FAQs: Review of evidence of long-term psychodynamic psychotherapy for the treatment of mood disorders

1. Why did the RANZCP undertake a review of long-term psychodynamic psychotherapy for the treatment of mood disorders?

The RANZCP Board established a Mood Disorders Psychodynamic Psychotherapy Evidence Review Steering Group (Steering Group) to oversee an independent review into the evidence for long-term psychodynamic psychotherapy (LTPP) in the treatment of mood disorders in response to members’ feedback. This feedback concerned the review of evidence within the 2020 RANZCP Clinical Practice Guidelines for mood disorders as it related to long-term psychodynamic therapy. 

The Board considers that respectful academic debate about the evidence for long-term psychodynamic psychotherapy and other psychiatric treatments is an appropriate way to contribute to psychiatrists’ education. The Board therefore agreed to fund an independent review into the evidence for long-term psychodynamic therapy. 

2. What was the role of the Mood Disorders Psychodynamic Psychotherapy Evidence Review Steering Group?

In October 2023 the Anna Freud Centre (AFC) was appointed by the College to conduct a review into the evidence for long-term psychodynamic psychotherapy in the treatment of mood disorders. The Steering Group has worked closely with the AFC to progress the project, and regular updates have been provided to member via the Mood Disorders Hub.

The Steering Group has met regularly since October 2023 to guide the review undertaken by the AFC. The role of the Steering Group was to advise AFC its review. Key areas of focus for the Steering Group were: 

• developing a request for quotation (RFQ) and advising on appointment of the AFC as the independent contractor; 
• advising on inclusion criteria for systematic reviews and meta-analyses, for registering with Prospero;
• ensuring that research was co-produced by lived experience, led by the Steering Group community member; 
• liaising on development questions to be asked as part of the experiential interviews with consumers, carers, and clinicians;
• advising on ethics approval processes – granted in the UK, Australia, and Aotearoa New Zealand;
• ensuring the research maintained a Bi-national focus;
• regularly updating members via the Mood Disorders Hub, including a dedicated podcast.

3. Who was on the Steering Group and what was the appointment process?

The Mood Disorders Psychodynamic Psychotherapy Evidence Review Steering Group was Chaired by Professor Bruce Singh AM. The membership of the Steering Group included clinicians with expertise in clinical experience in psychodynamic psychotherapies in Australia, Aotearoa New Zealand and internationally. The Steering Group also included lived experience membership. Membership of the Steering Group was by appointment by the Board in line with the Terms of Reference. 

4. How were Steering Group members’ conflicts of interests managed?

Members of the Steering Group signed a deed of undertaking at the time of appointment in which they agreed to declare any conflict, whether actual, potential, perceived or likely to arise. To manage conflicts of interest during the development process, a standing item at all Steering Group meetings asked all members to declare their conflicts of interest. Conflicts declared were primarily that members were trained in or practising psychotherapists and these were deemed as not requiring further action. Those who declared they had a previous relationship with any of the organisations submitting as part of the RFQ process were excluded from the discussions about the of appointment of the contractor. 

5. What was the cost of the review?

The fee paid to the AFC for the Mood Disorders Psychodynamic Psychotherapy Evidence Review cannot be disclosed as this is commercial in confidence. 

6. When and how is the review being published?

The Board has approved that the findings from the review be submitted for publication in an academic journal given that they will be of significant academic interest internationally. This will allow for greater dissemination of findings, as well as highlighting the evidence gaps and allow for peer review. The AFC will submit the findings to a journal of its choice. 

In recognition of the significant interest from members, the final report to the College from the AFC is available to members in advance of conclusion of the journal submission process. This is to avoid any issues with pre-publication that may impact on journal decisions as to whether to accept the research for publication only. Any publications arising from this process and the final report will subsequently be made publicly available. 

Researchers from the AFC will be required to declare any conflicts of interests and funding received as required as part of the journal submission process. 

7. What methodology informed the Mood Disorders Psychodynamic Psychotherapy Evidence Review methodology informed the evidence review?

The review included three key research components:

• Part I) A systematic review and meta-analysis of the effectiveness of LTPP and comparator treatments for mood disorder.
• Part II a) A qualitative systematic review and meta-aggregation of evidence in relation to the treatment of mood disorders from the perspective of consumers, treatment providers, and carers for consumers.
• Part II b) A qualitative semi-structured interview study in relation to the treatment of mood disorders from the perspective of consumers, treatment providers and carers for consumers based in in Australia and New Zealand/Aotearoa.

The research was conducted independently by the AFC to the highest current academic standards, using rigorous methodology and incorporating original and novel research. Lived experience is central to the report, heralding a new methodology that considers a broader range of evidence. As part of the research, 24 one-to-one interviews with people with lived experience of LTPP (consumers and carers), and clinicians delivering LTPP were conducted. The questions were co-designed with lived experience. 

The College acknowledges and commends the collaborative nature of the project between the Steering Group, the AFC, and lived experience that has contributed to delivery of a novel and meaningful methodology using co-production. 

8. What are the key findings from the evidence review?

Collectively, the three interrelated studies within report indicate that LTPP is an effective treatment for some individuals with mood disorders, including those with complex forms of depression. Meta-analytic findings show that LTPP reduced depressive symptoms and global distress. However, it is of note that participants in both the qualitative strands tended to emphasise functional improvements – for example in their work or family lives – rather than the symptomatic changes generally captured in randomised controlled trials (RCTs). Furthermore, both qualitative strands provide further context and insight into potential underlying mechanisms in LTPP, such as a strong therapeutic relationship, high levels of trust, an understanding of one’s past and the development of self-insight. 

9. Has the evidence review been peer reviewed?

Until the findings are published in an academic journal, the report has not been subject to formal peer review. It is noted that there are many reports externally commissioned by the College and other organisations, such as this, that do not undergo peer review. The AFC authors engaged researchers from outside of the core research team to provide advice on the project, and these are acknowledged within the final report. Further, the manuscripts sent by the AFC to journals for submission will be subject to for peer review.

10. Why is the Mood Disorders Clinical Practice Guideline still available if the evidence from the independent report is more current?

The AFC evidence review is viewed by the Board as a new resource given the new methodology applied, and the extent of the research involved. This review was undertaken in response to a specific question using novel and original research methodology - rather than as a critique of, or replacement for, the Mood Disorder CPG. It is acknowledged that the context of the definition of mood disorders in the AFC report, as well as the extent of the research undertaken, may be too broad for direct comparison with the CPG. 

The Board considers that the process of development for the 2020 RANZCP Clinical Practice Guidelines for mood disorders was such that the authors wrote the guidelines based on their interpretation of evidence at the time, which was then externally reviewed via the journal’s peer review process. The purpose of a CPG is to provide general rules, principles, advice and to improve care and outcomes for individuals and the community by synthesising and analysing up-to-date evidence, and by translating research funding and new insights into clinical practice. A CPG is one of a range of resources available to guide clinical practice.  

The Board commends the AFC report as a significant piece of research into LTPP and members are advised to review the findings from the report as the most current resource to inform the use of LTPP in clinical practice.  

11. Does the evidence review cover only Long-Term Psychodynamic Psychotherapy, or other types of psychotherapy?

The evidence review provides background regarding the treatment of psychotherapy and identifies that in addition to first-line antidepressant medication, psychotherapy plays a crucial role in treating mood disorders, with extensive literature supporting its acceptability and effectiveness across a wide range of outcomes and populations. 

The evidence review relates to long-term psychodynamic psychotherapy (LTPP) only. It does not cover brief psychodynamic psychotherapies, or other forms of psychotherapy e.g. Cognitive Behaviour Therapies. When the evidence report refers to psychotherapy, it is referring to LTPP specifically. 

A dual need to evaluate effectiveness and elucidate potential mechanisms of change relating to LTPP (i.e. how it may work) was at the heart of the report. LTPP might be particularly indicated for individuals suffering from severe and complex forms of psychopathology, where a substantial amount of time is often needed to develop trust, restore adaptive social-cognitive function and destabilise entrenched maladaptive schemas.

12. How is the College implementing the findings from the evidence review from the Anna Freud Centre?

The College has included the evidence review on its website. Members are advised that it is the most current evidence into the effectiveness of LTPP and the most current resource to inform the use of LTPP. 

The report has been referred to the Faculty of Psychotherapy for review and to consider implementation of findings. This may include review and update of the current RANZCP Position Statement on Psychotherapy conducted by Psychiatrists and/or development of further resources e.g. podcasts or Continuing Professional Development materials. The College approach to developing Best Practice Resources is relevant and new resources will be considered in the context of this. The barriers to accessing LTPP identified within the review will also be considered. 

The Steering Group has submitted an abstract for the Congress 2025: A new kind of methodology for an age-old question: A review of the effectiveness of long-term psychodynamic psychotherapy where members will have opportunity discuss the findings. 

13. Does the College support long-term psychodynamic therapy as a treatment?

The College’s position on the use of long-term psychodynamic therapy in clinical practice remains unchanged. Individual dynamic psychotherapies continue to form part of the RANZCP training program. The Mood Disorders CPG website provides links to further RANZCP resources relating to the treatment of mood disorders, including Position Statement Psychotherapy Conducted by Psychiatrists (July 2021). Furthermore, the College continues to support and advocate for improved access to intensive psychotherapy in private and public settings, acknowledging that LTPP is not readily available and affordable for many particularly within the public system. 

14. How has the College addressed the resolutions from the Members’ Requisition General Meeting?

Feedback by College members regarding the RANZCP Clinical Practice Guideline for Mood Disorders (2020) to a Members’ Requisition General Meeting (MRGM) on Tuesday 3 May 2022, where it was voted to commission an independent review into the evidence for long-term psychotherapy as a treatment for mood disorders. 

At the MRGM on 3 May 2022, the President, A/Prof Vinay Lakra, informed attendees of the next steps noting that any steps to be taken will be at the Board’s discretion as the resolutions of the MRGM are non-binding. The outcome of the resolution was an important consideration in the Board’s determination of next steps.

The Board has highlighted in the below table the action taken in response to each resolution following the receipt of the review of long-term psychodynamic psychotherapy in the treatment of mood disorders.  

Contact 

For further information please contact policy@ranzcp.org