New research published in journal Clinical Psychology: Science and Practice Both antidepressants and short-term psychodynamic therapy can help alleviate depression, but our findings suggest that pharmacotherapy may offer some benefit for those who begin with more severe symptoms. The study results provide evidence that both options lead to similar improvements in self-reported mood and anxiety, but when patients are assessed by expert clinicians, antidepressants tend to yield slightly better scores. These insights can help reveal how different people respond to common depression treatments and guide more personalized care.
Depression is a leading cause of disability worldwide. Because of the enormous burden on individuals and society, identifying effective and efficient treatments is a top priority for mental health professionals. The two main treatment options are antidepressants and various forms of talk therapy.
Medical guidelines often recommend a combination of medications and therapy for moderate to severe depression. Many patients prefer to use only one method. Some people worry about the drug’s side effects and the possibility of long-term use. Some people find that attending weekly therapy sessions takes too much time and money.
Single treatment approaches are so common that scientists need to understand how different options compare. Short-term psychodynamic psychotherapy is one widely used form of talk therapy. It typically involves 12 to 24 weekly sessions with a trained professional.
During these sessions, therapists help patients explore underlying emotional conflicts and unconscious defense mechanisms. These problems often stem from past negative experiences or relationships. Although this therapy is popular and widely taught, its effectiveness when compared directly to antidepressants is not fully understood.
“There has been a long-standing debate about the effectiveness and empirical status of psychodynamic therapy,” says Frederick J. Winnicke, Ph.D. candidate in the Department of Clinical Psychology, Institute of Behavioral Sciences, Radboud University, Nijmegen, Netherlands.
To investigate this question, Winicke and his colleagues launched an extensive project to assess the existing evidence for this particular type of treatment. Previous studies comparing depression treatments have often relied on standard meta-analyses. Meta-analysis is a statistical method that combines summary results from many different studies to find general trends.
This approach can be problematic because it relies on published averages. Published averages may exaggerate the benefits of a treatment or obscure important details about individual patients. Standard meta-analyses also have difficulty identifying which specific types of patients benefit most from a particular treatment.
To address these issues, the authors of the current study used a method called meta-analysis of individual participant data. Instead of looking at averages across studies, they collected raw, original data from everyone who participated in the initial trial.
“This means combining and reanalyzing participant-level data from multiple trials, rather than relying solely on summary statistics reported in published papers,” Winnicke explained. He said this approach “gives us more accurate estimates and allows us to see which patients benefit more from one treatment than another.”
Researchers systematically searched medical databases for clinical trials comparing antidepressants and short-term psychodynamic psychotherapy. The researchers looked for studies in which adults diagnosed with depression were randomly assigned to receive either medication or treatment.
“At the time of our literature review, we could identify only six trials comparing short-term psychodynamic psychotherapy with antidepressants, so the evidence base was smaller than expected for such a clinically important question,” Winicke said.
A systematic search completed in May 2024 identified a total of 472 participants across these six trials. The scientists then contacted the original researchers and requested the raw data. They were able to obtain individual participant data for four trials. This provided a final sample of 310 participants for analysis. This represents approximately 66 percent of the total available pool.
The average age of participants in the final analysis was approximately 38 years, and approximately 65 percent were female. The drugs used in the trial included common antidepressants such as fluoxetine, sertraline, and venlafaxine. Treatment groups received 8 to 20 sessions of manual-based short-term psychodynamic psychotherapy.
To measure depression, the study used a standardized rating scale. The primary scale is a clinician-rated scale in which a trained professional interviews the patient and scores symptoms based on a structured rubric. They also looked at self-report questionnaires in which patients rate their own depression, anxiety, and general health without clinician input.
Researchers found that at the end of the treatment program, antidepressants were slightly more effective than psychodynamic therapy at reducing symptoms of depression. This unique benefit was only seen for clinician-rated symptom scales. The effect size, which measures the magnitude of the difference between the two groups, was relatively small.
By examining questionnaires filled out by patients themselves, researchers found no significant differences between the two treatments. Patients in both groups reported similar improvements in depression, anxiety, and overall physical health. Follow-up assessments conducted several months after the end of treatment also showed no significant differences between the groups.
“The main takeaway is that short-term psychodynamic psychotherapy is an effective treatment for depression, with outcomes roughly equivalent to antidepressant treatment,” Winicke told SciPost.
The main goal of this study was to find out whether certain characteristics make one treatment better than the other. The scientists tested several potential moderators, including gender, age, and education. They found that the severity of a person’s depression before starting treatment played an important role in outcome.
Both treatments were equally effective for participants with less severe initial depression. For participants who started with more severe depression, antidepressants tended to reduce symptoms to a greater extent than psychodynamic therapy.
“The findings themselves were broadly consistent with current treatment guidelines,” Winicke added. “We found indications that antidepressants may be preferable to short-term psychodynamic psychotherapy for patients with high baseline depression severity.”
Researchers suggest that severe depression may make the deep introspection required for psychodynamic therapy difficult for patients. People with severe depression may lack the energy or emotional fortitude to cope with past painful experiences in the short term. In contrast, drug therapy works at a biological level and does not require patients to actively process difficult emotions in order to begin to experience relief.
While the study provides detailed insights into the treatment of depression, the researchers cautioned against drawing sweeping conclusions. “The differences observed between antidepressants and short-term psychodynamic psychotherapy were small, although statistically significant,” Winicke cautioned. “As a practical matter, this should not be interpreted as indicating that antidepressants are clearly or generally superior to STPP for all patients.”
Professor Winnicke emphasized that “small significant differences in observer-rated depressive symptoms should not be interpreted too broadly.” There are several limitations to keep in mind when evaluating research. The total number of participants in the analysis was relatively modest for a meta-analysis of individual participant data. Larger sample sizes may be needed to detect how these treatments work over time, especially subtle differences during the follow-up phase.
The diversity of participants was also limited. The sample consisted primarily of middle-aged women from middle- to high-income countries. Men, individuals from different cultural backgrounds, or people from low-income countries may respond differently to these particular treatments.
The study also relied on older clinical trials, with the most recent data coming from studies conducted more than a decade ago. Psychiatric treatments and the specific antidepressants prescribed may evolve over time. Some of the original trials also had methodological flaws, such as clinicians assessing patients not knowing which treatments patients were receiving, which could intentionally or unintentionally influence symptom ratings.
The practical impact of the findings must also be kept in mind. When researchers looked at the difference in raw scores on clinician-rated depression scales, the advantage for antidepressants was less than two points. Many experts argue that a difference of 3 to 8 points is needed for patients to see meaningful changes in their daily lives.
The authors cautioned against interpreting the findings as hard and fast rules for treating severe depression. The relationship between initial depression severity and medication success is an observation based on historical data. Validation by new large-scale clinical trials specifically designed to test this severity relationship is required.
Future research should continue to investigate how differences in patient characteristics influence treatment success. Identifying these patterns will help advance the field of personalized medicine in mental health care. “The clinically important question is not which treatment is best on average, but which treatment is best for which patients,” Dr. Winnicke said.
“We are currently working on a similar project comparing short-term psychodynamic psychotherapy with cognitive behavioral therapy, one of the most commonly used psychotherapies for depression,” Winicke said of future plans. “Our team is also working on projects aimed at better predicting who is most likely to drop out of treatment, who is likely to relapse after treatment ends, and how clinical predictive models can be used to improve depression treatment choices.”
The study, “Antidepressant treatment or short-term psychodynamic psychotherapy for depression? A systematic review and meta-analysis of individual participant data,” was authored by Frederik J. Wienicke, Jack JM Dekker, Jaap Peen, Henricus L. Van, Jacques P. Barber, Kevin S. McCarthy, Nili Solomonov, Hasse Karlsson, and Jarmo. Hietala, Jaime López Rodriguez, Valerio Villamil Salcedo, William J. Burke, Jan Spiker, Jos W. R. Tusk, Zachary D. Cohen, Pim Kuypers, Ellen Driessen.
