The Efficacy Of Psychodynamic Psychotherapy For Young Adults: Systematic Review & Meta-Analysis

Psychodynamic psychotherapy is a therapeutic approach that explores unconscious thoughts, feelings, and past experiences to understand current behaviors and relationships.

It works by helping individuals gain insight into their inner conflicts, defense mechanisms, and recurring patterns.

Through a supportive therapeutic relationship, clients can process unresolved issues and develop healthier coping strategies.

This approach may be particularly helpful for young adults as they navigate identity formation, relationships, and life transitions, allowing them to address underlying issues that may be impacting their mental health and personal growth.

Trotta, A., Gerber, A. J., Rost, F., Robertson, S., Shmueli, A., & Perelberg, R. J. (2024). The efficacy of psychodynamic psychotherapy for young adults: a systematic review and meta-analysis. Frontiers in Psychology, 15, 1366032. https://doi.org/10.3389/fpsyg.2024.1366032

Key Points

• The primary methods of evaluating psychodynamic psychotherapy for young adults include randomized controlled trials (RCTs) comparing psychodynamic therapy to other treatments or control conditions, as well as naturalistic studies examining outcomes in clinical settings.
• Factors like type of psychodynamic intervention, treatment duration, mental health diagnosis, and comparison condition significantly affect the measured outcomes and efficacy of psychodynamic therapy for young adults.
• This research has certain limitations such as high heterogeneity between studies, small sample sizes in many trials, and potential researcher allegiance bias.
• Psychodynamic psychotherapy appears to be an effective treatment option for young adults with various mental health issues, comparable to other established therapies and superior to control conditions. This is important given the high prevalence of mental health problems emerging in young adulthood.

Rationale

This systematic review and meta-analysis aimed to address the paucity of research on psychodynamic psychotherapy specifically for young adults transitioning from adolescence to adulthood.

The rationale for focusing on this age group includes:

• Around 75% of mental health disorders have their onset in young adulthood (Auerbach et al., 2018; Kessler et al., 2005).
• Young adults have higher prevalence of mental health problems compared to children and adults (Patel et al., 2007).
• There is limited evidence on effective treatment options specifically for young adults with mental health issues.
• Previous meta-analyses have focused on psychodynamic therapy for children or adults, but not specifically the young adult population (Abbass et al., 2013; Midgley et al., 2021; Steinert et al., 2017).
• Young adulthood (ages 18-27) is a critical developmental period involving identity formation and transition to adult roles and responsibilities (Arnett, 2011).
• Effective interventions in young adulthood could prevent long-term adverse consequences of untreated mental health problems.

The next step identified by the authors was to systematically review the existing evidence on psychodynamic therapy for young adults and conduct a meta-analysis to evaluate its efficacy compared to other treatments and control conditions.

Method

The authors conducted a systematic review and meta-analysis adhering to PRISMA guidelines. The study protocol was pre-registered on PROSPERO (ID: CRD42020169233).

Search strategy and terms:

• Databases searched: Ovid, Embase, PubMed, PsychINFO, and Cochrane
• Search terms included variations of “young adult”, “youth”, mental health terms (e.g. “psychiat*”, “mental*”), and psychoanalytic treatment terms
• Initial search conducted January 2020, updated July 2023
• Manual screening of relevant textbooks, systematic reviews, meta-analyses, and reference lists
• Consultation with field experts

Inclusion and exclusion criteria:

Inclusion:

• Studies of psychodynamic or psychoanalytic psychotherapies
• Published in English in peer-reviewed journals
• Subjects aged 18-27 years at start of therapy
• Receiving treatment for mental health issues
• RCTs, quasi-experimental studies, and naturalistic evaluations
• Quantitative outcome measures at baseline and follow-up

Exclusion:

• Studies of organic mental disorders
• No quantitative outcome measures

Statistical measures:

• Random effects meta-analysis model
• Calculated standardized mean differences (SMD) with 95% confidence intervals
• Heterogeneity assessed with Cochran’s Q test and I2 statistic
• Meta-regression to test effects of potential moderator variables
• Egger’s test to assess publication bias
• Sensitivity analyses to examine effects at follow-up and impact of outliers

Results

Study characteristics:

• 22 eligible studies identified (14 RCTs, 8 naturalistic studies)
• Total of 2,649 young adult participants
• Studies conducted mainly in Europe (n=14), with others from Asia (n=6), Australia (n=1), and Canada (n=1)
• Mental health conditions included emotional disorders, eating disorders, personality disorders, and psychosis
• Interventions ranged from brief (4 sessions) to long-term (up to 8 years) psychodynamic therapies

Quality assessment:

• RCTs: Average quality score of 33.4/48 on RCT-PQRS scale
• 8 RCTs rated as good or exceptionally good quality
• Naturalistic studies: Majority rated as “fair” quality, with one rated as “good”
• Common quality concerns: high attrition rates, lack of blinding

Meta-analysis results:

1. Psychodynamic therapy vs other treatments:

• No significant difference in efficacy: SMD = -0.341 (95% CI: -0.991 to 0.309), p = 0.304
• High heterogeneity between studies (I2 = 95%)

2. Psychodynamic therapy vs control conditions:

• Significant positive effect: SMD = -1.24 (95% CI: -1.97 to -0.51), p < 0.001
• Effect maintained but attenuated at follow-up: SMD = -0.75 (95% CI: -1.53 to 0.03), p < 0.001

Narrative synthesis of outcomes:

• Clinical symptoms: Significant reductions in general psychopathology, depression, anxiety, and eating disorder symptoms
• Recovery/relapse: Mixed findings, with some studies showing maintained improvements and others finding effects diminished over time
• Psychosocial functioning: Some evidence of improved social functioning, but effects not always maintained long-term
• Personality structure: Improvements in personality organization, defensive functioning, and borderline personality disorder severity
• Interpersonal relationships: Positive changes in reflective functioning, interpersonal problems, and therapeutic alliance

Moderator analyses:

• No significant impact of moderator variables (e.g. publication year, study quality, participant age, diagnosis) on effect sizes

Publication bias:

• No evidence of bias for studies comparing psychodynamic therapy to other treatments
• Some evidence of bias in studies comparing to control conditions

Insight

This systematic review and meta-analysis provides important insights into the efficacy of psychodynamic psychotherapy for young adults:

1. Comparable efficacy to established treatments: The finding that psychodynamic therapy shows no significant difference in efficacy compared to other evidence-based treatments (e.g. CBT) suggests it is a viable treatment option for young adults with various mental health issues.
2. Superior to control conditions: The large effect size (SMD = -1.24) favoring psychodynamic therapy over control conditions indicates it is significantly more effective than no treatment or treatment as usual for young adults.
3. Broad range of outcomes: The review highlights that psychodynamic therapy can improve not just symptoms, but also psychosocial functioning, personality organization, and interpersonal relationships in young adults.
4. Maintained effects: While somewhat attenuated, the positive effects of psychodynamic therapy were generally maintained at follow-up, suggesting lasting benefits.
5. Developmental considerations: By focusing specifically on the 18-27 age range, this study addresses an important developmental period often overlooked in previous research.

These findings extend previous research by:

• Providing the first comprehensive review of psychodynamic therapy specifically for young adults
• Demonstrating efficacy across a range of mental health conditions relevant to this age group
• Highlighting the potential of psychodynamic approaches to address both symptom reduction and broader psychosocial outcomes

Future research directions:

• Conduct more high-quality RCTs with larger sample sizes to reduce heterogeneity and increase confidence in findings
• Investigate moderators of treatment efficacy (e.g. specific diagnoses, treatment duration) to optimize interventions for young adults
• Examine long-term outcomes and cost-effectiveness of psychodynamic therapy for young adults
• Compare different psychodynamic approaches (e.g. brief vs. long-term) for specific presenting problems in young adults
• Explore mechanisms of change in psychodynamic therapy with this age group

Strengths

The study had many methodological strengths including:

1. Comprehensive search strategy: The authors used multiple databases, manual screening, and expert consultation to identify relevant studies.
2. Adherence to guidelines: The review followed PRISMA guidelines and pre-registered the protocol, enhancing transparency and rigor.
3. Inclusion of diverse study designs: By including both RCTs and naturalistic studies, the review captures a broad range of evidence.
4. Quality assessment: The use of standardized tools to assess study quality provides important context for interpreting findings.
5. Sophisticated statistical analysis: The meta-analysis used appropriate methods, including random effects models and tests for heterogeneity and publication bias.
6. Focus on young adult population: By specifically examining the 18-27 age range, the study addresses an important gap in the literature.
7. Examination of multiple outcomes: The review considered a wide range of outcomes beyond just symptom reduction, providing a more comprehensive picture of treatment effects.

Limitations

The authors acknowledge several limitations of the study:

1. Small number of eligible studies: Only 22 studies met inclusion criteria, with just 14 RCTs included in the meta-analysis, limiting generalizability.
2. High heterogeneity: There was significant variability between studies in terms of interventions, populations, and outcome measures, making direct comparisons challenging.
3. Potential bias: Some evidence of publication bias was found for studies comparing psychodynamic therapy to control conditions.
4. Focus on short-term interventions: Most included studies examined relatively brief psychodynamic treatments, which may not reflect typical clinical practice.
5. Limited geographical representation: The majority of studies were conducted in European countries, potentially limiting generalizability to other cultural contexts.
6. Lack of control for researcher allegiance: The authors could not account for potential bias stemming from researchers’ theoretical orientations.
7. Variable study quality: While some studies were high quality, others had methodological limitations like high attrition rates or lack of blinding.

These limitations impact the strength of conclusions that can be drawn and highlight the need for further high-quality research in this area.

Implications

The findings of this systematic review and meta-analysis have several important implications:

1. Treatment options for young adults: Psychodynamic therapy appears to be an effective treatment option for young adults with various mental health issues, comparable to other evidence-based approaches. This provides support for offering psychodynamic interventions as part of a range of treatment options for this age group.
2. Addressing developmental needs: The focus on young adulthood highlights the importance of tailoring interventions to the specific developmental challenges of this transitional period.
3. Holistic outcomes: The positive effects of psychodynamic therapy on both symptom reduction and broader psychosocial functioning suggest it may be particularly well-suited to addressing the complex needs of young adults.
4. Clinical practice: Clinicians working with young adults should consider psychodynamic approaches as a viable treatment option, particularly for those who may benefit from exploring interpersonal patterns, identity issues, and underlying psychological conflicts.
5. Service provision: Mental health services for young adults should consider incorporating psychodynamic therapies into their treatment offerings, alongside other evidence-based approaches.
6. Research priorities: The limitations identified highlight the need for more high-quality studies specifically examining psychodynamic therapy for young adults, including larger RCTs and long-term follow-up studies.
7. Training and education: The findings support the continued inclusion of psychodynamic approaches in clinical training programs for those working with young adult populations.
8. Policy implications: Given the high prevalence of mental health problems in young adulthood and the potential long-term consequences of untreated issues, these findings support investment in accessible, evidence-based psychotherapy services for this age group.

Variables influencing results:

• Type and duration of psychodynamic intervention
• Specific mental health diagnosis being treated
• Comparison condition (e.g. other active treatment vs. control)
• Cultural context and healthcare system
• Individual patient characteristics (e.g. severity of symptoms, motivation for treatment)

References

Primary reference

Trotta, A., Gerber, A. J., Rost, F., Robertson, S., Shmueli, A., & Perelberg, R. J. (2024). The efficacy of psychodynamic psychotherapy for young adults: a systematic review and meta-analysis. Frontiers in Psychology, 15, 1366032. https://doi.org/10.3389/fpsyg.2024.1366032

Other references

Abbass, A. A., Rabung, S., Leichsenring, F., Refseth, J. S., & Midgley, N. (2013). Psychodynamic psychotherapy for children and adolescents: A meta-analysis of short-term psychodynamic models. Journal of the American Academy of Child & Adolescent Psychiatry, 52(8), 863-875. https://doi.org/10.1016/j.jaac.2013.05.014

Arnett, J. J. (2010). Emerging adulthood (s). Bridging cultural and developmental approaches to psychology: New syntheses in theory, research, and policy, 255-275.

Auerbach, R. P., Mortier, P., Bruffaerts, R., Alonso, J., Benjet, C., Cuijpers, P., … & Kessler, R. C. (2018). WHO world mental health surveys international college student project: Prevalence and distribution of mental disorders. Journal of abnormal psychology, 127(7), 623.

Kessler, R. C., Berglund, P., Demler, O., Jin, R., Merikangas, K. R., & Walters, E. E. (2005). Lifetime prevalence and age-of-onset distributions of DSM-IV disorders in the National Comorbidity Survey Replication. Archives of general psychiatry, 62(6), 593-602.

Midgley, N., Mortimer, R., Cirasola, A., Batra, P., & Kennedy, E. (2021). The evidence-base for psychodynamic psychotherapy with children and adolescents: A narrative synthesis. Frontiers in psychology, 12, 662671. https://doi.org/10.3389/fpsyg.2021.662671

Patel, V., Flisher, A. J., Hetrick, S., & McGorry, P. (2007). Mental health of young people: a global public-health challenge. The lancet, 369(9569), 1302-1313.

Steinert, C., Munder, T., Rabung, S., Hoyer, J., & Leichsenring, F. (2017). Psychodynamic therapy: as efficacious as other empirically supported treatments? A meta-analysis testing equivalence of outcomes. American Journal of Psychiatry, 174(10), 943-953. https://doi.org/10.1176/appi.ajp.2017.17010057

Keep Learning

Socratic questions for a college class to discuss this paper

1. How might the developmental challenges specific to young adulthood impact the effectiveness of psychodynamic therapy for this age group?
2. What are the potential advantages and disadvantages of brief vs. long-term psychodynamic interventions for young adults?
3. How do the outcomes measured in these studies align with the theoretical goals of psychodynamic therapy? Are there important outcomes that may have been overlooked?
4. Given the high heterogeneity between studies, what factors should future researchers prioritize in designing more comparable trials?
5. How might cultural differences influence the applicability of these findings across different countries and healthcare systems?
6. What ethical considerations arise when conducting psychotherapy research with young adults, particularly those with severe mental health issues?
7. How do the findings of this review challenge or support common perceptions about the efficacy of psychodynamic therapy compared to other treatment approaches?
8. In what ways might psychodynamic therapy be particularly well-suited (or ill-suited) to addressing the mental health needs of today’s young adults?
9. How should clinicians integrate the findings of this review with their own clinical experience and patient preferences when making treatment decisions?
10. What are the potential societal implications of investing in psychodynamic therapy services for young adults, considering both costs and potential long-term benefits?