Individual psychodynamic psychotherapy and psychoanalysis for schizophrenia and severe mental illness

Lena Malmberg; Mark Fenton; John Rathbone

doi:10.1002/14651858.CD001360

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Figure 1

Methodological quality summary: review authors' judgements about each methodological quality item for each included study.

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Analysis 1.1

Comparison 1 INDIVIDUAL PSYCHODYNAMIC PSYCHOTHERAPY versus MEDICATION, Outcome 1 Committed suicide by three years.

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Analysis 1.2

Comparison 1 INDIVIDUAL PSYCHODYNAMIC PSYCHOTHERAPY versus MEDICATION, Outcome 2 Global impression: 1. Not able to be discharged (long term).

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Analysis 1.3

Comparison 1 INDIVIDUAL PSYCHODYNAMIC PSYCHOTHERAPY versus MEDICATION, Outcome 3 Global impression: 2. Given medication during 12 months to three years follow up.

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Analysis 1.4

Comparison 1 INDIVIDUAL PSYCHODYNAMIC PSYCHOTHERAPY versus MEDICATION, Outcome 4 Global impression: 3. Achieved best level of health MHSS ‐ long term (high=good).

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Analysis 1.5

Comparison 1 INDIVIDUAL PSYCHODYNAMIC PSYCHOTHERAPY versus MEDICATION, Outcome 5 Global impression: 4. Treatment not considered successful by treatment team (long term).

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Analysis 1.6

Comparison 1 INDIVIDUAL PSYCHODYNAMIC PSYCHOTHERAPY versus MEDICATION, Outcome 6 Global impression: 5. Hospital re‐admission (long term).

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Analysis 1.7

Comparison 1 INDIVIDUAL PSYCHODYNAMIC PSYCHOTHERAPY versus MEDICATION, Outcome 7 Leaving the study early (long term).

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Analysis 2.1

Comparison 2 INDIVIDUAL PSYCHODYNAMIC PSYCHOTHERAPY AND MEDICATION versus MEDICATION ALONE, Outcome 1 Committed suicide by three years.

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Analysis 2.2

Comparison 2 INDIVIDUAL PSYCHODYNAMIC PSYCHOTHERAPY AND MEDICATION versus MEDICATION ALONE, Outcome 2 Global impression: 1. Not able to be discharged (long term).

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Analysis 2.3

Comparison 2 INDIVIDUAL PSYCHODYNAMIC PSYCHOTHERAPY AND MEDICATION versus MEDICATION ALONE, Outcome 3 Global impression: 2. Given medication during 12 months to three years follow up.

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Analysis 2.4

Comparison 2 INDIVIDUAL PSYCHODYNAMIC PSYCHOTHERAPY AND MEDICATION versus MEDICATION ALONE, Outcome 4 Global impression: 3. Achieved best level of health ‐ MHSS ‐ high=good (long term).

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Analysis 2.5

Comparison 2 INDIVIDUAL PSYCHODYNAMIC PSYCHOTHERAPY AND MEDICATION versus MEDICATION ALONE, Outcome 5 Global impression: 4. Treatment not considered successful by treatment team (long term).

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Analysis 2.6

Comparison 2 INDIVIDUAL PSYCHODYNAMIC PSYCHOTHERAPY AND MEDICATION versus MEDICATION ALONE, Outcome 6 Global impression: 5. Hospital re‐admission (long term).

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Analysis 2.7

Comparison 2 INDIVIDUAL PSYCHODYNAMIC PSYCHOTHERAPY AND MEDICATION versus MEDICATION ALONE, Outcome 7 Leaving the study early (long term).

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Analysis 3.1

Comparison 3 INSIGHT‐ORIENTED PSYCHODYNAMIC PSYCHOTHERAPY versus REALITY‐ADAPTIVE PSYCHOTHERAPY, Outcome 1 Global impression: 1. Not able to perform major household responsibilities (long term).

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Analysis 3.2

Comparison 3 INSIGHT‐ORIENTED PSYCHODYNAMIC PSYCHOTHERAPY versus REALITY‐ADAPTIVE PSYCHOTHERAPY, Outcome 2 Global impression: 2. Not able to enjoy a significant relationship (long term).

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Analysis 3.3

Comparison 3 INSIGHT‐ORIENTED PSYCHODYNAMIC PSYCHOTHERAPY versus REALITY‐ADAPTIVE PSYCHOTHERAPY, Outcome 3 Global impression: 3. Not self supporting (long term).

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Analysis 3.4

Comparison 3 INSIGHT‐ORIENTED PSYCHODYNAMIC PSYCHOTHERAPY versus REALITY‐ADAPTIVE PSYCHOTHERAPY, Outcome 4 Global impression: 4. Hospital re‐admission (long term).

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Analysis 3.5

Comparison 3 INSIGHT‐ORIENTED PSYCHODYNAMIC PSYCHOTHERAPY versus REALITY‐ADAPTIVE PSYCHOTHERAPY, Outcome 5 Leaving the study early:.

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Analysis 4.1

Comparison 4 INDIVIDUAL PSYCHODYNAMIC PSYCHOTHERAPY versus GROUP PSYCHOTHERAPY, Outcome 1 Global impression: 1. Returned to hospital (long term).

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Analysis 4.2

Comparison 4 INDIVIDUAL PSYCHODYNAMIC PSYCHOTHERAPY versus GROUP PSYCHOTHERAPY, Outcome 2 Global impression: 2. Not improved at 24 months.

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Analysis 4.3

Comparison 4 INDIVIDUAL PSYCHODYNAMIC PSYCHOTHERAPY versus GROUP PSYCHOTHERAPY, Outcome 3 Global impression: 3. Discharged from therapy (long term).

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Analysis 4.4

Comparison 4 INDIVIDUAL PSYCHODYNAMIC PSYCHOTHERAPY versus GROUP PSYCHOTHERAPY, Outcome 4 Global impression: 4. Remaining in therapy (long term).

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Analysis 5.1

Comparison 5 INDIVIDUAL PSYCHODYNAMIC THERAPY AND MEDICATION versus INDIVIDUAL PSYCHODYNAMIC THERAPY, Outcome 1 Global impression: 1. Hospital re‐admission (long term).

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Table 1. . Suggested design of study

Methods	Allocation: randomised, block, fully explicit description. Blinding: single, tested. Duration: 12 weeks treatment, and then follow up to at least 26 weeks.
Participants	Diagnosis: schizophrenia (ICD). N=300.* Age: adults. Sex: both.
Interventions	1. Individual Psychodynamic Psychotherapy. N=150. 2. Standard care. N=150.
Outcomes	General: time to all‐cause treatment failure marked by its discontinuation, relapse, general impression of clinician (CGI), career/other (CGI), compliance with treatment., healthy days, Mental state: CGI. Quality of life. CGI. Family burden: CGI. Social functioning: return to everyday living for 80% of time.* Adverse events: any adverse event recorded. Economic outcomes.
Notes	* Powered to be able to identify a difference of ˜20% between groups for primary outcome with adequate degree of certainty.

Table 1. . Suggested design of study

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Summary of findings for the main comparison. INDIVIDUAL PSYCHODYNAMIC PSYCHOTHERAPY versus MEDICATION for schizophrenia and severe mental illness

INDIVIDUAL PSYCHODYNAMIC PSYCHOTHERAPY versus MEDICATION for schizophrenia and severe mental illness
Patient or population: patients with schizophrenia and severe mental illness Settings: in hospital Intervention: INDIVIDUAL PSYCHODYNAMIC PSYCHOTHERAPY versus MEDICATION
Outcomes	*Illustrative comparative risks (95% CI)**		Relative effect (95% CI)	No of Participants (studies)	Quality of the evidence (GRADE)	Comments
	Assumed risk	Corresponding risk
	Control	INDIVIDUAL PSYCHODYNAMIC PSYCHOTHERAPY versus MEDICATION
Committed suicide by three years	42 per 1000	22 per 1000 (2 to 234)	RR 0.52 (0.05 to 5.56)	94 (1 study)	⊕⊕⊝⊝ low^1,2
Global impression: 1. Not able to be discharged (long term)	42 per 1000	351 per 1000 (85 to 1000)	RR 8.35 (2.03 to 34.3)	94 (1 study)	⊕⊕⊝⊝ low^1,2
Global impression: 2. Given medication during 12 months to three years follow up ‐ by 12 months	958 per 1000	613 per 1000 (479 to 776)	RR 0.64 (0.5 to 0.81)	94 (1 study)	⊕⊕⊝⊝ low^1,2
Global impression: 2. Given medication during 12 months to three years follow up ‐ by three years	1000 per 1000	850 per 1000 (750 to 960)	RR 0.85 (0.75 to 0.96)	94 (1 study)	⊕⊕⊝⊝ low^1,2
The basis for the assumed risk* (e.g. the median control group risk across studies) is provided in footnotes. The corresponding risk (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI). CI: Confidence interval; RR: Risk ratio;
GRADE Working Group grades of evidence High quality: Further research is very unlikely to change our confidence in the estimate of effect. Moderate quality: Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate. Low quality: Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate. Very low quality: We are very uncertain about the estimate.
¹ Randomisation undertaken but not clearly described. ² One small single study.

Summary of findings for the main comparison. INDIVIDUAL PSYCHODYNAMIC PSYCHOTHERAPY versus MEDICATION for schizophrenia and severe mental illness

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Comparison 1. INDIVIDUAL PSYCHODYNAMIC PSYCHOTHERAPY versus MEDICATION

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Committed suicide by three years Show forest plot	1	94	Risk Ratio (M‐H, Fixed, 95% CI)	0.52 [0.05, 5.56]

2 Global impression: 1. Not able to be discharged (long term) Show forest plot	1	94	Risk Ratio (M‐H, Fixed, 95% CI)	8.35 [2.03, 34.30]

3 Global impression: 2. Given medication during 12 months to three years follow up Show forest plot	1		Risk Ratio (M‐H, Fixed, 95% CI)	Subtotals only

3.1 by 12 months	1	94	Risk Ratio (M‐H, Fixed, 95% CI)	0.64 [0.50, 0.81]
3.2 by three years	1	94	Risk Ratio (M‐H, Fixed, 95% CI)	0.85 [0.75, 0.96]
4 Global impression: 3. Achieved best level of health MHSS ‐ long term (high=good) Show forest plot	1	92	Mean Difference (IV, Fixed, 95% CI)	5.80 [1.61, 9.99]

5 Global impression: 4. Treatment not considered successful by treatment team (long term) Show forest plot	1	92	Risk Ratio (M‐H, Fixed, 95% CI)	16.36 [2.25, 118.81]

6 Global impression: 5. Hospital re‐admission (long term) Show forest plot	1	24	Risk Ratio (M‐H, Fixed, 95% CI)	0.63 [0.29, 1.36]

7 Leaving the study early (long term) Show forest plot	1	94	Risk Ratio (M‐H, Fixed, 95% CI)	1.04 [0.28, 3.93]

Comparison 1. INDIVIDUAL PSYCHODYNAMIC PSYCHOTHERAPY versus MEDICATION

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Comparison 2. INDIVIDUAL PSYCHODYNAMIC PSYCHOTHERAPY AND MEDICATION versus MEDICATION ALONE

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Committed suicide by three years Show forest plot	1	92	Risk Ratio (M‐H, Fixed, 95% CI)	0.16 [0.01, 2.93]

2 Global impression: 1. Not able to be discharged (long term) Show forest plot	1	92	Risk Ratio (M‐H, Fixed, 95% CI)	1.09 [0.16, 7.42]

3 Global impression: 2. Given medication during 12 months to three years follow up Show forest plot	1		Risk Ratio (M‐H, Fixed, 95% CI)	Subtotals only

3.1 by 12 months	1	92	Risk Ratio (M‐H, Fixed, 95% CI)	0.95 [0.85, 1.06]
3.2 by three years	1	92	Risk Ratio (M‐H, Fixed, 95% CI)	0.95 [0.88, 1.03]
4 Global impression: 3. Achieved best level of health ‐ MHSS ‐ high=good (long term) Show forest plot	1	90	Mean Difference (IV, Fixed, 95% CI)	‐0.80 [‐5.35, 3.75]

5 Global impression: 4. Treatment not considered successful by treatment team (long term) Show forest plot	1	92	Risk Ratio (M‐H, Fixed, 95% CI)	2.18 [0.20, 23.23]

6 Global impression: 5. Hospital re‐admission (long term) Show forest plot	1	24	Risk Ratio (M‐H, Fixed, 95% CI)	1.0 [0.39, 2.58]

7 Leaving the study early (long term) Show forest plot	1	92	Risk Ratio (M‐H, Fixed, 95% CI)	0.82 [0.19, 3.45]

Comparison 2. INDIVIDUAL PSYCHODYNAMIC PSYCHOTHERAPY AND MEDICATION versus MEDICATION ALONE

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Comparison 3. INSIGHT‐ORIENTED PSYCHODYNAMIC PSYCHOTHERAPY versus REALITY‐ADAPTIVE PSYCHOTHERAPY

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Global impression: 1. Not able to perform major household responsibilities (long term) Show forest plot	1	164	Risk Ratio (M‐H, Fixed, 95% CI)	1.13 [0.99, 1.29]

2 Global impression: 2. Not able to enjoy a significant relationship (long term) Show forest plot	1	164	Risk Ratio (M‐H, Fixed, 95% CI)	1.08 [0.96, 1.21]

3 Global impression: 3. Not self supporting (long term) Show forest plot	1	164	Risk Ratio (M‐H, Fixed, 95% CI)	1.05 [0.90, 1.23]

4 Global impression: 4. Hospital re‐admission (long term) Show forest plot	1	164	Risk Ratio (M‐H, Fixed, 95% CI)	1.20 [0.93, 1.56]

5 Leaving the study early: Show forest plot	1		Risk Ratio (M‐H, Fixed, 95% CI)	Subtotals only

5.1 at six months	1	164	Risk Ratio (M‐H, Fixed, 95% CI)	0.46 [0.31, 0.68]
5.2 at 12 months	1	164	Risk Ratio (M‐H, Fixed, 95% CI)	0.46 [0.34, 0.62]
5.3 at 24 months	1	164	Risk Ratio (M‐H, Fixed, 95% CI)	0.54 [0.44, 0.67]

Comparison 3. INSIGHT‐ORIENTED PSYCHODYNAMIC PSYCHOTHERAPY versus REALITY‐ADAPTIVE PSYCHOTHERAPY

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Comparison 4. INDIVIDUAL PSYCHODYNAMIC PSYCHOTHERAPY versus GROUP PSYCHOTHERAPY

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Global impression: 1. Returned to hospital (long term) Show forest plot	1		Risk Ratio (M‐H, Fixed, 95% CI)	Subtotals only

1.1 at 12 months	1	100	Risk Ratio (M‐H, Fixed, 95% CI)	1.07 [0.58, 1.98]
1.2 at 24 months	1	100	Risk Ratio (M‐H, Fixed, 95% CI)	1.16 [0.72, 1.86]
2 Global impression: 2. Not improved at 24 months Show forest plot	1	100	Risk Ratio (M‐H, Fixed, 95% CI)	1.27 [0.96, 1.67]

3 Global impression: 3. Discharged from therapy (long term) Show forest plot	1		Risk Ratio (M‐H, Fixed, 95% CI)	Subtotals only

3.1 at 12 months	1	100	Risk Ratio (M‐H, Fixed, 95% CI)	0.75 [0.18, 3.18]
3.2 at 24 months	1	100	Risk Ratio (M‐H, Fixed, 95% CI)	0.6 [0.33, 1.09]
4 Global impression: 4. Remaining in therapy (long term) Show forest plot	1		Risk Ratio (M‐H, Fixed, 95% CI)	Subtotals only

4.1 at 12 months	1	100	Risk Ratio (M‐H, Fixed, 95% CI)	0.68 [0.46, 1.00]
4.2 at 24 months	1	100	Risk Ratio (M‐H, Fixed, 95% CI)	0.56 [0.20, 1.54]

Comparison 4. INDIVIDUAL PSYCHODYNAMIC PSYCHOTHERAPY versus GROUP PSYCHOTHERAPY

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Comparison 5. INDIVIDUAL PSYCHODYNAMIC THERAPY AND MEDICATION versus INDIVIDUAL PSYCHODYNAMIC THERAPY

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Global impression: 1. Hospital re‐admission (long term) Show forest plot	1	24	Risk Ratio (M‐H, Fixed, 95% CI)	1.0 [0.39, 2.58]

Comparison 5. INDIVIDUAL PSYCHODYNAMIC THERAPY AND MEDICATION versus INDIVIDUAL PSYCHODYNAMIC THERAPY

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