NICE guideline for depression ranks short‐term psychodynamic psychotherapy (STTP)

Abstract

The clinical practice guidelines for mood disorders, published under the auspices of The Royal Australian and New Zealand College of Psychiatrists (RANZCP), are somewhat unique in that they address the management of both bipolar and depressive disorders. For the treatment of acute major depression, the RANZCP guideline recommends six psychological interventions, 1 and while short-term psychodynamic therapy (STPP) features among the recommended treatments, longterm psychodynamic psychotherapy (LTPP) does not.* The reason for this is straightforward, in that there is no compelling evidence to support the use of LTPP in the treatment of acute major depression.Nevertheless, the inclusion of only STPP ignited an intense debate concerning the use of psychodynamic therapy in the management of acute depression, and the fact that LTPP is not advocated by the guideline has drawn considerable ongoing criticism.

Contradictions, methodological flaws, and potential for misinterpretations in ranking treatments of depression

“…In summary, neither the indirect nor direct comparisons carried out by the NICE committee nor the cost‐effectiveness analyses or independent research 5 support Malhi et al's claim of superiority of counseling over STPP, prioritizing CBT over other treatments, and ranking STPP among the least effective treatments 1 …”

“…In this journal, Malhi et al recently argue 1 that the UK National Institute for Health and Care Excellence (NICE) guidelines for depression 2 rank short‐term psychodynamic therapy (STPP) as last of 11 therapies recommended for less severe depression and 7 out of 10 treatments recommended for more severe depression. They stress that STPP was ranked by NICE below counseling and that individual cognitive‐behavior therapy (CBT) has the highest ranking 1 .…”

“…In this journal, Malhi et al recently argue 1 that the UK National Institute for Health and Care Excellence (NICE) guidelines for depression 2 rank short‐term psychodynamic therapy (STPP) as last of 11 therapies recommended for less severe depression and 7 out of 10 treatments recommended for more severe depression. They stress that STPP was ranked by NICE below counseling and that individual cognitive‐behavior therapy (CBT) has the highest ranking 1 . However, we argue that the NICE guidelines for depression are ambiguous in that they recommend multiple treatments as equal first‐line treatments for depression on the one hand, but then go on to rank order them in terms of effectiveness and cost‐effectiveness based on the NICE guideline's committee interpretation of the available evidence.…”

“…This contradiction creates considerable ambiguity and allows for (mis‐)interpretation of the NICE guidelines as prioritizing some treatments over others, as appears to be the case by Malhi et al 1 For example, for less severe depression, Malhi et al state 1 , p. 468 : “Notably, antidepressants are ranked below CBT, BA, and IPT but are recommended ahead of STPP.” For more severe depression, Malhi et al concluded from the NICE treatment ranking 1 , p. 468 : “This suggests that individuals with severe acute depression should be offered CBT, BA, antidepressant, individual problem‐solving, and counseling prior to considering STPP…”. According to the NICE recommendations, however, treatment ranking is secondary to patient preferences and other factors when it comes to deciding which first‐line treatment to provide 2 ,.…”

“…With differences in effect sizes below the threshold of clinical significance defined by the NICE committee itself, treatment ranking carries considerable uncertainty 3 Malhi et al mistakenly assert that the NICE treatment ranking was based on direct comparisons 1 ,. p. 467 In fact, however, this was not the case, they were based on indirect comparisons of the various treatments with TAU or placebo as described above (see 1). The NICE committee did report head‐to‐head comparisons of active treatments but only in a supplement and did not take these results as a basis for deriving treatment rankings.…”