Background

The prevalence of psychiatric disorders in Finland

Mood and anxiety disorders are prevalent and incapacitating disorders that commonly run a recurrent and chronic course (WHO 2000). One fifth of the Finnish adult population is estimated to suffer from psychiatric disorders; mood (7 %) and anxiety disorders (4 %) being the most prevalent (Pirkola et al. 2005). Approximately 2-3 % of the population in Finland are estimated to be in the need of psychotherapy and about 8 % use antidepressant medication.

Every second person suffering from major depressive disorder is currently without treatment and for half of those treated the treatment is insufficient. The total societal costs due to psychiatric disorders have been calculated to be more than 3 billion euros a year in Finland (Sillanpää et al. 2008, Maljanen, personal communication 2010).

Psychotherapy in Finland

Different psychotherapies, short and long, are widely applied in the treatment of psychiatric disorders. Long-term psychodynamic psychotherapy has for long been the most popular form of individual psychotherapy in Finland. At the beginning of the HPS in 1994, 80 % of the therapies given were estimated to be psychodynamic (Pylkkänen et al. 1995). Still, long-term psychodynamic treatments are widely used in Finland, although the proportion of therapists giving different varieties of short-term therapies has grown (Valkonen et al., 2011).

Effectiveness of psychotherapies in the treatment of psychiatric disorders

  • Both short- and long-term psychotherapies have been shown to be effective for the treatment of patients suffering from mood or anxiety disorders (Leichsenring et al. 2006, de Maat et al. 2009)
  • Therapies of the same length have, on average, been found to be equally effective (Cuijpers et al. 2008).
  • Short-term therapies, which cover most of the studies, have mainly been found as effective as psychiatric medication and more effective than being on a waiting-list, thus proving that improvement in treatment is not just due to placebo effect or regression to the mean (Churchill et al. 2001, de Maat et al. 2006).
  • More intensive and more structured long-term psychotherapies are suggested to be more effective than less intensive, lengthy therapies in the treatment of complex mental disorders (Leichsenring & Rabung 2008).
  • Long-term therapies have, however, been less studied, and especially comparative research on the effectiveness of long-term and short-term therapies is scarce.
  • Few studies have explored the effectiveness of therapies during a long follow-up and from many perspectives, such as with respect to work ability and social functioning.

Efficacy of psychotherapies in the treatment of psychiatric disorders

  • Efficacy describes the true effect of a treatment within standardized treatment conditions, unaffected by other potential intervention effects.
  • Of ethical and practical reasons, in psychotherapy trials with a long follow-up time, an efficacy study cannot be performed.
  • Proxy estimation of efficacy taking into account compliance and use of auxiliary treatment can be done but development of complicated statistical methods, such as dynamic models with Bayesian inference are required.

Sufficiency of short- versus long-term treatments

  • Research on which therapy is the most effective for whom is scarce; evidence is lacking on many disorder categories and treatment types, as well as on mechanisms affecting treatability (Roth & Fonagy 2005, Fonagy 2009).
  • Due to considerably longer duration and more frequent therapy sessions, long-term therapy may produce substantially higher costs compared to shorter therapies. On the other hand, referring all patients to short-term therapies is not clinically justifiable since not all patients are considered to benefit from short-term therapy. Both short- and long-term psychotherapies are thus required for patients with different types of disorders and treatment needs.
  • Insufficient response to treatment, reflected by the need and realization of further treatment, may occur after both short- and long-term therapies. However, little is known about incidence and determinants of auxiliary psychiatric treatments following start of short- and long-term psychotherapies.
  • As the need for treatment continues to increase, the health care resources need to be allocated more efficiently based on the patient's needs. Research-based information is needed on the long-term effects of different treatments, including sustained remission and the need of auxiliary treatments long after the initial therapy has ended.

Suitability for different psychotherapies

  • There is no generally accepted or scientifically proven model of the mechanisms or curative factors underlying psychotherapeutic change (Kazdin et al. 2008).
  • Variables related to patient, therapist, and therapy process have been suggested to contribute to therapy outcome (Lambert and Barley 2002), the patient variables having been considered the most important (Lambert 1992). Of them, especially patient's socio-economic factors (Ogrodniczuk et al. 2001), psychiatric symptoms and diagnosis (Cooper et al. 2002) psychiatric history (Piper et al. 1991), social factors (Piper et al. 1985) and personality (Piper et al. 1985, Valbak 2004) have often been considered essential for suitability for psychotherapy (Blenkiron 1999) and to predict its outcome.
  • Therapists' professional and personal characteristics have been thought to affect psychotherapy outcome (Beutler et al. 2004) and therefore their potential role should be considered when making outcome predictions based on patient variables.
  • Of the factors related to the therapy process, especially the form (modality and theoretical orientation) and length of therapy, have been studied as predictors of therapeutic outcome (Orlinsky et al. 2004). Also the patient-therapist alliance has been considered important when predicting the outcome (Horvath and Symonds 1991).
  • The knowledge on the mutual importance of the factors related to patient, therapist, and therapy process is still fragmentary (Lambert and Barley 2002), however. Patients' suitability for psychotherapies of different length thus needs to be more thoroughly studied and selection criteria for treatment choice based on this research evidence formed in order to prevent treatment failure and unnecessary suffering. Deeper understanding of the effects of therapists and other factors related to the therapy process and outcome would further help in monitoring the effectiveness of treatments.

In summary

In summary, prior to the start of the Helsinki Psychotherapy Study (HPS), little information was available from trials on the forms of therapy commonly used in Finland. Differences in the effectiveness between long-term and short-term therapy had apparently not been studied in trials at all. The effectiveness of psychoanalysis and psychodynamic psychotherapy had usually been studied without comparative design and has suffered from various methodological. Evidence-based information on factors affecting sufficiency and suitability to treatments was largely missing.

Updated: