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Randomized trial on the effectiveness of long- and short-term psychotherapy on psychiatric symptoms and working ability during a 5-year follow-up PAUL KNEKT , OLAVI LINDFORS , LAURA SARES-J Ä SKE , ESA VIRTALA , TOMMI H Ä RK Ä NEN
Knekt P, Lindfors O, Sares-J ä ske L, Virtala E, H ä rk ä nen T. Randomized trial on the effectiveness of long- and short-term psychotherapy on psychiatric symptoms and working ability during a 5-year follow-up. Nord J Psychiatry 2013;67:59–68.
Background: The information on whether long-term psychotherapy is superior in comparison with short-term therapies during a long time-perspective in the treatment of mood and anxiety disorder is incomplete. Aims: The present study addresses this question in a clinical trial with an exceptionally long follow-up. Methods: In the Helsinki Psychotherapy Study, 326 outpatients with mood or anxiety disorder were randomly assigned to long-term psychodynamic psychotherapy and two types of short-term psychotherapy (short-term psychodynamic psychotherapy and solution-focused therapy) and were followed up for 5 years from the start of treatment. The outcome measures were psychiatric symptoms measured by Beck Depression Inventory (BDI), Hamilton Depression Rating Scale (HDRS), Symptom Check List, anxiety scale (SCL-90-Anx), Hamilton Anxiety Rating Scale (HARS) and Symptom Check List, Global Severity Index (SCL-90-GSI), and working ability measured by the Work Ability Index (WAI), the Work-subscale (SAS-Work) of the Social Adjustment Scale (SAS-SR) and the Perceived Psychological Functioning Scale (PPF). Furthermore, remission variables based on changes in psychiatric symptoms and use of auxiliary treatment, were used. Results: After the 5-year follow-up, the rate of recovery from psychiatric symptoms and the work ability improvement rate remained higher in the long-term therapy group, whereas no differences in the effectiveness of the two short-term therapies of different modalities were found. Conclusions: Long-term psychotherapy is more effective than short-term therapy during a long follow-up, suggesting the need for a careful evaluation of suitability to short-term therapy. More research on the long-term effects of psychotherapy in large-scale studies is still needed, however.
• Depression , psychodynamic , psychotherapy , solution-focused , trial.
Paul Knekt, Research Professor, Ph.D., National Institute for Health and Welfare, PO Box 30,
00271 Helsinki, Finland, E-mail: [email protected] ; Accepted 26 March 2012.
It has been demonstrated mainly in studies with short
follow-up times that short-term psychotherapy is more
effective than treatment as usual and as effective as psycho-
tropic medication in the treatment of mood and anxiety
disorder (1, 2). However, the information on what the effect
of short-term therapies is in the long run is incomplete
(3 – 5). Moreover, data on whether long-term psychotherapy
is superior over short-term interventions are incomplete
and contradictory (6 – 8).
The Helsinki Psychotherapy study compared the
effectiveness of two types of short-term psychotherapy
[short-term psychodynamic psychotherapy (SPP) and
solution-focused therapy (SFT)] and of 3-year long-term
psychodynamic psychotherapy (LPP) on psychiatric
symptoms and working ability during a 3-year follow-up
(3, 4). The study showed that the short-term therapies
were more effective during the fi rst year of follow-up
but that long-term therapy was more effective at the
3-year follow-up point. Follow-up studies have demon-
strated that changes may continue along different
domains of symptoms and functioning after LPP (9),
and those benefi ts can remain after short-term therapies,
even without further treatment (10). However, as far as the
present authors know, there is no comparative information
© 2013 Informa Healthcare DOI: 10.3109/08039488.2012.680910
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60 NORD J PSYCHIATRY·VOL 67 NO 1·2013
Patients and settings A total of 459 eligible outpatients were referred to the
Helsinki Psychotherapy Study from psychiatric services
in the Helsinki region from June 1994 to June 2000
(Fig. 1). Patients considered eligible were 20 – 45 years of
age and suffered from a long-standing ( � 1 year) disor-
der causing dysfunction in work ability. They were also
required to meet DSM-IV criteria (13) for anxiety or
mood disorders. Patients were excluded from the study if
any of the following criteria were met: psychotic disorder
or severe personality disorder, adjustment disorder, sub-
stance-related disorder, organic disease. Individuals treated
with psychotherapy within the previous 2 years, psychiat-
ric health employees and persons known to the research
team members were also excluded. Of the eligible
patients, 133 refused to participate and the remaining 326
patients were randomly assigned in a 1:1:1.3 ratio to SFT
(97 patients), SPP (101 patients) and LPP (128 patients).
After selection for treatment, the patients were moni-
tored at baseline examination and nine times during a
follow-up of 5 years. After assignment to the treatment
groups, four SFT patients, three SPP patients and 26
LPP patients refused to participate. Of the patients start-
ing the assigned therapy, 42 (11 assigned to SFT, 10 to
SPP and 21 to LPP) discontinued the treatment prema-
turely. The major reasons for discontinuing the study
were the patients ’ life situation or disappointment with
available on the persistence of changes in psychiatric
symptoms or working ability among patients suffering
from depression or anxiety disorder after completion of
short-term vs. long-term therapy. The determination of a
realistic picture of the effects of the different therapies
especially during long follow-up times is confounded by
the fact that psychiatric patients make much use of psy-
chiatric treatments during and after participation in clinical
trials (11).
This follow-up stage of the Helsinki Psychotherapy
Study addresses the stability of the effects of 3-year LPP
in comparison with that of two short-term, psychody-
namic and solution-focused therapies during a 5-year fol-
low-up using psychiatric symptoms and working ability
as outcome measures. We also studied the effect of the
psychotherapies on recovery from psychiatric symptoms
including the use of auxiliary treatment.
Patients and Methods The patients and settings, therapies and therapists, and
assessment methods and statistical methods have been
presented in more detail elsewhere (3, 12) and are sum-
marized briefl y here. The project follows the Helsinki
Declaration and was approved by the Helsinki University
Central Hospital ethics committee. The patients gave their
written informed consent.
Fig. 1. Number of eligible patients who were assigned to study group and completed the protocol (41).
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EFFECTIVENESS OF LONG- AND SHORT-TERM PSYCHOTHERAPY
NORD J PSYCHIATRY·VOL 67 NO 1·2013 61
Indicators on changes in psychiatric symptoms and work
ability and remission were used as outcome measures.
Depressive symptoms were assessed using the Beck Depres-
sion Inventory (BDI) (18) and the Hamilton Depression
Rating Scale (HDRS) (19). Anxiety symptoms were
assessed using the Symptom Check List, anxiety scale
(SCL-90-Anx) (20) and the Hamilton Anxiety Rating
Scale (HARS) (21). General psychiatric symptoms were
assessed using the Symptom Check List, Global Severity
Index (SCL-90-GSI) (20). Work ability measures were a
modifi cation of the Work Ability Index (WAI) (4, 22), the
Work-subscale (SAS-Work) of the Social Adjustment
Scale (SAS-SR) (23) and the Perceived Psychological
Functioning Scale (PPF) (24). Information on realized
work ability as active participation in work or studies and
the number of sick leave days from work during the past
3 months was collected by single-item questions included
in a follow-up questionnaire developed in the project. This
item was used in its original form and using the cut-off 7
days as an indicator of high-level absenteeism (25).
Recovery from psychiatric symptoms (measured by
BDI, SCL-90-Anx and SCL-90-GSI) in a single point of
follow-up was defi ned as a 50% reduction of symptoms
in comparison to the baseline level or a measurement
value lower than the remission level (i.e. BDI � 10,
SCL-90-Anx � 0.9 and SCL-GSI � 0.9). Information on
the use of psychotropic medication (antidepressant, anxi-
olytic, neuroleptic and psychiatric combination medica-
tion), additional psychotherapy (individual short-term or
long-term, group, couple or family or other) or hospital-
ization for psychiatric reasons were continuously assessed
using questionnaires and nationwide public health regis-
ters (11). An expanded remission variable was defi ned by
including lack of auxiliary treatment at the measurement
point as a third criterion.
The psychiatric diagnosis on axis I (13) was assessed
at baseline using a semi-structured interview (12). Previ-
ous psychiatric treatment (psychotherapy, psychotropic
medication and hospitalization) and socio-economic fac-
tors (employment, marital status and education) were
assessed at baseline using questionnaires and interviews.
Statistical methods The effectiveness of the three therapies was studied in a
design with repeated measurements of the outcome vari-
ables mainly as ‘ intention-to-treat ’ (ITT) analyses (3, 26).
The primary analyses were based on the assumption of
ignorable drop-outs, and in secondary analyses missing
values were replaced by multiple imputation (27). Besides
the ITT analyses, complementary ‘ as-treated ’ (AT) analy-
ses were performed.
The statistical analyses were based on linear mixed
models for continuous outcome variables (28) and logistic
regression models and generalized estimating equations
the treatment. The mean drop-out rate over the 10 mea-
surement occasions during the follow-up was 16% in the
SFT group, 14% in the SPP group, and 11% in the LPP
group. The major reason for dropping out from measure-
ment was that the study was perceived as mentally stress-
ful or the patient was disappointed with the treatment.
The therapies SFT is a brief, resource-oriented, goal-focused therapeutic
approach, which helps clients change by constructing
solutions, based on an approach developed by de Shazer
et al. (14). The frequency of sessions in SFT was fl exible,
usually one session every second or third week, up to a
maximum of 12 sessions, over no more than 8 months.
SPP is a brief, focal, transference-based therapeutic
approach, which helps patients by exploring and working
through specifi c intrapsychic and interpersonal confl icts.
The orientation was based on approaches described by
Malan (15) and Sifneos (16). SPP was scheduled for 20
treatment sessions, one session per week.
LPP is an open-ended, intensive, transference-based
therapeutic approach, which helps patients by exploring
and working through a broad area of intrapsychic and
interpersonal confl icts. Therapy includes both expressive
and supportive elements, depending on the patient ’ s
needs. The orientation followed the clinical principles of
LPP (17). The frequency of sessions in LPP was two to
three times a week for about 3 years.
The therapists A total of 55 therapists participated in the study; six pro-
vided SFT, 12 SPP and 41 LPP. 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 (range 3 – 15) in SFT, 9 (range
2 – 20) in SPP and 18 (range 6 – 30) in LPP. None of the
SFT therapists had received any training in psychody-
namic psychotherapy. Only SFT was manualized and
adherence monitoring was performed. Psychodynamic
psychotherapies and PA were conducted in accordance
with clinical practice, where the therapists might modify
their interventions according to the patient ’ s needs within
the respective framework. The mean ( � standard devia-
tion) length of therapy was 7.5 � 3.0 months, 5.7 � 1.3
months and 31.3 � 11.9 months in SFT, SPP and LPP,
respectively.
Assessments The measurements were based on interviews conducted
by experienced clinical raters at baseline and four times
thereafter (at 7, 12, 36, and 60 months from baseline) and
self-report questionnaires conducted at baseline and nine
times thereafter (at 3, 7, 9, 12, 18, 24, 36, 48 and 60
months from baseline) during the 5-year follow-up (12).
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62 NORD J PSYCHIATRY·VOL 67 NO 1·2013
and more than one out of fi ve had an academic educa-
tion. A total of 84.7% of them suffered from mood disor-
der, 43.6% from anxiety disorder and 18.1% from
personality disorder. No statistically signifi cant differ-
ences among treatment groups were found with respect
to baseline socio-economic variables, psychiatric diagno-
sis or previous psychiatric treatment.
Treatment effects on symptoms and working ability during the fi rst 3 years of follow-up During the fi rst year of follow-up, patients treated with
SPP recovered faster from both depressive and anxiety
symptoms, and patients treated with SFT recovered faster
from depressive symptoms than patients receiving LPP
(Table 3 of reference 3). After 3 years of follow-up, how-
ever, the situation was reversed with a stronger treatment
effect in the LPP treatment group for both depressive and
anxiety symptoms. The differences observed in impact
between short- and long-term therapy were moderate but
relatively consistent over all fi ve outcome measures
considered.
The WAI and the PPF values improved more in the
short-term therapies than in the LPP during the fi rst 7
months of follow-up (4), but as with the symptom fi nd-
ing, at the end of the 3-year follow-up, the LPP was sta-
tistically signifi cantly more effective than the short-term
therapies for all three measures of work ability (Table 2
of reference 4). No differences were found in realized
work ability.
No statistically signifi cant score differences were
found between the two short-term therapies at any of the
measurement points during the 5-year follow-up for any of
the symptom or work ability scores (Table 3 of reference 3,
Table 2 of reference 4).
for binary responses (29). Model-adjusted statistics using
predictive margins were calculated for different design
points (30, 31). The delta method was used for calculat-
ing confi dence intervals (32). Statistical signifi cance was
tested with the Wald test.
Two primary models were used in the ITT analyses.
The basic model included the main effects of time, treat-
ment group, the difference between theoretical and real-
ized date of measurement, and fi rst-order interaction of
time and treatment group. A completed model further
adjusted for the baseline level of the outcome measures.
The symptom measures BDI, HDRS, SCL-90-Anx,
HARS and SCL-90-GSI, the work ability measures WAI,
SAS-Work and PPF, adequate work ability, and the recov-
ery measures for BDI, SCL-90-Anx and SCL-90-GSI
were used as outcome variables. The main AT analyses
were performed by including variables describing com-
pliance as baseline variables (waiting time from random-
ization to initiation of treatment and withdrawal before
start of treatment) and as time dependent covariates (dis-
continuation of the study treatment and use of auxiliary
treatment during follow-up) as main effects in the ITT
models. Finally, another AT analysis was performed
based on the ITT model with the recovery variables, tak-
ing the auxiliary treatment into account, as part of the
outcome variables.
The statistical analyses were performed using SAS
Software 9.1 (33).
Results Characteristics at baseline examination The patients were relatively young and predominantly
female (Table 1). About half of them were living alone
Table 1 . Baseline characteristics of the 326 patients by treatment group.
Characteristic
Solution-focused
therapy ( n � 97)
Short-term psychodynamic
psychotherapy ( n � 101)
Long-term psychodynamic
psychotherapy ( n � 128)
P -value for
difference
Socio-economic variables
Age (years) 33.6 (7.2) * 32.1 (7.0) 31.6 (6.6) 0.08
Males (%) 25.8 25.7 21.1 0.63
Employed or student (%) 83.2 85.1 75.4 0.14
Living alone (%) 56.7 48.5 49.2 0.44
Academic education (%) 28.9 19.8 28.1 0.26
White collar or entrepreneur (%) 71.1 55.4 65.5 0.06
Psychiatric treatment
Psychotherapy (%) 20.0 18.8 19.0 0.98
Psychotropic medication (%) 27.8 21.8 17.6 0.19
Hospitalization (%) 2.1 0.0 2.4 0.31
Psychiatric diagnosis
Mood disorder (%) 86.6 78.2 88.3 0.09
Anxiety disorder (%) 46.4 49.5 36.7 0.12
Personality disorder (%) 18.6 24.8 12.5 0.06
Psychiatric co-morbidity (%) 45.4 48.5 36.7 0.17
* Mean (standard deviation).
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EFFECTIVENESS OF LONG- AND SHORT-TERM PSYCHOTHERAPY
NORD J PSYCHIATRY·VOL 67 NO 1·2013 63
Tab
le 2
. M
ean s
core
lev
els
(sta
ndar
d e
rror,
SE
) of
psy
chia
tric
sym
pto
ms
in t
reat
men
t g
roups
and m
ean s
core
dif
fere
nce
s (9
5%
confi
den
ce i
nte
rval
, C
I) b
etw
een t
he
trea
tmen
t g
roups.
Mea
n s
core
s † (
SE
)M
ean s
core
dif
fere
nce
§ (
95%
CI)
Outc
om
e va
riab
le
Tim
e
(yea
r)
Solu
tion-f
ocu
sed t
her
apy
(SF
T)
( n �
97)
Short
-ter
m p
sych
odynam
ic
psy
choth
erap
y (
SP
P)
( n �
101)
Long-t
erm
psy
chodynam
ic
psy
choth
erap
y (
LP
P)
( n �
128)
SF
T v
s L
PP
SP
P v
s L
PP
SP
P v
s S
FT
BD
I0
18.2
(0.8
)17.9
(0.9
)18.7
(0.7
)0
00
110.7
*
(1.0
)9.5
*
(1.0
)12.6
*
(0.9
) �
2.0
( �
4.4
, � 0
.5)
� 2
.7
( � 5
.1, �
0.4
) �
0.8
( �
3.3
, � 1
.7)
210.2
(1.1
)9.5
(1.0
)10.0
*
(0.9
) �
0.1
( � 2
.6,
� 2
.9)
� 0
.1( �
2.7
, �
2.5
) �
0.2
( � 3
.1,
� 2
.7)
310.0
(1.0
)10.3
(1.0
)7.4
*
(0.8
) �
2.5
( �
0.0
, � 0
.5)
� 3
.4
( � 1
.0, �
5.7
) �
0.8
( � 1
.8,
� 3
.5)
48.7
(1.0
)8.7
*
(0.9
)6.9
(0.8
) �
1.6
( � 0
.9,
� 4
.1)
� 2
.2( �
0.2
, �
4.5
) �
0.5
( � 2
.1,
� 3
.2)
59.7
(1.0
)8.5
(0.9
)7.6
(0.8
) �
2.0
( � 0
.4,
� 4
.5)
� 1
.2( �
1.2
, �
3.5
) �
0.9
( � 3
.4,
� 1
.7)
P -v
alue
(tim
e) †
‡
� 0
.001
P -v
alue
(gro
up) §
¶ �
0.0
01
HD
RS
015.8
(0.5
)15.4
(0.5
)15.8
(0.4
)0
00
111.4
*
(0.7
)10.7
*
(0.6
)12.6
*
(0.6
) �
1.3
( � 3
.0,
� 0
.4)
� 1
.8
( � 3
.5, �
0.2
) �
0.5
( � 2
.3,
� 1
.2)
310.7
(0.7
)11.0
(0.6
)9.1
*
(0.6
) �
1.6
( � 0
.1,
� 3
.3)
� 2
.0
( � 0
.4, �
3.7
) �
0.4
( � 1
.3,
� 2
.2)
510.5
(0.7
)9.1
*
(0.7
)8.9
(0.6
) �
1.5
( � 0
.3,
� 3
.4)
� 0
.3( �
1.5
, �
2.1
) �
1.3
( � 3
.2,
� 0
.6)
P -v
alue
(tim
e) †
‡
� 0
.001
P -v
alue
(gro
up) §
¶ �
0.0
01
SC
L-9
0-A
nx
01.2
7(0
.07)
1.2
6(0
.07)
1.1
9(0
.06)
00
0
10.9
1 *
(0.0
8)
0.8
2 *
(0.0
7)
0.9
1 *
(0.0
7)
� 0
.05
( � 0
.23,
� 0
.12)
� 0
.13
( � 0
.30,
� 0
.04)
� 0
.08
( � 0
.26,
� 0
.11)
20.9
5(0
.09)
0.8
3(0
.08)
0.7
8 *
(0.0
7)
� 0
.11
( � 0
.09,
� 0
.30)
� 0
.02
( � 0
.17,
� 0
.20)
� 0
.09
( � 0
.30,
� 0
.11)
30.8
4(0
.07)
0.8
3(0
.07)
0.6
1 *
(0.0
6)
� 0
.18
( � 0
.01,
� 0
.37)
� 0
.18
( � 0
.00,
� 0
.36)
�
0.0
0( �
0.2
0,
� 0
.20)
40.7
6(0
.07)
0.7
1 *
(0.0
6)
0.5
4(0
.06)
� 0
.16
( � 0
.02,
� 0
.33)
� 0
.13
( � 0
.04,
� 0
.29)
� 0
.03
( � 0
.22,
� 0
.15)
50.7
5(0
.07)
0.6
2(0
.07)
0.5
7(0
.06)
� 0
.12
( � 0
.06,
� 0
.29)
� 0
.01
( � 0
.16,
� 0
.18)
� 0
.10
( � 0
.29,
� 0
.08)
P -v
alue
(tim
e) †
‡
� 0
.001
P -v
alue
(gro
up) §
¶ 0.1
5
HA
RS
014.9
(0.5
)15.0
(0.5
)14.8
(0.5
)0
00
110.7
*
(0.6
)10.0
*
(0.6
)11.3
*
(0.6
) �
0.6
( � 2
.2,
� 0
.9)
� 1
.4( �
2.9
, �
0.1
) �
0.8
( � 2
.4,
� 0
.8)
310.2
(0.6
)9.8
(0.6
)8.3
*
(0.5
) �
1.9
( �
0.4
, � 3
.4)
� 1
.4( �
0.0
, �
2.9
) �
0.5
( � 2
.0,
� 1
.1)
59.9
(0.7
)9.0
(0.7
)8.1
(0.6
) �
1.8
( �
0.1
, � 3
.6)
� 0
.9( �
0.9
, �
2.6
) �
0.9
( � 2
.8,
� 0
.9)
P -v
alue
(tim
e) †
‡
� 0
.001
P -v
alue
(gro
up) §
¶ 0.0
05
SC
L-9
0-G
SI
01.3
1(0
.05)
1.2
7(0
.05)
1.2
6(0
.05)
00
0
10.8
9 *
(0.0
6)
0.8
1 *
(0.0
6)
0.9
5 *
(0.0
5)
� 0
.10
( � 0
.24,
� 0
.04)
� 0
.15
( � 0
.28,
� 0
.02)
�
0.0
5( �
0.1
9,
� 0
.10)
20.9
4 *
(0.0
7)
0.8
7(0
.07)
0.8
4 *
(0.0
6)
� 0
.06
( � 0
.11,
� 0
.22)
� 0
.02
( � 0
.14,
� 0
.17)
� 0
.04
( � 0
.21,
� 0
.14)
30.8
7(0
.06)
0.8
5(0
.06)
0.6
9 *
(0.0
5)
� 0
.14
( � 0
.02,
� 0
.30)
� 0
.15
( � 0
.01,
� 0
.30)
� 0
.01
( � 0
.16,
� 0
.17)
40.8
0(0
.06)
0.7
6 *
(0.0
6)
0.6
3(0
.05)
� 0
.13
( � 0
.02,
� 0
.28)
� 0
.12
( � 0
.03,
� 0
.26)
� 0
.01
( � 0
.17,
� 0
.15)
50.7
7(0
.06)
0.6
9(0
.06)
0.6
7(0
.05)
� 0
.06
( � 0
.09,
� 0
.20)
� 0
.01
( � 0
.13,
� 0
.16)
� 0
.04
( � 0
.20,
� 0
.11)
P -v
alue
(tim
e) †
‡
� 0
.001
P -v
alue
(gro
up) §
¶ 0.0
3
BD
I, B
eck D
epre
ssio
n I
nven
tory
; H
DR
S,
Ham
ilto
n D
epre
ssio
n R
atin
g S
cale
; S
CL
-90-A
nx,
Sym
pto
m C
hec
k L
ist,
anxie
ty s
cale
; H
AR
S,
Ham
ilto
n A
nxie
ty R
atin
g S
cale
; S
CL
-90-G
SI,
Sym
pto
m C
hec
k L
ist,
Glo
bal
Sev
erit
y I
ndex
.
Bold
entr
ies
hav
e P
-val
ues
� 0
.05.
* A
sta
tist
ical
ly s
ignifi
can
t ch
ange
occ
urr
ed i
n c
om
par
ison w
ith t
he
valu
e at
the
pre
vio
us
tim
e poin
t.
† B
asic
model
: ad
just
ed f
or
tim
e, t
reat
men
t g
roup,
the
dif
fere
nce
bet
wee
n t
heo
reti
cal
and r
eali
zed d
ate
of
mea
sure
men
t, a
nd fi
rst
-ord
er i
nte
ract
ion o
f ti
me
and t
reat
men
t g
roup.
§ B
asic
model
adju
sted
for
the
bas
elin
e le
vel
of
the
outc
om
e m
easu
re c
onsi
der
ed.
‡ P
-val
ue
for
tim
e dif
fere
nce
for
the
trea
tmen
t g
roups
com
bin
ed.
¶ P -v
alue
for
gro
up d
iffe
rence
over
tim
e.
Nor
d J
Psyc
hiat
ry 2
013.
67:5
9-68
.D
ownl
oade
d fr
om in
form
ahea
lthca
re.c
om b
y T
echn
isch
e U
nive
rsite
it E
indh
oven
on
11/1
5/14
. For
per
sona
l use
onl
y.
P KNEKT ET AL.
64 NORD J PSYCHIATRY·VOL 67 NO 1·2013
Tab
le 3
. M
ean s
core
lev
els
(sta
ndar
d e
rror,
SE
) of
funct
ional
cap
acit
y i
n t
reat
men
t g
roups
and m
ean s
core
dif
fere
nce
s (9
5%
confi
den
ce i
nte
rval
, C
I) b
etw
een t
he
trea
tmen
t g
roups.
Mea
n s
core
s † (
SE
)M
ean s
core
dif
fere
nce
§ (
95%
CI)
Outc
om
e va
riab
leT
ime
(yea
r)
Solu
tion-f
ocu
sed
ther
apy (
SF
T)
( n �
97)
Short
-ter
m p
sych
odynam
ic
psy
choth
erap
y (
SP
P)
( n �
101)
Long-t
erm
psy
chodynam
ic
psy
choth
erap
y (
LP
P)
( n �
128)
SF
T v
s L
PP
SP
P v
s L
PP
SP
P v
s S
FT
WA
I0
33.5
(0.7
0)
34.1
(0.6
8)
33.4
(0.6
1)
00
0
137.6
*
(0.7
8)
37.8
*
(0.7
4)
37.0
*
(0.6
9)
� 0
.7( �
1.2
, �
2.6
) �
0.6
( � 1
.3,
� 2
.4)
� 0
.1( �
2.1
, �
1.8
)
238.0
(0.8
3)
38.6
(0.7
6)
39.3
*
(0.6
8)
� 1
.3( �
3.3
, �
0.7
) �
0.9
( � 2
.8,
� 0
.9)
� 0
.4( �
1.7
, �
2.5
)
338.1
(0.8
5)
37.7
(0.7
9)
39.4
(0.7
3)
� 1
.3( �
3.4
, �
0.8
) �
2.1
( �
4.1
, � 0
.0)
� 0
.8( �
3.0
, �
1.4
)
438.5
(0.8
3)
38.8
*
(0.7
7)
40.2
(0.7
1)
� 1
.6( �
3.7
, �
0.5
) �
1.6
( � 3
.6,
� 0
.4)
� 0
.0( �
2.2
, �
2.2
)
538.5
(0.8
7)
37.3
*
(0.8
3)
39.9
(0.7
3)
� 1
.3( �
3.4
, �
0.9
) �
2.8
( �
4.9
, � 0
.7)
� 1
.5( �
3.8
, �
0.8
)
P -v
alue
(tim
e) † ‡
� 0
.001
P -v
alue
(gro
up) §
¶ 0.0
1
SA
S-W
ork
02.2
1(0
.06)
2.1
3(0
.06)
2.2
3(0
.05)
00
0
11.9
5 *
(0.0
6)
1.9
1 *
(0.0
6)
2.0
1 *
(0.0
6)
� 0
.07
( � 0
.22,
� 0
.08)
� 0
.06
( � 0
.21,
� 0
.09)
� 0
.02
( � 0
.14,
� 0
.17)
21.9
3(0
.07)
1.8
8(0
.06)
1.8
7 *
(0.0
6)
� 0
.06
( � 0
.11,
� 0
.22)
� 0
.05
( � 0
.10,
� 0
.21)
� 0
.00
( � 0
.17,
� 0
.17)
31.8
7(0
.07)
1.8
8(0
.06)
1.7
4 *
(0.0
6)
� 0
.13
( � 0
.03,
� 0
.30)
� 0
.20
( � 0
.04,
� 0
.36)
�
0.0
7( �
0.1
0,
� 0
.24)
41.8
2(0
.06)
1.8
1(0
.05)
1.7
3(0
.05)
� 0
.09
( � 0
.06,
� 0
.23)
� 0
.13
( � 0
.01,
� 0
.27)
� 0
.04
( � 0
.11,
� 0
.19)
51.8
2(0
.06)
1.8
0(0
.06)
1.8
1(0
.05)
� 0
.01
( � 0
.15,
� 0
.17)
� 0
.04
( � 0
.11,
� 0
.20)
� 0
.03
( � 0
.14,
� 0
.20)
P -v
alue
(tim
e) † ‡
� 0
.001
P -v
alue
(gro
up) §
¶ 0.1
5
PP
F0
25.5
(0.5
4)
24.7
(0.5
3)
25.4
(0.4
7)
00
0
120.8
*
(0.6
5)
20.6
*
(0.6
1)
21.9
*
(0.5
8)
� 1
.3( �
3.0
, �
0.3
) �
1.2
( � 2
.8,
� 0
.4)
� 0
.2( �
1.5
, �
1.8
)
221.6
(0.7
4)
20.8
(0.6
6)
20.0
*
(0.6
0)
� 1
.4( �
0.4
, �
3.2
) �
1.0
( � 0
.7,
� 2
.7)
� 0
.4( �
2.3
, �
1.5
)
320.6
(0.6
1)
20.7
(0.5
6)
19.0
*
(0.5
3)
� 1
.4( �
0.2
, �
2.9
) �
2.0
( �
0.5
, � 3
.5)
� 0
.6( �
1.0
, �
2.2
)
419.8
(0.6
1)
20.1
(0.5
5)
18.6
(0.5
1)
� 1
.1( �
0.5
, �
2.7
) �
1.8
( �
0.3
, � 3
.2)
� 0
.7( �
1.0
, �
2.3
)
520.4
(0.6
4)
20.6
(0.6
2)
19.0
(0.5
4)
� 1
.2( �
0.5
, �
2.8
) �
1.7
( �
0.1
, � 3
.3)
� 0
.6( �
1.2
, �
2.3
)
P -v
alue
(tim
e) † ‡
�
0.0
01
P -v
alue
(gro
up) §
¶ 0.0
01
Curr
entl
y e
mplo
yed
or
studyin
g (
%)
083.1
(4.0
)85.1
(3.9
)75.6
(3.5
)0
00
187.1
(4.3
)79.7
(4.1
)76.4
(3.7
) �
8.5
( � 2
.3,
� 1
9.3
) �
0.6
( � 9
.9,
� 1
1.0
) �
7.9
( � 1
9.2
, �
3.4
)
280.6
(5.1
)82.3
(4.5
)81.6
(3.9
) �
3.9
( � 1
6.4
, �
8.6
) �
2.9
( � 1
4.6
, �
8.7
) �
0.9
( � 1
2.3
, �
14.2
)
377.8
(4.9
)80.7
(4.5
)76.8
(4.0
) �
0.8
( � 1
3.0
, �
11.3
) �
1.0
( � 1
0.5
, �
12.6
) �
1.9
( � 1
0.8
, �
14.6
)
481.2
(5.1
)78.1
(4.6
)78.4
(4.0
) �
0.2
( � 1
2.9
, �
12.6
) �
3.1
( � 1
5.0
, �
8.8
) �
2.9
( � 1
6.4
, �
10.5
)
583.6
(4.4
)84.1
(4.2
)82.3
(3.7
) �
0.3
( � 1
1.7
, �
11.1
) �
1.5
( � 1
2.6
, �
9.5
) �
1.2
( � 1
3.3
, �
10.9
)
P -v
alue
(tim
e) †
‡
0.2
6
P -v
alue
(gro
up) §
¶ 0.9
2
Nor
d J
Psyc
hiat
ry 2
013.
67:5
9-68
.D
ownl
oade
d fr
om in
form
ahea
lthca
re.c
om b
y T
echn
isch
e U
nive
rsite
it E
indh
oven
on
11/1
5/14
. For
per
sona
l use
onl
y.
EFFECTIVENESS OF LONG- AND SHORT-TERM PSYCHOTHERAPY
NORD J PSYCHIATRY·VOL 67 NO 1·2013 65
Num
ber
of
sick
-lea
ve
day
s duri
ng l
ast
3
month
s
05.9
8(1
.33)
4.4
7(1
.26)
5.2
2(1
.17)
00
0
13.6
9(0
.98)
2.9
3(0
.96)
4.7
3(1
.04)
� 0
.17
( � 2
.56,
� 2
.89)
� 0
.69
( � 3
.38,
� 2
.00)
� 0
.85
( � 3
.49,
� 1
.79)
23.6
1(0
.86)
3.4
6(0
.78)
2.5
6(0
.68)
� 1
.45
( � 0
.88,
� 3
.78)
� 1
.38
( � 0
.84,
� 3
.60)
� 0
.07
( � 2
.55,
� 2
.42)
35.6
9(1
.57)
5.1
1(1
.48)
3.3
6(1
.41)
� 2
.85
( � 2
.11,
� 7
.81)
� 3
.82
( � 0
.89,
� 8
.54)
� 0
.97
( � 4
.11,
� 6
.05)
44.0
1(0
.75)
2.2
2 *
(0.6
7)
1.7
0(0
.66)
� 2
.27
( � 0
.10,
� 4
.43)
�
0.2
3( �
1.8
2,
� 2
.28)
� 2
.04
( � 4
.26,
� 0
.18)
53.0
6(0
.60)
2.6
3(0
.60)
1.6
1(0
.53)
� 1
.21
( � 0
.51,
� 2
.92)
� 0
.89
( � 0
.81,
� 2
.60)
� 0
.31
( � 2
.11,
� 1
.49)
P -v
alue
(tim
e) † ‡
0.0
05
P -v
alue
(gro
up) §
¶ 0.3
7
Mo
re t
han
7
sick
-lea
ve
day
s
du
rin
g l
ast
3 m
on
ths
(%)
023.2
(5.3
)19.7
(5.1
)16.4
(4.7
)0
00
111.6
*
(4.5
)9.2
*
(4.4
)15.8
(4.7
) �
3.0
( � 1
6.6
, �
10.6
) �
6.9
( � 2
0.2
, �
6.5
) �
3.9
( � 1
7.1
, �
9.3
)
210.4
(5.2
)21.2
(4.7
)8.9
(4.2
) �
7.3
( � 6
.8,
� 2
1.3
) �
12.3
( � 1
.1,
� 2
5.7
) �
5.0
( � 9
.9,
� 2
0.0
)
320.3
(4.8
)10.8
*
(4.3
)9.4
(4.2
) �
13.3
( � 0
.8,
� 2
7.4
) �
0.4
( � 1
3.2
, �
12.5
) �
13.7
( � 2
7.9
, �
0.6
)
410.8
(4.5
)8.0
(3.9
)7.0
(3.9
) �
2.8
( � 9
.8,
� 1
5.4
) �
1.2
( � 1
0.7
, �
13.1
) �
1.6
( � 1
4.5
, �
11.3
)
514.2
(3.9
)10.6
(3.9
)5.1
(3.4
) �
7.0
( � 4
.0,
� 1
8.0
) �
5.1
( � 5
.9,
� 1
6.1
) �
1.9
( � 1
3.5
, �
9.6
)
P -v
alue
(tim
e) † ‡
0.0
2
P -v
alue
(gro
up) §
¶ 0.7
2
WA
I, W
ork
Abil
ity I
ndex
; S
AS
-Work
, th
e W
ork
-subsc
ale
of
the
Soci
al A
dju
stm
ent
Sca
le;
PP
F, t
he
Per
ceiv
ed P
sych
olo
gic
al F
unct
ionin
g S
cale
(P
PF
).
Bold
entr
ies
hav
e P
-val
ues
� 0
.05.
* A
sta
tist
ical
ly s
ignifi
can
t ch
ange
occ
urr
ed i
n c
om
par
ison w
ith t
he
valu
e at
the
pre
vio
us
tim
e poin
t.
† B
asic
model
: ad
just
ed f
or
tim
e, t
reat
men
t g
roup,
the
dif
fere
nce
bet
wee
n t
heo
reti
cal
and r
eali
zed d
ate
of
mea
sure
men
t, a
nd fi
rst
-ord
er i
nte
ract
ion o
f ti
me
and t
reat
men
t g
roup.
§ B
asic
model
adju
sted
for
the
bas
elin
e le
vel
of
the
outc
om
e m
easu
re c
onsi
der
ed.
‡ P
-val
ue
for
tim
e dif
fere
nce
for
the
trea
tmen
t g
roups
com
bin
ed.
¶ P -v
alue
for
gro
up d
iffe
rence
over
tim
e.
Treatment effects on symptoms and working ability during the 4th and 5th year of follow-up All excess effects on psychiatric symptoms of LPP at the
3-year follow-up point disappeared during the following
2 years in comparison to both short-term therapy groups,
with the exception of HARS, for which the effect per-
sisted in comparison to SFT (Table 2). For work ability,
however, the effect persisted for PPF and WAI statisti-
cally signifi cantly in comparison to the SPP and non-sig-
nifi cantly in comparison to SFT (Table 3). Also the
number of sick-leave days was smaller in the LPP group
than in the SFT group at the 4-year follow-up point
(Table 3) and adequate work ability was more common
in the LPP group than in the SPP group at the 5-year
follow-up point (data not shown). No differences between
the short-term therapies were found for any outcome
variable at any measurement point.
Auxiliary treatment Out of the 326 patients, 63.4% used some type of auxil-
iary treatment during the 5-year follow-up. Auxiliary
treatment was more common in the SFT and SPP groups
(69% and 74%, respectively) than in the LPP group
(56%) ( P � 0.001) (11). This difference was mainly due
to differences in the use of auxiliary psychotherapy, the
prevalence of which was 47% in both short-term therapy
groups and 28% in the LPP group ( P � 0.002). After
addition of the auxiliary therapies to the treatment given
by the project, the average total number of therapy ses-
sions among patients starting the therapy in SFT, SPP
and LPP was 60.2 � 97.6 (range 3 – 416), 69.9 � 99.3
(range 7 – 512) and 240 � 103 (range 8 – 448), respectively.
A total of 45% of the patients in the SFT group and the
LPP group used psychiatric medication, but in the SPP
group the percentage was higher at 61% ( P � 0.008). The
average length of use of psychotropic medication varied
statistically signifi cantly between the therapy groups,
being 48 weeks for SFT, 57 weeks for SPP and 41 weeks
for LPP. Psychiatric hospitalization was used far more
frequently in the psychodynamic therapies (7% of the
patients hospitalized in the SPP and LPP groups and 1%
in the SFT group).
Treatment effects on recovery It cannot be excluded that the lack of differences in the
impact of short-term and long-term therapies on the psy-
chiatric symptoms at the 4- and 5-year follow-up points
may be due to the higher amount of auxiliary therapy in
the short-term groups. Therefore, we studied the recovery
from psychiatric symptoms also requiring lack of auxil-
iary treatment to satisfy the recovery criteria. It appeared
that, when the impact of auxiliary treatment was not
acknowledged, the recovery from symptoms was statistically
signifi cantly higher in the LPP group than in the short-
term groups SPP and SFT at the 3-year follow-up point
Nor
d J
Psyc
hiat
ry 2
013.
67:5
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66 NORD J PSYCHIATRY·VOL 67 NO 1·2013
of treatment. In accordance with this hypothesis, and our
previous fi ndings during a 3-year follow-up (4), LPP
showed a more benefi cial outcome in work ability than
shorter therapies during the 5-year follow-up, even when
additional treatments were not adjusted for.
As far as the present authors know, the present study
is the fi rst clinical trial to compare the long-term effec-
tiveness of the markedly different therapeutic modalities,
SFT and SPP, on symptomatic and functional outcomes.
As expected in the light of the general literature (5), the
modality seems not to have any notable effect, as SFT
and SPP showed practically equal long-term effective-
ness. Contrary, additional benefi ts after the termination
of SPP have been postulated and suggested in the treat-
ment of depressive and anxiety disorders in some (37)
but not all previous studies (38, 39). Although SFT and
SPP appeared to produce, on average, equal effects on
changes in psychiatric symptoms and work ability in the
but not at the 4 – 5-year points (data not shown). After
inclusion of auxiliary treatment in the recovery criteria,
the superiority of the LPP group could also be seen at
the 4 – 5-year follow-up points as well for adequate work
ability as for symptoms (Figs. 2 – 5).
Discussion Findings and interpretations It has been shown that 3 years after starting therapy, LPP
is more effective in reducing psychiatric symptoms than
SPP or SFT (3). However, the present follow-up of the
study shows that the advantages did not persist during
the following 2 years, as no notable differences were
noted in psychiatric symptoms or recovery from psychiat-
ric symptoms at the 4- and 5-year follow-up points. This
fi nding is in variance with the theoretical suggestion (34),
backed up by little research evidence (35) that, as a con-
sequence of long-term psychodynamic therapy, vulnera-
bility to life stresses and emergence of symptoms still are
reduced after the therapy ends to a greater extent than in
shorter interventions. One possible reason for the lack of
difference in symptoms may be due to the considerable
use of auxiliary treatment especially in the short-term
therapy groups (11). In accordance with this hypothesis,
recovery from psychiatric symptoms was more common
in the LPP group during the 4th and 5th year of fol-
low-up after adjustment of auxiliary treatment.
Unlike the symptom results, working ability was more
improved at the end of the follow-up in the long-term
therapy group, suggesting that the effect of auxiliary treat-
ment on work ability is relatively small, possibly because
of the harmful effects of not receiving adequate treatment
initially. Problems with working ability, especially in
depressive patients, are known to be relatively pervasive in
nature, even after symptomatic remission is reached (36),
and may thus necessitate greater dosage or longer duration
Fig. 2. Adequate work ability (Work Ability Index ,WAI � 36) and
no auxiliary treatment.
Fig. 4. Recovery from depressive symptoms (Beck Depression
Inventory, BDI) and no auxiliary treatment.
Fig. 3. Recovery from general psychiatric symptoms (Symptom
Check List, Global Severity Index, SCL-90-GSI) and no auxiliary
treatment.
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EFFECTIVENESS OF LONG- AND SHORT-TERM PSYCHOTHERAPY
NORD J PSYCHIATRY·VOL 67 NO 1·2013 67
as adjusted mean differences or relative risks — standard
measures of strength of association — instead of the inap-
propriate Cohen ’ s d (40), widely used in the psychother-
apy literature. Unavoidable weaknesses in a study like this
are the fact that effi cacy cannot be exactly measured, the
lack of manuals for the therapies used, the lack of a con-
trol group, and the lack of blindness of assessments.
Conclusions LPP is more effective than SPP or SFT, with respect to
recovery from psychiatric symptoms and improvement
of work ability during a 5-year period from the start of
therapy. There seems to be no difference in effective-
ness between two short-term therapies of different
modalities. More randomized clinical trials comparing
short- and long-term therapy with long follow-up times
are needed.
Acknowledgements — This study was funded by the Academy of Finland,
grant no 138876 and Social Insurance Institution of Finland. The Helsinki
Psychotherapy Study Group, which was responsible for data collection, is
defi ned in reference (12).
Declaration of interest : The authors report no confl icts of
interest. The authors alone are responsible for the content
and writing of the paper.
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their effectiveness might be established if more stringent
selection criteria were used. The fact that the patients in
the present study were randomly assigned to the three
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as its proponents have suggested that several suitability
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and work ability. Finally, the effect size was estimated
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