) and the factor “group” (wait-list vs. intervention) were calculated for patient and parent ratings. The interaction effects of group ⫻ time yielded a trend toward significance and a moderate effect (parent: F ⫽ 1.609, p ⱕ .213, d ⫽ 0.46; patient: F ⫽ 3.822, p ⱕ .060, d ⫽ 0.70; see also Table 2 and Figures 2 and 3).

Figure 2. Patient report of depressive symptoms (CDI) for the wait-list and the intervention group. Note. Child Depression Inventory (CDI) cutoff ⬍18 normal range, t0 ⫽ beginning of wait-list interval, t1 ⫽ beginning of therapy, tE ⫽ end of therapy.

Post Hoc Comparison of Study Completers and Dropouts A post hoc comparison between the dropouts and the completer group at the first time point yielded no significant differences (between p ⬎ .331 and p ⬎ .859) in terms of age, gender, depressive pathology, level of functioning, comorbidity, and parental relationship status.

Follow-Up Data Health-Related QoL According to the patient report, health-related QoL improved significantly over the course of treatment with moderate effect sizes (Mpre ⫽ 41.17, SDpre ⫽ 6.36, Mpost ⫽ 45.98, SDpost ⫽ 7.36, F ⫽ 13.993, p ⱕ .001, d ⫽ 0.56). Likewise, the parents reported a significant improvement of the patient’s QoL with large effect sizes (Mpre ⫽ 38.51, SDpre ⫽ 5.94, Mpost ⫽ 45.33, SDpost ⫽ 7.44, F ⫽ 16.090, p ⱕ .001, d ⫽ 0.83). No equivalent data were available for the control group (see also Figure 4).

Currently, follow-up data are being collected. Preliminary results of the analysis of these data show a sustained positive effect up to 1 year after treatment. A diagnostic K-SADS interview has been conducted with 15 of the patients in the intervention group so far. In this subsample, 53% of the patients did not have any psychiatric disorder. There was one patient with a depressive disorder (7%), two patients with an anxiety disorder (13%), three with a disruptive disorder (20%), and one patient with a stress disorder (7%). Two patients had a comorbid disorder. In light of the fact that 100% of the interview

Table 2 Analyses of Variance With the Factor Time for Depressive Pathology of the Wait-List and the Intervention Group for Patient and Parent Informants

Group Parent ratings Wait-list Intervention Time ⫻ group Patient ratings Wait-list Intervention Time ⫻ group

Time 1

Time 2

n

M (SD)

M (SD)

F

p

Cohen’s d

15 25

22.13 (6.47) 22.20 (6.50)

17.93 (6.85) 14.68 (7.26)

9.687 20.536 1.609

.008 ⬍.001 .213

0.49 0.88 0.46

13 21

17.46 (8.00) 20.38 (5.39)

16.69 (7.69) 14.62 (8.51)

0.480 11.545 3.822

.502 .003 .060

0.07 0.68 0.70

WEITKAMP ET AL.

25 22.13

22.20

20 17.93

15 CDI

14.68 10 5

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0 t0

t1

tE

Measurement points Wait-list control (n=15) Therapy (n=25)

Figure 3. Parent report of depressive symptoms (CDI) for the wait-list and the intervention group. Note. Child Depression Inventory (CDI) cutoff ⬍18 normal range, t0 ⫽ beginning of wait-list interval, t1 ⫽ beginning of therapy, tE ⫽ end of therapy.

sample had a diagnosis at beginning of therapy, with 70% even suffering from more than one psychiatric condition, these results suggest a lasting therapeutic effect of psychoanalytic treatment for a number of patients.

Discussion The aim of the study was to evaluate psychoanalytic psychotherapies as they are delivered in the naturalistic health care system in Germany and to extend the findings by Horn et al. (2005) and Trowell et al. (2007). The results provide evidence that psychoanalytic therapy can significantly reduce target symptoms and increase QoL. During the wait-list interval (with minimal treatment), no such significant symptom reduction occurred. The symptom reduction of the intervention group was in the range of moderate to large effect sizes. Ethical and practical reasons prevented us from keeping children and adolescents in the wait-list condition for the same amount of time the treatment lasted. We can therefore only compare a 3-month wait period with the full treatment period, which, on average, lasted 24 months. However, the results of the wait-list group mostly indicate symptom stability over time from the patients’ perspective. The parents, on the other hand, reported a significant symptom reduction during the wait-list period. From a clinical perspective, this might mirror a parental wish or the relief parents might experience by sharing their burden with a therapist and by envisioning subsequent improvement of the child’s suffering. The patients and the parents in our study both reported a significant improvement on the measure of QoL. The improvements were in the range of moderate to large effect sizes. This indicates that the therapeutic process did not only alleviate psychopathology but that the treatment effect also generalizes to the daily functioning and well-being of the adolescents’ lives to a certain degree. Our findings are in contrast to the small to medium effect sizes of CBT and interpersonal therapy for depressive disorders in children and adolescents (Bachmann et al., 2008). The Horn study

yielded a clinically significant and reliable change (CSRC) rate of 20% for depressed patients treated with 25 sessions of psychoanalytic therapy (Horn et al., 2005). This discrepancy might be due to the longer treatment duration in our sample, with an average duration of 24 months (on average 96 sessions). In that study, a significant number of patients needed longer treatment than 25 sessions. The current data seem to suggest that longer duration of therapy leads to a higher number of significantly improved children and adolescents, although the number of young people who received short-term therapy was too small (n ⫽ 3) to undertake a differential analysis. When comparing the results, one needs to keep in mind that the Horn data were based on clinical expert ratings of the level of impairment, whereas in the current study, improvement was established based on patient and parent ratings of depressive pathology. Although both may be considered as valid and reliable sources, they would have differed in terms of their backgrounds and observations. We chose to use depression ratings rather than depression diagnosis or level of impairment as inclusion criteria and outcome measures to enable a patient-centered analysis and comply with the methodological standard set by the German board for therapy evaluation. However, it is interesting to note that one-third of the sample scoring above the cutoff on the depression measure was not formally diagnosed with an affective disorder. The small sample size prevented us from comparing patients with and without a diagnosis of an affective disorder. As comorbidity was high in this naturalistic sample, depressive symptoms might have been deemed secondary in these cases. However, it can be argued that this approach was closer to the clinical reality and the patients’ and families’ needs. Even in cases in which a child or adolescent did not meet the diagnostic criteria for a full-blown depressive disorder, burden of pathology and depressiveness was high and needed clinical attention. Future studies should discuss the effect of diagnosis versus symptom severity as inclusion criteria. First cautious results on the diagnostic status at 1-year follow-up suggested that about 53% of the patients did not have any psychiatric disorder. These first tentative follow-up results on a sustained positive effect of the psychoanalytic treatment 1 year after the end of therapy seem positive in contrast to results

50

45.98

45 41.17 KIDSCREEN

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45.33

40 38.51

35 30 25 20 t1

tE Measurement points Parent (n = 24)

Patient (n = 20)

Figure 4. Change in health-related quality of life during treatment— parent and patient informant. Note. KIDSCREEN cutoff ⱖ45 normal range, t1 ⫽ beginning of therapy, tE ⫽ end of therapy.

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of a meta-analysis (Weisz, McCarty, & Valeri, 2006) of mainly CBT treatments for child and adolescent depression, in which follow-ups with lags of 1 year and more showed essentially no lasting treatment effect. However, this rate of 53% is lower than the one found by Trowell et al. (2007) at the 6-month follow-up for short-term focused psychoanalytic therapy, in which the treatment led to improvement for 75% of cases, who were no longer clinically depressed at the end of therapy, and for 100% after the 6-month follow-up. Still, comparisons should be drawn with caution, as both samples differ in terms of inclusion criteria (self-reported depressive pathology vs. K-SADS diagnosis), outcome measure (CDI vs. diagnostic status), and, possibly, comorbidity status. It is not clearly stated in the Trowell study whether the patients had comorbidities with disorders other than affective disorders such as anxiety disorders. Thus, the higher success rate of the focused psychoanalytic therapy in the Trowell study compared with the long-term therapy in this study cannot be interpreted conclusively. Therapy discontinuation was low (10%). On an international level, attrition rates of 47% have been reported in a meta-analytic review of 125 studies (Wierzbicki & Pekarik, 1993). In a current German study on dropouts of outpatient treatment, an attrition rate of 25% was reported (Cinkaya, Schindler, & Hiller, 2011). The low dropout rate in our sample might have been due to the highly motivated therapists who were not blinded to the patient participation in the study. Another possible explanation is that the patients in this sample being primarily depressed show higher continuation rates than, for instance, patients with a dominant externalizing pathology. Even with such extensive therapy, deterioration of pathology was reported by two of the adolescents (10% of patient ratings). Neither Horn and colleagues (2005) nor Trowell and colleagues (2007) reported the rate of nondesirable therapy effects. However, in the adult psychotherapy literature, comparable rates have been reported. Lambert and Ogles (2004) stated a rate of 5% to 10% negative effects of psychotherapy treatments. Mohr (1995) reported similar rates on nonpsychotic adult psychotherapy patients. Hence, our finding is fairly typical for psychotherapy research. However, we should always be concerned about negative effects of therapy. More research to understand why some children and adolescents deteriorate during treatment is called for. These naturalistic data clearly have some strengths and limitations. First, the sample was not strictly randomized to the treatment group and wait-list control group. However, the two groups did not differ significantly at the first measurement point, although patient ratings on depressive pathology differed, with d ⫽ 0.45 between the intervention group and the control group (with the intervention group reporting greater pathology), suggesting that group allocation might have been biased, in that the waitlist group entered that period closer to normal functioning. The different time intervals between the wait-list and the intervention group limit the explanatory power of the results. However, due to ethical reasons, a longer waiting period for the control group was not possible. Additionally, therapy duration within the treatment group varied greatly. Another limitation was the fact that some of the wait-list control patients did get some therapeutic support by the therapists during the wait-list interval. This means that the comparator group might be better understood as a minimal treatment than an untreated control group.

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A methodological limitation was the small sample size of both groups. Furthermore, there were a number of treatment dropouts and study noncompleters, due to which the results might be biased. However, a post hoc analysis of both groups at the beginning of treatment showed no significant differences between the completers and the dropouts. Due to the small sample size, no differential analyses between short-term and long-term treatments were possible. Another limitation is the retrospective nature and possible lack of objectivity of the treatment fidelity measure, which was rated by the therapists at the end of treatment. Ideally, independent ratings by additional trained clinicians should be acquired throughout the therapeutic process. However, due to the naturalistic nature of this study, such assessments were not available. Thus, the fidelity measure can only be seen as a rough indicator of therapeutic adherence. Future studies should try to combine a naturalistic approach with stricter measures of treatment fidelity. Although these limitations pose a risk to the internal validity of the results, the external validity of this study was very high: naturalistic access paths, unselected patients, no strictly manualized treatments, and “real-life” therapists in their own private practices. Future directions for the study are more methodologically advanced data analyses. Latent growth curve modeling will be carried out for the completed sample to better account for the varying time intervals of therapy duration and the notable attrition rate of study participation.

Conclusion To conclude, the results suggest that psychoanalytic therapy can be successfully implemented in a naturalistic setting and that psychoanalytic therapy significantly alleviates depressive pathology and improves QoL in depressed children and adolescents. Particularly noteworthy are the stability of the improvements over time as well as the low dropout rates. However, two adolescents reported symptom aggravation; and findings from the study have to be treated as preliminary, given some of the methodological limitations discussed earlier. Nevertheless, this naturalistic trial provides evidence for the effectiveness of the psychoanalytic psychotherapy as a treatment for severe depressive psychopathology in children and young people.

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Received June 24, 2013 Accepted June 25, 2013 䡲

Psychoanalytic psychotherapy for children and adolescents with severe depressive psychopathology: preliminary results of an effectiveness trial.

This waitlist-controlled field study aimed to evaluate the effectiveness of psychoanalytic short- and long-term psychotherapy for children and adolesc...
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