Randomized trial on the effectiveness of long- and short-term psychotherapy on psychiatric symptoms and working ability during a 5-year follow-up

Efficacy of systemic therapy on adults with depressive disorders: A meta-analysis

OBJECTIVE

This meta-analysis evaluates the efficacy of systemic therapy approaches on adult clients with depressive disorders.

METHODS

The illness-specific systematic review updates a previous meta-analysis on the efficacy of systemic therapy on psychiatric disorders in adulthood. It integrates the results of 30 randomized controlled trials (RCTs) comparing systemic psychotherapy for depression with an untreated control group or alternative treatments. Studies were identified through systematic searches in relevant electronic databases and cross-referencing. A random-effects model calculated weighted mean effect sizes for each type of comparison (alternative treatments, control group with no alternative treatment/waiting list) on two outcomes (depressive symptoms change, drop-out rates).

RESULTS

On average, systemic interventions show larger improvements in depressive symptoms compared to no-treatment controls at post-test (g = 1.09) and follow-up (g = 1.23). Changes do not significantly differ when comparing systemic interventions with alternative treatments (post-test g = 0.25; follow-up g = 0.09). Results also vary, in part, by participant age, publication year, and active control condition.

CONCLUSION

This meta-analysis indicates the potential benefits of systemic interventions for adult patients with depression. Future randomized clinical trials in this area should enhance study quality and include relational and other relevant outcome measures.

Sick leave before, during, and after short-term outpatient psychotherapy: a cohort study on sick leave days and health care costs between behavioral and psychodynamic psychotherapies on anonymized claims data

BACKGROUND

Sick leave due to mental disorders poses a relevant societal and economic burden. Research on sick leave over a patient journey of individuals who received one of two treatment approaches - either behavioral (BT) or psychodynamic (PDT) psychotherapy - is scarce.

METHODS

We conducted a cohort study on anonymized German claims data for propensity-score matched patients who received short-term outpatient BT or PDT. We analyzed sick leave days and direct health care costs one year before, during, and one year after psychotherapy.

RESULTS

We analyzed data of patients who received BT and PDT, with N = 14 530 patients per group after matching. Patients showed sick leave days per person year of 33.66 and 35.05 days before, 35.99 and 39.74 days during, and 20.03 and 20.95 days after BT and PDT, respectively. Sick leave rates were overall higher in patients who received PDT. Both patient groups showed reductions of roughly 14 sick leave days per year, or 40%, from before to after therapy without a difference between BT and PDT (difference-in-difference [DiD] = -0.48, 95%-confidence interval [CI] -1.61 to 0.68). Same applies to direct health care costs which reduced in both groups by roughly 1800 EUR (DiD = 0, 95%-CI -158 to 157).

CONCLUSIONS

Results suggest similar reductions in sick leave days and direct health care costs from before to after BT and PDT. As sick leave is discussed to serve as an indicator of overall health and functioning in mental disorders, both treatments may have a similar positive impact on mental health.

The effect of individual short- and long-term psychotherapy on perceived social support: analysis of secondary outcomes of a randomized clinical trial

PURPOSE

Social support is important for maintaining and restoring psychological well-being but the effects of individual psychotherapies on perceived social support are not well known. In this analysis of secondary outcomes from a randomized clinical study, we compared the effects of long-term psychotherapy and two short-term psychotherapies on social support during a 5-year follow-up.

MATERIALS AND METHODS

Altogether 326 adult outpatients suffering from depressive and/or anxiety disorders were randomly assigned to long-term psychodynamic psychotherapy (LPP, n = 126), short-term psychodynamic psychotherapy (SPP, n = 101) and solution-focused therapy (SFT, n = 97). Outcome was measured by the global index and six subscores of the self-reported Brief Inventory of Social Support and Integration scale (BISSI) at baseline and at 1, 2, 3, 4 and 5 years after the beginning of the therapy.

RESULTS

Social support improved in all therapy groups and the improvement was relatively stable, lasting several years after the end of therapy. Little difference in improvement was observed either between therapy orientations or durations.

CONCLUSIONS

While no major differences were observed between treatment groups, the slight differences call for further research to verify these findings and to better understand how different therapies may improve perceived social support.

Strength-based methods - a narrative review and comparative multilevel meta-analysis of positive interventions in clinical settings

OBJECTIVE

In psychotherapy, strength-based methods (SBM) represent efforts to build on patients' strengths while addressing the deficits and challenges that led them to come to therapy. SBM are incorporated to some extent in all major psychotherapy approaches, but data on their unique contribution to psychotherapy efficacy is scarce.

METHODS

First, we conducted a systematic review and narrative synthesis of eight process-outcome psychotherapy studies that investigated in-session SBM and their relation to immediate outcomes. Second, we conducted a systematic review and multilevel comparative meta-analysis contrasting strength-based bona fide psychotherapy vs. other bona fide psychotherapy at post-treatment (57 effect sizes nested in 9 trials).

RESULTS

Despite their methodological variability, the pattern of results in the process-outcome studies was generally positive, such that SBM were linked with more favorable immediate, session-level patient outcomes. The comparative meta-analysis found an overall weighted average effect size of g = 0.17 (95% CIs [0.03, 0.31], p < .01) indicating a small but significant effect in favor of strength-based bona fide psychotherapies. There was non-significant heterogeneity among the effect sizes (Q(56) = 69.1, p = .11; I2 = 19%, CI [16%, 22%]).

CONCLUSION

Our findings suggest that SBMs may not be a trivial by-product of treatment progress and may provide a unique contribution to psychotherapy outcomes. Thus, we recommend integration of SBM to clinical training and practice across treatment models.

The efficacy of psychodynamic therapy for social anxiety disorder-A comprehensive meta-analysis

The efficacy of psychodynamic therapy (PDT) on social anxiety disorder (SAD) is controversial among different randomized controlled trials (RCTs), so we decide to conduct a comprehensive meta-analysis to study the efficacy of PDT on SAD. Relevant literatures were searched in PubMed, Embase, Web of Science, Cochrane Central Register of Controlled Trials, PsycINFO, Clinical Trails, and Ovid Medline. Twelve RCTs including 1,213 patients were identified. The primary analysis showed that the efficacy of PDT was weaker than the active group (SMD = 0.15 [0.02, 0.28]) and stronger than the inactive group (SMD = -0.77 [-0.95, -0.58]). It suggested that there was significant difference between individual PDT and group PDT (Chi² = 2.84, P = 0.09), and no difference between PDT and CBT on SAD and in the dropout rate. Secondary analysis suggested that depression may be alleviated concurrently (SMD = -0.20 [-0.40, 0.00]). Meta-regression analysis revealed no linear associations between dropout rate and effect size (t = 0.79, P = 0.449), neither does the dose-response relationship between session and effect size (t = -0.01, P = 0.992). These findings demonstrated that PDT could produce significant SAD symptoms reduction and supported its application in treating SAD.

Predicting improvement of work ability in modalities of short- and long-term psychotherapy: The differential impact of reflective ability and other aspects of patient suitability

OBJECTIVES

We investigated how patients' psychological capacities to engage in psychotherapy predict changes in work ability in short- and long-term psychotherapy.

METHODS

A cohort study of 326 patients, aged 20-46 years and suffering from mood and anxiety disorders, treated by short-term solution-focused, short-term psychodynamic, or long-term psychodynamic psychotherapy, followed-up for 5 years. The Suitability for Psychotherapy Scale, assessed at baseline, was the predictor. Outcomes were assessed at baseline and at six follow-up occasions using the Work Ability Index as the primary indicator.

RESULTS

Patients with good pretreatment psychological suitability for psychotherapy, good reflective ability in particular, improved more than patients with poor suitability in short-term psychodynamic psychotherapy. Comparisons between therapy groups showed poorer suitability to predict more improvement in solution-focused and in long-term psychodynamic psychotherapy than in short-term psychodynamic psychotherapy.

CONCLUSION

Patients' psychological suitability for psychotherapy has a different impact on work ability in different therapy modalities and durations.

"All My Problems Go Away for 90 Minutes": How Football and Psychotherapy Improves Young Men's Mental Health

This qualitative research sought to establish the impact of an 8-week program combining football and one-to-one psychotherapy on young males' mental health, determining the factors that predict help-seeking behaviors in this group of men. Pre- and post-participation focus groups were used as the method of data collection. Six males (19-35 years old; M = 25.5) completed both pre-intervention and follow-up focus groups. Help-seeking behaviors were influenced by the appeal of football and the perception of the counselor being accessible. Barriers included gender norms, socialization, financial difficulties, and challenging social landscapes. Post-participation focus groups revealed that positive social and counseling relationships facilitated improved mental health. Sport was deemed an acceptable medium to deliver a mental health intervention as it increased social connections and facilitated help-seeking. Findings support previous research indicating that combining sports and psychotherapy positively impacts young males' mental health.

Interventions to improve return to work in depressed people

BACKGROUND

Work disability such as sickness absence is common in people with depression.

OBJECTIVES

To evaluate the effectiveness of interventions aimed at reducing work disability in employees with depressive disorders.

SEARCH METHODS

We searched CENTRAL (The Cochrane Library), MEDLINE, Embase, CINAHL, and PsycINFO until April 4th 2020.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) and cluster-RCTs of work-directed and clinical interventions for depressed people that included days of sickness absence or being off work as an outcome. We also analysed the effects on depression and work functioning.

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted the data and rated the certainty of the evidence using GRADE. We used standardised mean differences (SMDs) or risk ratios (RR) with 95% confidence intervals (CI) to pool study results in studies we judged to be sufficiently similar.  MAIN RESULTS: In this update, we added 23 new studies. In total, we included 45 studies with 88 study arms, involving 12,109 participants with either a major depressive disorder or a high level of depressive symptoms. Risk of bias The most common types of bias risk were detection bias (27 studies) and attrition bias (22 studies), both for the outcome of sickness absence. Work-directed interventions Work-directed interventions combined with clinical interventions A combination of a work-directed intervention and a clinical intervention probably reduces days of sickness absence within the first year of follow-up (SMD -0.25, 95% CI -0.38 to -0.12; 9 studies; moderate-certainty evidence). This translates back to 0.5 fewer (95% CI -0.7 to -0.2) sick leave days in the past two weeks or 25 fewer days during one year (95% CI -37.5 to -11.8). The intervention does not lead to fewer persons being off work beyond one year follow-up (RR 0.96, 95% CI 0.85 to 1.09; 2 studies, high-certainty evidence). The intervention may reduce depressive symptoms (SMD -0.25, 95% CI -0.49 to -0.01; 8 studies, low-certainty evidence) and probably has a small effect on work functioning (SMD -0.19, 95% CI -0.42 to 0.06; 5 studies, moderate-certainty evidence) within the first year of follow-up.  Stand alone work-directed interventions A specific work-directed intervention alone may increase the number of sickness absence days compared with work-directed care as usual (SMD 0.39, 95% CI 0.04 to 0.74; 2 studies, low-certainty evidence) but probably does not lead to more people being off work within the first year of follow-up (RR 0.93, 95% CI 0.77 to 1.11; 1 study, moderate-certainty evidence) or beyond (RR 1.00, 95% CI 0.82 to 1.22; 2 studies, moderate-certainty evidence). There is probably no effect on depressive symptoms (SMD -0.10, 95% -0.30 CI to 0.10; 4 studies, moderate-certainty evidence) within the first year of follow-up and there may be no effect on depressive symptoms beyond that time (SMD 0.18, 95% CI -0.13 to 0.49; 1 study, low-certainty evidence). The intervention may also not lead to better work functioning (SMD -0.32, 95% CI -0.90 to 0.26; 1 study, low-certainty evidence) within the first year of follow-up.   Psychological interventions A psychological intervention, either face-to-face, or an E-mental health intervention, with or without professional guidance, may reduce the number of sickness absence days, compared with care as usual (SMD -0.15, 95% CI -0.28 to -0.03; 9 studies, low-certainty evidence). It may also reduce depressive symptoms (SMD -0.30, 95% CI -0.45 to -0.15, 8 studies, low-certainty evidence). We are uncertain whether these psychological interventions improve work ability (SMD -0.15 95% CI -0.46 to 0.57; 1 study; very low-certainty evidence). Psychological intervention combined with antidepressant medication Two studies compared the effect of a psychological intervention combined with antidepressants to antidepressants alone. One study combined psychodynamic therapy with tricyclic antidepressant (TCA) medication and another combined telephone-administered cognitive behavioural therapy (CBT) with a selective serotonin reuptake inhibitor (SSRI). We are uncertain if this intervention reduces the number of sickness absence days (SMD -0.38, 95% CI -0.99 to 0.24; 2 studies, very low-certainty evidence) but found that there may be no effect on depressive symptoms (SMD -0.19, 95% CI -0.50 to 0.12; 2 studies, low-certainty evidence). Antidepressant medication only Three studies compared the effectiveness of SSRI to selective norepinephrine reuptake inhibitor (SNRI) medication on reducing sickness absence and yielded highly inconsistent results. Improved care Overall, interventions to improve care did not lead to fewer days of sickness absence, compared to care as usual (SMD -0.05, 95% CI -0.16 to 0.06; 7 studies, moderate-certainty evidence). However, in studies with a low risk of bias, the intervention probably leads to fewer days of sickness absence in the first year of follow-up (SMD -0.20, 95% CI -0.35 to -0.05; 2 studies; moderate-certainty evidence). Improved care probably leads to fewer depressive symptoms (SMD -0.21, 95% CI -0.35 to -0.07; 7 studies, moderate-certainty evidence) but may possibly lead to a decrease in work-functioning (SMD 0.5, 95% CI 0.34 to 0.66; 1 study; moderate-certainty evidence). Exercise Supervised strength exercise may reduce sickness absence, compared to relaxation (SMD -1.11; 95% CI -1.68 to -0.54; one study, low-certainty evidence). However, aerobic exercise probably is not more effective than relaxation or stretching (SMD -0.06; 95% CI -0.36 to 0.24; 2 studies, moderate-certainty evidence). Both studies found no differences between the two conditions in depressive symptoms.

AUTHORS' CONCLUSIONS

A combination of a work-directed intervention and a clinical intervention probably reduces the number of sickness absence days, but at the end of one year or longer follow-up, this does not lead to more people in the intervention group being at work. The intervention may also reduce depressive symptoms and probably increases work functioning more than care as usual. Specific work-directed interventions may not be more effective than usual work-directed care alone. Psychological interventions may reduce the number of sickness absence days, compared with care as usual. Interventions to improve clinical care probably lead to lower sickness absence and lower levels of depression, compared with care as usual. There was no evidence of a difference in effect on sickness absence of one antidepressant medication compared to another. Further research is needed to assess which combination of work-directed and clinical interventions works best.

Exploring the Effectiveness of an Integrated Mixed Martial Arts and Psychotherapy Intervention for Young Men's Mental Health

This research sought to establish the impact of a 10-week program combining mixed martial arts (MMA) and one-to-one psychotherapy on young males’ mental health and determine factors that predict help-seeking behavior in at-risk males. Preparticipation and post-participation interviews were employed as the method of data collection. Seven males (20–35 years; M = 24.57) completed preparticipation interviews and five completed follow-up interviews. Thematic analysis of preparticipation revealed that help-seeking behavior in at-risk males is impeded by the presence of male gender stereotypes, the absence of positive role models, as well as difficulty navigating challenging social landscapes. Post-participation interviews revealed that the sport provided structure and fitness for at-risk males, while the counseling was pivotal for personal growth. Improved relationships, work life, and self-esteem were also observed. The sporting element of the program helped to reduce stigma associated with engaging in psychotherapy, and positive male relationships were noted as particularly impactful. Findings support previous research indicating that combining sports and psychotherapy positively impacts young males’ mental health. Sport provides an acceptable doorway to psychotherapy, providing space to explore personal issues.

Effectiveness of psychoanalysis and long-term psychodynamic psychotherapy on personality and social functioning 10 years after start of treatment

The evidence on potentially greater benefits of psychoanalysis (PA) vs. long-term psychodynamic psychotherapy (LPP) is scarce. This study compared the effectiveness of PA and LPP on personality and social functioning during a 10-year follow-up from the beginning of the treatments. The eligible patients, 41 self-selected for PA and 128 assigned to LPP, were 20-45 years of age and had anxiety or mood disorder. Outcomes were analyzed using ten standard measures of personality and social functioning, carried out 5-9 times during the follow-up. Different change patterns by time in PA and LPP emerged, suggesting less benefit of PA during the first years of follow-up and more benefit in most outcomes thereafter. Greater post-treatment improvement in PA than in LPP was seen up to 1-2 years after PA had ended in more mature defense style (DSQ), level of personality organization (LPO), more positive self-concept (SASB), more improved social adjustment (SAS-SR) and sense of coherence (SOC). However, at the 10-year follow-up the differences were non-significant. In conclusion, PA may give some additional benefits when long-term aims are linked to personality and social functioning. The relatively small differences and higher costs in comparison to LPP may restrict the feasibility of PA.

The frontoparietal network: function, electrophysiology, and importance of individual precision mapping

The frontoparietal network is critical for our ability to coordinate behavior in a rapid, accurate, and flexible goal-driven manner. In this review, we outline support for the framing of the frontoparietal network as a distinct control network, in part functioning to flexibly interact with and alter other functional brain networks. This network coordination likely occurs in a 4 Hz to 73 Hz θ/α rhythm, both during resting state and task state. Precision mapping of individual human brains has revealed that the functional topography of the frontoparietal network is variable between individuals, underscoring the notion that group-average studies of the frontoparietal network may be obscuring important typical and atypical features. Many forms of psychopathology implicate the frontoparietal network, such as schizophrenia and attention-deficit/hyperactivity disorder. Given the interindividual variability in frontoparietal network organization, clinical studies will likely benefit greatly from acquiring more individual subject data to accurately characterize resting-state networks compromised in psychopathology.

Childhood adversities as predictors of improvement in psychiatric symptoms and global functioning in solution-focused and short- and long-term psychodynamic psychotherapy during a 5-year follow-up

BACKGROUND

Childhood adversities are frequent among adults who seek treatment for depression or anxiety. These disorders are commonly treated by psychotherapy. Yet it is not known if specific types or durations of psychotherapy are particularly suited for patients who have suffered various early adversities.

METHODS

221 depressed and anxious adult outpatients from community, student, occupational, and private healthcare services filled the Childhood Family Atmosphere Questionnaire. They were randomly assigned to short- (solution-focused or psychodynamic) or long-term (psychodynamic) psychotherapy. Outcome was assessed via patient questionnaires and clinician interviews of psychiatric symptoms and global functioning during a 5-year follow-up. Linear regression analyses were conducted.

RESULTS

Less separations from caregivers expectedly predicted better outcomes in all therapies; unexpectedly, so did greater abuse. Family unhappiness and parental problems predicted faster or greater improvement when patients were assigned to a short- or long-term psychodynamic therapy model.

LIMITATIONS

As patients with psychotic, substance abuse, and severe personality disorders were screened out, findings might not generalize to these patient groups.

CONCLUSIONS

Patients with certain childhood adversities appear to respond with faster or greater improvement when the psychotherapy model is explicitly focused on working through the potential connections between past and current problems. If confirmed by in-depth studies, the findings may help match psychotherapeutic models with given patient complaints, as well as fine-tune different psychosocial interventions to individual needs for optimizing treatment outcomes.

"The Whole Is Greater Than the Sum of the Parts": Prison Staff Perceptions of Domestic Violence Rehabilitation Programs

This qualitative study is part of a mixed methods research project that examined the effectiveness of the primary rehabilitation program for domestic violence offenders in the Israeli Prison Services-the "House of Hope." The quantitative part of the study showed that the "House of Hope" program was effective in reducing recidivism among participating inmates. The purpose of this qualitative study was to describe the rehabilitation program according to the perspectives of the program staff. For this purpose, semistructured interviews were conducted with the department staff during the study as well as with past directors. The qualitative findings suggested that the success of the program probably stemmed from a synergistic combination of several components, for example, identifying the characteristics of domestic violence offenders and adjusting treatment programs to their needs, along with exposure to psychological treatment in varied therapies (cognitive behavioral therapy, psychoeducational, and psychodynamic) and formats (group therapy and individual therapy) during a 1-year stay in a hierarchical therapeutic community. Other components mentioned are staff professionalism, stability, and the program's location in a therapeutic-oriented prison that is architecturally designed and built to create a less stressful environment for the inmates and the staff.

Pathways towards different long-term outcomes after naturalistic psychotherapy

This study suggests some potential pathways leading towards maintained gains or further growth versus deterioration after naturalistic psychotherapy with experienced clinicians. This is explored in a way that transcends specific theoretical orientations. Sixteen therapies, all showing reliable improvement on Outcome Questionnaire 45.2 (OQ-45) at treatment termination but varying in later post-therapy development, were included in this study. Building on previous content and correlational analyses, individual cases were explored qualitatively in search for developmental patterns of potential relevance for long-term outcome. Patterns re-emerging across several cases were described in light of the OQ-45 trajectories of clients providing them. Six pathways, associated with different long-term outcomes, emerged. Four of these, "Reflective route towards regulation of affects," "Gaining autonomy through a secure holding relationship," "Opening up as a new relational/emotional experience," and "Lasting acceptance of «reality»," re-emerged in clients showing maintained/growing treatment effects. Two pathways, entitled "Residual problems grow and overshadow progress" and "Core problems remain beneath superficial change," seemed linked to deterioration after termination of therapy. We suggest the former pathways as some possible routes towards enduring good outcome, and the latter as some patterns to avoid when trying to secure therapy gains will not be only temporary.

The prediction of the level of personality organization on reduction of psychiatric symptoms and improvement of work ability in short- versus long-term psychotherapies during a 5-year follow-up

OBJECTIVES

How level of personality organization (LPO) predicts psychiatric symptoms and work ability in short- versus long-term psychotherapies is poorly known. We investigated the importance of the LPO on the benefits of short-term versus long-term psychotherapies.

DESIGN

A cohort study based on 326 outpatients with mood or anxiety disorder was allocated to long-term (LPP) and short-term (SPP) psychodynamic psychotherapy, and solution-focused therapy (SFT).

METHODS

The LPO was assessed by interview at baseline and categorized into neuroses and higher level borderline. Outcome was assessed at baseline and 4-9 times during a 5-year follow-up, using self-report and interview-based measures of symptoms and work ability.

RESULTS

For patients receiving SPP, improvement in work ability, symptom reduction, and the remission rate were more considerable in patients with neuroses than in higher level borderline patients, whereas LPP or SFT showed no notable differences in effectiveness in the two LPO groups. In patients with neuroses, improvement was more considerable in the short-term therapy groups during the first year of follow-up, and in higher level borderline patients LPP was more effective after 3 years of follow-up. The remission rate, defined as both symptom reduction and lack of auxiliary treatment, was higher in LPP than in SPP for both the LPO groups considered.

CONCLUSIONS

In neuroses, short-term psychotherapy was associated with a more rapid reduction of symptoms and increase in work ability, whereas LPP was more effective for longer follow-ups in both LPO groups. Further large-scale studies are needed.

PRACTITIONER POINTS

Level of personality organization is relevant for selection between short- and long-term psychotherapies. Short-term therapy gives faster benefits for neurotic patients but not for patients with higher level borderline personality organization. Sustained remission from symptoms is more probable after long-term than short-term therapy.

Effects of clay art therapy on adults outpatients with major depressive disorder: A randomized controlled trial

BACKGROUND

Depression has become a critical global health problem, affecting millions of people. Cost-effective nonpharmacological treatment in community settings has been proposed to complement medical treatment. Short-term clay art therapy (CAT) is an alternative treatment that promotes the enhancement of various aspects of mental health for depressed individuals.

METHODS

One-hundred and six adults with depression were randomized into a CAT group or visual art (VA) control group for six 2.5-h weekly sessions. Intervention effects were measured using the Beck Depression Inventory, 12-Item General Health Questionnaire (Chinese version), Body-Mind-Spirit Well-Being Inventory, and 20-Item Toronto Alexithymia Scale (Chinese version) at baseline, immediately postintervention (T1), and 3-weeks postintervention (T2).

RESULT

Multivariate analysis of covariance results indicated a more significant time × group effect for CAT than for VA on depressive signs, general health, and body-mind-spirit well-being (all p<0.05). Significant within-groups changes were observed in these three aspects after treatment and at T2 (all p<0.001) and in alexithymia at T2 (p<0.01) in the CAT group, but the change was nonsignificant in the VA group at T1 and T2.

LIMITATIONS

The homogeneity of the participants affected the generalizability of the study findings. The short-term postintervention follow-up (3 weeks) presented difficulties in demonstrating the long-term effects of CAT.

CONCLUSIONS

CAT can aid emotion regulation and benefit various aspects of mental health in adults. The short duration of the intervention suggests additional application value in treating depression. Further investigation is warranted regarding the potential effect of CAT on alleviating physical symptoms and improving social function.

The impact of internet-based cognitive behavior therapy on work ability in patients with depression - a randomized controlled study

Objectives

The aim of this randomized controlled trial (RCT) was to investigate the effects of internet-based cognitive behavior therapy (ICBT) treatment for depression compared to treatment-as-usual (TAU) on improving work ability and quality of life in patients with mild-to-moderate depression. We also examined whether patients treated with ICBT returned to work more rapidly, that is, had fewer days of sick leave, than patients treated with TAU.

Design

This study is based on material from the PRIM-NET RCT that took place between 2010 and 2013.

Setting

Primary care centers in Region Vastra Gotaland, Sweden, population about 1.6 million.

Patients

A total of 77 patients with depression randomized to either ICBT (46 patients) or TAU (31 patients). Mean age of participants was 35.8 years, and 67.5% were women.

Main outcome measures

Work ability was measured with the Work Ability Index, depressive symptoms with Montgomery Asberg Depression Rating Scale – self-rating version (MADRS-S), quality of life with EuroQoL-5D (EQ-5D), and number of sick leave days.

Results

Both groups showed an association between improved work ability and reduction of depressive symptoms and between improved work ability and better quality of life. ICBT could not be shown to improve work ability more than TAU among patients with mild-to-moderate depression. There were no differences between the groups concerning number of patients with sick leave or number of sick leave days.

Conclusion

Our study indicates that a high level of work ability has an association with high health-related quality of life in patients with mild-to-moderate depression, whether they are treated with ICBT or TAU. ICBT has previously been found to be cost-effective and can be seen as a good alternative to TAU. In addition to the ICBT, an intervention oriented toward the work place might improve work ability and reduce the number of sick leave days among patients with depression.

Solution-focused group therapy for common mental health problems: Outcome assessment in routine clinical practice

OBJECTIVES

This study aimed to assess the effectiveness of solution-focused group therapy (SFGT) for psychological distress and mild to moderate depression in a routine clinical practice setting.

DESIGN AND METHODS

A naturalistic pre/post-study involving 132 mental health service users was carried out. Clients received seven structured sessions of SFGT, and pre-therapy self-report scores (Spanish brief version of Beck Depression Inventory and Hospital Anxiety and Depression Scale) were compared with post-therapy scores. Additional data on effectiveness of intervention (discharges, clients returning for help and dropout rate) were analysed at 6, 12, and 24 months after initiating intervention and compared with a control sample (132 mental health service users, frequency-matched by local health board, clinical diagnosis, and gender to the group intervention) receiving usual care (UC: Psychotropic medication and/or individual psychotherapy).

RESULTS

Mean post-SFGT levels were significantly lower than mean pre-SFGT levels on each self-report measure in the SFGT sample. In addition, SFGT showed a significantly higher percentage of discharges and fewer clients returning for help than with UC.

CONCLUSIONS

SFGT included in routine clinical practice may enhance the effectiveness of treatment in clients who suffer from depression and/or psychological distress.

PRACTITIONER POINTS

Therapists could use SFGT as a brief and effective tool to deal with the most prevalent mental health problems at mental healthcare centres (MHCs) in Spain, without changing day-to-day clinical routines. SFGT might be effectively incorporated in routine clinical practice for helping people with psychological distress and depressive episodes of mild and moderate severity. This study should encourage systemic therapists and strategically oriented clinicians to continue delivering and offering outcome measures of solution-focused therapy.

The outcome of short- and long-term psychotherapy 10 years after start of treatment

BACKGROUND

Empirical evidence on whether patients' mental health and functioning will be more improved after long-term than short-term therapy is scarce. We addressed this question in a clinical trial with a long follow-up.

METHOD

In the Helsinki Psychotherapy Study, 326 out-patients with mood or anxiety disorder were randomly assigned to long-term psychodynamic psychotherapy (LPP), short-term psychodynamic psychotherapy (SPP) or solution-focused therapy (SFT) and were followed for 10 years. The outcome measures were psychiatric symptoms, work ability, personality and social functioning, need for treatment, and remission.

RESULTS

At the end of the follow-up, altogether 74% of the patients were free from clinically elevated psychiatric symptoms. Compared with SPP, LPP showed greater reductions in symptoms, greater improvement in work ability and higher remission rates. A similar difference in symptoms and work ability was observed in comparison with SFT after adjustment for violations of treatment standards. No notable differences in effectiveness between SFT and SPP were observed. The prevalence of auxiliary treatment was relatively high, 47% in SFT, 58% in SPP and 33% in LPP, and, accordingly, the remission rates for general symptoms were 55, 45 and 62%, respectively.

CONCLUSIONS

After 10 years of follow-up, the benefits of LPP in comparison with the short-term therapies are rather small, though significant in symptoms and work ability, possibly due to more frequent use of auxiliary therapy in the short-term therapy groups. Further studies should focus on the choice of optimal length of therapy and the selection of factors predicting outcome of short- v. long-term therapy.

The cost-effectiveness of short-term and long-term psychotherapy in the treatment of depressive and anxiety disorders during a 5-year follow-up

Both short-term and long-term psychotherapies are used extensively in treating different mental disorders, but there have been practically no attempts to compare their cost-effectiveness. The aim of this study, which is part of the Helsinki Psychotherapy Study, is to assess the cost-effectiveness of two short-term therapies compared to that of a long-term therapy. In this study 326 outpatients suffering from mood or anxiety disorder were randomized to solution-focused therapy (SFT), short-term psychodynamic psychotherapy (SPP) or to long-term psychodynamic psychotherapy (LPP). Psychiatric symptoms and working ability were assessed at baseline and then 4-9 times during a 5-year follow-up using eight widely used measures including e.g. Beck Depression Inventory (BDI), Hamilton Depression Rating Scale (HDRS), Symptom Check List, anxiety scale (SCL-90-Anx), Hamilton Anxiety Rating Scale (HARS), Symptom Check List, Global Severity Index (SCL-90-GSI), and the Work-subscale (SAS-Work) of the Social Adjustment Scale (SAS-SR). Both direct and indirect costs were measured. During the 5-year follow-up period statistically significant improvements were observed in all health indicators in all therapy groups. At first the recovery was faster in the short-term therapy groups than in the LPP group, but taking the whole follow-up period into account, the effectiveness of the LPP was somewhat greater than that of the short-term therapies. Especially the direct costs were, however, much higher in the LPP group than in the short-term therapy groups. Thus the long-term therapy can hardly be regarded as cost-effective compared to short-term therapies when patients are randomized to the therapy groups.

Randomized trial on the effectiveness of long- and short-term psychotherapy on psychosocial functioning and quality of life during a 5-year follow-up

Knowledge is incomplete on whether long-term psychotherapy is more effective than short-term therapy in treating mood and anxiety disorder, when measured by improvements in psychosocial functioning and life quality. In the Helsinki Psychotherapy Study, 326 outpatients with mood or anxiety disorder were randomized to solution-focused therapy (SFT), short-term psychodynamic psychotherapy (SPP), or long-term psychodynamic psychotherapy (LPP), and followed up for 5 years from the start of treatment. The outcome measures comprised 4 questionnaires on psychosocial functioning, assessing global social functioning (Social Adjustment Scale (SAS-SR), sense of coherence (Sense of Coherence Scale (SOC)), perceived competence (Self-Performance Survey), dispositional optimism (Life Orientation Test (LOT)), and 1 questionnaire assessing quality of life (Life Situation Survey (LSS)). Short-term therapies improved psychosocial functioning and quality of life more than LPP during the first year. The only exceptions were LOT and perceived competence, which did not differ between SPP and LPP. Later in the follow-up, SOC and perceived competence showed significantly more improvement in LPP than in the short-term therapy groups. No direct differences between SFT and SPP were noted. Short-term therapy has consistently more short-term effects on psychosocial functioning and quality of life than LPP, whereas LPP has some additional long-term benefits on psychosocial functioning.

The efficacy of psychotherapy: focus on psychodynamic psychotherapy as an example

The growing number of individuals seeking treatment for mental disorders calls for intelligent and responsible decisions in health care politics. However, the current relative decrease in reimbursement of effective psychotherapy approaches occurring in the context of an increase in prescription of psychotropic medication lacks a scientific base. Using psychodynamic psychotherapy as an example, we review the literature on meta-analyses and recent outcome studies of effective treatment approaches. Psychodynamic psychotherapy is an effective treatment for a wide variety of mental disorders. Adding to the known effectiveness of other shorter treatments, the results indicate lasting change in many cases, especially for complex and difficult to treat patients, ultimately reducing health-care utilization. Research-informed health care decisions that take into account the solid evidence for the effectiveness of psychotherapy, including psychodynamic psychotherapy, have the potential to promote choice, increase mental health, and reduce society's burden of disease in the long run.

The effectiveness of short- and long-term psychotherapy on personality functioning during a 5-year follow-up

BACKGROUND

Only few randomized trials comparing sustained effects of short- and long-term psychotherapies in personality functioning are available. In this study we compared the effects of two short-term therapies and long-term psychodynamic psychotherapy on patients' personality functioning during a 5-year follow-up.

METHODS

Altogether 326 patients of the Helsinki Psychotherapy Study, with anxiety or mood disorder, were randomly assigned to either short-term psychotherapy of about six months (solution-focused therapy (SFT, n=97) or short-term psychodynamic psychotherapy (SPP, n=101)), or to long-term psychodynamic psychotherapy (LPP, n=128), lasting on average three years. Outcomes in personality functioning (i.e., self-concept, defense style, interpersonal problems, and level of personality organization) were assessed five to seven times using, respectively, questionnaires (SASB, DSQ, IIP) and interview (LPO) during the 5-year follow-up from randomization.

RESULTS

Personality functioning improved in all therapy groups. Both short-term therapies fared better than LPP during the first year of follow-up, by faster improvement in self-concept and decrease in immature defense style. SFT also showed more early reduction of interpersonal problems. However, LPP thereafter showed larger and more sustained benefits than SFT and SPP, through greater changes in self-concept. Additionally, LPP outperformed SFT at the end of the follow-up in IIP and LPO, after adjustment for auxiliary treatment. No differences were noted between the short-term therapies at any measurement point.

LIMITATIONS

Auxiliary treatment was used relatively widely which limits generalization to exclusive use of short- or long-term therapy.

CONCLUSIONS

LPP seems to be somewhat more effective than short-term therapies in facilitating longterm changes in personality functioning.

Intelligence as a predictor of outcome in short- and long-term psychotherapy

Intelligence has been suggested as a suitability factor for short-term therapy whereas its possible effect on short-term versus long-term therapy still is unknown. The aim of this study was to compare the prediction of intelligence on the level of psychiatric symptoms and psychosocial functioning in psychotherapies of different lengths. A total of 251 outpatients from the Helsinki Psychotherapy Study, aged 20–46 years, and suffering from mood or anxiety disorders were allocated to two long-term and two short-term therapies. Intelligence was assessed at baseline with the Wechsler Adult Intelligence Scale (WAIS-R). Psychiatric symptoms and psychosocial functioning were assessed 5–10 times during a 5-year follow-up using two primary symptom measures (HDRS and HARS) and one primary measure of psychosocial functioning (GAF). Short-term therapy was more effective than long-term therapy during the first year of follow-up. During the second to fourth follow-up year no differences between short- and long-term therapies or the intelligence groups were found. At the fifth follow-up year, however, long-term psychotherapy showed a statistically significantly larger change in all three primary measures compared to short-term therapy among those with higher intelligence. No differences between therapy groups were noted in those with lower intelligence. People with higher intelligence may benefit more from long-term than from short-term psychotherapy. These findings should be confirmed.

Interventions to improve return to work in depressed people

BACKGROUND

Work disability such as sickness absence is common in people with depression.

OBJECTIVES

To evaluate the effectiveness of interventions aimed at reducing work disability in employees with depressive disorders.

SEARCH METHODS

We searched CENTRAL (The Cochrane Library), MEDLINE, EMBASE, CINAHL, and PsycINFO until January 2014.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) and cluster RCTs of work-directed and clinical interventions for depressed people that included sickness absence as an outcome.

DATA COLLECTION AND ANALYSIS

Two authors independently extracted the data and assessed trial quality. We used standardised mean differences (SMDs) with 95% confidence intervals (CIs) to pool study results in the studies we judged to be sufficiently similar. We used GRADE to rate the quality of the evidence.

MAIN RESULTS

We included 23 studies with 26 study arms, involving 5996 participants with either a major depressive disorder or a high level of depressive symptoms. We judged 14 studies to have a high risk of bias and nine to have a low risk of bias. Work-directed interventions We identified five work-directed interventions. There was moderate quality evidence that a work-directed intervention added to a clinical intervention reduced sickness absence (SMD -0.40; 95% CI -0.66 to -0.14; 3 studies) compared to a clinical intervention alone.There was moderate quality evidence based on a single study that enhancing the clinical care in addition to regular work-directed care was not more effective than work-directed care alone (SMD -0.14; 95% CI -0.49 to 0.21).There was very low quality evidence based on one study that regular care by occupational physicians that was enhanced with an exposure-based return to work program did not reduce sickness absence compared to regular care by occupational physicians (non-significant finding: SMD 0.45; 95% CI -0.00 to 0.91). Clinical interventions, antidepressant medication Three studies compared the effectiveness of selective serotonin reuptake inhibitor (SSRI) to selective norepinephrine reuptake inhibitor (SNRI) medication on reducing sickness absence and yielded highly inconsistent results. Clinical interventions, psychological We found moderate quality evidence based on three studies that telephone or online cognitive behavioural therapy was more effective in reducing sick leave than usual primary or occupational care (SMD -0.23; 95% CI -0.45 to -0.01). Clinical interventions, psychological combined with antidepressant medication We found low quality evidence based on two studies that enhanced primary care did not substantially decrease sickness absence in the medium term (4 to 12 months) (SMD -0.02; 95% CI -0.15 to 0.12). A third study found no substantial effect on sickness absence in favour of this intervention in the long term (24 months).We found high quality evidence, based on one study, that a structured telephone outreach and care management program was more effective in reducing sickness absence than usual care (SMD - 0.21; 95% CI -0.37 to -0.05). Clinical interventions, exercise We found low quality evidence based on one study that supervised strength exercise reduced sickness absence compared to relaxation (SMD -1.11; 95% CI -1.68 to -0.54). We found moderate quality evidence based on two studies that aerobic exercise was no more effective in reducing sickness absence than relaxation or stretching (SMD -0.06; 95% CI -0.36 to 0.24).

AUTHORS' CONCLUSIONS

We found moderate quality evidence that adding a work-directed intervention to a clinical intervention reduced the number of days on sick leave compared to a clinical intervention alone. We also found moderate quality evidence that enhancing primary or occupational care with cognitive behavioural therapy reduced sick leave compared to the usual care. A structured telephone outreach and care management program that included medication reduced sickness absence compared to usual care. However, enhancing primary care with a quality improvement program did not have a considerable effect on sickness absence. There was no evidence of a difference in effect on sickness absence of one antidepressant medication compared to another. More studies are needed on work-directed interventions. Clinical intervention studies should also include work outcomes to increase our knowledge on reducing sickness absence in depressed workers.

The frontoparietal control system: a central role in mental health

Recent findings suggest the existence of a frontoparietal control system consisting of flexible hubs that regulate distributed systems (e.g., visual, limbic, motor) according to current task goals. A growing number of studies are reporting alterations of this control system across a striking range of mental diseases. We suggest this may reflect a critical role for the control system in promoting and maintaining mental health. Specifically, we propose that this system implements feedback control to regulate symptoms as they arise (e.g., excessive anxiety reduced via regulation of amygdala), such that an intact control system is protective against a variety of mental illnesses. Consistent with this possibility, recent results indicate that several major mental illnesses involve altered brain-wide connectivity of the control system, likely altering its ability to regulate symptoms. These results suggest that this "immune system of the mind" may be an especially important target for future basic and clinical research.

[Evaluation of outpatient psychodynamic psychotherapy: results of a controlled field study ]

OBJECTIVES

The discussion about the effectivity of psychodynamic psychotherapy is being renewed by recent meta-analyses. Although some well-designed studies have been presented, there is still a dearth of research in this field.

METHODS

In a controlled prospective field study we investigated the outcome of outpatient psychodynamic psychotherapy in a pre-post design. This evaluation includes data from the symptom inventories VDS90, VDS30, and HEALTH for 90 patients with different mental disorders before therapy and after the regular end of therapy, compared to a waiting list control group.

RESULTS

We found a significant improvement in symptoms, dysfunctional personality features, and quality of life. Rates of statistically and clinically significant improvement were markedly higher after therapy than in the waiting list condition.

CONCLUSIONS

Psychodynamic psychotherapy shows an effect on symptoms, dysfunctional personality features, and quality of life.

A register-based study of long-term healthcare use before and after psychotherapy

BACKGROUND

Psychotherapeutic treatment for non-psychotic disorders is associated with significant reduction in patients' symptoms, and therefore it is believed that treatment improves health and decreases the need for additional healthcare. However, little is known about long-term changes in utilization of healthcare services.

AIM

To investigate long-term changes in utilization of public healthcare services for patients referred to psychotherapeutic treatment.

METHODS

A pre-post study with 761 consecutive patients and 15,220 matched individuals in a matched population reference group. Data from a comprehensive set of healthcare services were collected from central registries for 4 years prior to intake and for 4 years after completion of treatment.

RESULTS

Of the 761 patients, 216 did not show up for treatment and 545 completed treatment. Completer patients achieved a substantial reduction in symptoms (effect size, ES = 0.99). However, completer patients increased their use of all healthcare services by 296% (ES = 0.58) in the 4th year pre-post comparison, while the reference group increased usage by 99% (ES = 0.23). Completer patients had significantly higher increase in contacts with psychiatric hospitals (P < 0.008), contacts with primary care psychologists (P < 0.001), psychotropic medication (P < 0.001) and contacts with primary care physicians (P < 0.001) than the reference group at the 4th year pre-post comparison.

CONCLUSION

Over a long-term period, patients who completed psychotherapeutic treatment increased utilization of healthcare services. Studies are needed to clarify how and why psychotherapeutic treatment does not necessarily lead to a reduction in the utilization of healthcare services for the average patient and to evaluate other potential interventions for patients with mental problems and include efficiency studies in this evaluation.

The efficacy of long-term psychodynamic psychotherapy, fluoxetine and their combination in the outpatient treatment of depression

OBJECTIVE

There are few randomized controlled trials examining the efficacy of long-term psychodynamic psychotherapy (LTPP) in depression treatment. LTPP was compared with fluoxetine treatment and their combination;

METHODS

272 depressed patients (aged 26-34, 72% with a first episode of depression) were randomized to receive LTPP (one session/week), fluoxetine treatment (20-60 mg/day) or their combination for 24 months. Beck Depression Inventory (BDI) was the outcome measure. The psychotherapy was not manualized and the treatment took place under real-life conditions in an outpatient psychiatric clinic.

RESULTS

Intention-to-treat analyses indicated that all the treatments were associated with significant reductions in the BDI scores (mean reduction of 18.88 BDI points). Furthermore, LTPP and combination therapy were more effective in reducing BDI scores than fluoxetine alone (22.08 and 22.04 vs. 12.53 BDI points).

CONCLUSIONS

LTPP, pharmacological treatment with fluoxetine and their combination are effective in reducing symptoms of patients with moderate depression. LTPP and combined treatment were more effective compared to fluoxetine alone. These findings have implications for patients with depression who may benefit from long-term psychotherapy or combined treatment, or for depressed patients who do not wish to take medications such as fluoxetine.

Efficacy of systemic therapy on adults with mental disorders: A meta-analysis

OBJECTIVE

To evaluate the efficacy of systemic therapy on psychiatric disorders in adulthood.

METHODS

This meta-analysis integrates results of 37 randomized controlled trials (RCT) of therapy with an explicit systemic focus on adults with psychiatric disorders. Studies were identified through systematic searches in electronic databases and cross-referencing.

RESULTS

On average, systemic therapy had stronger short-term (g = .51) and long-term (g = .55) efficacies than control groups without alternative treatment and stronger short-term effects than alternative active treatments (g = .25). In addition, efficacy of systemic therapy was similar to those of other bona fide psychotherapies. Individuals receiving systemic therapy plus medication showed stronger improvements at posttest (g = .71) and follow-up (g = .87) than those receiving only medication. Illness-specific analyses showed positive short-term efficacy of systemic therapy on eating disorders, mood disorders, obsessive-compulsive disorders, schizophrenia, and somatoform disorders. At follow-up, efficacy of systemic therapy was only found on eating disorders, mood disorders, and schizophrenia. In addition, systemic therapy had lower dropout rates than alternative treatments. For certain comparisons, effect sizes were moderated by participant age, study quality, and year of publication.

CONCLUSIONS

We conclude that the present meta-analysis found some evidence for the efficacy of systemic therapy on five disorders, but the number of available RCT is still limited. More research is needed on systemic therapy of other disorders, such as anxiety disorders and substance use disorders.