Depression not so “Treatment-Resistant” after psychodynamic psychotherapy


A recent study published in Psychotherapy suggests that Intensive Short-Term Psychodynamic Psychotherapy (ISTDP) is an effective treatment for treatment-resistant depression (TRD). The study found that ISTDP had positive results, especially for patients who did not experience relief from depressive symptoms while taking antidepressants.

During the randomized controlled trial (RCT), researchers discovered that ISTDP significantly decreased negative affect and emotional repression, both of which are linked to depression. Additionally, participants continued to experience the benefits of treatment even three months after the trial ended.

“The findings show that ISTDP for TRD’s effect is not limited to depressive symptoms, but that negative affect is more broadly reduced. ISTDP can decrease emotional repression, which is consistent with its presumed working mechanisms,” the authors write. “Together, this indicates that ISTDP might be a promising treatment for TRD. This is of considerable relevance, as TRD is a prevalent disorder associated with significant personal and societal costs, for which other psychotherapies have failed to be shown efficacious relative to treatment-as-usual.”

The study was conducted by Rasoul Heshmati of the University of Tabriz alongside Frederik J. Wienicke and Ellen Driessen from Radboud University’s Behavioural Science Institute.


Psychodynamic psychotherapy continues demonstrating significant effectiveness in treating psychological distress or psychiatric disorders, as termed by biomedical models of treatment. A number of randomized control trials have demonstrated this approach’s effectiveness in reducing symptoms of depression and bipolar disorder, anxiety and panicpost-traumatic stress, psychosomatic problems, and so-called personality disorders. Additionally, meta-analytic studies have confirmed the efficacy of these treatments.

Like other approaches to therapy, psychodynamic psychotherapy has many treatment models, including ISTDP. This model is characterized by its confrontational nature and emotion-focus (rather than symptom focus), in which therapeutic interventions promote the experiencing and processing of unconscious emotions to reduce distress and change behavior. Although previous research has demonstrated the effectiveness of this approach, including for “treatment-resistant” depression, there is limited research on the reduction of negative affect and emotional repression – which are among the theoretical mechanisms of change.

The researchers conducted a randomized control trial to test their theoretical assumptions. The trial involved patients who had not experienced a reduction in depressive symptoms after psychopharmacological treatment. The goal of the trial was to assess the effectiveness of ISTDP in reducing symptoms in this group, as well as reducing negative affect and emotional repression.

In 2020, the team enrolled participants who were adults between 18 and 60 years of age with at least a high school education. These participants met the criteria for Major Depressive Disorder, as per the Diagnostic and Statistical Manual of Mental Disorders (DSM), which was assessed through the Mini-International Neuropsychiatric Interview-Plus.

To participate in the study, individuals had to meet the criteria for treatment-resistant depression, meaning they did not respond to at least one open trial of antidepressants. After screening, 86 participants were selected, with 43 assigned to the experimental group (who would receive treatment) and 43 to the control group (who would not receive treatment).

Two experienced psychotherapists who specialize in Intensive Short-Term Dynamic Psychotherapy (ISTDP) delivered a total of 20 individual sessions twice a week for ten weeks. One therapist treated 22 participants, and the other treated 21 participants. The participants’ sociodemographic information, such as age, gender, marital status, education level, employment status, and socioeconomic status, was collected by the researchers. In addition, the Weinberger Adjustment Inventory (WAI) and Positive and Negative Affect Schedule (PANAS) were used to assess the participants’ depressive symptoms, negative affect, and repressed emotion at baseline, post-treatment, and three months after treatment.

Initially, there were no significant differences between the control and experimental groups. However, the participants who underwent ISTDP treatment showed significantly lower levels of depressive symptoms, emotional repression, and negative affect when compared to the control group. The effect size of the treatment was large in all areas, both immediately after treatment and three months after treatment, when compared to the initial baseline. Additionally, the effect size was significant when comparing changes in depression and emotional repression between the post-treatment and 3-month follow-up.

Regarding negative emotions, the effect size was large both immediately after the treatment and three months after the treatment. However, the effect size was medium between these two time points. These findings indicate that ISTDP has a long-lasting positive impact on the participants even after the treatment has concluded.

These results continue to support evidence of psychodynamic psychotherapy’s effectiveness and highlight the importance and relevance of treatment models that are not symptom-focused, many of which have been proven to be ineffective in the treatment of so-called “treatment-resistant depression.”

Additionally, it presents evidence against the “treatment-resistant” concept, which assumes that patients cannot experience relief from treatment instead of recognizing the limitations and problems of psychiatric treatment.

Through an emotion-focused treatment that involves a deep connection between participant and therapist and seeks to address some of the underlying issues that lead to distress (as opposed to simply reducing symptoms), many patients who have not experienced well-being or a reduction in psychological distress through pharmacological treatment can heal or feel a sense of relief from their suffering.



Heshmati, R., Wienicke, F. J., & Driessen, E. (2023). The effects of intensive short-term dynamic psychotherapy on depressive symptoms, negative affect, and emotional repression in single treatment-resistant depression: A randomized controlled trial. Psychotherapy. Advanced online publication. (Link)


Editor’s note: this post was originally published on our sister site, Mad in America, and is reposted here with permission 

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MIA Research News Team: José G. Luiggi-Hernández is a Clinical Psychology PhD student at Duquesne University with a background in public health. His current research and clinical interests involve understanding the lived experience of colonization using phenomenological, psychoanalytic, and decolonial frameworks. He has previously worked on research related to LGBTQ issues, health behaviors, mindfulness for chronic pain, CBT for diabetes and depression, among other projects.


  1. Thank you for this wonderful article. I will report just one of the thousands of cases where a lady who was prescribed antidepressants for her “treatment-resistant” depression. ISTDP treatment was NOT offered, NOR would it have been beneficial. She died of ovarian cancer.

    Yet, another woman regarded as hysterical, too emotional and labelled. It is the families and friends that need to heal because of the unnecessary, tragic loss of a loved one. Their emotions can have a negative affect and they tend not to repress their emotions at baseline. They are extremely angry and want answers as to why the woman was so severely let down. It may be worth studying how effective Intensive Short-Term Dynamic Psychotherapy is for the family who suffer the bereavement. It is highly likely that they score the same in their post-treatment and 3-month follow-up.