Psycho-educational interventions focused on maternal or infant sleep for pregnant women to prevent the onset of antenatal and postnatal depression: A systematic review

AIMS

This systematic review aimed to evaluate randomized controlled trials (RCTs) to examine the effect of maternal and infant sleep intervention during women's pregnancy for the purpose of preventing perinatal depression.

METHOD

A systematic search (from inception to January 28, 2019) for RCTs using five electronic databases-the Cochrane Controlled Register of Trials (CENTRAL), Embase, PubMed, PsycINFO, and Ichushi Web (Japan Medical Abstracts Society)-was conducted. Twelve investigators independently conducted initial screenings based on title and abstract, and then, two researchers performed full-text reviews one by one. A meta-analysis would be conducted if at least three studies were found. However, only two articles that met inclusion criteria, and narrative data synthesis was conducted for these two articles. The study protocol has been registered at PROSPERO (CRD42019119999).

RESULT

A total of 13 654 studies were initially searched. After removing duplicates, 10 547 studies were screened, and finally, two studies met the inclusion criteria. In both studies, the intervention was a one-time face-to-face session during pregnancy to deliver the behavioral knowledge and skills for optimizing sleep hygiene for both infant and mother. Effectiveness of the intervention in improving maternal mood was not significant in one study. In the other, there was a significant difference in maternal mood between the intervention and control group. No mood comparison was made between baseline and postintervention.

CONCLUSION

This study found limited evidence to support the effectiveness of sleep intervention for all pregnant women, which means "universal intervention," to protect maternal mental health. Further well-designed RCTs are needed to confirm these findings.

Promotion, prevention and treatment interventions for mental health in low- and middle-income countries through a task-shifting approach

Recently, mental health and ill health have been reframed to be seen as a continuum from health to ill health, through the stages of being asymptomatic 'at risk', to experiencing 'mental distress', 'sub-syndromal symptoms' and finally 'mental disorders'. This new conceptualisation emphasised the importance of mental health promotion and prevention interventions, aimed at reducing the likelihood of future disorders with the general population or with people who are identified as being at risk of a disorder. This concept generated discussion on the distinction between prevention and treatment interventions, especially for those mental health conditions which lie between psychological distress and a formal psychiatric diagnosis. The present editorial aims to clarify the definition of promotion, prevention and treatment interventions delivered through a task-shifting approach according to a global mental health perspective.

One-year outcome of low-intensity booster sessions versus care as usual in psychosis patients after a short-term psychoeducational intervention

Objective

In this study we aimed to evaluate long-term effects of a community-based, quality of life oriented psychoeducational intervention for schizophrenia with and without booster sessions.

Method

One hundred and three outpatients with a diagnosis of schizophrenia or schizoaffective disorder completed a 9-week psychoeducational programme. At the end of the programme groups were block-randomised to either an extension programme comprising monthly booster sessions for a further nine months (booster condition) or routine clinical care with no further group meetings (non-booster condition). Outcome measures were applied before and after the seminar and at 6 and 12 months.

Results

Positive effects were observed after the short-term 9-week programme with regard to symptoms, knowledge about the illness, illness concept, control convictions and quality of life. These effects were retained over the 12-month period in both conditions. The only relevant difference between the booster and the non-booster conditions concerned external control convictions.

Conclusion

Overall this 9-week programme has shown encouraging effects still present at 12 months after baseline independent of booster or non-booster conditions. Further studies are needed to explore whether a subgroup of patients, those with impaired neurocognitive and social functioning, can benefit significantly from booster sessions.

Predictors of treatment initiation for alcohol use disorders in primary care

BACKGROUND

We identified predictors of receiving treatment (brief therapy [BT] and/or extended-release injectable naltrexone [XR-NTX]) for the treatment of alcohol use disorders (AUDs) in primary care. We also examined the relationship between receiving BT and XR-NTX.

METHODS

Secondary data analysis of SUMMIT, a randomized controlled trial of collaborative care. Participants were 290 individuals with AUDs who reported no past 30-day opioid use and who were receiving primary care at a multi-site Federally Qualified Health Center. Bivariate and multivariate analyses examined predictors of BT and/or XR-NTX.

RESULTS

Thirty-two percent (N = 93) received either BT or XR-NTX, 28% (N = 82) received BT and 13% (N = 37) received XR-NTX; 9% (N = 26) received both BT and XR-NTX. Older age, white race, talking with a professional about alcohol use and having more negative consequences all predicted receipt of evidence-based treatment; being homeless was a negative predictor. The predictors of receiving BT included not being homeless and previously talking with a professional; the predictors of receiving XR-NTX included older age, white race and experiencing more negative consequences. In 80% of those who received both BT and XR-NTX, receipt of BT preceded XR-NTX.

CONCLUSIONS

Patient factors were important predictors of receiving primary-care based AUD treatment and differed by type of treatment received. Receiving BT was associated with subsequent use of XR-NTX and may be associated with a longer duration of XR-NTX treatment. Providers should consider these findings when considering ways to increase primary-care based AUD treatment.

Comparison of the Safety Planning Intervention With Follow-up vs Usual Care of Suicidal Patients Treated in the Emergency Department

Importance

Suicidal behavior is a major public health problem in the United States. The suicide rate has steadily increased over the past 2 decades; middle-aged men and military veterans are at particularly high risk. There is a dearth of empirically supported brief intervention strategies to address this problem in health care settings generally and particularly in emergency departments (EDs), where many suicidal patients present for care.

Objective

To determine whether the Safety Planning Intervention (SPI), administered in EDs with follow-up contact for suicidal patients, was associated with reduced suicidal behavior and improved outpatient treatment engagement in the 6 months following discharge, an established high-risk period.

Design, Setting, and Participants

Cohort comparison design with 6-month follow-up at 9 EDs (5 intervention sites and 4 control sites) in Veterans Health Administration hospital EDs. Patients were eligible for the study if they were 18 years or older, had an ED visit for a suicide-related concern, had inpatient hospitalization not clinically indicated, and were able to read English. Data were collected between 2010 and 2015; data were analyzed between 2016 and 2018.

Interventions

The intervention combines SPI and telephone follow-up. The SPI was defined as a brief clinical intervention that combined evidence-based strategies to reduce suicidal behavior through a prioritized list of coping skills and strategies. In telephone follow-up, patients were contacted at least 2 times to monitor suicide risk, review and revise the SPI, and support treatment engagement.

Main Outcomes and Measures

Suicidal behavior and behavioral health outpatient services extracted from medical records for 6 months following ED discharge.

Results

Of the 1640 total patients, 1186 were in the intervention group and 454 were in the comparison group. Patients in the intervention group had a mean (SD) age of 47.15 (14.89) years and 88.5% were men (n = 1050); patients in the comparison group had a mean (SD) age of 49.38 (14.47) years and 88.1% were men (n = 400). Patients in the SPI+ condition were less likely to engage in suicidal behavior (n = 36 of 1186; 3.03%) than those receiving usual care (n = 24 of 454; 5.29%) during the 6-month follow-up period. The SPI+ was associated with 45% fewer suicidal behaviors, approximately halving the odds of suicidal behavior over 6 months (odds ratio, 0.56; 95% CI, 0.33-0.95, P = .03). Intervention patients had more than double the odds of attending at least 1 outpatient mental health visit (odds ratio, 2.06; 95% CI, 1.57-2.71; P < .001).

Conclusions and Relevance

This large-scale cohort comparison study found that SPI+ was associated with a reduction in suicidal behavior and increased treatment engagement among suicidal patients following ED discharge and may be a valuable clinical tool in health care settings.

Early assessment of implementing evidence-based brief therapy interventions among secondary service psychiatric therapists

This implementation study was part of the Ostrobothnia Depression Study, in Finland, which covered implementation of motivational interviewing (MI) and behavioral activation (BA) within regional public psychiatric secondary care. It aimed to evaluate the mid-term progress of implementation and related factors. Altogether, 80 therapists had been educated through the implementation program by the point of the mid-term evaluation. Eligible information for evaluation was gathered using two questionnaires (q1, q2) with a one-year interval. A total of 45 of the 80 therapists completed q1, 30 completed q2, and 24 completed both questionnaires. Professional education was the only background factor associated with adopting the interventions (q1: p=0.059, q2: p=0.023), with higher education indicating greater activity. On the basis of trends such as changes in overall usefulness score from q1 to q2, the most involved therapists were slightly more likely to adopt MI/BA. Our experience so far suggests that encouraging staff to begin using new interventions during education is very important. The Consolidated Framework for Implementation Research was found to be a useful tool for constructing the evaluation.

Screening for unhealthy alcohol and other drug use by health educators: do primary care clinicians document screening results?

OBJECTIVES

Health educators are increasingly being used to deliver preventive care including screening and brief intervention (SBI) for unhealthy substance use (SU) (alcohol or drug). There are few data, however, about the "handoff" of information from health educator to primary care clinician (PCC). Among patients identified with unhealthy SU and counseled by health educators, the objective of this study was to examine (1) the proportion of PCC notes with documentation of SBI and (2) the spectrum of SU not documented by PCCs.

METHODS

Before the PCC-patient encounter, health educators screened for SU, assessed severity (Alcohol, Smoking, and Substance Involvement Screening Test), and counseled patients. They also conveyed this information to the PCC before the PCC-patient encounter. Researchers reviewed the electronic medical record for PCC documentation of SBI performed by the health educator and/or the PCC.

RESULTS

Among patients with the health educator-identified SU, only 69% (342/495) of PCC notes contained documentation of screening by the health educator and/or the PCC. Documentation was found in all encounters with patients with likely dependent SU, but only 62% and 59% of encounters with patients with risky alcohol and drug use, respectively. Documentation of cocaine or heroin use was higher than that of alcohol or marijuana use but still not universal. Although all SU-identified patients had received a brief intervention (from a health educator and possibly a PCC), only 25% of PCC notes contained documentation of a brief intervention.

CONCLUSIONS

Among patients screened and counseled by health educators for unhealthy SU, SBI was often not documented by PCCs. These results suggest that strategies are needed to integrate SBI by primary care team members to advance the quality of care for patients with unhealthy SU.

Passive coping response to depressive symptoms among low-income homebound older adults: does it affect depression severity and treatment outcome?

Due to their homebound state, lack of financial resources, and/or other life demands, a significant proportion of depressed, low-income homebound older adults experience depression. Because of their limited access to psychotherapy, most of these older adults self-manage their depressive symptoms. The purposes of this study were to examine (1) the relationship between homebound older adults' coping responses to depressed mood and the severity of their depressive symptoms at baseline (n = 121), and (2) the moderating effect of passive coping responses on the relationship between participation in problem-solving therapy (PST: in-person or telehealth delivery) and depressive symptoms at 12- and 24-week follow-ups. Controlling for the effects of demographic and disability characteristics, cognitive passive coping was significantly associated with baseline depressive symptoms, while behavioral passive coping was not. The main effect of baseline cognitive passive coping response was also significant in mixed-effects regression analysis, but the interaction between coping pattern and group was not significant. The results point to a possibility that cognitive passive copers may have benefited as much from PST as the rest of the PST participants. Further research needs to examine the moderating effect of coping responses to depressive symptoms on treatment efficacy of PST and other psychosocial interventions for late-life depression.

Comment on the paper by Suffoletto et al. entitled: Text-message-based assessments and brief intervention for young adults discharged from the emergency department

BACKGROUND

This commentary discusses the importance of the recent article by Suffoletto and colleagues (in press), from the perspective of the developing role that technology such as text-messaging is serving as a means of increasing the reach of brief interventions for harmful alcohol use.

RESULTS

This study is important as it offers evidence from a well-designed study that text-messaging can be used to survey young adults about their alcohol use shows promising results for the potential efficacy of this technology to reduce alcohol use, including risky heavy episodic use. There are ethical and clinical considerations around text-messaging that need to be examined.

CONCLUSIONS

Future adequately powered randomized studies are needed to show the comparative effect of new technologies, such as text-messaging, in comparison with more traditional methods of providing interventions in reducing harmful alcohol use.

Treatment completion in a brief motivational intervention in the emergency department: the effect of multiple interventions and therapists' behavior

BACKGROUND

The aim of this study was to identify therapist behaviors during a brief motivational intervention (BMI) given to injured emergency department patients that predicted participant return for a second BMI session and 12-month alcohol-related outcomes.

METHOD

This was a secondary data analysis of a randomized controlled trial (n = 539) previously demonstrating that random assignment to a BMI and booster session resulted in a significant reduction of 12-month post-intervention alcohol-related injuries and negative consequences relative to standard care.

RESULTS

Participants who actually received 2 BMI sessions had significantly less alcohol-related negative consequences than those who received only 1 BMI session. Therapists who reported a higher focus on emotional support and low focus on participant drinking behaviors during the initial BMI session were more likely to have assigned participants return for the second BMI session.

CONCLUSION

The results of these secondary analyses show that compliance with a 2-session therapeutic intervention (BIB) predicted fewer negative alcohol-related consequences, and that therapists' supportive emotional emphasis during the first BMI session was important in predicting participants returning for the second MI session.

Treatment and prevention of mental disorders in low-income and middle-income countries

We review the evidence on effectiveness of interventions for the treatment and prevention of selected mental disorders in low-income and middle-income countries. Depression can be treated effectively in such countries with low-cost antidepressants or with psychological interventions (such as cognitive-behaviour therapy and interpersonal therapies). Stepped-care and collaborative models provide a framework for integration of drug and psychological treatments and help to improve rates of adherence to treatment. First-generation antipsychotic drugs are effective and cost effective for the treatment of schizophrenia; their benefits can be enhanced by psychosocial treatments, such as community-based models of care. Brief interventions delivered by primary-care professionals are effective for management of hazardous alcohol use, and pharmacological and psychosocial interventions have some benefits for people with alcohol dependence. Policies designed to reduce consumption, such as increased taxes and other control strategies, can reduce the population burden of alcohol abuse. Evidence about the efficacy of interventions for developmental disabilities is inadequate, but community-based rehabilitation models provide a low-cost, integrative framework for care of children and adults with chronic mental disabilities. Evidence for mental health interventions for people who are exposed to conflict and other disasters is still weak-especially for interventions in the midst of emergencies. Some trials of interventions for prevention of depression and developmental delays in low-income and middle-income countries show beneficial effects. Interventions for depression, delivered in primary care, are as cost effective as antiretroviral drugs for HIV/AIDS. The process and effectiveness of scaling up mental health interventions has not been adequately assessed. Such research is needed to inform the continuing process of service reform and innovation. However, we recommend that policymakers should act on the available evidence to scale up effective and cost-effective treatments and preventive interventions for mental disorders.

Levels and Patterns of the Therapeutic Alliance in Brief Psychotherapy

We examined the relevance of the level and pattern of the therapeutic alliance in 44 cases of three different, manualized 30-session treatments using patient ratings of the Working Alliance Inventory after each session. It was hypothesized that both high-alliance level and either a linear increase in alliance rating or a series of brief rupture-and-repair episodes would be found in successful treatments. We also hypothesized that a more global high-low-high pattern predicted in the literature would not be present. Consistent with the literature, higher alliance levels were found to be related to improved outcome. As predicted, we did not find a global, high-low-high pattern. Local rupture-and-repair patterns were found in 50% of the cases; linear trends were found in 66% of the cases. There was no relationship between outcome and either pattern. We found no differences among the treatments.

A retrospective study of weight changes and the contributing factors in short term adult psychiatric inpatients

INTRODUCTION

The authors endeavored to determine if there is significant weight gain during acute psychiatric inpatient hospitalization for adults and, if so, what are the contributing factors.

METHODS

A retrospective chart review was conducted of all patients admitted to the psychiatric inpatient unit of a University Hospital in the year 2001. The study was approved by the Institutional Review Board.

RESULTS

Out of 535 charts reviewed, 96 patients met the inclusion criteria. The group on average gained 3.9 +/- 13.3 lbs. (P = 0.005; 95% CI = 1.2, 6.6). Lower admission body weight was associated with more weight gain. Patients with diagnoses of bipolar disorder and schizophrenia gained more compared to those diagnosed with major depressive disorder. Patients who were prescribed atypical antipsychotics gained more compared to those who were not prescribed such medications. Smokers gained more weight than nonsmokers, and males gained more than females. Weight at the time of the admission (inverse relationship) and Axis I diagnosis were the strongest predictors of weight gain.

CONCLUSIONS

This study demonstrates that significant numbers of patients are at risk of gaining weight when they are admitted to a psychiatric inpatient unit. Patients with lesser degrees of overweight at the time of admission, patients with diagnoses of bipolar disorder and schizophrenia, and those receiving atypical antipsychotics may be more vulnerable to such effects.

Stationäre Kurz- und Langzeitpsychotherapie - Indikationen, Ergebnisse, Prädiktoren/ Short-term and Long-term Inpatient Psychotherapy – Indications, Results, Predictors

OBJECTIVES

This study investigated differences between patients in both short-term and long-term inpatient psychotherapy. Results for both settings as well as predictors of treatment outcomes were determined.

METHODS

Consecutive patients of the Giessen University Clinic for Psychosomatics and Psychotherapy, who were treated during a two-year period in both short- and long-term treatment settings, were studied prospectively (N = 166; return-rate 70 %). Standardized questionnaires were applied for distress (SCL-90 R), physical complaints (GBB 24) and interpersonal problems (IIP-D) as well as for object relationships (IPO).

RESULTS

In concordance with treatment concepts, patients in short-term psychotherapy had a more acute onset of symptoms, were more highly distressed and better occupationally integrated; patients in long-term treatment suffered more frequently from chronic psychosomatic disorders, personality disorders and comorbid somatic conditions. In both treatment settings distress and physical complaints decreased considerably and remained quite stable during follow-up. Concurring predictors of outcome were more adaptive patterns of object and interpersonal relationships as well as social resources. No differences were seen between the short-term and long-term treatment for utilization of ambulatory psychotherapy after discharge.

DISCUSSION

The study shows that a differentiation between short- and long-term treatments, even within one psychosomatic hospital unit, allows for differential indication and treatment concepts.

The efficacy of short-term psychodynamic psychotherapy in specific psychiatric disorders: a meta-analysis

BACKGROUND

The efficacy of psychodynamic therapy is controversial. Previous meta-analyses have reported discrepant results.

OBJECTIVE

To test the efficacy of short-term psychodynamic psychotherapy (STPP) in specific psychiatric disorders by performing a meta-analysis of more recent studies. We assessed outcomes in target problems, general psychiatric symptoms, and social functioning.

DESIGN

We identified studies of STPP published between January 1, 1970, and September 30, 2004, by means of a computerized search using MEDLINE, PsychINFO, and Current Contents. Rigorous inclusion criteria, included randomized controlled trials, use of treatment manuals and insurance of treatment integrity, therapists experienced or specifically trained in STPP, treatment of patients with specific psychiatric disorders, reliable and valid diagnostic measures, and data necessary to calculate effect sizes. Studies of interpersonal therapy were excluded. Seventeen studies fulfilled the inclusion criteria. The information was extracted by 3 raters. Effect sizes were calculated for target problems, general psychiatric symptoms, and social functioning using the data published in the original studies. To examine the stability of outcome, we assessed effect sizes separately for end of therapy and follow-up assessment. The effect sizes of STPP were compared with those of waiting-list control patients, treatments as usual, and other forms of psychotherapy.

RESULTS

Short-term psychodynamic psychotherapy yielded significant and large pretreatment-posttreatment effect sizes for target problems (1.39), general psychiatric symptoms (0.90), and social functioning (0.80). These effect sizes were stable and tended to increase at follow-up (1.57, 0.95, and 1.19, respectively). The effect sizes of STPP significantly exceeded those of waiting-list controls and treatments as usual. No differences were found between STPP and other forms of psychotherapy.

CONCLUSIONS

Short-term psychodynamic psychotherapy proved to be an effective treatment in psychiatric disorders. However, further research of STPP in specific psychiatric disorders is needed, including a study of the active ingredients of STPP. Effectiveness studies should be included.

[Utilization and effectiveness of short-term counseling in child guidance]

This study investigates the utilization and effectiveness of short-term counseling in child guidance. For this purpose a comparison was made between short-term and long-term counseling (each N = 89) and a catamnestic telephone interview of the parents who had had short-term counseling was conducted (N = 70).

RESULTS

1. The rate of short-term counseling amounts to 39%. 2. The individuals seeking short-term counseling are significantly less burdened with problems. 3. In stating the reason for a short-term counseling, 58% of the individuals concerned claim that the number of counseling sessions held had been sufficient, that there had been an improvement with regard to the problems, or that according to the counselor there had been no need for further activity; 24% were dissatisfied with the counseling and for this reason broke it off; 10% were directed to other institutions. 4. On the whole the persons seeking advice evaluated the short-term counseling mainly positively. The evaluation of satisfaction and success corresponds with the evaluation commonly gained in educational guidance: 70% of the individuals seeking counseling were satisfied with the results, 44% reported positive changes due to the advice they received, and 66% seem to have gained a better understanding for their children. 5. The good relationship between the counselor and the person seeking advice appeared to be particularly important.

[Adaptive indication in outpatient psychodynamic short-term psychotherapy. Results of a prospective naturalistic research study]

Health care insurers in Germany fund long-term psychotherapy of up to 240 sessions as well as brief psychotherapeutic interventions of up to 25 sessions. In a former study, it was observed that a substantial proportion of interventions initially designed as brief psychotherapy were changed into long-term therapy. The present study investigated the criteria of such decisions to change treatment plans and is part of a more comprehensive auditing study in outpatient psychotherapy. Twenty-six psychotherapists in private practice participated in the study. During a 12-month recruitment period, 70 patients started with brief psychodynamic psychotherapy. Thirty-six therapies were evaluated according to the study protocol. The results provide evidence that motivation for psychotherapy, satisfaction with the results of therapy, persistence of psychological symptoms at the end of short-term intervention, and aspects of the patient's personality are factors predictive of treatment selection. Patients who changed from short-term to long-term therapy were more motivated towards their therapy (prognostic indication), displayed more severe symptoms, were less satisfied with the results of short-term psychotherapy (adaptive indication), and scored higher on the "structure of personality organization" parameter according to the OPD diagnostic system.

Time is of the essence: A selective review of the fall and rise of brief therapy research

For compelling reasons of equity and the advance of public health, brief psychotherapy has become the dominant format in both practice and research. One consequence of this is the apparent decline of a distinct stream of brief therapy research. However, much of the agenda formerly identified with that research stream is of increasing importance to the field. Time is indeed of the essence in current psychotherapy research. For example, factors conducive to the time efficiency of brief psychodynamic therapy have been described recently. The important question 'How much therapy is enough?' has been addressed by studies inspired by the dose-response analysis of Howard and colleagues. The value of ultra-brief interventions has been examined. These issues are considered in a selective review, drawing in particular on the work of the Sheffield/Leeds psychotherapy of depression research group. This research treats the number of treatment sessions as an independent variable, thereby providing a causal analysis of the dose-response relationship over a range from two to 16 sessions, illuminated by a comparative analysis of change processes in treatments of different durations. Its results enable some specification of the extent and nature of incremental benefit derived from additional sessions in the psychotherapy of depression.

Kurzfristige Effekte der station�ren Akutbehandlung alkoholabh�ngiger Patienten

BACKGROUND

In spite of a high prevalence of patients with alcohol addiction being treated in mental hospitals, the acute treatment of alcoholism has seldom been evaluated.

METHODS

This follow-up study was conducted in five mental hospitals in northwestern Germany. Enrolled were 479 consecutively admitted patients, of whom 411 (86%) could be interviewed 3 months after discharge.

RESULTS

3 months after discharge, 60.5% of the intention-to-treat sample and 54% of the follow-up sample had relapsed. Twenty-eight percent had taken part in inpatient rehabilitation programmes, and 26.5% had had at least one further inpatient withdrawal treatment. There were highly significant reductions in quantity of consumed alcohol, numbers of drinking days, and numbers of intoxication days. Multivariate analyses revealed that biographical, social, and treatment-related items were predictors of unfavourable outcome (excessive alcohol consumption and/or readmission to inpatient treatment). A short length of stay was identified as a predictor of unfavourable health status after 3 months.

CONCLUSIONS

For many patients, inpatient acute treatment is an effective intervention which promotes abstinence, reduces alcohol consumption, and enhances integration into the addiction treatment system. For chronically addicted and repeat patients, this treatment as a repetitive crisis intervention helps in the short term but does not result in lasting changes in the course of illness.

Clinicians' predictions of length of psychotherapy

The study examined therapists' accuracy in predicting the length of individual outpatient psychotherapy for 109 clients and attempted to identify variables associated with predicted and actual treatment lengths. The mean predicted treatment length (9.7 months) was significantly longer than the mean length of actual treatment (6.6 months). Therapists correctly predicted treatment length to the nearest month in 26 percent of the cases. Predictions were more accurate for older clients. Treatment tended to be shorter for clients with less than a high school education. Therapists more often predicted shorter treatments for clients with an adjustment disorder and those with less education. Predicting treatment length appears to be difficult.

Outpatient psychotherapy in the United States, II: Patterns of utilization

OBJECTIVE

The purpose of this article is to characterize the use of psychotherapy based on episode duration.

METHOD

Data were analyzed from the household section of the 1987 National Medical Expenditure Survey. The authors determined the demographic characteristics, provider and reason for visit distribution, mental and physical health status, and expenditures associated with very short-term (one to two sessions), short-term (three to 10 sessions), intermediate-term (11 to 20 sessions), and long-term (> 20 sessions) psychotherapy.

RESULTS

Long-term psychotherapy accounted for 15.7% of psychotherapy users and 62.9% of total psychotherapy expenditures. Age above 65 years, black race, and less than 12 years of education decreased the likelihood of receiving long-term psychotherapy. Whereas long-term psychotherapy episodes tended to be provided by the specialty sector (65.7%) for specific mental conditions (53.8%), very short-term episodes were predominantly provided by the general medical sector (72.2%) for general medical or unspecified conditions (68.3%). Psychotropic medication use and, to less extent, psychiatric hospitalization tended to be more common among longer- as opposed to shorter-term users.

CONCLUSIONS

Long-term and short-term psychotherapy tend to be provided by different health care professionals for the treatment of different types of health conditions. To help ensure the future of third-party payment for long-term psychotherapy, research is needed to better define the conditions under which long-term psychotherapy achieves benefits that equal or surpass those of other medical services or procedures of similar cost.

Do therapist experience, diagnosis and functional level predict outcome in short term psychotherapy?

The purpose of this study was to investigate the effects of clinical diagnosis, functional level and therapist experience on the outcome of brief psychotherapy. Patients (N = 123) were clinically diagnosed and assigned to either a psychiatrist, psychiatry resident, family practice resident or medical student. Global Assessment of Functioning (GAF) scores and the Global Severity Index (GSI) of the SCL-90 were rated at baseline, at the end of therapy and at six month follow-up. The Client Satisfaction Questionnaire was also scored after therapy. All groups of patients improved significantly. Neither therapist type and diagnostic category nor their interaction were related to outcome GAF or to GSI. Patients improved irrespective of their baseline symptom severity. Satisfaction with therapy was highly related ot increased functioning and decreased symptom severity. The number of therapy sessions attended by patients was modestly related to outcome and patient satisfaction. The results suggest that many diagnostic groups benefit from brief psychotherapy administered by therapists of varying experience. Furthermore, the results support the practice of having medical students conduct psychotherapy under supervision during their training.

The efficacy of brief dynamic psychotherapy: a meta-analysis

OBJECTIVE

Insurance companies, legislators, and funding agencies have become increasingly concerned with efficacy and accountability in regard to psychotherapy, and psychodynamic therapy is a primary target of concern because it is widely practiced in outpatient settings. This paper is a meta-analytic review of recent well-controlled studies of the efficacy of brief dynamic therapy.

METHOD

The meta-analysis included both published studies, located through an extensive computerized search of psychiatry and psychology journals, and studies reported at conferences. Eleven studies met the inclusion criteria: use of a specific form of short-term dynamic psychotherapy as represented in a treatment manual or manual-like guide; comparison of brief dynamic therapy and a waiting list control condition, nonpsychiatric treatment, alternative psychotherapy, pharmacotherapy, or other form of dynamic therapy; provision of the information necessary for calculation of effect sizes; at least 12 therapy sessions; and therapists who were trained and experienced in brief dynamic therapy. The outcome measures compared were target symptoms, psychiatric symptoms generally, and social functioning.

RESULTS

Brief dynamic therapy demonstrated large effects relative to waiting list conditions but only slight superiority to nonpsychiatric treatments. Its effects were about equal to those of other psychotherapies and medication.

CONCLUSIONS

These data confirm previous indications that various psychotherapies do not differ in effectiveness, although this finding should not be generalized to all patient populations, outcome measures, and treatment types. Also, the highly controlled conditions of these studies limit conclusions about actual practice. Future studies should address various treatment lengths, follow-up assessments, and specific treatments, patient groups, and outcome measures.