People with schizophrenia and severe mental illness may require considerable support from health care professionals, in most cases over a long period of time. Research on the effects of psychotherapy for schizophrenia has shown mixed results. Although pharmacological interventions remain the treatment of choice, the effects of treatments focusing on psychosocial factors affecting schizophrenia are important.
To review the effects of psychodynamic psychotherapy, psychoanalysis, or both, for people with schizophrenia or severe mental illness.
For the updated review, we searched the Cochrane Schizophrenia Group Trials Register (June 2008) which is based on regular searches of BIOSIS, CENTRAL, CINAHL, EMBASE, MEDLINE and PsycINFO.
We sought all randomised trials of individual psychodynamic psychotherapy or psychoanalysis for people with schizophrenia or severe mental illness.
Data collection and analysis
We extracted data independently. For dichotomous data we calculated relative risks (RR) and their 95% confidence intervals (CI) on an intention-to-treat basis using a fixed-effect model. We calculated numbers needed to treat/harm (NNT/NNH) where appropriate. For continuous data, we calculated mean differences (MD) and weighted mean differences (WMD) using a fixed-effect model.
We included four randomised trials (total 528 participants, 5 comparisons). All used a psychodynamic approach and reported limited data.
For individual psychodynamic therapy versus medication alone we found significantly more participants in the therapy group were unable to be discharged (n=92, RR 8.35 CI 2.0 to 34.3, NNH 3 CI 2 to 6). We found no significant difference between groups in the number of participants who were re-hospitalised (n=24, RR 0.63 CI 0.3 to 1.4) during long-term analyses. At 12 months, fewer participants in the psychotherapy groups needed additional medications compared with those who did receive medication (n=74, RR 0.64 CI 0.5 to 0.8, NNT 3 CI 3 to 6), and also at three years follow up (n=87, RR 0.85 CI 0.8 to 1.0, NNT 7 CI 5 to 26).
For individual psychodynamic therapy plus medication versus medication alone we found no significant difference in suicide (n=92, RR 0.16 CI 0.01 to 2.9) or suitability for discharge (n=92, RR 1.09 CI 0.2 to 7.4). Also, we found re-hospitalisation rates in long-term analyses were equivocal (n=24, RR 1.00 CI 0.4 to 2.6). For insight-orientated psychodynamic psychotherapy versus reality adaptive psychotherapy we found no significant difference in re-hospitalisation rates (n=164, RR 1.20 CI 0.9 to 1.6), but we found study attrition favoured the insight-orientated psychodynamic psychotherapy group at 12 months (n=164, RR 0.46 CI 0.3 to 0.6, NNT 2 CI 2 to 4). For individual psychodynamic psychotherapy versus group psychotherapy we found no significant difference in global state ‘not improved’ (n=100, RR 1.27 CI 1.0 to 1.7). For individual psychodynamic therapy plus medication versus individual psychodynamic therapy we found rates of re-hospitalisation during long-term analyses were equivocal (n=24, RR 1.00 CI 0.4 to 2.6). There is no clear evidence of any positive effect of psychodynamic therapy and the possibility of adverse effects seems never to have been considered. We did not identify any trials using a psychoanalytic approach.
Current data do not support the use of psychodynamic psychotherapy techniques for hospitalised people with schizophrenia. If psychoanalytic therapy is being used for people with schizophrenia there is an urgent need for trials.