Medication-Free Treatment in Mental Health Care How Does It Differ from Traditional Treatment?

Background: Norwegian authorities have implemented treatment units devoted to medication-free mental health treatment nationwide to improve people's freedom of choice. This article examines how medication-free treatment differs from treatment as usual across central dimensions. Methods: The design was mixed methods including questionnaire data on patients from a medication-free unit and two comparison units (n 59 + 124), as well as interviews with patients (n 5) and staff (n 8) in the medication-free unit. Results: Medication-free treatment involved less reliance on medications and more extensive psychosocial treatment that involved a culture of openness, expression of feelings, and focus on individual responsibility and intensive work. The overall extent of patient influence for medication-free treatment compared with standard treatment was not substantially different to standard treatment but varied on different themes. Patients in medication-free treatment had greater freedom to reduce or not use medication. Medication-free treatment was experienced as more demanding. For patients, this could be connected to a stronger sense of purpose and was experienced as helpful but could also be experienced as a type of pressure and lack of understanding. Patients in medication-free treatment reported greater satisfaction with the treatment, which may be linked to a richer psychosocial treatment package that focuses on patient participation and freedom from pressure to use medication. Conclusion: The findings provide insights into how a medication-free treatment service might work and demonstrate its worth as a viable alternative for people who are not comfortable with the current medication focus of mental health care. Patients react differently to increased demands and clinicians should be reflexive of the dimensions of individualism-relationism in medication-free treatment services. This knowledge can be used to further develop and improve both medication-free treatment and standard treatment regarding shared decision-making. Trial Registration: This study was registered with ClinicalTrials.gov (Identifier NCT03499080) on 17 April 2018.

Drinking to Cope Mediates the Association between Dyadic Conflict and Drinking Behavior: A Study of Romantic Couples during the COVID-19 Pandemic.

The COVID-19 pandemic spurred public health measures to reduce viral spread. Concurrently, increases in alcohol consumption and conflict in romantic partnerships were observed. Pre-pandemic research demonstrated a bidirectional association between couples' conflict and drinking. Recent research shows one's drinking motives (proximal predictors of drinking behavior) can influence another person's drinking in close relationships. It is possible that individuals are drinking to cope with distress following romantic conflict. The current study examined 348 cohabitating couples during the first lockdown in the spring of 2020. Our analyses examined coping motives as a mediator between dyadic conflict and drinking behavior using actor-partner interdependence models. Results showed that conflict was associated with greater reports of own drinking in gendered (distinguishable) and nongendered (indistinguishable) analyses through coping motives. Further, in mixed-gender couples, men partners' coping motives predicted less drinking in women, while women partners' coping motives predicted marginally more drinking in men. Partner effects may have been observed due to the increased romantic partner influence during the COVID-19 lockdown. While these results suggest that men's coping motives may be protective against women's drinking, more concerning possibilities are discussed. The importance of considering dyadic influences on drinking is highlighted; clinical and policy implications are identified.

The status of psychodynamic psychotherapy as an empirically supported treatment for common mental disorders - an umbrella review based on updated criteria.

To assess the current status of psychodynamic therapy (PDT) as an empirically supported treatment (EST), we carried out a pre-registered systematic umbrella review addressing the evidence for PDT in common mental disorders in adults, based on an updated model for ESTs. Following this model, we focused on meta-analyses of randomized controlled trials (RCTs) published in the past two years to assess efficacy. In addition, we reviewed the evidence on effectiveness, cost-effectiveness and mechanisms of change. Meta-analyses were evaluated by at least two raters using the proposed updated criteria, i.e. effect sizes, risk of bias, inconsistency, indirectness, imprecision, publication bias, treatment fidelity, and their quality as well as that of primary studies. To assess the quality of evidence we applied the GRADE system. A systematic search identified recent meta-analyses on the efficacy of PDT in depressive, anxiety, personality and somatic symptom disorders. High quality evidence in depressive and somatic symptom disorders and moderate quality evidence in anxiety and personality disorders showed that PDT is superior to (inactive and active) control conditions in reducing target symptoms with clinically meaningful effect sizes. Moderate quality evidence suggests that PDT is as efficacious as other active therapies in these disorders. The benefits of PDT outweigh its costs and harms. Furthermore, evidence was found for long-term effects, improving functioning, effectiveness, cost-effectiveness and mechanisms of change in the aforementioned disorders. Some limitations in specific research areas exist, such as risk of bias and imprecision, which are, however, comparable to those of other evidence-based psychotherapies. Thus, according to the updated EST model, PDT proved to be an empirically-supported treatment for common mental disorders. Of the three options for recommendation provided by the updated model (i.e., "very strong", "strong" or "weak"), the new EST criteria suggest that a strong recommendation for treating the aforementioned mental disorders with PDT is the most appropriate option. In conclusion, PDT represents an evidence-based psychotherapy. This is clinically important since no single therapeutic approach fits all psychiatric patients, as shown by the limited success rates across all evidence-based treatments.

Efficacy and moderators of short-term psychodynamic psychotherapy for depression: A systematic review and meta-analysis of individual participant data.

BACKGROUND: Short-term psychodynamic psychotherapy (STPP) is frequently used to treat depression, but it is unclear which patients might benefit specifically. Individual participant data (IPD) meta-analyses can provide more precise effect estimates than conventional meta-analyses and identify patient-level moderators. This IPD meta-analysis examined the efficacy and moderators of STPP for depression compared to control conditions. METHODS: PubMed, PsycInfo, Embase, and Cochrane Library were searched September 1st, 2022, to identify randomized trials comparing STPP to control conditions for adults with depression. IPD were requested and analyzed using mixed-effects models. RESULTS: IPD were obtained from 11 of the 13 (84.6%) studies identified (n = 771/837, 92.1%; mean age = 40.8, SD = 13.3; 79.3% female). STPP resulted in significantly lower depressive symptom levels than control conditions at post-treatment (d = -0.62, 95%CI [-0.76, -0.47], p < .001). At post-treatment, STPP was more efficacious for participants with longer rather than shorter current depressive episode durations. CONCLUSIONS: These results support the evidence base of STPP for depression and indicate episode duration as an effect modifier. This moderator finding, however, is observational and requires prospective validation in future large-scale trials.

Intensive Short-Term Dynamic Psychotherapy (ISTDP) associated with healthcare reductions in patients with functional seizures.

Intensive Short-Term Psychodynamic Therapy (ISTDP) has demonstrated promising evidence for the treatment of Functional Neurological Disorders (FND) including functional seizures. This paper aimed to further examine the therapeutic effects of a 3-session course of this treatment focusing on its potential to maintain reduced healthcare utility within a group of patients with complex difficulties, across an extended time period, post-therapy. The original study followed a mixed methods case series design and recruited 18 patients from secondary adult mental health care and specialist neurology services. Seventeen participants completed the intervention and attendance rates were very high (95%). In this follow-up study, which was solely focused on the utilization of healthcare resources, results showed decreases when comparing 12 months prior and 12 months post three sessions of ISTDP. The results provide further support for the use of ISTDP in this group of participants with complex clinical presentations, specifically, its capacity to reduce healthcare usage over 12 months post-therapy. Further evidence from controlled and randomized studies with larger sample sizes is warranted.

Effects of mandatory homeschooling during COVID-19 on conflict in romantic couples.

In early 2020, schools across Canada closed due to the COVID-19 pandemic, requiring parents to homeschool their children. We examined the association between homeschooling and romantic conflict among couples during the COVID-19 pandemic. Canadian couples (N = 756) completed online measures, including whether they were homeschooling, hours spent homeschooling, and romantic conflict during the month of April 2020. Two hundred ten couples (27.8%) reported that they were homeschooling their children during this period, with 173 (22.9%) couples homeschooling due to the pandemic. Multilevel regressions were used to examine the association between homeschooling status and romantic conflict, and actor-partner interdependence models (APIMs) were used to examine the association between homeschooling hours and romantic conflict among homeschoolers. In our APIM analyses, significant links between hours spent homeschooling and romantic conflict were observed, even when controlling for demographic variables. We found significant actor effects, where an individual's own homeschooling hours were positively related to the conflict they enacted toward their partner, and significant partner effects, where the partner's homeschooling hours were positively related to conflict received by the individual. Among all couples, we found significant positive associations between homeschooling status (i.e., nonhomeschooler or homeschooler) and both types of romantic conflict. However, these associations were nonsignificant when controlling for demographic variables. Our findings suggest the number of hours spent in homeschooling may be an important contributor to romantic conflict between partners during the pandemic. We discuss implications for schools and governments in providing additional support for families homeschooling children during mandated school closures. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Empirically supported psychodynamic psychotherapy for common mental disorders-An update applying revised criteria: Systematic review protocol.

The approach of evidence-based medicine has been extended to psychotherapy. More than 20 years ago, criteria for empirically supported psychotherapeutic treatments (ESTs) were defined. Meanwhile a new model for empirically supported psychotherapeutic treatments has been proposed. While the empirical status of psychodynamic therapy (PDT) was assessed in several reviews using the previous criteria, the proposed new model has not yet been applied to PDT. For this reason, we will carry out a systematic review on studies of PDT in common mental disorders applying the revised criteria of ESTs. As suggested by the new model we will focus on recent systematic quantitative reviews. A systematic search for meta-analyses on the efficacy of PDT in common mental disorders will be carried out. Meta-analyses will be selected and evaluated by at least two raters along the criteria of the new proposed model. In addition, systematic reviews and individual studies addressing mechanisms of change in PDT, effectiveness under real-world conditions, cost-effectiveness and adverse events will be systematically searched for and evaluated. Finally, quality of evidence, the extent to which benefits exceed harms and strength of recommendations will be assessed per disorder using GRADE.

A review of the treatment of functional neurological disorder with intensive short-term dynamic psychotherapy.

The purpose of this article was to raise awareness of an under-recognized but well-supported treatment for Functional Neurological Disorders (FND) termed Intensive Short-term Dynamic Psychotherapy (ISTDP). There has been significant interest in the role of psychological mechanisms in FND onset and maintenance with specific evidence for maladaptive emotional processing. We outline how this supports the theoretical basis for ISTDP as an option in FND treatment and undertake a literature review of the current evidence base. We describe the application of ISTDP to FND illustrated through direct therapy transcripts. We conclude with reflections on the strengths and limitations of ISTDP as well as recommendations regarding future research.

The anger-depression mechanism in dynamic therapy: Experiencing previously avoided anger positively predicts reduction in depression via working alliance and insight.

A central tenet of psychodynamic theory of depression is the role of avoided anger. However empirical research has not yet addressed the question of for which patients and via what pathways experiencing anger in sessions can help. The therapeutic alliance and acquisition of patient insight are important change processes in dynamic therapy and may mediate the anger-depression association. This study was embedded into a randomized trial testing the efficacy of Intensive Short-Term Dynamic Psychotherapy (ISTDP) for treatment resistant depression. In-session patient affect experiencing (AE) was coded for every available session (475/481) by blinded observers in 27 patients randomized to ISTDP. Dynamic Structural Equation Modeling was used to examine within-person associations between variation in depression scores session-by-session and both patient ratings (alliance) and observer ratings (AE and insight) of the treatment process. Alliance and insight were independent mediators of the effect of anger on next-session depression. However, the relative importance of these two indirect effects of anger on depression was conditional on pretreatment patient personality pathology (PP). In patients with higher PP, in-session anger was negatively related to depressive symptoms next session, with this effect operating through higher alliance. In patients with low PP, in-session anger was negatively related to depressive symptoms next session, with this effect operating through enhanced patient insight. These findings highlight an anger-depression mechanism of change in dynamic therapy. Depending upon patient personality, either an "insight pathway" or a "relational pathway" may promote the effectiveness of facilitating arousal and expression of patients' in-session feelings. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Why Service Users Choose Medication-Free Psychiatric Treatment: A Mixed-Method Study of User Accounts.

PURPOSE: Medication has been a central part of treatment for severe mental disorders in Western medicine since the 1950s. In 2015, Norwegian Health Authorities decided that Norwegian health regions must have treatment units devoted to medication-free mental health treatment to enhance service users' freedom of choice. The need for these units has been controversial. The aim of this study was to examine why service users choose medication-free services. This article examines what purpose these units serve in terms of the users' reasons for choosing this service, what is important for them to receive during the treatment, and what factors lay behind their concerns in terms of medication-related views and experiences. METHODS: Questionnaires were answered by 46 participants and 5 participants were interviewed in a mixed-method design integrated with a concurrent triangulation strategy applying thematic analysis and descriptive statistics. RESULTS: Negative effects of medications and unavailable alternatives to medication in ordinary health care were important reasons for wanting medication-free treatment. Medication use may conflict with personal values, attitudes, and beliefs. CONCLUSION: This study broadens the understanding of why the demand for separate medication-free units has arisen. The findings may contribute to making medication-free treatment an option in mental health care in general. To this end, clinicians are advised to communicate all treatment alternatives to service users and to be mindful of the effect of power imbalances in their interactions with them.

Intensive short-term dynamic psychotherapy provided by novice psychotherapists: effects on symptomatology and psychological structure in patients with anxiety disorders.

This study examines the effectiveness of psychotherapy provided by novice therapists, in an attempt to clarify the controversial relationship between treatment effectiveness and therapist experience. To achieve this, we examined the short- and long-term effectiveness of intensive short-term dynamic psychotherapy (ISTDP) in the treatment of patients with the Diagnostic and Statistical Manual of Mental Disorder, IV edition - Text Revision anxiety disorders, as provided by novice psychology trainees. Twenty-two patients with anxiety disorders were provided ISTDP. Patients improved significantly on all outcome indices, including the global assessment of functioning, the symptom checklist and the inventory of interpersonal problems, at the end of the treatment and at 6 and 12 month follow-up. In addition to these results, there was marked structural personality change as evidenced by ratings on the Shedler Westen assessment procedure (SWAP-200), at the same assessment moments; the SWAP-200 psychological health index score showed a meaningful increase in adaptive psychological resources and capacities, while the mean number of personality diagnoses decreased from the beginning to the end of therapy, and all patients maintaining their gains in 6-12 month follow-up. We conclude that ISTDP provided by novice psychotherapists is efficacious in bringing broad and in-depth change to pathology that can perpetuate anxiety disorders and other psychiatric conditions.

Short-term psychodynamic psychotherapy for functional somatic disorders: A systematic review and meta-analysis of within-treatment effects.

OBJECTIVE: A recent meta-analysis of 17 randomized, controlled trials (RCTs) showed that Short-term Psychodynamic Psychotherapy (STPP) for functional somatic disorders (FSD) reduced somatic symptoms compared to wait list, minimal treatment, and treatment-as-usual controls. A clinically important yet unanswered question is how much improvement patients experience within STPP treatment. METHODS: Following a systematic search, we identified STPP trials presenting data at baseline and post-treatment/follow-up. Meta-analyses determined the magnitude of changes in somatic symptoms and other outcomes from before to after STPP, and analyses examined effect sizes as a function of study, therapy, and patient variables. RESULTS: We identified 37 trials (22 pre-post studies and 15 RCTs) totaling 2094 patients treated an average of 13.34 sessions for a range of FSD. Across all studies, somatic symptoms improved significantly from pre-treatment to short-term follow-up with a large effect size (SMD = -1.07), which was maintained at long-term follow-up (SMD = -0.90). After excluding two outlier studies, effects at short- and medium-term follow-up remained significant but were somewhat reduced in magnitude (e.g., short-term SMD = -0.73). Secondary outcomes including anxiety, depression, disability, and interpersonal problems had medium to large effects. Effects were larger for studies of STPP that were longer than 12 sessions or used an emotion-focused type of STPP, and for chronic pain or gastrointestinal conditions than for functional neurological disorders. CONCLUSIONS: STPP results in moderate to large improvements in multiple outcome domains that are sustained in long-term follow-up. STPP is an effective treatment option for FSD and should be included in treatment guidelines.

Alliance rupture-repair processes in intensive short-term dynamic psychotherapy: Working with resistance.

Intensive short-term dynamic psychotherapy (ISTDP) was developed to manage treatment impasses preventing the experiencing of feelings related to childhood attachment interruptions, such as parental loss. According to ISTDP theory, certain categories of patients will exhibit habitual patterns of responding within the treatment relationship (called defenses) to certain anxiety-provoking thoughts and feelings. Such defensive behaviors interrupt awareness of one's own feelings, self-directed compassion and engagement in close human attachments, including the bond with the therapist. Rupture-repair sequences in ISTDP are primarily considered in the context of a patient's defenses and the responses a therapist has to these defenses. By understanding and clarifying these defenses, this risk of subsequent misalliance, that is negative shifts or ruptures in the alliance, are minimized. In this paper we summarize ISTDP theory and technique through the use of clinical vignettes to illustrate defense management as a rupture-repair equivalent in ISTDP.

Efficacy of intensive short-term dynamic psychotherapy in mood disorders: A critical review.

BACKGROUND: Intensive Short-Term Dynamic Psychotherapy (ISTDP) is an intervention introduced by Davanloo in order to treat anxiety, mood and somatic symptom, and personality disorders. It is a brief intervention aiming to identify and process painful or forbidden emotions and consequently to override symptoms and self-destructive tendencies. In this review we examine the efficacy of ISTDP on symptoms in patients with Major Depressive Disorder (MDD) and Bipolar Disorder (BD). METHODS: A thorough search of articles in Pubmed, PsycINFO, Isi Web of Knowledge was carried out in order to obtain available studies of ISTDP for BD and MDD. We included all studies conducted on patients with a diagnosis of MDD or BD and who received ISTDP. RESULTS: Eight studies were included. These were two randomized controlled trials and six observational studies. Overall the results of the included manuscripts suggest a positive effect of ISTDP on depressive symptoms for patients affected by mood disorders. Furthermore, they suggest ISTDP may be cost-effective through reducing doctor visits and hospitalizations in follow-up. LIMITATIONS: Most studies had small samples and consisted of non-randomized trials. CONCLUSIONS: These are preliminary positive results on the effectiveness of this approach for the treatment of depressive symptoms. They have to be confirmed by studies with larger sample sizes and by comparing this technique with other psychological treatments such as cognitive-behavioral therapy.