Short-Term Psychodynamic Psychotherapy for Somatic Disorders

Background: Somatic symptom disorders are common, disabling and costly. Individually provided short-term psychodynamic psychotherapies (STPP) have shown promising results. However, the effectiveness of STPP for somatic symptom disorders has not been reviewed. Methods: We undertook a systematic review of randomized controlled trials and controlled before and after studies. The outcomes included psychological symptoms, physical symptoms, social-occupational function, healthcare utilization and treatment continuation. Results: A total of 23 studies met the inclusion criteria and covered a broad range of somatic disorders. Thirteen were RCTs and 10 were case series with pre-post outcome assessment. Of the included studies, 21/23 (91.3%), 11/12 (91.6%), 16/19 (76.2%) and 7/9 (77.8%) reported significant or possible effects on physical symptoms, psychological symptoms, social-occupational function and healthcare utilization respectively. Meta-analysis was possible for 14 studies and revealed significant effects on physical symptoms, psychiatric symptoms and social adjustment which were maintained in long-term follow-up. Random-effect modeling attenuated some of these relationships. There was Received: February 19, 2008 Accepted after revision: July 18, 2008 Published online: July 11, 2009 Dr. Allan Abbass 5909 Veterans Memorial Lane, Room 8203 Abbie J. Lane Building, QEII Health Sciences Center Halifax, NS, B3H 2E2 (Canada) Tel. +1 902 473 2514, Fax +1 902 473 4545, E-Mail [email protected] © 2009 S. Karger AG, Basel 0033–3190/09/0785–0265$26.00/0 Accessible online at: www.karger.com/pps Abbass /Kisely /Kroenke Psychother Psychosom 2009;78:265–274 266 medical disorders are influenced as much by psychological factors as by the severity of the underlying medical disorder [7, 8] . While some patients with medically unexplained symptoms meet criteria for somatoform disorders, the boundaries are not always clear-cut between somatoform symptoms and the distressing and persistent somatic symptoms experienced by patients with functional somatic disorders, depression, anxiety and even some medical conditions [8] . The treatment of somatoform disorders and related conditions manifested by poorly explained somatic symptoms has been covered in several recent comprehensive reviews [9–15] . Cumulatively, these reviews confirm that 2 of the most evidence-based treatments are cognitivebehavioral therapy (CBT) and antidepressants. Too few studies of other treatments were then found to lend themselves to a meta-analysis. Unresolved unconscious emotional issues have long been considered an important causal factor in a range of physical illnesses and somatic symptom disorders [16] . In clinical practice, psychodynamic psychotherapies focus on this unconscious process by which emotions translate into somatic symptoms, somatic focus and, indeed, objectively measurable physical sequelae. Short-term psychodynamic psychotherapies (STPP) are a group of brief therapy methods developed over the past 50 years by proponents including Mann, Sifneos, Malan and Davanloo [17] . Some STPP methods aim for insight into various unconscious phenomena, while others seek to address alexithymia, or difficulty identifying and experiencing emotions. With these different goals, technical differences have developed over time, with some methods being more versus less focused on emotional experiencing. They share the common goals of making unconscious phenomena conscious and working through underlying conflicts. The efficacy of STPP across a range of common mental disorders was reviewed in 2 recent meta-analyses [18, 19] . There are limitations to the generalizability of these findings to the treatment of somatic disorders. One review only included a single study with somatoform disorders [18] , and the other excluded studies with formal psychotherapy treatment controls. Both reviews were restricted to RCTs of individual STPP methods. Thus, the great majority of all STPP studies for somatic symptom disorders have never been reviewed. The purpose of this paper was to critically review and meta-analyze, where appropriate, data from studies using both RCT and nonRCT designs in order to examine the effectiveness of STPP in patients with somatic symptom disorders. Methods Selection of Studies We included studies of STPP therapies in somatic symptom disorders covering both medically explained and unexplained symptoms without regard to the presence of a formal psychiatric disorder to better reflect the case mix seen in general medical settings. We included both RCTs as well as before and after studies such as mirror designs of the same subjects. Studies of STPP delivered in either individual or group format were included. Search Strategy We searched PsycInfo from 1967 to the present, Medline from 1966 to the present and the Cochrane Library from 2005 to the present up to July 2007. Many papers had been found in a previous broad search conducted for a Cochrane review of STPP therapies for mental disorders [19] . Our strategy included broad searches with the following terms: psychotherapy, psychodynamic, dynamic or short-term therapy and clinical trial, naturalistic study, or randomized trial and 37 specific terms, such as chest pain, abdominal pain and headache. We searched for further trials by scrutinizing the reference lists of initial studies identified and other relevant review papers. We also contacted selected authors and experts. Two reviewers (A.A. and S.K.) independently extracted data. Two reviewers collated and independently assessed abstracts. Study Description The studies were reviewed for treatment characteristics, study methodology, sample characteristics, outcome measures, and reported results on primary indices under the categories psychological symptoms, somatic symptoms, social-occupational functioning and healthcare utilization. We specifically noted which studies were manualized, which had adherence ratings and which had blinded ratings of outcome. For RCTs, we used the Cochrane Collaboration Depression Anxiety and Neurosis (CCDAN) quality rating scale to numerically rate the study quality. This 23-item scale includes a broad range of indicators such as allocation concealment and sample size and has a maximum value of 46. Meta-Analysis Where appropriate, we combined the results of the studies using meta-analysis. We used Review Manager version 4.1, a statistical software package for managing and analyzing a Cochrane Collaboration systematic review, for our analysis. We divided the outcomes into short-term (up to 3 months), medium-term (3–9 months) and long-term ( 1 9 months), and measured effect size (ES) using standardized mean differences (SMD). We defined ES as small (ES = 0.20–0.49), medium (ES = 0.5–0.79) and large (ES 6 0.8) [20] . We assessed significance using 95% confidence intervals (CI) and heterogeneity with the Q and I 2 statistic. A value 1 50% for the I 2 statistic indicates heterogeneity. We evaluated publication bias using the fail-safe N statistic. This is the number of nonsignificant studies that would be necessary to reduce the ES to a negligible value of 0.10. This was calculated applying the WinPepi statistical package [21] .