A randomized controlled trial for identifying the most suitable treatment for depression based on patients’ attachment orientation.

Abstract

Objective: Many active treatments exist for major depressive disorder (MDD), but little is known about their differential effects for various subpopulations of patients to guide precision medicine. This is the first randomized controlled trial (RCT) designed to identify differential treatment effects based on patients' attachment orientations. We tested an a priori preregistered hypothesis of the potential moderating effect of patients' attachment orientation on the outcome of supportive therapy (ST) versus supportive-expressive therapy (SET). Methods: The RCT was conducted between 2015 and 2021. Individuals with MDD were randomly assigned to 16-week ST or SET. The predefined primary outcome measure was the Hamilton Rating Scale for Depression. Hypotheses were formulated and preregistered before data collection. Results: One hundred patients with MDD were enrolled, 57% women, average age 31.2 (SD = 8.25). Data were analyzed using the intention-to-treat approach. Our hypothesis that attachment anxiety is a significant moderator of treatment outcome was supported (B = −0.09, p = .016): Patients with higher levels of attachment anxiety showed greater treatment efficacy following SET than ST. Although the hypothesis regarding a potential moderating effect of avoidant attachment was not supported, sensitivity analyses revealed that individuals with disorganized attachment orientation (higher scores on both anxious and avoidant attachment) benefited more from SET than from ST (B = −0.07, p = .04). Conclusion: The findings support the clinical utility of patients' attachment orientation in selecting the most suitable treatment for individuals and demonstrate the methodological utility of RCTs predesigned to test theoretically based models of personalized treatment. What is the public health significance of this article?This study is the first randomized controlled trial (RCT) predesigned to test the differential effect of treatments based on the patients' pretreatment attachment orientations. The findings demonstrate the ability of attachment orientation to serve as an empirically informed tool for a personalized match between individuals and their most effective treatment.

Is alliance therapeutic in itself? It depends.

“…In all supervisions, extensive use was made of video-taped sessions for feedback. As reported in the article detailing the main outcome of the trial (Zilcha-Mano et al, 2021), external observer coding of adherence revealed high adherence in both treatment conditions. The treatments were not found to differ in their efficacy or dropout level.…”

“…Empirical research demonstrates the importance of disentangling the trait-like and state-like components of alliance (for review, see Zilcha-Mano & Fisher, 2022). Findings suggest that the trait-like alliance is at least partially a product of the patient's pretreatment characteristics, such as attachment style and interpersonal abilities (for a review, see Zilcha-Mano & Fisher, 2022).…”

“…Empirical research demonstrates the importance of disentangling the trait-like and state-like components of alliance (for review, see Zilcha-Mano & Fisher, 2022). Findings suggest that the trait-like alliance is at least partially a product of the patient's pretreatment characteristics, such as attachment style and interpersonal abilities (for a review, see Zilcha-Mano & Fisher, 2022). Findings focusing on state-like changes in the alliance suggest that increases in statelike (within-patient) alliance predict subsequent improvement in treatment outcomes (Flückiger et al, 2020) and are associated with curative processes in treatment, such as corrective relational experiences with the therapists (Huang et al, 2016) and improved emotional experiences (Fisher et al, 2016).…”

The efficacy of group psychotherapy for adults with perfectionism: A randomized controlled trial of dynamic-relational therapy versus psychodynamic supportive therapy.

“…Given substantial meta-analytic evidence supporting the efficacy of PST (e.g., Barth et al, 2016) and indications of the importance of using supportive techniques and approaches in the treatment of perfectionism (e.g., Greenspon, 2014; Halgin & Leahy, 1989), we selected it as our active comparator. The use of supportive techniques to facilitate corrective emotional experiences is the focus of supportive treatment (Book, 1998; Leibovich et al, 2018; Rockland, 1989; Zilcha-Mano et al, 2021), and these principles are theorized to be salient in effecting change in patients with perfectionism (Ashby et al, 2005; Greenspon, 2014; Halgin & Leahy, 1989). Moreover, because DRT and PST are both rooted in psychodynamic principles, they share common elements, such as an emphasis on the therapeutic alliance, but differ in their use of exploratory/interpretive interventions.…”

Unpacking the heterogeneity in treatment effects as a path to personalized psychotherapies: Are we there yet?

“…For example, the PDT category includes a range of treatment modalities with different key techniques. A recent randomized controlled trial found that for patients with attachment anxiety, Supportive Expressive Therapy was more effective than Supportive Therapy (Zilcha-Mano et al, 2021). This finding suggests that treatment efficacy could be enhanced by utilizing expressive interventions with patients with this clinical profile.…”