Changes in symptoms and interpersonal problems during the first 2 years of long-term psychoanalytic psychotherapy and psychoanalysis.

OBJECTIVES: Longitudinal measurements can provide important information regarding variations in developmental trajectories of patients in long-term treatment. The present study investigated changes in general symptoms, depression, anxiety, and interpersonal problems during the first 2 years of long-term psychoanalytic psychotherapy (PP) and psychoanalysis (PA). It was expected that interpersonal problems would diminish more slowly compared to symptomatic dysfunction. DESIGN: An accelerated longitudinal design with five consecutive measurement points across two cohorts of patients was used. METHODS: Changes on the Symptom Checklist-90-R (SCL-90-R), Beck Depression Inventory-II (BDI-II), State-Trait Anxiety Inventory (STAI), and Inventory of Interpersonal Problems-64 (IIP-64) were investigated during the first 2 years of long-term PP (n = 73) and PA (n = 40). Linear regression analysis was performed to model the different courses of improvement. RESULTS: After 2 years of treatment, patients in both groups still presented moderate to high levels of symptoms and interpersonal problems compared to non-clinical populations. As expected, interpersonal problems changed less rapidly. PP patients changed both with regard to symptomatic and interpersonal problems, whereas the only significant change in the PA group was on one of the symptomatic subscales. Slopes in the PA group and in PP group did not differ significantly from each other, except for the IIP-64 scale intrusive, with PP patients showing significantly more improvement than PA patients. The height of intake values of the outcome variables appeared to predict the speed of symptomatic recovery. CONCLUSIONS: Symptoms and interpersonal problems did not decrease notably within the first 2 years of psychoanalytic treatment. This is consistent with the idea that significant change takes time for patients with chronic mental disorders and personality pathology. In regular practice, it is advisable to monitor changes routinely in order to identify slow responders more quickly and change the treatment plan, if necessary.

The effects of long-term psychoanalytic treatment on healthcare utilization and work impairment and their associated costs.

Long-term psychoanalytic treatment is perceived as an expensive ambulatory treatment for mental illnesses. However, there are indications that psychoanalytic treatment can result in cost savings in the long term. In this study, we investigated the effects of long-term psychoanalytic treatment on healthcare utilization and work impairment and calculated the associated societal costs. We assessed healthcare utilization and work impairment of patients before, during, and after long-term psychoanalytic treatment (N=231). Our results show that the difference in total costs associated with healthcare utilization and work impairment between pre- and post-treatment was euro2444 (U.S.$3070 using average exchange rates for 2006, the year for which these data were calculated) per person per year. Two years after treatment termination, these cost savings had increased to euro3632 ($4563) per person per year. This indicates that we can expect decreased consumption of medical care and higher work productivity right after psychoanalytic treatment, but also that longterm psychoanalytic treatment can generate economical benefits in the long run. However, we cannot conclude that all invested costs will be earned back eventually. More research is needed on the cost-effectiveness of psychoanalytic treatment.

A cost-utility analysis of psychoanalysis versus psychoanalytic psychotherapy.

OBJECTIVES: Despite the considerable and growing body of research about the clinical effectiveness of long-term psychoanalytic treatment, relatively little attention has been paid to economic evaluations, particularly with reference to the broader range of societal effects. In this cost-utility study, we examined the incremental cost-effectiveness ratio (ICER) of psychoanalysis versus psychoanalytic psychotherapy. METHODS: Incremental costs and effects were estimated by means of cross-sectional measurements in a cohort design (psychoanalysis, n = 78; psychoanalytic psychotherapy, n = 104). Quality-adjusted life-years (QALYs) were estimated for each treatment strategy using the SF-6D. Total costs were calculated from a societal perspective (treatment costs plus other societal costs) and discounted at 4 percent. Psychoanalysis was more costly than psychoanalytic psychotherapy, but also more effective from a health-related quality of life perspective. The ICER--that is, the extra costs to gain one additional QALY by delivering psychoanalysis instead of psychoanalytic psychotherapy--was estimated at 52,384 euros per QALY gained. CONCLUSIONS: Our findings show that the cost-utility ratio of psychoanalysis relative to psychoanalytic psychotherapy is within an acceptable range. More research is needed to find out whether cost-utility ratios vary with different types of patients. We also encourage cost-utility analyses comparing psychoanalytic treatment to other forms of (long-term) treatment.

Clinical significance of long-term psychoanalytic treatment.

The present study evaluated the clinical significance of long-term psychoanalytic treatment in four groups of about 60 patients in different phases of treatment (before, during, after, follow-up) with normative comparisons on four symptom questionnaires (SCL-90, BDI-II, STAI, IIP-64) and two personality assessment instruments (MMPI-2, Rorschach-CS). In each group, the proportion of patients with clinically elevated scores was calculated by comparing their scores with clinical and nonclinical reference groups for each instrument. The authors also calculated a combined percentage of clinically elevated scores based on the six instruments as a conservative estimate of improvement to nonclinical levels after long-term psychoanalytic treatment. Compared to pretreatment levels, the authors found a significant decrease in the percentage of clinical cases after treatment. For the personality assessment, these results became even more evident at follow-up. It appears that long-term psychoanalytic treatment was clinically significant for patients with chronic mental disorders. In the discussion, the authors point out that the evaluation of clinical significance at group level should be followed by an examination of individual changes over a longer period of time.

Identifying clinical cases among patients assigned to psychoanalytic treatment.

The present study compared 89 patients assigned to long-term psychoanalytic psychotherapy or psychoanalysis in the Netherlands with psychiatric and nonclinical norm groups with regard to symptoms and personality pathology as assessed with six instruments. Patients filled in four self-report questionnaires (Symptom Checklist-90-Revised [SCL-90-R], Beck Depression Inventory-II [BDI-II], State-Trait Anxiety Inventory [STAI]) and underwent a personality assessment (Minnesota Multiphasic Personality Inventory-2 [MMPI-2], Rorschach-CS). The authors used statistically defined cutoff values for each measure. For each instrument separately, about 50% of the patients reported clinical levels of psychopathology, some patients being more depressed and others reporting other symptoms. By combining the test scores of the different instruments, the authors found that 91% of the patients were identified as clinical cases. Compared to psychiatric norm groups, these patients appeared to report lower levels of symptom distress, but similar levels of personality pathology. The next step will be to investigate the level of improvement after long-term psychoanalytic treatment.

Severity Indices of Personality Problems (SIPP-118): development, factor structure, reliability, and validity.

This article describes a series of studies involving 2,730 participants on the development and validity testing of the Severity Indices of Personality Problems (SIPP), a self-report questionnaire covering important core components of (mal)adaptive personality functioning. Results show that the 16 facets constituted homogeneous item clusters (i.e., unidimensional and internally consistent parcels) that fit well into 5 clinically interpretable, higher order domains: self-control, identity integration, relational capacities, social concordance, and responsibility. These domains appeared to have good concurrent validity across various populations, good convergent validity in terms of associations with interview ratings of the severity of personality pathology, and good discriminant validity in terms of associations with trait-based personality disorder dimensions. Furthermore, results suggest that the domain scores are stable over a time interval of 14-21 days in a student sample but are sensitive to change over a 2-year follow-up interval in a treated patient population. Taken together, the final instrument, the SIPP-118, provides a set of 5 reliable, valid, and efficient indices of the core components of (mal)adaptive personality functioning.