Mood Disorders Psychodynamic Psychotherapy Evidence Review

Quick reference guide

Key recommendations

Recommendation 1: Long-Term Psychodynamic Psychotherapy (LTPP) is an empirically supported treatment option for depression.

Based on contemporary, rigorous evaluative standards, LTPP warrants a “strong recommendation” for reducing depressive symptoms. This conclusion is supported by high- and moderate-certainty evidence of clinically meaningful benefits across all eligible trials and in comparisons with other active treatments. LTPP warrants a weak recommendation when compared with active control conditions, reflecting lower certainty arising principally from imprecision and limited available evidence. There is currently insufficient evidence to determine whether effectiveness varies according to the specific LTPP approach, treatment format, duration or intensity, or patient comorbidity.

Clinicians should discuss LTPP as a credible treatment option, particularly where longer-term treatment may be appropriate. Furthermore, clinical practice guidelines should recognise LTPP as an empirically supported treatment for depressive disorders, including complex presentations, and relevant care pathways should be encouraged to provide access to it.

Recommendation 2: Develop and validate patient-selection methods for LTPP.

As with other psychotherapy approaches, current evidence cannot yet support robust conclusions about which individuals are likely to benefit more from LTPP than from shorter-term or alternative treatments, despite evidence that LTPP is effective at the group level. Therefore, research into the development and validation of patient-selection methods is needed. Comorbid personality difficulties—particularly longstanding interpersonal and relational problems—are a leading candidate predictor of greater benefit and should be prioritised for investigation. Other potential predictors include developmental or attachment-related trauma, illness chronicity, previous negative treatment response, treatment preference, and the capacity to engage in sustained therapy. However, until adequately tested, these factors should not be treated as validated patient-selection criteria.

Recommendation 3: Establish clear pathways for earlier consideration of intensive psychotherapy.

In this report, patients often described receiving multiple psychological and pharmacological interventions before accessing LTPP, typically without feeling that their underlying difficulties had been adequately addressed. Therapists similarly described LTPP currently as a “last-resort” treatment, offered only after other approaches had failed. However, the burdens of stepped care are not evenly distributed: people with the most complex needs are more likely to experience repeated non-response and therefore bear the greatest cumulative burden of delayed escalation, prolonged distress, repeated treatment exposure, and associated costs. In some cases, apparent “treatment resistance” may reflect treatments that were inadequately matched or insufficiently dosed for the person’s needs, including psychotherapy that was too brief to address longstanding difficulties.

People should not be required to demonstrate poor response to multiple treatments before more intensive psychotherapy is considered. Care pathways should include predefined review points at which persistent non-response, recurrent relapse, or indicators of clinical complexity prompt specialist assessment of whether a more intensive psychotherapy, including LTPP, is appropriate, rather than continued cycling through brief interventions and medication trials. Research is urgently needed to determine whether earlier, stratified escalation to LTPP improves outcomes, reduces overall time spent in treatment, and is more cost-effective than usual stepped-care pathways.

Recommendation 4: Provide clear orientation and collaborative planning at the outset of LTPP.

Some types of LTTP are characterised by therapeutic neutrality, abstinence and non-directiveness. However, participants in the primary interview study and across the published qualitative literature described the early stages of these types of LTPP as marked by uncertainty and confusion, and at times as anxiety-provoking and frustrating. Some therapists described comparable difficulties, including patients experiencing silence and neutrality as frightening or invalidating. Before sufficient safety and trust have been established, some consumers—particularly those with complex presentations or pronounced difficulties establishing trust—may struggle to tolerate or benefit from a highly abstinent stance or interpretive interventions.

At the outset, clinicians should therefore explain how LTPP works, the respective roles of patient and therapist, its non-directive features and emotional demands, and how progress and treatment continuation will be reviewed. Although preparatory psychoeducation has sometimes been resisted within the psychodynamic tradition, evidence suggests it can be incorporated without compromising core principles. Pre-treatment or introductory orientation, collaborative planning and normalisation of the adjustment period may ease early anxiety, support engagement and help prevent premature dropout.

Recommendation 5: Support appropriate involvement of carers and personal support networks.

Carers described uncertainty about the therapeutic process, feeling excluded from care, and bearing substantial emotional and financial burdens while remaining “in the dark.” Although these concerns are not unique to psychodynamic therapy, they may be particularly salient in LTPP because its intensity, relational focus and confidential nature can leave carers supporting treatment over extended periods with limited information.

Where appropriate and with the patient’s consent, carers and other members of the patient’s support network should receive general information about LTPP, its expected course, practical and financial demands, confidentiality boundaries, and how they can support the patient. Consistent with wider psychiatric practice emphasising shared decision-making and involvement of the patient’s support network in treatment, clinicians and services should establish clear routes through which carers can raise concerns and, where clinically appropriate, contribute to safety and treatment planning while respecting confidentiality boundaries.

Services should also recognise carers’ own support needs and provide or signpost appropriate assistance. Psychoeducation, transparent communication and appropriate involvement may reduce the uncertainty and emotional burden of supporting someone while preserving the therapeutic frame and patient autonomy.

Target audience

This resource is primarily for psychiatrists, psychologists, psychotherapists, and other mental health professionals involved in the assessment and treatment of patients experiencing depression. In particular, it is relevant to clinicians working with patients who present with more complex or severe forms of depression, including individuals experiencing persistent or recurrent depressive symptoms, significant comorbidity or limited response to previous treatments. This may include professionals working within specialist mental health and personality disorder services, where patients may present with complex and overlapping psychological difficulties that can complicate the assessment and treatment of depression.

The resource is also relevant to mental health service providers, policymakers, and other stakeholders involved in the development, delivery, and evaluation of psychological treatments for people experiencing complex depression.

In addition, the resource may be of interest to patients experiencing a mood disorder or complex depression, as well as their carers and families. Providing accessible information about the effectiveness of psychotherapy may support patients and their carers to better understand available treatment options and contribute to informed discussions and shared decision-making with mental health professionals.

Implementation considerations

Delineate subgroups at the level of treatment stratification to better identify individuals who may benefit from longer-term interventions such as LTPP. From an implementation perspective, this would require services to have clear and clinically meaningful criteria for identifying patients who may benefit from longer-term psychotherapy. These criteria could consider the chronicity and recurrence of depression, the presence of comorbid personality disorder or other mental health conditions, previous treatment history, level of psychosocial impairment, and response to shorter-term interventions. Establishing clear stratification processes may also support more efficient allocation of specialist resources by directing longer-term interventions towards patients for whom they are most appropriate.

Implementation may also involve providing information about LTPP for psychiatrists, psychologists, GPs, and other mental health professionals regarding relevant services, referral criteria, eligibility requirements, and available treatment options. This could include incorporating signposting information into local referral pathways, service directories, and professional education resources. This is particularly important given variation in the availability of specialist psychological services across jurisdictions and between metropolitan, regional, and rural areas.

Related resources

Barrett, A., Campbell, C., Luyten, P., Fonagy, P., & Moser, M. (2026). Patient experiences of long-term psychodynamic psychotherapy for mood and personality disorders: A systematic review and meta-aggregation of qualitative studies. Journal of Counseling Psychology, 73 (1), 101–115. https://doi.org/10.1037/cou0000844

Moser, M., Barrett, A., Luyten, P., Ozols, I., Every-Palmer, S., Fonagy, P., & Campbell, C. (2026). Patient experiences of long-term psychodynamic psychotherapy for mood disorders: A naturalistic semistructured interview study. Psychotherapy, 63 (1), 1–12. https://doi.org/10.1037/pst0000609

Moser, M., Barrett, A., Woll-Weber, Christian F. J., Fonagy, P., Luyten, P., & Campbell, C. (2026). Long-term psychodynamic psychotherapy for depression: A systematic review and meta-analysis of randomized controlled trials. Depression and Anxiety (Forthcoming)

Kudos summary - Patient Experiences of Long-Term Psychodynamic Psychotherapy for Mood Disorders: A Naturalistic semistructured Interview Study