Effectiveness of psychoanalysis and long-term psychodynamic psychotherapy on personality and social functioning 10 years after start of treatment.

The evidence on potentially greater benefits of psychoanalysis (PA) vs. long-term psychodynamic psychotherapy (LPP) is scarce. This study compared the effectiveness of PA and LPP on personality and social functioning during a 10-year follow-up from the beginning of the treatments. The eligible patients, 41 self-selected for PA and 128 assigned to LPP, were 20-45 years of age and had anxiety or mood disorder. Outcomes were analyzed using ten standard measures of personality and social functioning, carried out 5-9 times during the follow-up. Different change patterns by time in PA and LPP emerged, suggesting less benefit of PA during the first years of follow-up and more benefit in most outcomes thereafter. Greater post-treatment improvement in PA than in LPP was seen up to 1-2 years after PA had ended in more mature defense style (DSQ), level of personality organization (LPO), more positive self-concept (SASB), more improved social adjustment (SAS-SR) and sense of coherence (SOC). However, at the 10-year follow-up the differences were non-significant. In conclusion, PA may give some additional benefits when long-term aims are linked to personality and social functioning. The relatively small differences and higher costs in comparison to LPP may restrict the feasibility of PA.

Growth of diabetes drug expenditure decomposed-A nationwide analysis.

OBJECTIVES: The aim of this study was to quantify different factors underlying the growth of diabetes drug expenditure in Finland. METHODS: Data representing purchases of antidiabetic agents between 2003 and 2015 were extracted from a nationwide prescription register. By using Fisher's Ideal Indexes, the per capita expenditure growth for both insulins and non-insulin antidiabetic agents was decomposed into six different determinants: purchase volume, purchase size, switches between therapeutic classes, switches within therapeutic classes, unit costs and switches to generic alternatives. RESULTS: Between 2003 and 2015, the per capita expenditure on insulins increased by €8.64 and on non-insulins by €13.73. For insulins, holding other factors constant, change in the number of purchases represented a €4.67 increase in expenditure, change in the size of purchases a €4.33 increase and switches between therapeutic classes a €4.07 increase. For non-insulins, change in the number of purchases represented a €10.22 increase in expenditure and switches between therapeutic classes, a €10.17 increase. Changes in purchase size increased the non-insulin per capita expenditure by €1.48. For both insulins and non-insulins, changes in prices and product level switches had decreasing effects on expenditures. CONCLUSIONS: The main drivers of the growth in diabetes drug expenditure were volume growth and switches to newer and more expensive drugs. Price changes, however, had a decreasing effect on the overall diabetes drug expenditure.

The cost-effectiveness of short-term and long-term psychotherapy in the treatment of depressive and anxiety disorders during a 5-year follow-up.

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.

Confounding and missing data in cost-effectiveness analysis: comparing different methods.

INTRODUCTION: Common approaches in cost-effectiveness analyses do not adjust for confounders. In nonrandomized studies this can result in biased results. Parametric models such as regression models are commonly applied to adjust for confounding, but there are several issues which need to be accounted for. The distribution of costs is often skewed and there can be a considerable proportion of observations of zero costs, which cannot be well handled using simple linear models. Associations between costs and effectiveness cannot usually be explained using observed background information alone, which also requires special attention in parametric modeling. Furthermore, in longitudinal panel data, missing observations are a growing problem also with nonparametric methods when cumulative outcome measures are used. METHODS: We compare two methods, which can handle the aforementioned issues, in addition to the standard unadjusted bootstrap techniques for assessing cost-effectiveness in the Helsinki Psychotherapy Study based on five repeated measurements of the Global Severity Index (SCL-90-GSI) and direct costs during one year of follow-up in two groups defined by the Defence Style Questionnaire (DSQ) at baseline. The first method models cumulative costs and effectiveness using generalized linear models, multiple imputation and bootstrap techniques. The second method deals with repeated measurement data directly using a hierarchical two-part logistic and gamma regression model for costs, a hierarchical linear model for effectiveness, and Bayesian inference. RESULTS: The adjustment for confounders mitigated the differences of the DSQ groups. Our method, based on Bayesian inference, revealed the unexplained association of costs and effectiveness. Furthermore, the method also demonstrated strong heteroscedasticity in positive costs. CONCLUSIONS: Confounders should be accounted for in cost-effectiveness analyses, if the comparison groups are not randomized. JEL CLASSIFICATION: C1; C3; I1.

The cost-effectiveness of short-term psychodynamic psychotherapy and solution-focused therapy in the treatment of depressive and anxiety disorders during a one-year follow-up.

BACKGROUND: Mood and anxiety disorders are characterized by a high and increasing prevalence, they cause a lot of costs and human suffering and there are many treatment options with differing costs. The benefits of identifying the treatments with the most favourable cost-effectiveness ratios can be substantial. However, the number of randomized trials where psychological treatments are compared with each other and where economic aspects, too, are taken into account is still relatively small. AIM: To compare the cost-effectiveness of two short-term psychotherapies in the treatment of depressive and anxiety disorders during a one-year follow-up. METHODS: In the Helsinki Psychotherapy Study, 198 patients, who were 20--45 years of age and met DSM-IV criteria for anxiety or mood disorder, were randomized to short-term psychodynamic psychotherapy (SPP) or solution-focused therapy (SFT). Psychiatric symptoms were assessed at baseline and 4 times during the one-year follow-up from the start of therapy using the Beck Depression Inventory and the Symptom Check List Anxiety Scale, and 2 times using the Hamilton Depression Rating Scales and Hamilton Anxiety Rating Scales. Both direct costs (therapy sessions, outpatient visits, medication, inpatient care) and indirect costs (production losses due to work absenteeism, value of neglected household work, lost leisure time and unpaid help received) due to mental disorders were measured. Mean total costs were compared and incremental cost-effectiveness ratios analyzed. RESULTS: According to all 4 psychiatric outcome measures, symptoms of depression and anxiety were reduced statistically significantly in both therapy groups during the one-year follow-up. The relative changes were about the same size according to all four outcome measures. In both groups the reductions took place mainly in the first half of the follow-up. The reductions were somewhat greater with SPP, but the differences between the two groups were small and not statistically significant at any measurement point. The mean total direct costs were 1791 euros in the SPP group, being 346 euros (16%) lower than those of the SFT group, but this difference was not statistically significant either. Also the incremental cost-effectiveness ratio points calculated by 500 bootstrap iterations favoured SPP. The total indirect costs in the SPP group were, in contrast to direct costs, higher than those in the SFT group, but, again, the difference was not statistically significant. LIMITATIONS: The generalization of our results may be weakened by the fact that the patients included in our study were relatively young, and the follow-up period was restricted to one year. IMPLICATIONS: This study suggests that there are no notable differences in cost-effectiveness between SPP and SFT. If one were obliged to choose between these two therapies our results would support the choice of SPP. However, more research with extensive data about both costs and effectiveness, compiled over a period longer than one year, are needed before any firm conclusions can be drawn about the cost-effectiveness of the two therapies compared in this study.

Antipsychotics and antidepressants: an analysis of cost growth in Finland from 1999 to 2005.

BACKGROUND: Antipsychotics and antidepressants are among the fastest-growing therapeutic classes, but the reasons behind recent cost growth are not clear. OBJECTIVE: The aim of this study was to assess the explicit factors behind ambulatory antipsychotic and antidepressant cost growth in Finland, as well as the relative importance of the factors associated with the drug group-specific cost growth. METHODS: The data used in this study were retrospectively collected from the Finnish National Health Insurance's register on reimbursed drug purchases. The study period ranged from January 1, 1999, through December 31, 2005, and the obtained data included information on the patient identity number, total cost of the purchase, Anatomic Therapeutic Chemical classification code of the purchased product, and defined daily dose amount of the purchase. Using the retrieved data, antipsychotic and antidepressant cost growth was disaggregated into price and volume factors to create a formula that includes factors about the size of the population, patients per population, volume of treatment per patient, and the mean cost per 1 day of treatment. The relative effect of the factors associated with the drug group-specific cost growth was also examined. Because the purpose of this work was to analyze the factors contributing to the cost growth, we disregarded factors that were negative. RESULTS: During the study period, the proportion of antipsychotic users of the total population decreased from 2.4% to 2.2% and the mean cost per 1 day of treatment with antipsychotics increased from euro1.37 to euro2.94. The proportion of antidepressant users increased from 4.8% to 6.3%, and mean cost per 1 day of treatment decreased from euro1.06 to euro0.79. In 1999, the consumption of second-generation antipsychotics accounted for 22% of total consumption, and in 2005 their proportion was 62%. Drug choices among anti-depressants did not change substantially. The total cost growth of antipsychotics and antidepressants was 211% and 19%, respectively. Approximately 80% of the antipsychotic cost growth resulted from the rise in the mean cost per 1 day of treatment. The increase in patients per population accounted for approximately 60% of the antidepressant cost growth. CONCLUSION: This retrospective analysis found that the factors associated with the growing antipsychotic and antidepressant expenditures in Finland from 1999 through 2005 varied between these 2 drug classes.