Around 8-12% of the general population experiences multiple childhood adversities, including abuse or neglect, typically within the caregiving environment. These early-life traumas often lead to chronic, recurrent depressive episodes that ‘resist’ traditional treatments, deeply impacting one’s sense of safety and ability to form relationships (Rokita et al., 2018).
The empirical literature has been inconclusive about which therapeutic intervention works best for this clinical population, particularly regarding long-term treatments (e.g. Fonagy et al., 2015; Leuzinger et al., 2019). While some evidence suggests that patients with family-related trauma respond better to psychodynamic approaches compared to solution-focused therapy, more research is needed.
The large trial of long-term psychotherapies for chronic depression, known as the LAC Study (Krakau et al., 2024), investigated whether psychoanalytic therapy (PAT) might be more effective than cognitive-behavioural therapy (CBT) for chronic depression patients with a history of trauma. Each intervention focused on different elements; PAT aims to understand symptoms within disrupted developmental processes, addressing unconscious conflicts within the therapeutic relationship itself, while CBT targets cognitive dysfunctions and irrational beliefs resulting from past trauma, focusing on symptom management through specific skills and techniques. Both interventions aim to promote long-lasting changes to depressive symptoms in the ‘here and now’ that may stem from childhood adversities.
The authors of this study hypothesised that PAT’s specific treatment focus on addressing early disruptions through exploring life narratives and past experiences and its longer duration might be particularly beneficial for this group compared to CBT.
Can psychoanalytic therapy better address the deep-rooted impact of childhood trauma on chronic depression than CBT?
Methods
The Outcomes of Long-term Psychotherapies of Chronically Depressed Patients (LAC) study was a multicentre, controlled, single-blind 4-arm trial, with separate sections for randomised participants and those who were assigned according to preference of which psychotherapy modality they wished to receive. The study was conducted across 4 study centers in Germany (Frankfurt, Mainz, Berlin and Hamburg) and examined 252 participants aged 21-60 with chronic depression. Outcome measures included yearly assessments of depressive symptoms over five years using the Beck Depression Inventory-II and Quick Inventory of Depressive Symptomatology Clinician Rating for assessment. Childhood trauma was measured using the Childhood Trauma Questionnaire (CTQ).
Psychoanalytic Therapy (PAT)
PAT focused on addressing embodied memories and early trauma, working through unconscious conflicts within the therapeutic relationship. The approach recognises how childhood trauma affects safety and trust, using transference to facilitate healing.
Cognitive-Behavioural Therapy (CBT)
CBT followed an established protocol with five key modules, including behavioural activation, cognitive restructuring, and social skill training. The approach targeted threat-related processing and emotional reactivity in the context of trauma.
Participants could either choose their treatment or be randomised to either therapeutic modality, so this was not a standard randomised controlled trial, but rather a partially randomised patient preference trial. Treatment length varied significantly, with CBT comprising up to 80 sessions and PAT extending to 300 sessions under insurance coverage. Both treatments demonstrated strong adherence to their respective therapeutic approaches.
Results
From an initial cohort of 554 participants who underwent diagnostic interviews, 252 were included in the intention-to-treat sample and 210 participants were included in the final analysis with exclusions made due to missing data. Linear mixed-effects models were used to analyse the interaction between therapy type, childhood trauma, and time on depressive symptom changes. The analysis accounted for baseline depression severity and therapy dose.
The study revealed patterns in the types of early traumatic experiences among participants. Emotional neglect emerged as the most prevalent form of childhood trauma, affecting 53.6% of participants, followed by emotional abuse at 42.5%. Physical neglect was reported by 31.7%, while sexual abuse and physical abuse were experienced by 24.6% and 15.5% of participants, respectively.
Both CBT and PAT demonstrated significant reductions in depressive symptoms over time. The treatment length varied markedly between approaches, with median session numbers at 242 for PAT compared to CBT’s 59. The analysis revealed that while both treatments showed similar effectiveness for patients with lower trauma levels, PAT demonstrated superior outcomes for those with higher levels of childhood trauma, which was demonstrated by a significant three-way interaction between time, treatment type and CTQ (Childhood Trauma Questionnaire) levels on changes in depressive symptoms (p = 0.016). Furthermore, within the PAT treatment group, participants with higher trauma levels showed more substantial improvement over time, suggesting that PAT’s approach may be especially beneficial for individuals whose depression is rooted in significant childhood adversity. Analysing the subscales of the CTQ separately, a significant interaction was found for the sexual abuse (p = 0.016) and family inconsistency (p = 0.019) subscales of the CTQ. A trend for the models testing physical abuse (p = 0.080) and physical neglect (p = 0.053) was observed, but neither reached significance.
These results suggest that PAT (psychoanalytic therapy) may be more helpful to patients who have experienced specific types of trauma in their childhoods.
The research faced substantial participant drop out over its five-year course, with missing data ranging from 26.58% in year one to 52.38% by year four. Sensitivity analyses largely confirmed the main findings, particularly regarding the overall trauma score. At the five-year mark, 17 PAT participants and one CBT participant were still receiving treatment, reflecting the longer-term nature of psychoanalytic therapy.
Psychoanalytic therapy showed greater long-term benefits than CBT, especially for individuals with histories of sexual abuse and family instability.
Conclusions
This study provides evidence that patients with higher levels of childhood trauma may benefit more from psychoanalytic therapy than cognitive-behavioural therapy over a five-year period. However, the confounding effect of treatment intensity and methodological limitations suggest these findings should be replicated in studies with more comparable treatment doses. Future research should focus on disentangling the effects of treatment modality from treatment intensity.
Adults with chronic depression and experiences of childhood trauma respond differently to long-term psychoanalytic and cognitive behavioural therapy.
Strengths and limitations
This study stands out for its comprehensive comparison of two major therapeutic approaches within a single trial, using consistent measurement points and instruments. It is commendable to conduct such a far-reaching longitudinal study into treatment effects. The long-term follow-up period of five years provides valuable insights into treatment sustainability. The inclusion of both randomised and preference-based treatment allocation enhances ecological validity, reflecting real-world clinical practice, however, certain limitations also arise from this – to be discussed in the limitations section next.
Several limitations warrant careful interpretation of the results. The substantial difference in session numbers between PAT (242 sessions) and CBT (59 sessions) makes it difficult to determine whether outcomes are attributable to treatment modality or simply treatment intensity. While the study hypothesised that PAT’s focus on life narratives and past experiences would be more beneficial for trauma survivors, the significantly higher number of PAT sessions confounds this interpretation – improved outcomes could simply reflect more intensive treatment rather than the specific therapeutic approach.
The high attrition rate (52.38% by year 4) raises concerns about selection bias and the representativeness of the final sample. The missing data was accounted for with the missing at random assumption, which could be problematic as often data is not missing at random. This is increasingly likely given the complexity of the design, long duration of the study and the recruitment of a patient population that tends to be resistant to treatment, which could all be factors to missing data not occurring at random.
The trial was a single-blind trial where participants could indicate their preference of treatment group, which has implications for interpreting results. This resulted in the PAT preference group (N = 101) being larger than the CBT preference group (N = 63). Where participants did not indicate a preference, they were randomised into the groups so that the ‘randomised to intervention’ samples were of more equal size. The post-hoc nature of the trauma analysis suggests these findings weren’t part of the original study design. The trial was originally intended as a chronic depression study rather than a chronic depression related to childhood trauma study. While the baseline levels of childhood trauma were comparable between the groups, this was not stratified during the randomisation process.
Additionally, the reliance on self-reported childhood trauma, while pragmatic, may be subject to recall bias. Finally, the merging of randomised and preference-based treatment groups, though statistically justified, could mask important differences in patient characteristics and treatment engagement. Participants’ ability to choose their treatment allocation could impact their engagement levels, but also potentially their treatment expectations.
The large difference in therapy session numbers complicates interpretation, yet the study’s five-year follow-up provides rare insights into long-term treatment effects.
Implications for practice
This study offers important insights for personalising treatment approaches for chronic depression, particularly for individuals with childhood trauma histories. The findings suggest that psychoanalytic therapy may be beneficial for patients with significant childhood trauma, especially those reporting sexual abuse and family inconsistency experiences.
The results challenge the current “one-size-fits-all” approach to depression treatment. While both CBT and PAT showed effectiveness, the superior outcomes of PAT for trauma survivors suggest that trauma history should be considered in treatment planning. This could inform how we prioritise referrals and allocate limited psychotherapy resources.
The study raises important questions about healthcare coverage and session limits. The significant difference in session numbers between PAT (242) and CBT (59) highlights the need to consider longer-term therapeutic approaches when clinically indicated. The superior outcomes for trauma survivors in PAT suggest that limiting coverage to brief interventions may be counterproductive for this population.
Indeed, in another paper I covered for the Mental Elf, the cost-effectiveness of long-term psychoanalytic psychotherapy for treatment-resistant depression was deemed low, while it was acknowledged that the current typical evaluation timeframes may be too short to capture the full benefits of psychoanalytic therapy. This study sheds light onto some of those benefits, and where the costs may be increasingly worthwhile. The evidence suggests that while PAT requires greater initial investment, its potential for reducing long-term healthcare utilisation and improving sustained outcomes for trauma survivors could make it the most valuable treatment option long-term.
This study validates the clinical intuition that some patients need more than symptom management – they need space to process and integrate their traumatic experiences within a secure therapeutic relationship. However, the significant time commitment and costs required for PAT do raise practical challenges in many healthcare settings as covered in my previous blog.
The findings suggest a need to balance evidence-based practice with personalized care. While CBT remains a valuable treatment option, the availability of longer-term psychoanalytic approaches should be preserved and supported by healthcare systems, particularly for patients with significant trauma histories. Further research addressing the study’s current limitations is needed to investigate how adequate blinding and matching the number of sessions in the therapy conditions impacts these results and their implications, so we can better understand what truly are driving symptom improvements in those with ‘treatment-resistant depression’ and a history of trauma.
Considering trauma history in treatment planning could improve outcomes, highlighting the need for greater access to long-term psychoanalytic therapy for trauma survivors.
Links
Primary paper
Krakau, L., Ernst, M., Hautzinger, M., Beutel, M. E., & Leuzinger-Bohleber, M. (2024). Childhood trauma and differential response to long-term psychoanalytic versus cognitive–behavioural therapy for chronic depression in adults. The British Journal of Psychiatry, 1-8.
Other references
Fonagy, P., Rost, F., Carlyle, J. A., McPherson, S., Thomas, R., Pasco Fearon, R. M., … & Taylor, D. (2015). Pragmatic randomized controlled trial of long‐term psychoanalytic psychotherapy for treatment‐resistant depression: the Tavistock Adult Depression Study (TADS). World Psychiatry, 14(3), 312-321.
Koeser, L., Rost, F., Gabrio, A., Booker, T., Taylor, D., Fonagy, P., … & McCrone, P. (2023). Cost-effectiveness of long-term psychoanalytic psychotherapy for treatment-resistant depression: RCT evidence from the Tavistock Adult Depression Study (TADS). Journal of Affective Disorders, 335, 313-321.
Leuzinger-Bohleber, M., Hautzinger, M., Fiedler, G., Keller, W., Bahrke, U., Kallenbach, L., … & Beutel, M. (2019). Outcome of psychoanalytic and cognitive-behavioural long-term therapy with chronically depressed patients: a controlled trial with preferential and randomized allocation. The Canadian Journal of Psychiatry, 64(1), 47-58.
Rokita, K. I., Dauvermann, M. R., & Donohoe, G. (2018). Early life experiences and social cognition in major psychiatric disorders: A systematic review. European psychiatry, 53, 123-133.
My previous Mental Elf blog and the paper it covered: https://www.nationalelfservice.net/treatment/psychotherapy/long-term-psychoanalytic-psychotherapy-treatment-resistant-depression/
