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The Cost-Effectiveness of Intensive Short-Term Dynamic Psychotherapy



CME Educational Objectives 1. Expose the reader to various sources of health care costs and diagnoses responsible for these. 2. Review the evidence for multiple categories of cost reduction for intensive short-term dynamic psychotherapy (ISTDP). 3. Review the return-to-work rates for patients receiving ISTDP treatment. The health care burden of chronic disability, with mental illness and somatic symptom disorders leading the way, is crippling to global economies. 1 In the recent JAMA report by the U.S. Burden of Disease Collaborators, the top diseases with the largest number of years lived with disability in 2010 were low back pain, major depressive disorder, other musculoskeletal disorders, neck pain, and anxiety disorders. Migraine, drug use, alcohol use and dysthymia were also in the top 20. The authors noted that half of the health system cost is due to disability and morbidity. 1
The health care burden of chronic
disability, with mental illness
and somatic symptom disorders
leading the way, is crippling to global
economies.1 In the recent JAMA report
by the U.S. Burden of Disease Collabo-
rators, the top diseases with the largest
number of years lived with disability in
2010 were low back pain, major depres-
sive disorder, other musculoskeletal dis-
orders, neck pain, and anxiety disorders.
Migraine, drug use, alcohol use and dys-
thymia were also in the top 20. The au-
thors noted that half of the health system
cost is due to disability and morbidity.1
Based on extensive research dur-
ing the past 20 years, psychotherapy is
now acknowledged to be an effective
and cost-effective treatment for a broad
range of conditions.2 Given evidence
that psychotherapy is beneficial, the
relative cost of treatment has become
an important consideration in clinical
decision making.3 With this in mind,
the shorter and less expensive a psycho-
therapy model can be while retaining ef-
fectiveness, the greater the effect it can
have on widespread health system costs.
Based on long wait lists and wait
times for long-term psychotherapy in
public clinics, Habib Davanloo, MD, of
McGill University developed his method
of intensive short-term dynamic psycho-
therapy (ISTDP) between the 1970s and
2000s.4 Thus, two major reasons for this
development were to improve service
access and to reduce service cost per
patient in publically funded Canadian
ISTDP is a brief treatment designed
to achieve broad-based gains across
symptoms and personality difficulties.
At its core, the objective of ISTDP is
to help patients overcome emotional
blocks that lead to occupational disabil-
ity, somatic symptoms, depression, anx-
iety, and self-defeating behaviors. The
method includes a specialized series of
interventions designed to overcome high
levels of resistance, low levels of emo-
tional tolerance (depression, somatiza-
tion, conversion), and dissociation (frag-
ile character structure). ISTDP has been
The Cost-Effectiveness of Intensive
Short-Term Dynamic Psychotherapy
1. Expose the reader to various
sources of health care costs and
diagnoses responsible for these.
2. Review the evidence for multiple
categories of cost reduction for
intensive short-term dynamic
psychotherapy (ISTDP).
3. Review the return-to-work rates for
patients receiving ISTDP treatment.
Allan Abbass, MD, FRCPC, is Professor
and Director of Education, as well as Di-
rector, Centre for Emotions and Health,
Dalhousie University Department of
Psychiatry. Jeffrey W. Katzman, MD, is
Professor and Vice Chair, Education and
Academic Affairs, University of New Mex-
ico Department of Psychiatry.
Address correspondence to: Allan Ab-
bass MD, FRCPC, Room 8203, 5909 Veter-
ans Memorial Lane, Halifax NS, Canada
B3H 2E2; email:
Disclosure: Drs. Abbass and Katzman
have no relevant financial relationships
to disclose.
doi: 10.3928/00485713-20131105-04
Allan Abbass, MD, FRCPC; and Jeffrey W. Katzman, MD
© Shutterstock
Psychiatric Annals - Proof Copy
studied empirically with evidence sup-
porting its effectiveness across the range
of conditions described above, including
anxiety, depression, back pain, headache,
and chronic pain, as well as other condi-
tions such as personality disorders.5
Because it is a brief model of thera-
py, averaging fewer than 20 sessions in
published studies, one would expect it to
be more cost-effective when compared
to longer treatments. Since it addresses
characterological problems and treat-
ment resistance as well as symptoms,
ISTDP may also prove cost-effective
relative to treatments that focus on only
one component of the patient’s problem.
In this article, available published
studies that evaluate ISTDP’s effects on
Study Description and Reported Cost Reductions After ISTDP Treatment
Sample nNumber of
Control Reference Time Period Cost Domains Included Total Cost
Reduction Per
Panic disorder13 40 15 Clomipramine
alone. Randomized.
18-month follow-up
after stopping clomip-
Medication use rates only
Mixed sample8166 16.9 Wait list. Non-
Before vs. 1.75-year
passive follow-up
Medication use, disability rates
Mixed sample6* 89 14.9 1-2 years post vs. 1 year
Hospital costs, physician costs,
medication costs, disability costs
Personality disorders993 Up to 6
2 years post vs. 1 year pre Hospital costs, physician costs,
health professionals cost. Utiliza-
tion rates only
Mixed sample11† 88 14.9 3 years follow-up vs.
Hospital costs, physician costs $1,827
10 13.6 6 months post vs. 6
months pre
Hospital costs, medication costs,
disability costs
Chronic headache7* 29 19.7 1 year post vs. 1 year pre Medication costs, disability costs $7,009
Personality disorder15 27 27.7 Randomized wait
2 years post vs. 1 year
Medication costs, disability costs $10,148
Mixed sample. Trial
30 1 Pre vs 1 month post Employment rate, medication
use only
Medically unex-
plained symptoms17, 18
50 3.8 Non-randomized.
Patients referred
but not seen
1 year post vs. 1 year pre Medical (emergency) visits and
Personality disorder10§155 Up to 6
10 years post vs. 1 year
Employment rates only
Psychiatry inpatients12 33 9.0 Other psychiatric
ward. Non-random-
1 year post vs. 1 year pre Electroconvulsive therapy costs $1,400§
Mixed sample19 140 9.9 3 years post vs. 1 year
Physician costs, hospital costs $3,773
*Subsample of Abbass.6
†Extension of Abbass.6
‡Based on estimated cost of $1,000 per electroconvulsive therapy service.
§Sample partially overlaps with Cornelissen,9 counted as 26 sessions.
ISTDP = intensive short-term dynamic psychotherapy.
Psychiatric Annals - Proof Copy
health service costs, disability costs, and
medication costs are reviewed.
In 2012, we published a review of
all the available outcome studies of
ISTDP retrieved through a broad litera-
ture search.5 This search was repeated in
April 2013. Each of these articles was
scanned for any notation of cost and
service use measurement. All such mea-
sures were tabulated.
These data were tabulated and re-
viewed in terms of total cost-benefits
and then again separately by health ser-
vice use, medication use, and employ-
ment/disability costs.
A total of 13 studies included cost-
bearing measures. Treatments ranged
from an average of one session to 27.7
sessions and averaged 15.3 (SD 8.2)
sessions overall. Two articles6, 7 includ-
ed a sub-sample of Abbass, 2002a;8
one was an extension of Cornelissen
et al, 2002,9 with a larger sample and
longer follow-up,10 and the other in-
volved a follow-up evaluation from an
earlier study.11 Three studies included
inpatients in an acute care hospital12
or residential treatment facility,9,10
whereas the remainder involved out-
patient samples.13-19 In all, the studies
included two randomized, controlled
trials13,15 and three non-randomized,
controlled trials.8,12,17 The remainder
were case series.
These publications included five
studies of mixed psychiatric samples,
three of personality disorders, one of
treatment resistant depression, one of
panic disorder, one of chronic head-
ache and one of medically unexplained
symptoms. A further study published in
this volume examined the cost-effective-
ness of ISTDP provided by psychiatry
residents. The mixed samples included
patients with most DSM-IV diagnos-
tic groups, including major depression,
anxiety disorders, substance-use disor-
ders, bipolar disorder, dissociative dis-
orders, eating disorders, and psychotic
disorders. Thus, the studies combined
reflect the broad utility of this method in
clinical practice (see Table 1, page 497).
Data reported in the studies included
different outcome domains of health
care use, medication use, and disability
costs. Data were not reported in a uni-
form fashion between studies and had
varying follow-up periods. The cost
reductions reported ranged from $910
counting only emergency visit cost re-
duction over 1 year of follow-up to
$10,148 per patient counting disability
cost and medication cost reduction over
2 years of follow-up (see Table 1, page
Seven studies included medication
use and cost measures (see Table 2).
These included studies of panic disorder,
headache, treatment-resistant depression,
personality disorder, and mixed disor-
ders. The mean number of medications
reduced per medicated patient was 0.92
(SD .29) medications. The mean percent
of these patients stopping all medica-
tions was 59.7%, including those pro-
vided only one session of treatment, and
increased to 74.5% when excluding this
group. The mean cost reduction in the
follow-up intervals was $558.5 (SD 226).
Six studies included measures of
health service use and costs. Three stud-
ies reported reductions in hospital use.
Two showed modest reductions in physi-
cian use. One reported reductions in com-
bined hospital and physician costs. One
showed a 69% reduction in repeat emer-
gency visits in patients with medically
unexplained symptoms, whereas another
showed a nearly two-thirds reduction in
electroconvulsive therapy (ECT) use.
These last two studies included naturalis-
tic, non-randomized control patients who
did not experience any such service use
reduction (see Table 3, page 499).
Medication Use and Cost Reduction
Number of
Stopped per
Medicated Patient
Percent of All
Percent of
Cases Stopping
all Medications
Reduction per
Panic disorder13 0.80 80% 80%
Mixed sample8 69% –
Mixed sample60.83 71% – $454/year
1.4 56% 30% $880 / 6
Chronic headache70.83 65.2% – $360/year
Personality disor-
1.1 74% $540 / 2 years
Mixed sample: trial
0.55 35%* –
*Response to single trial therapy session.
Psychiatric Annals - Proof Copy
Seven studies reported changes in
employment status and/or disability
costs (see Table 4, page 500). Patients
in these samples were disabled for a
long period of time, averaging 67.2
weeks out of work. Overall, there were
large cost reductions owed to high
return-to-work rates. Between-study
average rates of return to work were
68.4% when including a study of sin-
gle-session trial therapies and 77.4%
when not including this study. Cost
reductions ranged from $6,720 per
patient during a follow-up period of 6
months to $28,114 per patient during a
1-year follow-up period.
The therapeutic objective of ISTDP
is to facilitate an emotional healing pro-
cess by allying with an individual’s
natural drive toward health to confront
self-destructive psychological defens-
es and anxiety. Through this process,
complex feelings are mobilized and ex-
perienced, overcoming anxiety and de-
fenses against these feelings. This trig-
gering event brings images and linkages
to unprocessed pathogenic emotions.
All of this is a process Davanloo4 and
several of his patients called “unlock-
ing the unconscious.” The degree of
unlocking, or dominance of therapeutic
forces over defenses, has been studied
in relation to cost-effectiveness in two
studies. In Town et al,20 patients with at
least one high-level unlocking, called
major unlocking, during treatment had
significantly greater health care cost
reductions. Abbass8 found those with
major unlockings had greater rates of
return to work [(100% (14/14) versus
50% (4/8)] and cessation of all medi-
cations [(92.6 (25/27) versus 37.5%
(6/16)] versus those without major un-
To consider cost-effectiveness, we must
consider the costs of providing the treat-
ment. Six studies noted an average therapy
cost of $1,471 for treatment averaging
13.1 sessions (see Table 5, page 500).
This mixed set of studies with di-
verse samples provides further data that
ISTDP is a cost-effective treatment.
Large cost reductions compared favor-
ably with relatively low cost estimates
of $1,471 per treated case. It is of fur-
ther interest to see cost reductions cor-
relating with what is considered the key
therapeutic ingredient of ISTDP, emo-
tional experiencing.8,20 This adds fur-
ther data to the notion that emotional
Health Service Use and Cost
Hospital Use
Physician Service
Use Reduction
Health Service Health Service
Cost Reduction
Total Health Care
Cost Reduction
Per Treated Case
Mixed sample685% $338/ 1 year 33% $206/ 1 year $544/ 1 year
2% had psychiat-
ric hospitalization
vs. 20.9% before
18% saw psychia-
trist/ psychologist
vs. 27.5% before
8% saw general
practitioner vs. 4.4%
30% had outpa-
tient psycho-
therapy vs. 39.6%
– –
Mixed sample11 $ 1,827/ 3 years
resistant depres-
$1,440/ 6
$1,440/ 6
symptoms17, 18
69% reduction in
emergency de-
partment visits
$910/ 1 year $910/ 1 year
Psychiatry in-
- 65.2% drop in
ECT services
$1,400/ 1 year $1,400/ 1 year
Mixed sample19 - $3,084/ 3
$393/ 3
$3,733/ 3 years
Psychiatric Annals - Proof Copy
processing and experiencing is a key
variable in psychodynamic psychother-
ap y,21,22 if not in psychotherapy overall.
The evidence for cost reduction in
disabled workers bears underscoring,
as this societal burden is a major drain
on global economies where positions
must be backfilled at great expense. As
noted in Table 4, more than two-thirds
of disabled patients were able to make
a return to work with a relatively short
treatment course after long disabilities.
Because of the efficacy of this treat-
ment in resistant and complex popula-
tions, it appears to facilitate returns to
work even in patients unemployed for
years. This is a striking finding consid-
ering population return-to-work rates
after 6 months disability are otherwise
less than 50%, and rates after 1 year of
disability are very low to negligible.23,24
Based on available data showing IST-
DP is effective with the most common
sources of disability, it represents an
inexpensive approach to these major
sources of economic burden.1
These data from published studies
have an array of limitations to consider.
First, therapists in most of these studies
were trained and experienced, calling
into question the generalizability of the
findings. The notable exception to this
was the case series treated by psychia-
try residents.19 Second, all cost-bearing
figures were not available in all studies,
and it is unclear in most studies which
cost measures were determined a priori.
This raises the likelihood of reporting
bias; thus, greater weight should be
given to those studies with more com-
plete reporting. Third, the majority of
these studies were not controlled, so the
causes of cost reduction may not relate
to treatment factors. Fourth, samples
and reporting time frames were highly
diverse rendering combined analysis
and comparison of the data difficult. Fi-
nally, study quality, including verifica-
tion of treatment adherence, was highly
variable,5 limiting our ability to deter-
mine the quality of cost-based outcome
This series of studies provides evi-
dence that this brief treatment is cost-
effective when applied to a wide range
of patients with benefits noted in studies
across several cost domains. Future re-
search in ISTDP should include further
controlled trials with clearly defined a
priori cost measures and reporting of all
possible cost-related outcomes. Further
research should examine which of the
ingredients, such as emotional experi-
encing, bring greater costs effects with
specific populations. This could inform
tailoring of psychotherapy approaches
to specific populations in order to en-
hance cost benefits.
Employment Rates and Reduced Cost of Disability
Sample Total
Duration Off
(In Weeks)
Rate of
Return to
Total Cost Reduction
Per Treated
Unemployed Patient
Mixed sample831 113.1 80.6 –
Mixed sample622 53.3 81.2 $21,899 / 1 year
5 104 80 $6,720 / 6 months
Chronic headache77 54 100 $28,114 / 1 year
Personality disor-
10 63.6 90 $25,920 / 2 years
Mixed sample. Trial
14 15 14.3* –
Personality disor-
97 32.7 –
* Response to single session trial therapy interview.
ISTDP = intensive short-term dynamic psychotherapy.
Costs of ISTDP Treatment
Study Number of
Setting Cost Estimate
Per Case
Mixed sample614.9 Private psychiatric
$ 1,680
Personality disorder15 27.7 Public and private
$ 3,370
Medically unexplained
3.8 Hospital clinic $ 404
Psychiatric inpatients12 9.0 Hospital clinic ~ $1,400
Mixed sample19 9.9 Hospital clinic ~ $500
Unweighted means 13.1 $ 1,471
ISTDP = intensive short-term dynamic psychotherapy.
Psychiatric Annals - Proof Copy
1. U.S. Burden of Disease Collaborators. The
State of U.S. Health, 1990-2010: Burden of
Diseases, Injuries, and Risk Factors. JAMA.
2. American Psychological Association. Rec-
ognition of Psychotherapy Effectiveness.
Available at:
resolution-psychotherapy.aspx. August
3. Lazar SG. Psychotherapy Is Worth It: A
Comprehensive Review of Its Cost-Effec-
tiveness. Arlington, VA: American Psychi-
atric Publishing Inc.; 2010.
4. Davanloo, H. Unlocking the Unconscious:
Selected Papers of Habib Davanloo. Chich-
ester, West Sussex, England: Wiley; 1990..
5. Abbass A, Town JM, Driessen E. Inten-
sive short-term dynamic psychotherapy:
a systematic review and meta-analysis of
outcome research. Harv Rev Psychiatry.
6. Abbass A. Intensive short-term dynamic
psychotherapy in a private psychiatric of-
fice: clinical and cost effectiveness. Am J
Psychother. 2002;56(2):252-232.
7. Abbass A, Lovas D, Purdy A. Direct diag-
nosis and management of emotional factors
in chronic headache patients. Cephalalgia.
8. Abbass A. Office-based research in inten-
sive short-term dynamic psychotherapy
(ISTDP): data from the first 6 years of
practice. Ad Hoc Bulletin of Short-term
Dynamic Psychotherapy. 2002;6(2):5-14.
9. Cornelissen K, Verheul R. Treatment out-
come of residential treatment with ISTDP.
Ad Hoc Bulletin of Short-term Dynamic
Psychotherapy. 2002; 6:14-23.
10. Cornelissen K, Smeets D, Willemsen S,
Busschbach JJV, Verheul R. Long-term
follow-up of a residential form of intensive
short-term dynamic psychotherapy in per-
sonality disorders. (In preparation)
11. Abbass A. Cost-effectiveness of short-term
dynamic psychotherapy. Expert Rev Phar-
macoecon Outcomes Res. 2003;3(5):535-
12. Abbass A, Bernier D, Town J. Intensive
Short-term dynamic psychotherapy asso-
ciated with decreases in electroconvulsive
therapy on adult acute care inpatient ward.
Psychother Psychosom. 2013; in press.
13. Wiborg IM, Dahl AA. Does brief dy-
namic psychotherapy reduce relapse rate
of panic disorder. Arch Gen Psychiatry.
14. Abbass A. Intensive short-term dynamic
psychotherapy of treatment-resistant de-
pression: a pilot study. Depress Anxiety.
15. Abbass A, Sheldon A, Gyra A, Kalpin A.
Intensive short-term dynamic psychother-
apy for DSM-IV personality disorders: a
randomized controlled trial. J Nerv Ment
Dis. 2008;196(3):211-216.
16. Abbass A, Joffres MR, Ogrodniczuk JS.
A naturalistic study of intensive short-
term dynamic psychotherapy trial thera-
py. Brief Treatment Crisis Intervention.
17. Abbass A, Campbell S, Magee K, Tarz-
well R. Intensive short-term dynamic psy-
chotherapy to reduce rates of emergency
department return visits for patients with
medically unexplained symptoms: prelimi-
nary evidence from a pre-post intervention
study. CJEM. 2009;11(6):529-534.
18. Abbass A, Campbell S, Magee K, Lenzer I,
Hann G, Tarzwell R. Cost savings of treat-
ment of medically unexplained symptoms
using intensive short-term dynamic psy-
chotherapy (ISTDP) by a hospital emer-
gency department. J Acad Med Psychol.
19. Abbass A, Rasic D, Kisely S, Katzman
J. Residency training in intensive short-
term dynamic psychotherapy: methods
and cost-effectiveness. Psychiatr Ann.
20. Town JM, Abbass A, Bernier D. Effective-
ness and cost-effectiveness of Davanloo’s
intensive short-term dynamic psycho-
therapy: does unlocking the unconscious
make a difference. Am J Psychother.
21. Abbass A, Kisely S, Kroenke K. Short-term
psychodynamic psychotherapy for somatic
symptom disorders: a systematic review
and meta-analysis. Psychother Psychosom.
22. Diener MJ, Hilsenroth MJ, Weinberger J.
Therapist affect focus and patient out-
comes in psychodynamic psychother-
apy: a meta-analysis. Am J Psychiatry.
23. Conroy M. Supporting an injured worker
to return to work. Review commissioned
by the Workplace Safety Initiative Dublin,
Ireland. Available at:
Retention%20Doc_interactive.pdf. Ac-
cessed Aug. 25, 2013.
24. Treasury Board of Canada Secretariat.
Managing for Wellness: Disability Man-
agement Handbook for Managers in the
Federal Public Service. Section 5.0 Support
for Recovery. Available at: www.tbs-sct.
pacite07-eng.asp. Accessed on Accessed
Aug. 25, 2013.
Psychiatric Annals - Proof Copy
... One variety of brief PDT called experiential dynamic therapy and that focuses on feelings related to attachment disruption, outperforms bona fide treatment comparisons as a collective when treating those with a broad range of common mental disorders (Lilliengren et al., 2016). Brief PDT methods have been shown to be cost effective, resulting in reduced healthcare, medication, and disability costs (Abbass & Katzman, 2013;Abbass et al., 2015). When it comes to somatic symptoms including chronic pain, these treatments appear to be more effective than CBT methods overall (Abbass et al., in press). ...
... It has also developed an award-winning service using ISTDP to treat emergency department patients with recurrent visits for somatic symptoms (Abbass et al., 2009). This method has also been shown to be efficacious for complex and refractory populations (Abbass, 2016;Town et al., 2017Town et al., , 2020, and cost effective (Abbass & Katzman, 2013;Abbass et al., 2015;Town et al., 2020). Despite these successes and large clinical demand from both mental health and medical services, this specialty service is chronically under-resourced while the province focuses on CBT training. ...
... Unfortunately, such decisions undervalue the implementation of PDT despite its evidence base. Of note, evidence suggests that PDT has broad applicability, is preferred in certain clinical situations, including where developmental trauma and certain personality disorders (Leichsenring & Rabung, 2011, Keefe et al., 2020 are present, and is cost effective (Lazar et al., 2018, Abbass & Katzman, 2013Abbass et al., 2015;Beutel et al., 2004;Dossmann. et al., 1997). ...
In this article, Canadian psychotherapy researchers and teachers review the state of psychodynamic therapy (PDT) in Canada. We review the ways in which PDT has been implemented, developed and researched within the public and private sector, and how psychoanalytic and psychodynamic practitioners regionally have responded to the challenges of evidence-based practice and the emphasis on empirically supported treatments (EST) as it is defined today. We note that neglect and misrepresentation of the scientific evidence behind PDT has resulted in its marginalization. There is also a dearth of evidence collected to measure the effectiveness of implementing EST. Based on its empirical standing, we propose a model of care that incorporates PDT as an effective, evidence-based model for first line treatment, and also as an alternative for those patients who do not respond to other treatments or who express a preference for PDT or insight-oriented therapy.
... Psychotherapy showed faster results, whereas psychoanalysis was more effective in the long run. Abbass and Katzman (2013) conducted a review of several studies and concluded that intensive short-term psychodynamic psychotherapy is cost-effective in returning to work and decreasing health care costs. Abbass, Kisely, Rasic, Town, and Johansson (2015), in a more recent and larger study (890 treated cases and 192 controls), found short-term dynamic psychotherapy to be beneficial in reducing health care expenditures. ...
... 1. In some studies (Altmann et al., 2016;Kraft et al., 2006), (Abbass & Katzman, 2013). In our study, we differentiated between psychiatric and somatic medication and found opposite trends: a posttherapy increase in the use of psychiatric medication and a reduction in the somatic medication use. ...
... 3. Previous studies examined the change in hospitalization days without differentiating between psychiatric and general hospitalization (Abbass & Katzman, 2013;Altmann et al., 2016;Altmann et al., 2018). In Altmann et al.'s (2016) study, the number of hospitalization days increased significantly in the year before treatment and decreased thereafter. ...
Our objective was to examine the effectiveness and efficiency of psychodynamic psychotherapy on the reduction in health care utilization and cost while controlling for age, gender, and year. Health care utilization and cost were examined yearly in 1,675 patients from 2 years before outpatient psychotherapy (i.e., baseline) to three consecutive years after psychotherapy in a naturalistic longitudinal design. A multilevel analytic approach (LMLM) was applied to account for repeated measures effect and missing data. In the year prior to psychotherapy, there was a significant increase in total cost compared with baseline (14.8%) and in use of health care services (primary and specialist doctors' visits and outsourced referrals). In the first year following therapy, there was a significant decrease in total cost (10%) and in use of health care services (all doctors' visits, imaging, and outsourced referrals). The decrease was to baseline levels or lower and was maintained for two additional years. Psychiatric medication usage increased significantly after psychotherapy and remained so. The overall cumulative decrease in total cost per patient over 3 years after therapy was 3,665.92 NIS, equalling a 69% average cost of psychotherapy. Further cost saving can be expected due to the reduction in sick leave, disability, and psychiatric hospitalization. These findings support the notion that providing outpatient psychodynamic psychotherapy can be financially beneficial to health care systems, although further research is required for causal inferences. Also, an increase in health care utilization along with scarce physical findings may indicate unaddressed psychological distress and warrant referral for mental assessment and possible psychotherapy.
... Building upon this, Sahli et al. (2015) found that accuracy of therapist interpretative interventions in rupture resolution sessions related to outcome. In addition to process research, ISTDP has been evaluated through over 50 studies and shown effective (Abbass et al, 2012) and cost effective (Abbass & Katzman, 2013) ...
Intensive short‐term dynamic psychotherapy (ISTDP) was developed to manage treatment impasses preventing the experiencing of feelings related to childhood attachment interruptions, such as parental loss. According to ISTDP theory, certain categories of patients will exhibit habitual patterns of responding within the treatment relationship (called defenses) to certain anxiety‐provoking thoughts and feelings. Such defensive behaviors interrupt awareness of one's own feelings, self‐directed compassion and engagement in close human attachments, including the bond with the therapist. Rupture‐repair sequences in ISTDP are primarily considered in the context of a patient's defenses and the responses a therapist has to these defenses. By understanding and clarifying these defenses, this risk of subsequent misalliance, that is negative shifts or ruptures in the alliance, are minimized. In this paper we summarize ISTDP theory and technique through the use of clinical vignettes to illustrate defense management as a rupture‐repair equivalent in ISTDP.
... Given the economic burden of mood disorders, it is notable that three studies in the present review (Abbass, 2006;Solbakken and Abbass, 2016;Abbass et al., 2019) supported ISTDP in terms of cost-effectiveness. This adds to existing evidence for the cost-effectiveness of this method for a spectrum of mental disorders (Abbass and Katzman, 2013;Abbass et al., 2015). These preliminary findings are in line with growing evidence for the efficacy of Short-Term Psychodynamic Psychotherapy for depressive disorders (Driessen et al., 2015). ...
Background Intensive Short-Term Dynamic Psychotherapy (ISTDP) is an intervention introduced by Davanloo in order to treat affective and somatic symptoms, and personality disorders. It is a brief intervention aimed to reach awareness of painful or forbidden emotions and consequently to override symptoms and self-destructive tendencies. In this review we examine the efficacy of ISTDP on symptoms of patients with Major Depressive Disorder (MDD) and Bipolar Disorder (BD). Methods A thorough search of articles in Pubmed, PsycINFO, Isi Web of Knowledge was carried out in order to obtain available studies of ISTDP for BD and MDD. We included all studies conducted on patients with a diagnosis of MDD or BD and who received ISTDP. Results Eight studies were included. These were two randomized controlled trials and six observational studies. Overall the results of the included manuscripts suggest a positive effect of ISTDP on depressive symptoms for patients affected by mood disorders. Furthermore, they suggest ISTDP maybe cost-effective through reducing doctor visits and hospitalizations in follow-up. Limitations Most studies had small samples and consisted of non-randomized trials. Conclusions These are preliminary positive results on the effectiveness of this approach for the treatment of depressive symptoms. They have to be confirmed by studies with larger sample sizes and by comparing this technique with other psychological treatments such as cognitive-behavioural therapy.
... Intensive short-term dynamic psychotherapy (ISTDP) is an evidence-based form of STPP that uses the treatment relationship to explore emotions and their expression, as well as a patient's attempts to avoid these emotions (Lilliengren, Johansson, Lindqvist, Mechler, & Andersson, 2016). Although ISTDP has not been studied in PTSD, meta-analyses of the efficacy of ISTDP show significant improvements in general psychopathology, depression, anxiety, interpersonal functioning and somatic symptoms while outperforming other control conditions (Abbass, Town, & Driessen, 2012;Town & Driessen, 2013) and this method has also been shown to be broadly cost-effective (Abbass & Katzman, 2013). ...
Introduction Posttraumatic stress disorder (PTSD) is associated with significant psychiatric morbidity and high healthcare costs. Objective The aim of this pilot study was to evaluate changes in healthcare costs and general psychiatric symptom severity in patients with PTSD following intensive short-term dynamic psychotherapy (ISTDP). Method Healthcare services cost and utilization data were compiled at intake, prior to starting ISTDP and then assessed annually for three years thereafter. Two validated self-report scales, the Brief Symptom Inventory and the Inventory of Interpersonal Problems, were administered at intake and termination. Results Results showed significant reductions in physician costs and physician visits at one-year post-treatment, with these persisting over the three-year follow-up period. There were also large but statistically non-significant reductions in hospital costs. At termination, self-reported psychiatric symptoms and interpersonal problems were reduced. Conclusion These preliminary findings suggest that ISTDP may lead to healthcare cost reductions and general psychiatric symptom improvement in patients with PTSD, with healthcare utilization benefits maintained at long-term follow up. Future research directions were discussed.
... With this high service use population, it is notable that the average cost reduction was greater than $80,000 per patient over 4 years, a sum over 100 times the cost of the actual treatment (<$708 CAD; Abbass, Kisely, et al., 2015) Although we do not have control data for patients with bipolar disorder alone, the mixed control group of the parent study (referred to the service but not seen for ISTDP treatment) did not experience any reductions in hospital costs or overall health care costs. This study offers further data that a treatment like ISTDP may be of economic benefit when provided to diverse clinical populations (Abbass & Katzman, 2013). The limitations of this study are significant, rendering these results preliminary and underscoring the need for further formal evaluation. ...
The aim of this study was to evaluate changes in long-term health care costs and symptom severity after adjunctive intensive short-term dynamic psychotherapy (ISTDP) individually tailored and administered to patients with bipolar disorder undergoing standard psychiatric care. Eleven therapists with different levels of expertise delivered an average of 4.6 one-hour sessions of ISTDP to 29 patients with bipolar disorders. Health care service costs were compiled for a one-year period prior to the start of ISTDP along with four one-year periods after termination. Two validated self-report scales, the Brief Symptom Inventory and the Inventory of Interpersonal Problems, were administered at intake and termination of ISTDP. Hospital cost reductions were significant for the one-year post-treatment period relative to baseline year, and all cost reductions were sustained for the follow-up period of four post-treatment years. Self-reported psychiatric symptoms and interpersonal problems were significantly reduced. These preliminary findings suggest that this brief adjunctive psychotherapy may be beneficial and cost-effective in select patients with bipolar disorders, and that gains may be sustained in long-term follow-up. Future research directions are discussed.
... Randomized controlled trials concerning depression showed that ISTDP was connected to partial or complete remission 6 months after treatment, and also to increased socialcognitive capacity (Ajilchi, Kisely, Nejati, & Frederickson, 2018;Town et al., 2017). Moreover, a meta-analysis of 15 studies showed that ISTDP is cost effective (Abbass & Katzman, 2013). Such beneficial results seem to be connected to ISTDP being a structured method (Abbas & Town, 2013) and structured methods have been recommended for patients in substance abuse treatment (Socialstyrelsen, 2014). ...
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Substance use disorders (SUDs) are connected to emotional and relational difficulties. Intensive Short-Term Dynamic Psychotherapy (ISTDP) aims at supporting emotion regulation and relational capacity through confronting the patient’s defenses. The authors assessed relational capacity, emotion regulation, and defenses in nine patients with severe SUD and a history of childhood maltreatment, using the semistructured method Karolinska Psychodynamic Profile. All participants had difficulties in handling interpersonal dependence and separations. Functioning in other areas varied. ISTDP could be useful in substance abuse treatment. Thorough assessment before starting ISTDP is however recommended so that treatment is planned according to the patients’ level of functioning.
Résumé Objectif Cet article propose une revue de littérature concernant l’évaluation et l’efficacité des psychothérapies psychanalytiques et de la psychanalyse (PPP). Méthode Après avoir proposé une vue d’ensemble de l’évaluation des psychothérapies, nous reprenons les travaux portant sur l’évaluation empirique et quantitative des PPP avant de nous centrer sur leur évaluation qualitative et processuelle. Résultats Les résultats des études menées en ce domaine démontrent que les psychothérapies sont efficaces aussi bien sur le court terme que le long terme. Leur efficacité est le plus souvent indépendante de l’obédience théorique du clinicien. En revanche, les facteurs communs comme l’alliance thérapeutique ou les particularités du thérapeute sont des éléments prévalents de même que la durée et la fréquence des psychothérapies. Concernant plus précisément l’évaluation des PPP, celles-ci sont démontrées empiriquement comme étant efficaces pour la plupart des troubles psychiatriques. Plusieurs caractéristiques des PPP sont en outre corrélées de manière significative avec l’efficacité thérapeutique. Discussion L’évaluation qualitative et processuelle des PPP apparaît complémentaire à ce premier niveau d’évaluation empirique qui présente plusieurs limites (biais d’allégeance, indistinction des processus, pratiques de recherches questionnables, etc.) mises notamment en évidence par la crise de la reproductibilité. La méthodologie des Essais Contrôlés Randomisés propose une évaluation de surface à laquelle doivent être associées des approches fondées davantage sur la pratique clinique. L’approche du groupe de Boston, l’analyse des processus psychothérapiques par le Psychotherapy Q-Sort (PQS) ainsi que la modélisation du processus de symbolisation par l’École de Lyon sont trois paradigmes de recherche qualitatifs particulièrement riches de ce point de vue. Conclusion Les PPP sont efficaces pour la plupart des troubles psychiatriques sur le court terme, en fin de thérapie et plusieurs années après celle-ci. Elles engendrent des transformations durables sur le plan des symptômes et de la personnalité. Elles apparaissent souvent plus efficaces que la pharmacothérapie et conduisent à des économies substantielles quand elles sont mises en œuvre dans des services de soin auprès de patients souffrant de pathologies variées.
Purpose: Short Term Psychodynamic Psychotherapy (STPP) has been demon- 10 strated as an effective treatment for several mental health difficulties. However, its implementation in secondary mental health services in the National Health Service (NHS) is scarce. The aim of this study was to bridge the gap between controlled trials and practice-based evidence, by exploring an initial estimate of the therapeutic effects of this intervention as well as its 15 safety in a secondary care NHS community mental health setting. Method: The study followed a quantitative case series design. Eight clients with com- plex, enduring mental health difficulties, supported by a community secondary mental health service received a course of STPP. They completed outcome measures at the start, at the end and eight-weeks following completion of 20 therapy. Results: All participants but one completed the therapy and atten- dance rates were high (>75%). No adverse effects were reported. All partici- pants but two reported improvement in the CORE-OM, BSI and the PHQ-9 and these were maintained at follow-up. Conclusions: The results suggested that STPP was a safe and acceptable intervention, that may have contributed to 25 clinical and reliable improvement for 4 participants, non-reliable improvement for 2 and non-reliable deterioration for one participant who finished the treatment.
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CME Educational Objectives 1. Understand the role of training in psychodynamic psychotherapy in psychiatry residency training programs. 2. Learn a potential model for training residents in a short-term model of psychodynamic psychotherapy. 3. Review the efficacy and cost-savings data in a study training residents in this model. Whereas psychiatry grows as a field through contributions from neuroscience, genetics, psychopharmacology, and diagnostic specificity, psychiatrists continue to value the importance of psychodynamic assessment and intervention. This is reflected in the current Royal College of Physicians and Surgeons of Canada 1 and American College of Graduate Medical Education (ACGME) guidelines in psychiatry, 2 requiring the demonstration of competency in psychodynamic psychotherapy. This has been further underscored through the roll out of the Next Accreditation System, 3 requiring faculty in psychiatry training programs to delineate the achievement of resident milestones in the area of psychodynamic psychotherapy.
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Importance: Understanding the major health problems in the United States and how they are changing over time is critical for informing national health policy. Objectives: To measure the burden of diseases, injuries, and leading risk factors in the United States from 1990 to 2010 and to compare these measurements with those of the 34 countries in the Organisation for Economic Co-operation and Development (OECD) countries. Design: We used the systematic analysis of descriptive epidemiology of 291 diseases and injuries, 1160 sequelae of these diseases and injuries, and 67 risk factors or clusters of risk factors from 1990 to 2010 for 187 countries developed for the Global Burden of Disease 2010 Study to describe the health status of the United States and to compare US health outcomes with those of 34 OECD countries. Years of life lost due to premature mortality (YLLs) were computed by multiplying the number of deaths at each age by a reference life expectancy at that age. Years lived with disability (YLDs) were calculated by multiplying prevalence (based on systematic reviews) by the disability weight (based on population-based surveys) for each sequela; disability in this study refers to any short- or long-term loss of health. Disability-adjusted life-years (DALYs) were estimated as the sum of YLDs and YLLs. Deaths and DALYs related to risk factors were based on systematic reviews and meta-analyses of exposure data and relative risks for risk-outcome pairs. Healthy life expectancy (HALE) was used to summarize overall population health, accounting for both length of life and levels of ill health experienced at different ages. Results: US life expectancy for both sexes combined increased from 75.2 years in 1990 to 78.2 years in 2010; during the same period, HALE increased from 65.8 years to 68.1 years. The diseases and injuries with the largest number of YLLs in 2010 were ischemic heart disease, lung cancer, stroke, chronic obstructive pulmonary disease, and road injury. Age-standardized YLL rates increased for Alzheimer disease, drug use disorders, chronic kidney disease, kidney cancer, and falls. The diseases with the largest number of YLDs in 2010 were low back pain, major depressive disorder, other musculoskeletal disorders, neck pain, and anxiety disorders. As the US population has aged, YLDs have comprised a larger share of DALYs than have YLLs. The leading risk factors related to DALYs were dietary risks, tobacco smoking, high body mass index, high blood pressure, high fasting plasma glucose, physical inactivity, and alcohol use. Among 34 OECD countries between 1990 and 2010, the US rank for the age-standardized death rate changed from 18th to 27th, for the age-standardized YLL rate from 23rd to 28th, for the age-standardized YLD rate from 5th to 6th, for life expectancy at birth from 20th to 27th, and for HALE from 14th to 26th. Conclusions and Relevance: From 1990 to 2010, the United States made substantial progress in improving health. Life expectancy at birth and HALE increased, all-cause death rates at all ages decreased, and age-specific rates of years lived with disability remained stable. However, morbidity and chronic disability now account for nearly half of the US health burden, and improvements in population health in the United States have not kept pace with advances in population health in other wealthy nations.
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More than 20 years ago Habib Davanloo coined the term unlocking of the unconscious to describe how the psychodynamic concept of the human unconscious can become accessible using the technique of Intensive Short-Term Dynamic Psychotherapy (ISTDP). According to Davanloo, the possibility that unconscious material will be revealed is greatly increased when therapeutic efforts promote dominance of the unconscious therapeutic alliance over unconscious resistance. When these ingredients are present there is a psychic shift that allows unacceptable painful feelings to come to the surface. Toward adding further empirical support for the concept, in this article we compare outcomes between patients who experienced one or more major unlocking of the unconscious (N = 57) to those who did not experience major unlocking (N = 32) during ISTDP treatment. Significant and widespread differences were seen between these two groups, those with major unlocking had greater symptom reduction, interpersonal gains, and cost reduction for treatment. The relevance of this to clinical practice and healthcare utilization will be discussed.
Acute care psychiatric inpatient admissions are frequently precipitated by psychosocial stress including interruptions in key relationships due to a move, separation or other transition. The emotions triggered by these events often induce depression, anxiety, psychotic phenomena and acting-out behavior. Electroconvulsive therapy (ECT) may be an effective tertiary treatment for select patients who fail to respond to first- and second-line guideline-driven treatment options for severe depression [1] . We implemented a form of brief psychotherapy, intensive short-term dynamic psychotherapy (ISTDP), in an acute care psychiatric inpatient service in Halifax, N.S., a city of 400,000 people. At the same time, a new treatment protocol for ECT, the ultra-brief impulse protocol, was implemented to try to reduce ECT side effects on memory loss [2] . The net result of this has previously been shown to be an increase in the number of required ECT procedures per treated case [3] . ISTDP is a brief method that assesses and augments the capacity to identify and feel the very complex emotions triggered in current stressors. The treatment can be effective with high anxiety, severe depression and paranoia through the use of combinations of supportive interventions, emotional focusing, challenge to defenses and cognitive recapitulation, all of which are tailored to patient capacities [4] . Based on a recently published meta-analysis, ISTDP has some empirical support for a wide range of patients including those with depression, anxiety, personality disorders and bipolar disorder who are frequently admitted to psychiatry wards [4] . We also found, in a 10-year follow-up study of 890 cases, a significant reduction in hospital use and costs after a brief course of this treatment (a mean of 7.3 sessions/patient) [5] . During the years 1998–2009, this method was used on an ad hoc basis to augment standard care for psychiatric inpatients with these conditions. We reported on the method, including case descriptions, illustrating how it appeared effective in preventing the need for ECT and helpful to some of those who failed ECT [6] . Based on these data, a part-time position for an inpatient psychologist trained in ISTDP was funded, starting in October 2010. To augment the understanding of the approach and facilitate the referral process the therapist joined in weekly team rounds to dis
The objective is to study the effectiveness of Intensive Short-Term Dynamic Psychotherapy (ISTDP) trial therapies. In a tertiary psychotherapy service, Brief Symptom Inventory (BSI), Inventory of Interpersonal Problems (IIP) medication use, and need for further treatment were evaluated before versus 1-month post trial therapy in a sequential series of 30 clients. Trial therapies were interviews with active focus on emotions and how they are experienced. The interviews resulted in statistically significant improvements on all BSI subscales and one of the IIP subscales. One-third of clients required no further treatment, seven stopped medications, and two returned to work following trial therapy. The ISTDP trial therapy appeared tobe clinicallyeffectiveandcosteffective. Future researchdirections arediscussed. (Brief Treatment and Crisis Intervention 8:164-170 (2008))
Habib Davanloo has spent his career developing and teaching methods to accelerate dynamic psychotherapy, including his technique of intensive short-term dynamic psychotherapy (ISTDP). Over the past 20 years, outcome studies using this treatment have been conducted and published. We performed a systematic review of the literature to obtain studies presenting ISTDP outcome data. We found 21 studies (10 controlled, and 11 uncontrolled) reporting the effects of ISTDP in patients with mood, anxiety, personality, and somatic disorders. Using the random-effects model, we performed meta-analyses including 13 of these studies and found pre- to post-treatment effect sizes (Cohen's d) ranging from 0.84 (interpersonal problems) to 1.51 (depression). Post-treatment to follow-up effect sizes suggested that these gains were maintained at follow-up. Based on post-treatment effect sizes, ISTDP was significantly more efficacious than control conditions (d = 1.18; general psychopathology measures). Study quality was highly variable, and there was significant heterogeneity in some analyses. Eight studies using various measures suggested ISTDP was cost-effective. Within limitations of study methodologies, this evidence supports the application of ISTDP across a broad range of populations. Further rigorous and targeted research into this method is warranted.
Somatization of emotions accounts for excess emergency department (ED) visits in the form of medically unexplained symptoms (MUS). Intensive short-term dynamic psychotherapy (ISTDP) has been used to diagnose and manage somatization. We examined the effectiveness of this procedure for ED patients with MUS. We implemented a service that included staff education, timely access to consultation and gathering of outcome data. Patients were assessed and treated shortly after referral. There was a mean reduction of 3.2 (69.0%) ED visits per patient (standard deviation [SD] 6.4) the year afterward (95% confidence interval [CI] 1.3-5.0, p< 0.001). In comparison revisit rates during the same time interval for 3 available ED populations (i.e., those matched by visit rates, those with matching complaints and all patients referred to the service but never seen) showed either smaller reductions or higher ED use (ranging from a 15% reduction to a 43% increase). Treatments averaged 3.8 sessions per patient (SD 5.3). Self reported symptoms improved significantly with the Brief Symptom Inventory global rating, which changed from a mean of 1.21 (SD 0.58) before assessment to 0.86 (SD 0.63) ( p< 0.01) at the end of contact with the service. The service appeared acceptable to both emergency physicians and patients. This emotion-focused assessment and treatment method appeared to be feasible and may be effective in reducing both symptoms and repeat ED use.