INTRODUCTION
Psychodynamic psychotherapy has been considered not to be an evidence-based treatment due to lack of studies confirming its utility and to its excessive duration; this in turn prevented it to be included as recommended treatment for quite a long time, although over the years it proved to be an effective therapy in the treatment of many disorders [1] and to have an effectiveness equal, if not superior to other manualized therapies [2] as well as longer lasting effects [2,3]. While there are many studies in the adult population that demonstrate the effectiveness of psychodynamic psychotherapy, the studies that include children and adolescents and the wide range of mental illnesses that afflict them are far less common [4-6].
Only recently, strong scientific evidence of the success of psychodynamic psychotherapy in the treatment of depression in childhood and adolescence has led to the inclusion of psychodynamic therapy in the English NICE Guidelines as a recommended treatment for moderate to severe depression [7]. However, the committee has recognized that there are fewer studies supporting the effectiveness of psychodynamic psychotherapy than other types of therapy, such as individual cognitive-behavioural therapy (CBT), and therefore psychodynamic therapy is still considered an alternative option and not the first choice. The committee also expressed a recommendation to expand studies on the effectiveness of psychodynamic psychotherapy to a wide range of mental disorders affecting children and adolescents.
A problem which has been reported for years is the duration of original psychodynamic psychotherapy, which made it too long and expensive for the public health system. At present, a few studies support the effectiveness of short-term psychodynamic psychotherapy in the treatment of psychological disorders in adulthood [8,9], and even fewer studies have examined the effectiveness of short-term psychodynamic psychotherapy in developmental age [10,11].
Considering that psychopathological disorders in childhood and adolescence are increasingly recognized [12] and that 50% of pathologies in adulthood begin in earlier stages of life, especially in adolescence [13], it is necessary to use effective treatments as early as possible, to try and reach significant results in the short term but also to gain long-term benefits.
Given this framework, we aimed to investigate the efficacy of short-term psychodynamic psychotherapy in a heterogeneous group of young patients, using validated observational scales that measure the severity of disease, the overall functioning of patients and the improvement of their disease after the treatment. We also wanted to check if the improvement was related to patient’s age, sex, or diagnostic category.
We hypothesized that taking part in a cycle of psychodynamic psychotherapy, even of short duration, could produce an improvement in the overall functioning of preadolescent and adolescent patients and an improvement in their symptoms. Moreover, we would expect patients diagnosed with internalizing disorders to better respond to psychotherapeutic treatment, independently of age or sex [3,14,15].
METHODS
Participants
We recruited 123 preadolescents and adolescents (61 females and 62 males; mean age=14.9 years, SD=1.79; SEM=0.16; age range: 11-19 years, extremes included) seen at the Child Neurology and Psychiatry Unit of the IRCCS Mondino Foundation in Pavia, Italy, between 2017 and 2018.
Patients younger than 11 years old or older than 19 years old, with insufficient comprehension of the Italian language or with an established diagnosis of intellectual disability were excluded. In accordance with guidelines and recent evidence, patients taking drug therapy were not excluded. In our sample, 3.33% assumed benzodiazepines, 3.33% antidepressants, 3.33% antipsychotic drugs, 0.8% mood stabilizers.
Procedure
We collected data within a larger project named “Study of prognosis and possible predictors of outcome in a population of adolescent patients with psychosis, attenuated psychosis and not psychotic psychiatric disorders,” authorized in 2017 by the Ethical Committee of Policlinico San Matteo in Pavia, Italy (P20170028892). We followed the code of good ethical practice and the ethical standards of The Declaration of Helsinki (1964) and its later amendments. All patients and their families gave their written informed consent to participate in the study and were free to retreat in any moment. We informed participant that data would have been used for research purposes only and we would have anonymized them to protect privacy.
We started with an evaluation phase which included meetings with patient and his/her family, to collect family and medical history through clinical interviews and diagnostic analysis. At baseline (T0) clinician or psychotherapist compiled two scales to assess the severity of the disease (CGI-S) and the patient’s global functioning (C-GAS). After the assessment, every participant underwent a cycle of manualized psychotherapy based on the model of “Brief Individuation Psychotherapy” by Tommaso Senise [16]. Treatment followed a protocol focusing on the separation-individuation process. The first two sessions were dedicated to the investigation of the patient’s relationships with siblings and adults, mainly focusing on conflicts relating to the process of definition of one’s own identity with a psychological separation especially from the parents. The following sessions were devoted to the exploration and elaboration of the more significant psychopathological nuclei. The major goal of the treatment was to allow the patient to develop an empathic identification with the therapist (mirror identification) in order to reach a progressively more adaptive understanding of his/her difficulties and ultimately to overcome them [17]. Treatment was administered by expert psychotherapists, with four-year specialization in psychotherapy and experience in the treatment of youth and adolescents. Patients with psychotic symptoms during therapy had no positive symptoms. After eight weekly sessions psychotherapy of one hour each (T1), the same clinician or psychotherapist who took charge the patient compiled a scale to indicate improvement (CGI-I) and recompiled the scale that indicates his/her global functioning (C-GAS).
Measures
To confirm the diagnosis, psychologists or child neuropsychiatrists conducted with both children/adolescents and their parents/caregivers the Kiddie Schedule for Affective Disorders and Schizophrenia (KSADS) [18], a diagnostic semi-structured interview based on DSM criteria for the assessment of psychopathological disorders in children and adolescents. We grouped the diagnoses from KSADS in five categories inspired by ASEBA system: no diagnosis, psychotic disorders, internalizing disorders (depressive disorders, anxiety disorders, OCD), externalizing disorders (ADHD, oppositional defiant disorder, conduct disorder), mixed disorders.
To assess the progress of patients’ conditions, clinician or psychotherapist filled in the:
Clinical Global Impression (CGI) [19,20]
One of the most widely used rapid assessment scales in psychiatry, both in the field of research and clinic. It measures the severity of the disease (CGI-Severity), the improvement or overall change of the patient (CGI-Improvement), and the therapeutic response. The evaluation of severity of the patient’s conditions must be expressed at each visit, including the first one, assigning scores from 1 (normal, not at all ill) to 7 (among the most extremely ill patients). The improvement assessment must be made during every visit after baseline choosing a score from 1 (very much improved) to 7 (very much worse). Each section of this scale is assessed separately and does not have an overall score.
Children’s Global Assessment Scale (C-GAS) [21,22]
This is a useful scale for the evaluation of the patient’s overall functioning. It provides a measure of the overall severity coded in 10 ranges from the lowest 1-10 (need for constant supervision as a consequence of self-destructive behaviour or dominated by important aggression, or a serious impairment of reality analysis, communication, cognitive, emotional or personal hygiene level) to the highest 91-100 (superior functioning in every area of daily life, both at home and at school and in relations with peers, involvement in a wide range of activities, presence of numerous interests, daily concerns constantly under control, good school performance, absence of symptoms). This scale is simple to compile and is characterized by excellent psychometric properties [21].
Evaluators shared assessment results with clinician or psychotherapist prior to treatment. At T0 clinician or psychotherapist compiled CGI-Severity and CGAS. After eight sessions of psychotherapy [17] (T1), the same clinician or psychotherapist who oversaw the patient filled in CGI-Improvement and a new CGAS.
Data analysis
Analyses were conducted using IBM SPSS Version 21 for Windows (IBM Corp., Armonk, NY, USA). After assessing descriptive statistics for each variable, a preliminary one-sample Kolmogorov-Smirnov test for normality was computed. Paired sample t-test was used to assess differences for normally distributed variables comparing the same subjects before and after treatment, while Spearman correlation coefficient was used to assess correlations involving ordinal variables.
RESULTS
Descriptive statistics
The sample included 123 preadolescents and adolescents (49.59% females) from 11 to 19 years old, with a mean age of 14.9 (SD=1.79; SEM=0.16). No patient dropped out of research before the end. Table 1 shows means, SDs and SEMs for all variables.
The most frequent diagnosis within the sample was internalizing disorders, and most participants received an evaluation of disease severity from 3 to 5 at baseline (Table 2).
First objective
Table 3 shows that most of participants received a score of illness improvement from 3 to 1 after treatment, showing improvement in 79 out of 123 patients (64.2%).
There was a statistically significant improvement in the overall functioning of patients after psychotherapeutic treatment measured with C-GAS [t(122)=-6.79, p<0.001] (Figure 1).
Second objective
We found no significant correlations between diagnosis and age or sex. In the same way, improvement score (CGI-I) did not correlate with age or sex. We found however a significant correlation between diagnostic category and improvement (r=0.185, p=0.041), as patients diagnosed with externalizing problems seemed to improve significantly less than the others (average CGI-I score 3.70±0.73 for externalizing disorders, versus an average of the other groups being 2.79±1.06 without statistically significant differences between the other diagnostic groups).
DISCUSSION
In our sample, internalizing disorders were, as also found in the Italian and international literature, those most diagnosed, followed by externalizing problems, mixed ones, and psychotic disorders [23-27].
Unlike other studies that found differences in prevalence due to age and gender [12], our sample does not present any significant correlation between KSADS diagnosis and age, and neither between KSADS diagnosis and gender. This can be explained by the choice not to divide the sample between preadolescents and adolescents, but also by the decision to combine the diagnoses into fewer broader diagnostic categories according to KSADS and ASEBA system (internalizing, externalizing, mixed, and psychotic disorders).
Moreover, our first hypothesis was confirmed. A group of youth of various ages was considered so as not to deprive anyone of treatment. To address the inhomogeneity of the sample, statistical analyses were conducted for paired samples, and, according to our findings, most of participants had an improvement in their mental health condition from minimal to considerable after treatment. In line with this, the scale used to evaluate the global functioning of patients (C-GAS) showed a statistically significant improvement in the overall functioning, as previously proven in adult patients affected by common mental disorders [8,9].
Regarding the second hypothesis, despite some studies that stated that younger children [28], and females [29] appear to benefit more from psychodynamic psychotherapy, according to our data the improvement in mental health condition and in the global functioning after short-term psychodynamic psychotherapy was independent of both age and sex of the patient. Our data seem to confirm, in line with previous studies [3,14,15], that patients who seem to benefit most from short-term psychodynamic psychotherapy are those diagnosed with internalizing disorders, mixed problems and psychotic disorders. Patients with internalizing disorders can more easily build a therapeutic alliance and are more willing to reflect on their emotional states. In fact, as expected from existing literature [14], patients suffering from externalizing disorders are those who showed the less enhancement, because they have more difficulties in building a therapeutic alliance and/or take longer to do so because of their severe behavioural impairment. Moreover, because few patients were taking drug treatment, we can assume that the changes seen after treatment are not mainly related to pharmacological interventions.
This study has limitations, in fact future research could include participants from other regions and a control group in order to confirm our findings and to test their strength. In this study, we could not have a control group because the setting was that of a research-action study (i.e., we had to balance research with clinical practice). Furthermore, we hope that future studies could also compare the evidence collected by clinicians with the perception of change from the point of view of patients and their families, e.g., using self-report questionnaires. The fact that our sample was quite heterogeneous represents a limitation on one hand, but also a positive aspect as it resembles real-life clinical practice. Moreover, future research should include a longer follow up to assess stability of obtained changes.
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