Dismissed for decades, psychodynamic therapy shows gains in schizophrenia that grow over three years
STUDY: Montag C et al, Lancet Psychiatry 2026
STUDY TYPE: Randomized controlled trial
FUNDING: Berlin Institute of Health and other German academic and nonprofit foundations
Background
Psychodynamic psychotherapy for schizophrenia fell out of use in the 1950’s and 1960’s, replaced by antipsychotics. Its fate was sealed in a 2001 meta-analysis that found no benefit with this insight-oriented approach. But while it may not treat core psychotic symptoms, what about functioning? That was the primary outcome in this, the first adequately powered trial to test it.
Inside the Therapy
Modified Psychodynamic Psychotherapy for Schizophrenia (MPP-S) was designed to address relationship problems common to schizophrenia-spectrum disorders. Rather than initially interpreting unconscious conflict or psychotic experience, it aims to strengthen functioning through mentalising, affect regulation, and self-other differentiation. The therapeutic relationship is used as a catalyst for change. As patients functioning improves, classic psychodynamic techniques are introduced and continuously adapted to the patient’s capacities.
The manual is in German.
The Study
- 130 Berlin outpatients aged 18-64 with schizophrenia or schizoaffective disorder, randomized to weekly psychodynamic therapy (30-plus sessions) plus usual care, or usual care alone.
- Assessed at baseline, 24-month post-treatment, and 36-month follow-up; 129 analyzed by intention to treat.
- Primary outcome: psychosocial functioning (Mini-ICF-APP), plus positive and negative symptoms.
Results
Psychosocial functioning improved more with therapy at post-treatment (effect size 0.70) and continued improving by 36 months (effect size 0.93). Negative symptoms improved similarly (0.83 and 1.07).
Therapy improved general psychopathology at post-treatment but not follow-up; positive symptoms and depression didn’t differ between groups.
Side Effects
No differences between groups.
Limitations
High drop out rate at 36 months; lack of blinding; usual care wasn’t matched for contact time.
Practice Implications
- This is the first adequately powered randomized trial of manualized psychodynamic therapy in schizophrenia. Although it did not treat psychotic symptoms directly, it brought other gains that grew over three years.
- Consider it as an add-on for stable outpatients with negative symptoms.
—Chris Aiken, MD
Director, Psych Partners
Editor in Chief, Carlat Psychiatry Report
