ArticlePDF Available

The Cost-Effectiveness of Short-Term Psychodynamic Psychotherapy and Solution-Focused Therapy in the Treatment of Depressive and Anxiety Disorders during a Three-Year Follow

Authors:

Abstract and Figures

Background: Various psychotherapies are used extensively in treating different mental disorders, but still relatively little is known about the long-term health and cost effects of different therapies. The aim of this study is to compare the cost-effectiveness of short-term psychodynamic psycho-therapy (SPP) and solution-focused therapy (SFT) in the treatment of depressive and anxiety dis-orders during a three-year follow-up. Methods: A total of 198 outpatients suffering from mood or anxiety disorder were randomized to SPP or SFT. Symptoms were assessed using the Beck De-pression Inventory, the Hamilton Depression Rating Scale, the Symptom Check List Anxiety Scale, the Hamilton Anxiety Rating Scale, and the Symptom Check List Global Severity Index. Both direct and indirect costs due to mental health problems were measured. Results: The symptoms of de-pression and anxiety were reduced statistically significantly according to all 5 psychiatric outcome measures during the first 7 months, after which only minor changes were observed. The differ-ences between the two groups were small and not statistically significant. The direct costs were about equal in both groups but the indirect costs were somewhat higher in the SPP group, al-though not statistically significantly. The costs of auxiliary treatments were much higher than the cost of SPP or SFT. Conclusions: With regard to cost-effectiveness, there is little difference between SPP and SFT. T. Maljanen et al.
Content may be subject to copyright.
Open Journal of Psychiatry, 2014, 4, 238-250
Published Online July 2014 in SciRes. http://www.scirp.org/journal/ojpsych
http://dx.doi.org/10.4236/ojpsych.2014.43030
How to cite this paper: Maljanen, T., et al. (2014) The Cost-Effectiveness of Short-Term Psychodynamic Psychotherapy and
Solution-Focused Therapy in the Treatment of Depressive and Anxiety Disorders during a Three-Year Follow-Up. Open
Journal of Psychiatry, 4, 238-250. http://dx.doi.org/10.4236/ojpsych.2014.43030
The Cost-Effectiveness of Short-Term
Psychodynamic Psychotherapy and
Solution-Focused Therapy in the
Treatment of Depressive and Anxiety
Disorders during a Three-Year
Follow-Up
Timo Maljanen1, Tommi Härkänen2, Esa Virtala2, Olavi Lindfors2, Päivi Tillman1,
Paul Knekt2,3
1Social Insurance Institution, Helsinki, Finland
2National Institute for Health and Welfare, Helsinki, Finland
3Biomedicum Helsinki, Helsinki, Finland
Email: timo.maljanen@kela.fi
Received 10 May 2014; revised 12 June 2014; accepted 16 July 2014
Copyright © 2014 by authors and Scientific Research Publishing Inc.
This work is licensed under the Creative Commons Attribution International License (CC BY).
http://creativecommons.org/licenses/by/4.0/
Abstract
Background: Various psychotherapies are used extensively in treating different mental disorders,
but still relatively little is known about the long-term health and cost effects of different therapies.
The aim of this study is to compare the cost-effectiveness of short-term psychodynamic psycho-
therapy (SPP) and solution-focused therapy (SFT) in the treatment of depressive and anxiety dis-
orders during a three-year follow-up. Methods: A total of 198 outpatients suffering from mood or
anxiety disorder were randomized to SPP or SFT. Symptoms were assessed using the Beck De-
pression Inventory, the Hamilton Depression Rating Scale, the Symptom Check List Anxiety Scale,
the Hamilton Anxiety Rating Scale, and the Symptom Check List Global Severity Index. Both direct
and indirect costs due to mental health problems were measured. Results: The symptoms of de-
pression and anxiety were reduced statistically significantly according to all 5 psychiatric outcome
measures during the first 7 months, after which only minor changes were observed. The differ-
ences between the two groups were small and not statistically significant. The direct costs were
about equal in both groups but the indirect costs were somewhat higher in the SPP group, al-
though not statistically significantly. The costs of auxiliary treatments were much higher than the
cost of SPP or SFT. Conclusions: With regard to cost-effectiveness, there is little difference between
SPP and SFT.
T. Maljanen et al.
239
Keywords
Depression, Anxiety, Psychotherapy, Cost Analysis
1. Introduction
Numerous studies have demonstrated that short-term psychotherapies are effective in the treatment of mood and
anxiety disorders, and in meta-analyses no significant differences in the effectiveness of different types of short-
term psychotherapies have been observed [1] [2]. However, as mood and anxiety disorders are frequently recur-
rent, the results of these studies must be interpreted with some caution, for the follow-up periods have in most
studies been relatively short. Besides that, more attention should have been paid to monitoring the use of aux-
iliary psychiatric treatments, which may have a crucial effect both on symptoms and costs, especially in the long
run [3]. The effects of auxiliary treatments are usually taken into account in economic evaluations, but although
the need for economic evaluations of psychotherapies has been recognized for years, the number of such evalua-
tions has remained modest, and especially studies with longer follow-up periods are rare. In addition to the
paucity of existing research, cost-effectiveness comparisons are complicated by the fact that there is remarkable
heterogeneity in the study designs due to differences in control treatments, patient inclusion criteria and outcome
measures, for example. Before any firm conclusions about the cost-effectiveness of different therapies can be
made more information is needed about the costs and effects of different therapies. The aim of this study is to
enlarge our knowledge in this respect by producing a comprehensive view of the various direct and indirect
costs arising when patients have been treated either with short-term psychodynamic psychotherapy (SPP) or so-
lution-focused therapy (SFT), as well as to assess changes in symptoms utilizing several health outcome indica-
tors during a 3-year follow-up period. The cost-effectiveness of short-term therapies has been evaluated in a
handful of studies [4] [5], but to our knowledge this is the first cost-effectiveness study where these two thera-
pies are compared over a follow-up period covering several years.
2. Population and Methods
This cost-effectiveness study is a part of the Helsinki Psychotherapy Study [6]. The study follows the Helsinki
Declaration and was approved by Helsinki University Central Hospitals ethics council. Patients gave written
informed consent at the beginning of the study. The study population and methods used in the study are summa-
rized only briefly here as they have been described in detail elsewhere [3] [6]-[8].
2.1. Patients and Settings
A total of 459 eligible and willing outpatients from the Helsinki region were referred for the Helsinki Psycho-
therapy Study from 1994 to 2000. Eligible patients were 20 - 45 years of age and had a longstanding (>1 year)
disorder causing work dysfunction. The patients had to meet DSM-IV criteria [9] for anxiety or mood disorders.
For the criteria of exclusion, see Knekt et al. [6]. Of the eligible patients, 133 refused to participate, and the re-
maining 326 patients were randomly assigned to short-term psychodynamic psychotherapy (SPP) (101 patients),
solution-focused therapy (SFT) (97 patients), and long-term psychodynamic psychotherapy (LPP) (128 patients).
The LPP group was not included in this study because the three-year follow-up was deemed to be too short to
cover the long-run effects of LPP, i.e., how symptoms and costs develop after the end of therapy. After assign-
ment to treatment groups 3 SPP patients and 4 SFT patients refused to participate. Of the patients starting the as-
signed therapy, 21 (10 assigned to SPP and 11 to SFT) discontinued the treatment prematurely.
2.2. Treatments
2.2.1. Therapies
SPP is a brief, focal, transference based therapeutic approach which helps patients by exploring and working
through specific intrapsychic and interpersonal conflicts. It is based on approaches described by Malan [10] and
Sifneos [11]. SPP was scheduled for 20 treatment sessions, each lasting about 45 minutes with a frequency of
one session per week. The SPP sessions were carried out, on average, over a period of 5.7 months (SD = 1.3).
T. Maljanen et al.
240
SFT is a brief, resource oriented, goal focused therapeutic approach which helps clients change by construct-
ing solutions [12]. It is based on an approach developed by de Shazer et al. [13]. The frequency of SFT sessions
was flexible, usually one 60 to 90 minute session every two or three weeks for a maximum of up to 12 sessions
over no more than 8 months. The mean duration of SFT was 7.5 months (SD = 3.0).
2.2.2. Therapists
SPP was provided by 12 therapists and SFT by 6 therapists. All therapists had received standard training in their
respective forms of therapy. The mean number of years of experience in the therapy provided was 9 for both
therapy forms. SPP was conducted in accordance with clinical practice, where the therapists might modify their
interventions according to the patients needs within the respective framework. None of the SPP therapists had
received any training in SFT and vice versa. SFT was manualized and adherence monitoring was performed.
2.3. Assessment
2.3.1. Effectiveness
Effectiveness was measured by changes in psychiatric symptoms. Symptoms of depression were assessed with
the Beck Depression Inventory (BDI) [14] and the Hamilton Depression Rating Scale (HDRS) [15]. Symptoms
of anxiety were assessed with the Symptom Check List Anxiety Scale (SCL-90-ANX) [16] and the Hamilton
Anxiety Rating Scale (HARS) [17]. Overall psychological distress was measured using the Symptom Check List
Global Severity Index (SCL-90-GSI) [16]. Assessments based on self-administered questionnaires (BDI, SCL-
90-ANX and SCL-90-GSI) were carried out at baseline and at 3, 7, 9, 12, 18, 24, and 36 months after baseline,
while assessments based on interviews (HDRS and HARS) were performed at baseline and at follow-up points
of 7, 12 and 36 months.
2.3.2. Costs
Altogether four different total cost components were estimated in this study. The most important of the four
were the direct costs due to the treatment of mental disorders, which included costs accruing from 1) protocol-
based and additional SPP and SFT sessions, 2) other psychotherapy sessions, 3) outpatient visits due to mental
disorders, 4) psychotropic medication (prescription-only medicines), 5) inpatient care due to mental disorders,
and 6) travel costs due to therapy visits. The indirect costs caused by mental disorders included 1) the value of
lost productivity due to absenteeism from work because of psychiatric problems or 2) therapy visits, 3) the value
of household work neglected because of psychiatric problems, 4) the value of leisure time lost due to therapy
visits, and 5) the value of unpaid help received because of mental disorders. Direct costs due to non-mental dis-
orders consisted of the cost of treatments (outpatient visits, inpatient care, and prescription-only medicines) for
somatic disorders. Indirect costs due to non-mental disorders consisted of the value of lost productivity due to
absenteeism from work and the value of household work neglected because of somatic problems.
Part of the cost data was readily available in monetary terms from patient registers covering all patients. Most
of the cost items were estimated by multiplying the amount of services used by the corresponding unit costs. In-
formation about the amounts of different services used was obtained either from patient level registers or from
the patients themselves in five inquiries, which covered 0 - 7, 8 - 12, 13 - 18, 19 - 24 and 25 - 36 monthsperi-
ods from the start of the therapy. All costs were included in the analysis in full regardless of the payer. All costs
were converted to the 2010 price level by using official price indices. The costs were discounted by using a three
percent yearly discount rate. Details of estimation of costs are described in Maljanen et al. [8].
2.3.3. Potential Confounding Factors
At baseline, demographic characteristics (age, sex, marital status, and education) and previous psychiatric treat-
ments (medication, psychotherapy and hospitalization) were assessed by questionnaire, and suitability for psy-
chotherapy [18], as well as factors related to psychiatric history (age at onset of first psychiatric disorder, child-
hood separation experiences), by interview.
2.4. Statistical Methods
2.4.1. Effectiveness
The effectiveness of the two therapies was studied in a design with repeated measurements of the outcome vari-
T. Maljanen et al.
241
ables as intention-to-treat” (ITT) analyses [6] [19]. The primary analyses were based on the assumption of ig-
norable dropouts, and in secondary analyses missing values were replaced by multiple imputation (MI) [20] [21].
The statistical analyses were based on linear mixed models, model-adjusted means and mean differences calcu-
lated using predictive margins [22] [23]. See Maljanen et al. for details [8].
The regression model for the effectiveness outcome assessed by repeated measurements included the main
effects of time, treatment group, difference between theoretical and realized date of measurement, and first order
interaction of time and treatment group [6]. Adjustment for the potential confounders was not found necessary.
2.4.2. Costs
The analyses of costs were based on comparisons of the arithmetic means of different cumulative cost items.
Our earlier study [8] as well as many other studies have shown that due to the extremely high costs of some pa-
tients the distributions of cost variables are very skewed, and therefore the statistical analyses were performed
using a non-parametric bootstrap approach [24]. In the cost analyses some of the missing values of cost vari-
ables were imputed using single-value imputation [8]. Potential confounding factors were not found in case of
the cost outcomes, and thus the treatment group was the sole covariate in the model.
2.4.3. Cost-Effectiveness
The cost-effectiveness of the therapies was compared with the incremental cost-effectiveness ratio (ICER) [25],
which is the difference in the mean costs of the two therapies divided by the difference of their mean effective-
ness, i.e.
( )
( )
SPP SFT SPP SFT
CC EE−−
, where
SPP
C
stands for the mean costs and
SPP
E
for the mean effec-
tiveness of SPP, and
SFT
C
and
SFT
E
respectively for SFT.
The effectiveness of the therapies was estimated by calculating the changes taken place in BDI, HDRS, SCL-
90-ANX, HARS and SCL-90-GSI during the three-year follow-up period. The calculation was based on the area
under the curve (AUC), a frequently used tool in clinical trials with repeated measurements, which is the mean
value of the clinical indicator during the follow-up period [26]. Changes in symptoms over the whole three-year
follow-up period were estimated by subtracting the AUC value of each psychiatric measure from the baseline
value of that measure. These estimates of the overall symptom changes are marked with the symbol B-AUC.
The confidence intervals of differences in average costs and the ICERs were calculated using the bootstrap
method [24] [27]. Both effectiveness and costs were discounted by using a three percent yearly discount rate.
The principles used in calculating ICERs were the same as those used in our earlier study with a one-year
follow-up period [8]. As these methods have been described in detail in an earlier article, only the main points
are taken up here.
In the cost-effectiveness analyses, missing data were handled with MI. The effect of missing data was as-
sessed using multi-dimensional sensitivity analyses [28]. The proportion of missing AUC values, and hence also
that of missing B-AUC values, was larger (23% - 42%) than the proportion of missing health outcome values of
the single measurement points, because a missing value at any of the measurement points of a patient causes a
missing value in the AUC value of such a patient.
The results of the cost-effectiveness analyses are presented using cost-effectiveness planes with bootstrap it-
erations. Depending on how the iteration points are spread out across the four quadrants one is able to draw con-
clusions about the uncertainty associated with the cost-effectiveness results.
2.4.4. Sensitivity Analysis
In the sensitivity analyses different methods of handling the problem of missing observations were utilized [29].
Due to the uncertainties associated with different imputation methods, analyses based solely on non-missing
observations were also performed. Also unit costs whose values were uncertain were changed to test the robust-
ness of the results of the basic analyses.
All statistical analyses were performed using SAS software version 9.2 [30].
3. Results
3.1. Baseline Characteristics
The majority of the patients were females in their thirties who were employed or students and suffering from
mood disorders (Table 1). Relatively few had received psychiatric treatment despite the fact that more than half
T. Maljanen et al.
242
Table 1. Baseline characteristics of the 198 patients intended to treat by treatment group.
Characteristic Treatment group
Short-term psychodynamic
Psychotherapy [n = 101] Solution-focused
Therapy [n = 97]
Age (years) 32.1 (7.0)a 33.6 (7.2)a
Males (%) 25.7 25.8
Full time employed or student (%) 61.4 65.2
Living alone (%) 48.5 56.7
University degree (%) 19.8 28.9
Primary psychiatric disorder at age < 22 years (%) 57.6 66.0
Recurrent episodes of major depressive disorder (%) 68.3 60.0
Duration of disorder over 5 years (%) 33.0 36.5
Attempted suicide (SSI) (%) 7.1 9.4
Psychotherapy (%) 18.8 20.0
Psychotropic medication (%) 21.8 27.8
Hospitalization (%) 0.0 2.1
Mood disorder (%) 78.2 86.6
Anxiety disorder (%) 49.5 46.4
Personality disorder (%) 24.8 18.6
Psychiatric co-morbidity (%) 48.5 45.4
aMean (SD).
had experienced recurrent episodes of major depression and a relatively early onset of psychiatric disorder.
There were no statistically significant differences between the treatment groups with respect to demographic
characteristics or the patientsbaseline clinical status.
3.2. Effectiveness
During the period when the patients were receiving study therapy, i.e., during the first 7 months of the follow-up,
the scores of the two outcome measures assessing the symptoms of depression (BDI and HDRS) as well as the
scores of the two outcome measures assessing the symptoms of anxiety (SCL-90-ANX and HARS) declined sta-
tistically significantly in both therapy groups (Table 2). A very similar development was observed in the overall
psychological distress measured by SCL-90-GSI (data not shown). From there to the end of the three-year fol-
low-up period the mean scores of all symptom indicators remained quite stable in both groups. There were no
statistically significant differences between the therapy groups at any point of the follow-up for any of the out-
come measures. Hence also the differences in the overall symptom changes (B-AUC values) were small and not
statistically significant.
3.3. Costs
After the single-value imputation of missing cost values, the share of non-missing observations varied, depend-
ing on the service used, from 75% (cost of psychiatric outpatient care in the SFT group) to 100% (costs of study
therapy visits and psychotropic medication in both groups). Complete cost data, i.e., information about all cost
items at every measurement point, were obtained from 79 SPP patients (78%) and from 72 SFT patients (74%).
The mean total direct costs of patients with complete cost data were 4867 euros in the SPP group, being only
marginally higher (by 29 euros, or 0.6%) than the costs in the SFT group (Table 3). If the total direct costs are
T. Maljanen et al.
243
Table 2. Mean health outcome scores (s.e.) and mean score differences (95% confidence interval) between treatment groups
by follow-up: ITT, Model 1.
Mean scoresa (s.e.)
Outcome
variable Time
(months) Short-term psychodynamic
Psychotherapy [n = 101] Solution-focused
therapy [n = 97] Mean score difference
b
(95% confidence interval)
BDI 0 17.9 (0.79) 18.2 (0.81) 0.0
3 12.8* (0.84) 12.4* (0.89) +0.7 (1.3, +2.8)
7 10.3* (0.88) 10.4* (0.90) +0.2 (2.0, +2.5)
9 9.6 (0.88) 10.7 (0.92) 0.8 (3.1, +1.5)
12 9.6 (0.97) 10.6 (1.02) 0.7 (3.2, +1.9)
18 8.7 (0.99) 10.1 (1.05) 1.0 (3.7, +1.8)
24 9.5 (1.03) 10.0 (1.14) 0.1 (3.0, +2.8)
36 10.3 (0.95) 9.8 (1.03) 0.9 (1.8, +3.5)
Total change B-AUCc
(= Baseline-AUC) 8.0 7.7 0.3 (2.3, +2.6)
SCL-ANX-90 0 1.26 (0.07) 1.27 (0.07) 0.00
3 1.02* (0.07) 1.03* (0.07) 0.01 (0.16, +0.15)
7 0.86* (0.08) 0.94 (0.08) 0.07 (0.26, +0.12)
9 0.82 (0.07) 0.87 (0.08) 0.04 (0.21, +0.14)
12 0.82 (0.07) 0.90 (0.08) 0.07 (0.25, +0.11)
18 0.74 (0.07) 0.86 (0.07) 0.10 (0.29, +0.09)
24 0.83 (0.08) 0.94 (0.09) 0.09 (0.29, +0.12)
36 0.82 (0.07) 0.82 (0.017) +0.01 (0.19, +0.21)
Total change B-AUCc
(= Baseline-AUC) 0.43 0.38 0.06 (0.12, +0.23)
HDRS 0 15.4 (0.48) 15.8 (0.49) 0.0
7 10.7* (0.60) 11.3* (0.61) 0.4 (2.0, +1.1)
12 10.5 (0.65) 11.4 (0.68) 0.7 (2.5, +1.0)
36 10.8 (0.62) 10.7 (0.66) +0.1 (1.6, +1.9)
Total change B-AUC
c
(= Baseline-AUC) 4.7 4.7 0.1 (1.5, +1.6)
HARS 0 15.0 (0.52) 14.9 (0.53) 0.0
7 10.2* (0.56) 10.8* (0.57) 0.5 (2.0, +0.9)
12 9.8 (0.59) 10.7 (0.62) 0.9 (2.5, +0.7)
36 9.6 (0.55) 10.2 (0.59) 0.7 (2.2, +0.9)
Total change B-AUC
c
(= Baseline-AUC) 5.1 4.4 0.7 (0.8, +2.3)
aBasic model. bBasic model adjusted for the baseline level of the outcome measure considered. cAccording to 500 bootstrap iterations. *A statistically
significant improvement from previous measurement point.
calculated by summing up the mean costs of the different cost items shown in Table 3 the difference between
the two groups turns out to be somewhat greater, with the total costs of the SPP group increasing to 5795 euros
and the costs of the SFT group to 5306 euros. This difference was due to the fact that the patients in the SPP
group used various auxiliary health care services more than or at least as much as the patients in the SFT group.
During the three-year follow-up period the costs of all auxiliary health care services were in both groups much
higher than the costs of study therapy: 247% and 98% higher, respectively, in the SPP and SFT groups. An
overwhelming majority of patients in both groups, 83% in the SPP group and 82% in the SFT group, received
some auxiliary treatments for their symptoms during the three-year follow-up period.
The largest cost item in both groups was auxiliary psychotherapy, which accounted for nearly 50% of all di-
T. Maljanen et al.
244
Table 3. Direct costs (euros) and resource use (in cursive and in parentheses) due to mental disorders in short-term psycho-
dynamic psychotherapy and solution-focused therapy group during the three-year follow-up period: Analysis based on non-
missing observations of the single-value imputation data [n = number of patients with data at every measurement point].
Resource Short-term psychodynamic
Psychotherapy (SPP) Solution-focused
Therapy (SFT) Difference of
means
(SPP-SFT)
95% confidence
intervals for mean
cost differencesa
Mean 10% - 90% quantiles (max)
Mean 10% - 90% quantiles (max)
Study therapy 1297 920 - 1644 (1874) 1779 564 - 2255 (2818) 482 652, 323
(number of visits) (18.0) [n=101] (9.4) [n = 97]
Other psychotherapy 2790 0 - 11 972 (28 723) 2448 0 - 8447 (36 621) +342 792, +1762
(number of visits) (32.9) [n = 98] (28.1) [n = 89]
Psychiatric outpatient careb
873 0 - 2339 (9639) 598 0 - 1838 (6968) +275 88, +573
(number of visits) (8.8) [n = 80] (5.6) [n = 73]
Psychotropic medication 368 0 - 1090 (3540) 373 0 - 1405 (4228) 5 193, +182
(number of psychotropic
medication days) (270.8) [n = 101] (297.4) [n = 97]
Psychiatric hospitalisation 368 0 - 0 (20 995) 0 0 - 0 (0) +368 +32, +920
(number of hospital days) (1.5) [n = 99] (0) [n = 96]
Travel to psychotherapyc 99 0 - 290 (803) 108 0 - 237 (3652) 9 104, +61
[n = 97] [n = 89]
Total direct costsd 4867 1268 - 13,559 (30,937) 4838 1800 - 11,238 (21,982) +29 1344, +1213
[n = 79] [n = 72]
aAccording to 500 bootstrap iterations. bHealth centre, occupational health care, mental health clinic, hospital outpatient clinic, private physician, etc.
cInformation about the number of psychotherapy visits resulting in travel costs is not available. dTotal di rect costs or the difference in total di rect costs do
not equal the sum of individual cost items because due to the varying number of missing observations the mean calculations of total costs and different
cost items are partly based on different sets of patient data.
rect costs in both groups. The relatively high cost of other psychotherapy was explained by the fact that in both
therapy groups there were some patients who had had numerous psychotherapy sessions not included in the
study protocol.
In both groups the mean direct costs were highest at the beginning of the three-year follow-up period when
patients were receiving study therapy. In the first year of the follow-up the mean costs of patients in the SFT
group were higher than the mean costs of the SPP group because SFT itself cost more than SPP. During the first
year the costs showed a steep declining trend in both groups, the reason being that the number of patients re-
ceiving study therapy continued to diminish. In the last two years of the follow-up the mean costs showed a
growing trend in both therapy groups and, unlike in the first year, the costs of the SPP group were consistently
higher (Figure 1).
The mean indirect costs due to mental disorders were, like the direct costs, higher in the SPP group (Table 4).
The reasons for this cost difference of 4128 euros was that both the value of lost productivity due to absenteeism
from work because of sickness and the value of unpaid help received because of mental health problems were
clearly higher in the SPP group. The share of these two cost items of all indirect costs was about 80% in the SPP
group and 70% in the SFT group. Also the value of lost leisure time due to therapy visits and the value of ne-
glected household work were considerable. No statistically significant differences between the two groups were
observed in any cost item. It is worth noticing that the indirect costs were in both groups higher than the direct
costs.
During the three-year follow-up, mean direct costs due to non-mental disorders were about the same in both
groups: 1838 euros in the SPP group and 1570 euros in the SFT group. This difference was not statistically sig-
nificant. In both therapy groups nearly 80% of these costs were caused by outpatient visits to physicians. Also
the mean indirect costs due to non-mental disorders were similar in the two therapy groups: 3957 euros in the
SPP group and 4066 euros in the SFT group. In both groups the indirect costs were mainly due to lost productiv-
ity.
T. Maljanen et al.
245
Figure 1. The mean monthly direct costs (euros) due to mental dis-
orders in short-term psychodynamic psychotherapy and solution-fo-
cused therapy group during the three-year follow-up period.
Table 4. Indirect costs (euros) due to mental disorders in short-term psychodynamic psychotherapy and solution-focused
therapy group during the three-year follow-up period: Analysis based on non-missing observations of the single-value impu-
tation data [n = number of patients with data at every measurement point].
Resource
Short-term psychodynamic
Psychotherapy (SPP)
Solution-focused
Therapy (SFT)
Difference of
means
(SPP-SFT)
95% confidence
intervals for mean
cost
differencesa
Mean 10% - 90% quantiles (max) Mean
10% - 90% quantiles
(max)
Productivity lost due
to sickness
6132 0 - 10 955 (118 459) 3526 0 - 8184 (39 173) +2606 846, +6220
[n = 73] [n = 61]
Productivity lost due
to therapy visits 31 0 - 0 (799) 61 0 - 270 (1162) 30 74, +16
[n = 98] [n = 84]
Neglected household
work due to sickness 850 0 - 1899 (13 163) 1148 0 - 2855 (13 242) 298 724, +460
[n = 65] [n = 55]
Leisure time lost due
to therapy visits
967 246 - 3007 (7920) 674 60 - 1729 (6667) +293 56, +593
[n = 98] [n = 89]
Informal help
1700
0 - 0 (59 191)
959
0 - 4679 (9085)
+741
525, +1985
[n = 63] [n = 57]
Total indirect costs
b
10 525 358 - 35,799 (122,546) 6397 179 - 17,087 (53,679) +4128 1420, +6602
[n = 59]
[n = 54]
aAccording to 500 bootstrap iterations. bTotal indirect costs or the difference in total indirect costs do not equal the sum of individual cost items because
due to the varying number of missing observations the mean calculations of total costs and different cost items are partly based on different sets of pa-
tient data.
3.4. Cost-Effectiveness
According to all five health outcome indicators the effectiveness of SPP seemed to be slightly better than that of
SFT. The differences were, however, very small and as a result of this there is a lot of uncertainty in the ICERs.
Due to this considerable uncertainty no point estimates or confidence intervals for this ratio were calculated. In-
stead, uncertainty associated with our results was analysed by running 500 ICER bootstrap iterations for each of
the four health outcome measures assessing symptoms of depression or anxiety and direct costs (Figure 2). Be-
cause the cost outcome of these four analyses was the same, the locations of the iteration points with respect to
the horizontal line were the same in all four Figures 2(a)-(d) excluding the variation caused by bootstrap itera-
tions and imputation of missing values. Regardless of the outcome measure studied the iteration points are con-
centrated heavily around the origin and spread quite evenly among all four quadrants. Thus this cost-effective-
T. Maljanen et al.
246
Figure 2. The incremental cost-effectiveness planes with 500 bootstrap iterations comparing short-term psycho-
dynamic psychotherapy and solution-focused therapy: direct costs due to mental disorders as cost variable and
BDI, HDRS, SCL-90-ANX and HARS as effectiveness variable.
ness analysis confirms our earlier findings that the differences between SPP and SFT are small both in terms of
effectiveness and costs.
3.5. Sensitivity Analysis
In the sensitivity analyses we tested different imputation methods and changed the unit cost of those resources
whose unit costs were known to be uncertain. The results for effectiveness, measured by all five health outcome
measures, remained very similar to the basic results regardless of the imputation methods: during the first seven
months the symptoms declined rapidly, but after that there were only small changes in the mean scores and no
statistically significant differences between the two therapy groups at any measurement point. This stability of
results is explained by the fact that the proportion of missing observations was reasonably small for all effec-
tiveness measures.
With the economic outcome measures, the sensitivity analyses changed the results of the basic analysis more,
but, again, the fundamental result remained the same: both direct and indirect costs due to mental disorders were
greater in the group having received SPP. The sensitivity analyses changed the basic results mainly in the re-
spect that the aggregate level of costs changed but the relationship between the two groups did not. This obser-
vation applies also to the costs arising from non-mental disorders. Independent of unit costs used or imputation
T. Maljanen et al.
247
method applied the differences in direct and indirect costs due to non-mental disorders were small between the
two groups.
4. Discussion
Our study showed that symptoms of depression and anxiety were reduced substantially and by about the same
amount in both therapy groups. The results thus confirm earlier findings indicating that both SPP and SFT are
effective therapeutic approaches in the treatment of mental disorders [4] [31]. Differences in the direct health
care costs due to mental disorders also were relatively small and not statistically significant either. As differ-
ences in the effectiveness means were very small the ICERs were extremely unstable and therefore no point es-
timates or confidence intervals for this ratio were estimated. Cost-effectiveness analysis in combination with the
bootstrap method could, however, be used to handle the uncertainty associated with our results. The 500 boot-
strap cost-effectiveness iterations made for each of the five health outcome measures supported the finding that
SPP and SFT are quite similar with regard to their cost-effectiveness as the iteration points are situated quite
evenly around the origin.
During the three-year follow-up period the mean total direct health care costs due to mental disorders were
only marginally higher in the SPP group than in the SFT group. This difference was, however, not statistically
significant, because the costs of individual patients varied considerably in both therapy groups. This difference
in the total costs was due to fact that patients in the SPP group used auxiliary mental health care services more
or at least as much as patients in the SFT group. Among the different cost items the greatest differences were,
however, observed in the costs of study therapy, which were 482 euros (37%) higher in the SFT group, and this
difference was also statistically significant. The reason for the observed difference in the cost of therapy sessions
was that the price of one SFT visit was fixed at 188 euros (at 2010 prices) whereas the average price of one SPP
visit was 71 euros. The higher price of an SFT visit was explained by the fact that the durations of SFT sessions
were longer (1 - 1.5 hours vs. 45 minutes) and SFT therapists could consult with other SFT therapists if they
considered it necessary. Both SPP and SFT therapists worked in the private sector, and so the price of a visit can
be used as a proxy for the cost of one visit. Thus, although the realized number of study therapy visits by pa-
tients in the SPP group was, as planned in the protocol, nearly twice as high (18.0 vs. 9.4) as the number of visits
by patients in the SFT group, the therapy costs were still clearly smaller in the SPP group.
An important finding in our study was that in the three-year follow-up period a great majority of patients in
both therapy groups needed other treatments besides SPP or SFT for their symptoms. Studies with relatively
short follow-up periods, too, have indicated that many patients need other treatments in addition to brief therapy
[5] [32]. This study, with a follow-up period of three years, highlights very clearly that the need for additional
treatments may be substantial especially in the long run, for the costs of all auxiliary treatments were observed
to be much higher than the costs of SPP or SFT. Most of the cost of auxiliary treatments in both groups was due
to the costs arising from the use of other psychotherapies received after the end of SPP or SFT. This indicates
that in the long run short-term psychotherapies are quite seldom sufficient treatments for persons suffering from
mood or anxiety disorders.
The total indirect costs due to mental disorders were in the SPP group as much as 4128 euros (65%) higher
than the indirect costs of the SFT group. This great difference was due to the fact that the value of productivity
lost and the value of informal help received because of mental disorders were much greater in the SPP group.
Indirect costs were in both therapy groups clearly higher than direct costs. The mean indirect costs were, how-
ever, even more than the direct costs affected by the very high costs accrued by some individual patients. In the
SPP group there were three patients with extremely high indirect costs which were due to productivity loss and
informal help. If these patients had been excluded from the analysis, the mean indirect costs of the two therapy
groups would have been quite similar.
The mean annual direct costs due to non-mental disorders during the three-year follow-up period were esti-
mated to be 613 euros in the SPP group and 523 euros in the SFT group. This is much less than the correspond-
ing average amount in the general Finnish population of same age (approximately 1100 euros in 2006) [33]. Al-
though one must be very careful when comparing figures from different types of data (as was the case here), the
differences in the above figures are so great that our finding does not seem to support the frequently expressed
view that persons with depressive or anxiety disorders also have many other health problems and that their
health care costs due to non-mental disorders are higher than those of persons without such disorders [34]. Pos-
T. Maljanen et al.
248
sible explanations for our low estimates may be that the patients had relatively high educational attainment and
that patients with severe organic diseases were excluded from our study. One further explanation could be that
the reference figures [33] were partly based on registers where a certain share of mental health care expenditures,
for instance, might be reported as somatic health care expenditures.
There are certain methodological considerations about our study that need to be addressed as well. First,
compared to most clinical psychotherapy studies the sample size of our study (n = 198) can be regarded as rela-
tively large, as sample sizes below 100 are very common [4] [31]. Second, in our study psychiatric symptoms
were assessed using five different psychiatric measures which all yielded very similar results. This consistency
of results together with the frequently repeated measurements increases the reliability of our results.
Third, the follow-up period of our study, three years, is considerably longer than what is usually the case with
psychotherapy studies because in most studies the follow-up period is one year or less. Especially with mental
health problems, which are often long-lasting and where relapses are frequent, a one-year follow-up period may
be too short to capture the health or economic effects of the treatments compared.
In this study we tried to collect cost information about all the medication used in the treatment of mood and
anxiety disorders. Some of the estimates on the direct costs of SPP and SFT can be regarded as highly reliable
because part of the cost data was obtained directly from registers containing patient-level information about
every patient. Part of the cost data was, however, based on information received from patients and with these
cost items there is some uncertainty because of missing observations. In the sensitivity analyses different meth-
ods of handling missing observations were used and regardless of the way the missing observations were han-
dled our results remained rather robust.
The missing observations were, however, a bigger problem in the case of indirect costs, as the estimation of
indirect costs depended completely on information given by the patients. An additional weakness related to the
estimation of indirect costs was that the estimation was partly based on questions to which it may have been dif-
ficult to give exact answers (e.g., for how long the respondent has been unable to study due to mental disorders
or how much informal help the respondent has received). Also, considerable uncertainty attaches to the methods
of valuing different indirect cost items, and there is no unanimity about how the valuation ought to be carried
out. Regardless of these problems, the estimation of indirect costs is, however, considered to augment our un-
derstanding of the costs related to the treatment of depressive and anxiety disorders, especially because rela-
tively few cost-effectiveness studies in the field of mental health have attempted to estimate indirect cost [35].
To our knowledge, this is the first economic long-term evaluation study comparing the costs and effects of
SPP and SFT. According to our results, symptoms of depression and anxiety were reduced to a very similar ex-
tent in both therapy groups and there were no significant differences in costs between the two groups. Thus our
results suggest that these two therapies are comparable in terms of cost-effectiveness, and this observation was
confirmed by bootstrap iterations. More research with extensive data both about the effects and costs of the
therapies compared, a sufficiently long follow-up period and rigorous economic evaluation are needed before
any definite conclusions about the cost-effectiveness of these therapies, or short-term therapies in general, can
be made.
Finding out the most cost-effective treatments for mood and anxiety disorders can be regarded as exceptionally
important for the prevalence of these disorders is high, they cause considerable human suffering and lead to re-
markable disability resulting in notable indirect costs, and there are various treatment options with probably very
different health and cost effects. Thus the benefits to be gained by identifying the most cost-effective treatments
for these disorders may be substantial and clearly surpass those obtainable with most other disorders.
Acknowledgements
The Helsinki Psychotherapy Study Group [7] was responsible for collection of the data. Financial support for the
study received from: The Academy of Finland (Grant No. 138876) and the Social Insurance Institution of Fin-
land.
References
[1] Cuijpers, P., van Straten, A., Andersson, G. and van Oppen, P. (2008) Psychotherapy for Depression in Adults: A Me-
ta-Analysis of Comparative Outcome Studies. Journal of Consulting and Clinical Psychology, 76, 909-922.
http://dx.doi.org/10.1037/a0013075
T. Maljanen et al.
249
[2] Cape, J., Whittington, C., Buszewicz, M., Wallace, P. and Underwood, L. (2010) Brief Psychological Therapies for
Anxiety and Depression in Primary Care: Meta-Analysis and Meta-Regression. BMC Medicine, 8, 38.
http://dx.doi.org/10.1186/1741-7015-8-38
[3] Knekt, P., Lindfors, O., Renlund, C., Sares-Jäske, L., Laaksonen, M.A. and Virtala, E. (2011) Use of Auxiliary Psy-
chiatric Treatment during a 5-Year Follow-Up among Patients Receiving Short- or Long-Term Psychotherapy. Journal
of Affective Disorders, 135, 221-230. http://dx.doi.org/10.1016/j.jad.2011.07.024
[4] Abbass, A.A., Hancock, J.T., Henderson, J. and Kisely, S.R. (2006) Short-Term Psychodynamic Psychotherapies for
Common Mental Disorders. Cochrane Database of Systematic Reviews, Issue 4.
[5] Bosmans, J., Schreuders, B., van Marwijk, H., Smit, J., van Oppen, P. and van Tulder, M. (2012) Cost-Effectiveness of
Problem-Solving Treatment in Comparison with Usual Care for Primary Care Patients with Mental Health Problems:
ARandomized Trial. BMC Family Practice, 13, 98. http://dx.doi.org/10.1186/1471-2296-13-98
[6] Knekt, P., Lindfors, O., Härkänen, T., Välikoski, M., Virtala, E., Laaksonen, M.A., Marttunen, M., Kaipainen, M.,
Renlund, C. and the Helsinki Psychotherapy Study Group (2008) Randomized Trial on the Effectiveness of Long- and
Short-Term Psychodynamic Psychotherapy and Solution-Focused Therapy on Psychiatric Symptoms during a 3-Year
Follow-Up. Psychological Medicine, 38, 689-703. http://dx.doi.org/10.1017/S003329170700164X
[7] Knekt, P. and Lindfors, O. (2004) A Randomized Trial of the Effect of Four Forms of Psychotherapy on Depressive
and Anxiety Disorders: Design, Methods, and Results on the Effectiveness of Short-Term Psychodynamic Psychothe-
rapy and Solution-Focused Therapy during a One-Year Follow-Up. Social Insurance Institution, Helsinki, 15-112.
http://www.ktl.fi/tto/hps/pdf/effectiveness.pdf.
[8] Maljanen, T., Paltta, P., Härkänen, T., Virtala, E., Lindfors, O., Laaksonen, M.A., Knekt, P. and the Helsinki Psycho-
therapy Study Group (2012) The Cost-Effectiveness of Short-Term Psychodynamic Psychotherapy and Solution-Fo-
cused Therapy in the Treatment of Depressive and Anxiety Disorders during a One-Year Follow-Up. Journal of Men-
tal Health Policy and Economics, 15, 13-23.
[9] American Psychiatric Association (1994) Diagnostic and Statistical Manual of Mental Disorders: DSM-IV. American
Psychiatric Association, Washington DC.
[10] Malan, D.H. (1976) The Frontier of Brief Psychotherapy: An Example of the Convergence of Research and Clinical
Practice. Plenum Medical Books, New York. http://dx.doi.org/10.1007/978-1-4684-2220-7
[11] Sifneos, P.E. (1978) Short-Term Anxiety Provoking Psychotherapy. In: Davanloo, H., Ed., Short-Term Dynamic Psy-
chotherapy, Spectrum, New York, 35-42.
[12] Johnson, L.D. and Miller, S.D. (1994) Modification of Depression Risk Factors: A Solution-Focused Approach. Psy-
chotherapy: Theory, Research, Practice, Training, 31, 244-253. http://dx.doi.org/10.1037/h0090220
[13] deShazer, S., Berg, I.K., Lipchik, E., Nunnally, E., Molnar, A., Gingerich, W. and Weiner-Davies, M. (1986) Brief
Therapy: Focused Solution Development. Family Process, 25, 207-221.
http://dx.doi.org/10.1111/j.1545-5300.1986.00207.x
[14] Beck, A.T., Ward, C.H., Mendelson, M., Mock, J. and Erbaugh, J. (1961) An Inventory for Measuring Depression.
Archives of General Psychiatry, 4, 561-571. http://dx.doi.org/10.1001/archpsyc.1961.01710120031004
[15] Hamilton, M. (1960) A Rating Scale for Depression. Journal of Neurology, Neurosurgery and Psychiatry, 23, 56-61.
http://dx.doi.org/10.1136/jnnp.23.1.56
[16] Derogatis, L.R., Lipman, R.S. and Covi, L. (1973) SCL-90: An Outpatient Psychiatric Rating ScalePreliminary Re-
port. Psychopharmacology Bulletin, 9, 13-28.
[17] Hamilton, M. (1959) The Assessment of Anxiety States by Rating. British Journal of Medical Psychology, 32, 50-55.
http://dx.doi.org/10.1111/j.2044-8341.1959.tb00467.x
[18] Laaksonen, M.A., Lindfors, O., Knekt, P. and Aalberg, V. (2012) Suitability for Psychotherapy Scale (SPS) and Its Re-
liability, Validity and Prediction. British Journal of Clinical Psychology, 51, 351-375.
http://dx.doi.org/10.1111/j.2044-8260.2012.02033.x
[19] Härkänen, T., Knekt, P., Virtala, E. and Lindfors, O. (2005) A Case Study in Comparing Therapies Involving Informa-
tive Drop-Out, Non-Ignorable Non-Compliance and Repeated Measurements. Statistics in Medicine, 24, 3773-3787.
http://dx.doi.org/10.1002/sim.2409
[20] Rubin, D.B. (1987) Multiple Imputation for Nonresponse in Surveys. John Wiley, New York.
http://dx.doi.org/10.1002/9780470316696
[21] Schafer, J.L. (1999) Multiple Imputation: A Primer. Statistical Methods in Medical Research, 8, 3-15.
http://dx.doi.org/10.1191/096228099671525676
[22] Lee, J. (1981) Covariance Adjustment of Rates Based on the Multiple Logistic Regression Model. Journal of Chronic
Diseases, 34, 415-426.http://dx.doi.org/10.1016/0021-9681(81)90040-0
T. Maljanen et al.
250
[23] Graubard, B.I. and Korn, E.L. (1999) Predictive Margins with Survey Data. Biometrics, 55, 652-659.
http://dx.doi.org/10.1111/j.0006-341X.1999.00652.x
[24] Efron, B. (1982) TheJackknife, the Bootstrap and Other Resampling Plans. CBMS-NSF Regional Conference Series in
Applied Mathematics, Monograph 38, SIAM. http://dx.doi.org/10.1137/1.9781611970319
[25] Drummond, M., Sculpher, M., Torrance, G., OBrien, B. and Stoddart, G.L. (2005) Methods for the Economic Evalua-
tion of Health Care Programmes. 3rd Edition, Oxford University Press, Oxford.
[26] Pruessner, J., Kirschbaum, C., Meinlschmid, G. and Hellhammer, D. (2003) Two Formulas for Computation of the
Area under the Curve Represent Measures of Total Hormone Concentration versus Time-Dependent Change. Psycho-
neuroendocrinology, 28, 916-931.http://dx.doi.org/10.1016/S0306-4530(02)00108-7
[27] Briggs, A.H. (2001) Handling Uncertainty in Economic Evaluation and Presenting the Results. In: Drummond, M. and
McGuire, A., Eds., Economic Evaluation in Health Care. Merging Theory with Practice, Oxford University Press,
Oxford, 172-214.
[28] Manning, W.G., Fryback, D.G. and Weinstein, M.C. (1996) Reflecting Uncertainty in Cost-Effectiveness Analysis. In:
Gold, M.R., Siegel, J.E., Russell, L.B. and Weinstein, M.C., Eds., Cost-Effectiveness in Health and Medicine, Oxford
University Press, Oxford, 247-275.
[29] Armitage, P. (2001) Theory and Practice in Medical Statistics. Statistics in Medicine, 20, 2537-2548.
http://dx.doi.org/10.1002/sim.727
[30] SAS Institute Inc. (2008) SAS/STAT® 9.2 Users Guide. SAS Institute Inc., Cary.
[31] Gingerich, W.J. and Eisengart, S. (2000) Solution-Focused Brief Therapy: A Review of the Outcome Research. Family
Process, 39, 477-498. http://dx.doi.org/10.1111/j.1545-5300.2000.39408.x
[32] Guthrie, E., Moorey, J., Margison, F., Barker, H., Palmer, S., McGrath, G., Tomenson, B. and Creed, F. (1999) Cost-
Effectiveness of Brief Psychodynamic-Interpersonal Therapy in High Utilizers of Psychiatric Services. Archives of
General Psychiatry, 56, 519-526. http://dx.doi.org/10.1001/archpsyc.56.6.519
[33] Hujanen, T., Peltola, M., Häkkinen, U. and Pekurinen, M. (2008) Mens and Womens Health Care Expenditures by
Age Groups in 2006 [in Finnish]. Stakesintyöpapereita 37/2008, Stakes, Helsinki.
[34] Simon, G., Ormel, J., VonKorff, M. and Barlow, W. (1995) Health Care Costs Associated with Depressive and Anxie-
ty Disorders in Primary Care. American Journal of Psychiatry, 152, 352-357.
[35] Konnopka, A., Leichsenring, F., Leibing, E. and König, H. (2009) Cost-of-Illness Studies and Cost-Effectiveness
Analyses in Anxiety Disorders: A Systematic Review. Journal of Affective Disorders, 114, 14-31.
http://dx.doi.org/10.1016/j.jad.2008.07.014
Scientific Research Publishing (SCIRP) is one of the largest Open Access journal publishers. It is
currently publishing more than 200 open access, online, peer-reviewed journals covering a wide
range of academic disciplines. SCIRP serves the worldwide academic communities and contributes
to the progress and application of science with its publication.
Other selected journals from SCIRP are listed as below. Submit your manuscript to us via either
submit@scirp.org or Online Submission Portal.
... On the other hand, the effectiveness of short-term solution-focused approach in helping people on a range of issues and problems has been approved (Archuleta, Grable, & Burr, 2015). Researchers have performed multiple studies regarding the effectiveness of this approach in different fields and have reported its effect on the improvement of behavioral performance (Pakrosnis & Cepukiene, 2015), improvement of family functioning and addiction treatment (Nameni, Shafi'abadi, Delavar, & Ahmadi, 2014), reduced depressive and anxiety disorders (Maljanen et al., 2014), recovery from trauma (Zhang, Yan, & Liu, 2014), increased health recovery (obtaining power and social optimism) (Roden et al., 2014), resolving problems and conflicts (Stermensky & Brown, 2014), interventional treatment of individuals' problems (Bayard, Rambo, & Richartz, 2015), possibility of building solutions (Bayard et al., 2015) and more positive and constructive interactions of students with their teachers and classmates (Willford et al., 2013). According to what was mentioned above, the present study intends to examine the effectiveness of short-term solution-focused approach training in the sense of psychological coherence among female adolescents. ...
... Several studies have been conducted in this respect, which are consistent with the present research. Among them are the studies by Yokotani et al. (2015), Pakrosnis and Cepukiene (2015), Shakarami et al. (2014), Maljanen et al. (2014), Roden et al. (2014), Bond et al. (2013), Arvand et al. (2012), Shafi'abadi et al. (2012), Safarpour et al. (2011 and Shahi and Ojinezhad (2014). The studies performed by Yokotani et al. (2015) are included here in that through short-term solution-focused therapy, they caused the individuals to think more about the solutions by controlling their talks about problems. ...
Article
Full-text available
Background and aim: This study aims to investigate the effectiveness of short-term solution-focused group counseling on sense of psychological ‎coherence. Method: This research is a pretest-posttest quasi-experimental study design with a nonequivalent ‎control group and two-month follow-up. The research statistical population comprises all female adolescents in the first grade of secondary school who referred (were referred) to counseling offices in Mashhad Education District in 2015 due to behavioral and academic problems. The research sample consisted of 30 adolescents’ 15 years old girl using available sampling method and was randomly assigned into two experimental (15 individuals) and control (15 individuals) groups. For data collection, the revised form of Flensborg Sense of Coherence Scale (2006) was applied. Both groups took a pretest. Then, the therapeutic model (short-term solution-focused method) was implemented during 8 weekly sessions of 1.5 hours for the experimental group, but the control group received no training. At the end of 8 weeks, a posttest was taken from both groups and a two-month follow-up was conducted. To analyze the data, analysis of variance with repeated measures was used.Findings: The obtained results demonstrated that short-term solution-focused training could significantly increase the sense of coherence (P<0.05) among adolescents’ girl in both posttest and two-month follow-up. Conclusion: Short-term solution-focused training may promote sense of psychological coherence among female adolescent students.
... Unlike traditional therapy methods, the Solution-Focused Therapy (SFT) argues that the patients can think over the solution and realize the solution and change by being aware of their experience and strengths (Arslan & Gümüşçağlayan, 2018;Aslan, 2020;Carrera et al., 2016;Gündoğdu et al., 2017;Güner, 2011;Karadağ et al., 2017;Panayotov et al., 2011;Sharry, 2016, p. 20;Trepper et al., 2013;Zhang et al., 2018). Although studies have found usability and positive impacts of SFT as an individual and group therapy in person with schizophrenia from different age groups (Arslan & Gümüşçağlayan, 2018;Aslan, 2020;Bal-Nedim & Kaya, 2017;Bilge & Engin, 2016;Carrera et al., 2016;Gündoğdu et al., 2017;Maljanen et al., 2014;Özbay, 2017;Panayotov et al., 2011;Şanal-Karahan, 2016;Sharry, 2016, p. 147;Siyez & Tan-Tuna, 2014;Smith et al., 2011;Sparrer, 2012;Trepper et al., 2013;Wakefield et al., 2010;Wand, 2010;Zhang et al., 2018;2020), no studies have been encountered including psychoeducation program integrated with SFT in the literature. Results of this study support that SFT can be integrated in every area of health for individuals, families and societies to acquire healthy lifestyle behaviors and change their behaviors and can be used successfully in the groups. ...
Article
ABSTRACT The study examined the effect of Solution-Focused Group Psychoeducation on self-esteem, subjective perception of recovery, and internalized stigma among patients with schizophrenia 39 patients with schizophrenia were recruited based design of the randomized control-group with pretest and posttest. The patients completed the “Rosenberg Self-Esteem Scale (RSES)”, “Subjective Recovery Assessment Scale (SubRAS)”, and “Internalized Stigma of Mental Illness (ISMI) Scale” in pretest and posttest. After the psychoeducation, ISMI scores decreased in the intervention group (p < 0.001) but increased in the control group (p = 0.599). The posttest RSES score was lower in the intervention group compared to the control group (p = 0.001). A statistically significant difference was found between the pretest and posttest SRAS scores of the intervention group when compared to the control group (p = 0.018). After the psychoeducation, intervention group’ self-esteem and subjective perception of recovery increased, while the severity of internalized stigma decreased.
Article
Both short-term and long-term psychotherapies are used extensively in treating different mental disorders, but there have been practically no attempts to compare their cost-effectiveness. The aim of this study, which is part of the Helsinki Psychotherapy Study, is to assess the cost-effectiveness of two short-term therapies compared to that of a long-term therapy. In this study 326 outpatients suffering from mood or anxiety disorder were randomized to solution-focused therapy (SFT), short-term psychodynamic psychotherapy (SPP) or to long-term psychodynamic psychotherapy (LPP). Psychiatric symptoms and working ability were assessed at baseline and then 4-9 times during a 5-year follow-up using eight widely used measures including e.g. Beck Depression Inventory (BDI), Hamilton Depression Rating Scale (HDRS), Symptom Check List, anxiety scale (SCL-90-Anx), Hamilton Anxiety Rating Scale (HARS), Symptom Check List, Global Severity Index (SCL-90-GSI), and the Work-subscale (SAS-Work) of the Social Adjustment Scale (SAS-SR). Both direct and indirect costs were measured. During the 5-year follow-up period statistically significant improvements were observed in all health indicators in all therapy groups. At first the recovery was faster in the short-term therapy groups than in the LPP group, but taking the whole follow-up period into account, the effectiveness of the LPP was somewhat greater than that of the short-term therapies. Especially the direct costs were, however, much higher in the LPP group than in the short-term therapy groups. Thus the long-term therapy can hardly be regarded as cost-effective compared to short-term therapies when patients are randomized to the therapy groups.
Article
To evaluate whether a mixed population of patients treated with Intensive Short-term Dynamic Psychotherapy (ISTDP) would exhibit reduced healthcare costs in long-term follow-up. A quasi-experimental design was employed in which data on pre- and post-treatment healthcare cost were compared for all ISTDP cases treated in a tertiary care service over a nine year period. Observed cost changes were compared with those of a control group of patients referred but never treated. Physician and hospital costs were compared to treatment cost estimates and normal population cost figures. 1082 patients were included; 890 treated cases for a broad range of somatic and psychiatric disorders and 192 controls. The treatment averaged 7.3 sessions and measures of symptoms and interpersonal problems significantly improved. The average cost reduction per treated case was 12,628over3followupyears:thiscomparedfavorablywiththeestimatedtreatmentcostof12,628 over 3 follow-up years: this compared favorably with the estimated treatment cost of 708 per patient. Significant differences were seen between groups for follow-up hospital costs. ISTDP in this setting appears to facilitate reductions in healthcare costs, supporting the notion that brief dynamic psychotherapy provided in a tertiary setting can be beneficial to health care systems overall. CLINICALTRIALS. NCT01924715. Copyright © 2015. Published by Elsevier Ltd.
Article
Full-text available
BACKGROUND: Mental health problems are common and are associated with increased disability and health care costs. Problem-Solving Treatment (PST) delivered to these patients by nurses in primary care might be efficient. The aim of this study was to evaluate the cost-effectiveness of PST by mental health nurses compared with usual care (UC) by the general practitioner for primary care patients with mental health problems. METHODS: An economic evaluation from a societal perspective was performed alongside a randomized clinical trial. Patients with a positive General Health Questionnaire score (score >/= 4) and who visited their general practitioner at least three times during the past 6 months were eligible. Outcome measures were improvement on the Hospital Anxiety and Depression Scale and QALYs based on the EQ-5D. Resource use was measured using a validated questionnaire. Missing cost and effect data were imputed using multiple imputation techniques. Bootstrapping was used to analyze costs and cost-effectiveness of PST compared with UC. RESULTS: There were no statistically significant differences in clinical outcomes at 9 months. Mean total costs were euro4795 in the PST group and euro6857 in the UC group. Costs were not statistically significantly different between the two groups (95% CI -4698;359). The cost-effectiveness analysis showed that PST was cost-effective in comparison with UC. Sensitivity analyses confirmed these findings. CONCLUSIONS: PST delivered by nurses seems cost-effective in comparison with UC. However, these results should be interpreted with caution, since the difference in total costs was mainly caused by 3 outliers with extremely high indirect costs in the UC group. TRIAL REGISTRATION: Nederlands Trial Register ISRCTN51021015
Article
Full-text available
M. Seligman (1990) postulated that 3 meaning frames determine whether temporary sad feelings persist and eventually evolve into clinical depression: the permanence, pervasiveness, and personal causation of negative or stressful events. Successful treatment is thought to consist of interventions that modify these 3 meaning frames that contribute to depression. The authors combine Seligman's observations with 3 types of intervention questions used by therapists in solution-focused psychotherapy: exception, outcome, and coping and/or externalization questions. It is suggested that use of certain classes of intervention from solution-focused psychotherapy may shorten and potentiate treatment of depression. Solution-focused psychotherapy techniques are illustrated using a case study of a 69-yr-old man treated for depression. (PsycINFO Database Record (c) 2012 APA, all rights reserved)
Chapter
This is a unique, in-depth discussion of the uses and conduct of cost-effectiveness analyses (CEA) as decision-making aids in the health and medical fields. The product of over two years of deiberation by a multi-disciplinary Public Health Service appointed panel that included economists, ethicists, psychometricians, and clinicians, it explores cost-effectiveness in the context of societal decision-making for resource allocation purposes. It proposes that analysts include a “reference-case” analysis in all CEA’s designed to inform resource allocation and puts forth the most expicit set of guidelines (together with their rationale) ever outlined of the conduct of CEAs. Important theoretical and practical issues encountered in measuring costs and effectiveness, valuing outcomes, discounting, and dealing with uncertainty are examined in separate chapters. These discussions are complemented by additional chapters on framing and reporting of CEAs that aim to clarify the purpose of the analysis and the effective communication of its findings. Primarily intended for analysts in medicine and public health who wish to improve practice and comparability of CEAs, this book will also be of interest to decision-makers in government, managed care, and industry who wish to consider the roles and limitations of CEA and become familiar with criteria for evaluating these studies.
Article
Background: It is known that a small number of patients with mental health problems have chronic disorders and account for a disproportionate amount of mental health costs. This randomized controlled trial evaluated the cost-effectiveness of psychodynamicinterpersonal therapy vs treatment as usual in patients with mental health problems who were unresponsive to usual treatment. Method: Subjects (N = 110) with nonpsychotic disorders unresponsive to 6 months of routine specialist mental health treatment were enrolled in a randomized controlled trial. Sixty-three percent were women, the mean age was 41.4 years, the median duration of illness was 5 years, 68% were unemployed or receiving state benefits because of illness, and 75.5% had a depressive illness. Intervention patients received 8 weekly sessions of psychodynamic-interpersonal psychotherapy. Control patients received usual care from their psychiatrist. Outcome measures included ratings of psychological distress and health status and a detailed economic evaluation. Analysis was conducted on an intent-to-treat basis. Results: Subjects randomized to psychotherapy had a significantly greater improvement than controls in psychological distress and social functioning 6 months after the trial. Baseline treatment costs were similar for both groups. Subjects who received psychotherapy showed significant reductions in the cost of health care utilization in the 6 months after treatment compared with controls. The extra cost of psychotherapy was recouped within 6 months through reductions in health care use. Conclusion: These preliminary findings suggest that brief psychodynamic-interpersonal therapy may be costeffective relative to usual care for patients with enduring nonpsychotic symptoms who are not helped by conventional psychiatric treatment. Arch Gen Psychiatry. 1999;56:519-526
Article
The difficulties inherent in obtaining consistent and adequate diagnoses for the purposes of research and therapy have been pointed out by a number of authors. Pasamanick12 in a recent article viewed the low interclinician agreement on diagnosis as an indictment of the present state of psychiatry and called for "the development of objective, measurable and verifiable criteria of classification based not on personal or parochial considerations, but on behavioral and other objectively measurable manifestations."Attempts by other investigators to subject clinical observations and judgments to objective measurement have resulted in a wide variety of psychiatric rating scales.4,15 These have been well summarized in a review article by Lorr11 on "Rating Scales and Check Lists for the Evaluation of Psychopathology." In the area of psychological testing, a variety of paper-and-pencil tests have been devised for the purpose of measuring specific
Article
Discusses the principles of brief psychotherapy, selection of candidates for therapy, therapeutic techniques, and psychodynamic assessments of outcome. Detailed case studies of 18 patients are presented, and the view that even patients with severe and chronic illnesses can benefit from brief psychotherapy is examined. (3 p ref) (PsycINFO Database Record (c) 2012 APA, all rights reserved)
Article
Objectives. To present an interview-based 7-item Suitability for Psychotherapy Scale (SPS) created to evaluate suitability for short- and long-term therapy, and to assess its reliability, validity, and prediction. Design. Reliability of the SPS was evaluated by measuring both repeatability and agreement (cross-sectional design). Validity of the SPS was evaluated by measuring both criterion and discriminating validity (cross-sectional design). Prediction of the SPS was evaluated using a cohort study design. Methods. Suitability of 326 psychiatric outpatients from the Helsinki Psychotherapy Study was assessed at baseline with the SPS, and a summary score of the seven items was formed. Reliability of the SPS was evaluated using kappa coefficients and validity using linear models. The ability of the SPS to predict changes in symptoms (SCL-90-GSI) during a 1-year follow-up was measured. The analysis of validity and prediction of SPS were based on data of all 326 patients and analysis of reliability of SPS on a sample of 28 patients. Results. Both the repeatability of the interviewers’ assessments over 3 years and agreement between interviewers and reference were fair or good. An association of the SPS with personality functions but not with psychiatric symptoms supported criterion and discriminating validity of the SPS. The SPS also significantly predicted changes in symptoms during follow-up. Conclusions. The SPS appeared to be a valid and reliable method for assessing pre-treatment suitability, with good prediction of psychotherapy outcome.