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Abbass, A., Kisely, S., Rasic, D., Town, J.M., & Johansson, R. (2015). Long-term healthcare cost reduction with Intensive Short-term Psychodynamic Psychotherapy in tertiary psychiatric care. Journal of Psychiatric Research, http://dx.doi.org/10.1016/j.jpsychires.2015.03.001

Several years ago Lazar (2010) published a book detailing the cost-effectiveness of psychotherapy for a variety of disorders. That is, her systematic review found that on most economic indicators (lost income, decreased disability, decreased health utilization) psychotherapy resulted in an immediate cost reduction over and above the cost of the treatment. In this study from Halifax, Canada, Abbass and colleagues looked at the effects of psychotherapy, specifically of Intensive Short-term Dynamic Psychotherapy (ISTDP), on the long-term reduction in hospital costs and physician visits. Abass and colleagues argue that adverse childhood events are an important determinant of adult mental health problems and of increased costs to the health system likely because of the consequence of problems with emotion regulation. Psychotherapies like ISTDP specifically address issues that are a consequence of childhood maltreatment and so might reduce some of the consequent health care costs. Abbass and colleagues provided ISTDP to 890 patients in the Halifax health care system who were referred to the psychotherapy service from emergency departments, physicians, and mental health providers. These patients’ outcomes were compared to 192 patients not seen by the clinic for various reasons. Most common diagnoses of the total sample were: somatoform disorder, anxiety disorder, personality disorder, and depressive disorder. Participant completed measures of psychological distress, and the research team were able to access provincial health usage data tracked over 3 years. Fifty eight therapists of various skill levels (psychiatrists, psychologists, family physicians, trainees) provided ISTDP. The average patient attended 7.3 sessions which cost $708 (estimated by salaries in 2006). Patients receiving psychotherapy had physician and hospital costs that decreased from $3,224 to $4759 in Canadian dollars per year over three years (again in 2006 dollars). Patients in the control condition not receiving ISTDP showed health care costs that increased from $368 to $2,663 per year. These trajectories of health care costs were significantly different. Yearly physician and health care costs for patients prior to being treated with ISTDP were greater than those of the general Canadian population, but 3 years post ISTDP their health care costs were less than the general Canadian population. In addition, compared to control patients those treated with psychotherapy showed a significant reduction in psychological distress.

Practice Implications

This study by Abbass and colleagues demonstrates that short term psychotherapy provided to a broad range of patients and targeting health and illness behaviors related to problems with emotion regulation can reduce health care costs. These reductions in hospital and physician visits occurred in the short term and were sustained over several years. Some patients may require longer treatment, but the evidence suggests that short term interventions should be tried first.

Author email: allan.abbass@dal.ca

Xie, C.L., Wang, X.D., Chen, J., Lin, H.Z., Chen, Y.H., Pan, J.L., & Wang, W.W. (2015). A systematic review and meta-analysis of cognitive behavioral and psychodynamic therapy for depression in Parkinson’s disease patients. Neurological Sciences, 1-11.

Parkinson’s disease (PD) is a neurodegenerative brain disorder that progresses slowly in most people. When dopamine producing cells in the brain are damaged or do not produce enough dopamine, motor symptoms of PD appear. Non-motor symptoms, including depression, apathy, and sleep disorders are also common so that in clinical settings about a 40% of patients with PD may have a depressive disorder. Depression is a top predictor of poor quality of life in patients with PD. Depression in PD is not well understood but may be due to neurobiological vulnerability and to psychological factors. Antidepressant medications are often prescribed for depression in PD but their efficacy is questionable. Xie and colleagues argue that long term use of some antidepressants may lead to worsening of some PD motor symptoms. In this meta analysis, Xie and colleagues examine the efficacy of brief psychological interventions, including cognitive behavioral therapy (CBT) and psychodynamic psychotherapy for depressive symptoms in PD. Twelve eligible studies were included in the meta analysis representing 766 patients with a mean age of 62 years (48% men). As an interesting note, 9 of the 12 studies were conducted in China and 3 were from the US or UK. Six of the studies used CBT for depression, and the remaining used psychodynamic therapy for depression in PD patients. Control conditions were often “treatment as usual”, and varied from antidepressant medication (e.g., Citalopram), nursing care, telephone calls, or no treatment for the depression. The effects of psychological interventions compared to control conditions on depressive symptoms were large, and remained large even after removing outlier studies. Outcomes for psychodynamic psychotherapy were better than for CBT, although both interventions resulted in large effects. There were also significant positive effects of brief psychotherapies on cognitive functioning, but not on quality of life. The authors were concerned that the quality of studies was variable and that many studies demonstrated a risk of bias. Further, most studies did not report outcomes at follow up periods.

Practice Implications

Significant depressive symptoms commonly occur in patients with Parkinson’s disease (PD). As a result, overall quality of life may be reduced in patients with PD. Medications for depression may be complicated by the neurodegenerative nature of PD – that is, effects of medications on depressive symptoms may be small and their neuro-motor side effects may be intolerable for some patients. This meta analysis by Xie and colleagues of 12 studies suggests that better research on psychotherapy for depression in PD needs to be conducted with adequate follow ups. Nevertheless, the findings suggest that brief psychological interventions may represent viable and effective alternatives for patients with PD who have a depressive disorder.

Wade, N.G., Hoyt, W.T., Kidwell, J.E., & Worthington, E.L. (2014). Efficacy of psychotherapeutic interventions to promote forgiveness: A meta-analysis. Journal of Consulting and Clinical Psychology, 82, 154-170.

Forgiveness can include reducing vengeful and angry thoughts and feelings, and may be accompanied by positive thoughts, feelings and motives towards the offending person. This does not necessarily include reconciliation with the offending person, nor does it require forgetting, condoning, or excusing the wrongdoing. Promoting forgiveness in psychotherapy includes helping clients move toward more positive and optimal functioning. There are two prominent empirically based models of forgiveness interventions. Enright’s model contains four phases: (1) uncovering negative thoughts about the offense, (2) decision to pursue forgiveness, (3) work toward understanding the offending person, and (4) discovery of unanticipated positive outcomes and empathy for the offending person. Worthington’s model has five steps: (1) recalling the hurt and emotions, (2) empathising with the offender, (3) altruistic view of forgiveness, (4) commitment to forgiveness, and (5) holding on to or maintaining forgiveness. Wade and colleagues conducted a meta analysis: to compare forgiveness outcomes and mental health outcomes of forgiveness interventions in general; to compare of forgiveness interventions to each other; and to compare forgiveness interventions to non-forgiveness psychotherapies or to control conditions. The meta analysis included 53 studies of 2,323 participants. Participants receiving forgiveness interventions reported significantly greater forgiveness compared to those not receiving treatment and compared to those who received alternative treatments that were not specific to forgiveness. Forgiveness interventions also resulted in greater positive changes in depression, anxiety, and hope compared to no-treatment conditions. There were no differences between Enright’s and Worthington’s approaches when duration of treatment and modality (individual vs group) were controlled. However, as an individual treatment, Enright’s model showed better outcomes. Longer duration of treatment was associated with greater forgiveness, and greater severity of the offense was also associated with greater forgiveness.

Practice Implications

Theoretically grounded forgiveness interventions may be the best choice to help a client to achieve resolution in the form of forgiveness. Other non-forgiveness therapeutic approaches may help but may not have as great an impact on forgiveness as those interventions that are specifically designed to improve forgiveness. Enright’s model delivered as an individual treatment was more effective than Worthington’s approach which is designed mostly as a group intervention. In addition to improving forgiveness, both approaches also had significant positive impact on depression, anxiety, and hope. The forgiveness interventions worked better if provided for longer duration and in the context of more severe offenses.

Budge, S.L., Moore, J.T., Del Re, A.C., Wampold, B.E., Baardseth, T.P., & Nienhuis, J.B. (2013). The effectiveness of evidence-based treatments for personality disorders when comparing treatment-as-usual and bona fide treatments. Clinical Psychology Review, 33, 1057-1066.

Personality disorders (PD) are more stable and enduring than other mental disorders and are characterized by pervasive, serious, and rigid self-destructive patterns in affect, cognition, interpersonal relations, and impulse control that reduce psychological well-being. PD are associated with higher rates of self injury, suicide, and health care costs. The prevalence of PD in the population ranges from 6% to 13%. The presence of PD in a patient often reduces the effectiveness of psychological treatments for Axis I disorders (e.g., depression, anxiety) that the patient may have. Psychotherapy may be more effective than other interventions, such as pharmacotherapy, for treating PD. In their meta analysis, Budge and colleagues (2013) addressed two questions. First, are manualized evidence-based treatments (EBT) as provided in clinical trials superior to treatment as usual (TAU), presumably as offered in naturalistic settings, for treating PD? Second, are there differences between bona fide treatments (i.e., psychotherapy administered by trained therapists and based on sound psychological theories) for PD? (A note about meta analyses: meta analyses are a statistical method to combine the findings of a large number of studies while accounting for the sample sizes, quality of the studies, and size of the effects. Meta analyses provide us with much more dependable results than any single study could provide). Regarding the first question, 30 studies were included in the meta analysis. Evidence-based treatments included psychodynamic therapies, cognitive behavioral therapies, and dialectical behavior therapy, among others. Overall, EBTs were more effective than TAUs, and the effect was medium sized. The positive effects in favor of EBT over TAU were larger for patients with borderline personality disorder. For the second study comparing bona fide treatments, only 12 studies were found and included in the meta analysis. Only three of the studies indicated that one bona fide therapy was more effective than another. It is also important to note that the average duration of treatment in the EBT studies was 1 year and peaked at 40 sessions.

Practice Implications

As Budge and colleagues (2013) concluded, with sufficient training, supervision, and dose hours, it appears that evidence based treatments (EBT) are more effective than treatments as usual (TAU) for personality disorders (PD). The results of the meta analysis suggested that training in evidence based psychotherapies may be necessary to achieve the best possible outcomes for patients with PD, especially those with borderline personality disorder. Are there differences in between EBTs for PD? The literature on this issue is quite small, so that 12 studies are not enough to make many conclusions. There is previous evidence that psychodynamic therapies and CBT yield very large effects for PD. The pervasiveness and complexity of PD symptoms make it so that effective treatments are necessarily longer term, which is consistent with previous research on this topic.

Cuijpers, P., Huibers, M., Ebert, D.D., Koole, S.L., & Andersson, G. (2013). How much psychotherapy is needed to treat depression? A metaregression analysis. Journal of Affective Disorders, 147, 1-13.

The question of the number of psychotherapy sessions and of frequency sessions (i.e., number of sessions per week) that are optimal for good outcomes could have implications for how psychotherapy is practiced and how it is reimbursed. In my August 2013 PPRNet Blog, I reported on research that indicated half of patients recover after 21 sessions of psychotherapy. However, that also means that half do not recover in that number of sessions. Many of those who do not recover require another 29 sessions to recover. Research and practice in psychotherapy is largely based on a “one-session-per-week” model. Some researchers, however, have found that an increase in the frequency sessions per week could improve or speed up outcomes. Cuijpers and colleagues (2013) did a meta-regression to assess these questions for short-term psychotherapies for depression. (Meta-regression is a type of meta-analysis in which predictors from many studies are aggregated and their averaged effects on the aggregated outcome are assessed. This produces much more reliable findings than are possible from a single study.) The authors assessed predictors such as the number and frequency of sessions, and they looked at symptom outcomes for depression. The authors found 70 controlled studies that included 5403 patients. More than two-thirds of the studies included CBT as the psychotherapy. Average length of treatment was 11 sessions, and the maximum number of sessions was 24. The number of sessions across studies ranged from .44 to 2 per week, and the average per week was 1. The overall effect size for the treatment was medium sized (g = .59), though the effect became smaller (g = .40) when publication bias was corrected. (Publication bias refers to the likelihood that some less favorable studies or results were not published thus creating an overestimation of the effect of the treatment. See my May 2013 PPRNet Blog). Cuijper and colleagues’ meta-regression showed a small but significant association between greater number of sessions and outcomes for depression; but more importantly, a greater number of sessions per week had a considerably larger positive influence on the effects of psychotherapy for depression.

Practice Implications

The findings from Cuijpers and colleagues (2013) meta-regression are particularly relevant to time limited treatment of depression with CBT. The total number of sessions was less important than the frequency of sessions per week. The results suggest that increasing the intensity or frequency of CBT sessions per week might result in a more efficient therapy and faster relief for patients with depression.

Author email: p.cuijpers@vu.nl

Handbook of Psychotherapy and Behavior Change: Starting in March 2013 I will review one chapter a month in the Handbook of Psychotherapy and Behavior Change in addition to reviewing psychotherapy research articles. Book chapters have more restrictive copy right rules than journal articles, so I will not provide author email addresses. If you are interested, the Handbook table of content can be viewed on Amazon.

Lambert, M.J. (2013). The efficacy and effectiveness of psychotherapy. In M.J. Lambert (Ed.) Bergin and Garfield’s handbook of psychotherapy and behaviour change (6^th ed.), pp. 169-218. Hoboken, N.J.: Wiley.

An important issue for patients, therapists, and agencies is the optimal dosage of psychotherapy that is necessary to reduce impairment and improve life functioning. In this part of the Handbook chapter on Efficacy and Effectiveness of Psychotherapy, Lambert tackles the issue of the psychotherapy dose-response relationship by reviewing the existing literature. That literature tends to focus on naturalistic national (U.S.) samples of patients (often N > 6,000) receiving routine care in Health Maintenance Organizations, Employee Assistance Programs, and Community Mental Health Clinics. Outcomes tend to be assessed by patient self report, and can include symptoms, character traits, quality of life, and interpersonal functioning, among others. Lambert defines “improved” patients as those who reliably changed but still are within the dysfunctional range on a measure, and he defines “recovered” patients as those who both reliably improved and were no longer in the dysfunctional range. He concluded that on average 50% of patients who begin treatment in the dysfunctional range achieve recovery following 21 sessions of psychotherapy. On the flip side, half of patients do not achieve recovery after 21 sessions. Almost 50 sessions are necessary for 75% of patients to recover. In other words, there is a rapid rate of recovery in which half of patients recover after 21 sessions, but then the rate of recovery slows down so that it takes up to 50 sessions for an additional 25% of patients to recover. The rates of recovery also differ depending on what is measured. Symptoms (depression, anxiety, etc.) tend to recover more quickly than characterological or interpersonal problems. Further, some patients experience sudden symptom gains in therapy that are long lasting. Between 17% and 50% of patients experience the majority of their symptom improvements within 7 sessions, and these early changes accounted for 50% of total symptom gains in therapy.

Practice Implications

The question of how much therapy is enough is important for practical and theoretical reasons. Research on this topic can help patients, therapists, and agencies make decisions about treatment planning. Research suggests that a sizeable proportion of patients (50%) reliably improve after 7 sessions and a similar percentage recover after 21 sessions. However, limiting treatment to less than 20 sessions will mean that about half of patients will not achieve a substantial benefit from therapy. Session limits need to be assessed carefully depending on how the patient is doing and what outcomes are important or valued. Agencies or clinicians that firmly set limits on the number of psychotherapy sessions that are too low will have the majority of their patients showing some improvement but not recovering.