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People with psychotic disorders have increased mortality compared to the general population. The mortality is mostly due to natural causes and it is disproportionately high compared to the somatic morbidity of people with psychotic disorders.
We aimed to find predictors of mortality in psychotic disorders and to evaluate the extent to which sociodemographic and health-related factors explain the excess mortality.
In a nationally representative sample of Finns aged 30–70 years (n = 5642), psychotic disorders were diagnosed in 2000–2001. Information on mortality and causes of death was obtained of those who died by the end of year 2013. Cox proportional hazards models were used to investigate the mortality risk.
Adjusting for age and sex, diagnosis of nonaffective psychotic disorder (NAP) (n = 106) was statistically significantly associated with all-cause mortality (HR 2.99, 95% CI 2.03–4.41) and natural-cause mortality (HR 2.81, 95% CI 1.85–4.28). After adjusting for sociodemographic factors, health status, inflammation and smoking, the HR dropped to 2.11 (95% CI 1.10–4.05) for all-cause and to 1.98 (95% CI 0.94–4.16) for natural-cause mortality. Within the NAP group, antipsychotic use at baseline was associated with reduced HR for natural-cause mortality (HR 0.25, 95% CI 0.07–0.96), and smoking with increased HR (HR 3.54, 95% CI 1.07–11.69).
The elevated mortality risk associated with NAP is only partly explained by socioeconomic factors, lifestyle, cardiometabolic comorbidities and inflammation. Smoking cessation should be prioritized in treatment of psychotic disorders. More research is needed on the quality of treatment of somatic conditions in people with psychotic disorders.
Disclosure of interest
Jaakko Keinänen owns shares in pharmaceutical company Orion.
Population attributable fraction (PAF) represents the proportion of treatment failure, which could be avoided, if the individuals at high risk were similar to the individuals at low risk. The PAF, however, has not been available for repeated measures designs.
A relatively prevalent and strong risk factor for many adulthood disorders, such as depression and anxiety, are adversities and traumas experienced in childhood. Little is, however, known of their implications for common treatments such as psychotherapy.
To develop PAF for repeated measures, and to provide a useful tool in various research fields to provide decision-makers results, which are easier to interpret.
This study will examine the relative importance of different childhood traumas as predictors of psychotherapy outcome in a patient population with depressive and anxiety disorders.
PAF was calculated using generalized linear mixed models and Bayesian predictive distributions.
The data is based on 326 outpatients, randomized in one long-term and two short-term psychotherapies by the Helsinki Psychotherapy Study. Patients were assessed up to 10 times during a 5-year follow-up. A combination of psychiatric symptoms measured, is used as the outcome measure.
The repeated measures PAF will provide a useful aggregate measure over the follow-up time and over the patient population.
The repeated measures PAF will provide insight on the relative importance of the different domains of childhood traumas on therapy outcome. Associations of individual-level risk factors do not provide guidelines for policy decisions, which should acknowledge also prevalences of the risk factors in the patient population.
Disclosure of interest
The authors have not supplied their declaration of competing interest.
Empirical evidence on whether patients’ mental health and functioning will be more improved after long-term than short-term therapy is scarce. We addressed this question in a clinical trial with a long follow-up.
In the Helsinki Psychotherapy Study, 326 out-patients with mood or anxiety disorder were randomly assigned to long-term psychodynamic psychotherapy (LPP), short-term psychodynamic psychotherapy (SPP) or solution-focused therapy (SFT) and were followed for 10 years. The outcome measures were psychiatric symptoms, work ability, personality and social functioning, need for treatment, and remission.
At the end of the follow-up, altogether 74% of the patients were free from clinically elevated psychiatric symptoms. Compared with SPP, LPP showed greater reductions in symptoms, greater improvement in work ability and higher remission rates. A similar difference in symptoms and work ability was observed in comparison with SFT after adjustment for violations of treatment standards. No notable differences in effectiveness between SFT and SPP were observed. The prevalence of auxiliary treatment was relatively high, 47% in SFT, 58% in SPP and 33% in LPP, and, accordingly, the remission rates for general symptoms were 55, 45 and 62%, respectively.
After 10 years of follow-up, the benefits of LPP in comparison with the short-term therapies are rather small, though significant in symptoms and work ability, possibly due to more frequent use of auxiliary therapy in the short-term therapy groups. Further studies should focus on the choice of optimal length of therapy and the selection of factors predicting outcome of short- v. long-term therapy.
Little is known about long-term effects of psychotherapy on depressive or anxiety disorders.
To compare the effectiveness of three psychotherapies of different length in a clinical trial with a 5-year follow-up.
In the Helsinki Psychotherapy Study, 326 outpatients with mood or anxiety disorder were randomly assigned to longterm psychodynamic psychotherapy (LPP), short-term psychodynamic psychotherapy (SPP), and solution-focused therapy (SFT), and were followed up for 5 years from start of treatment. Depressive, anxiety and general psychiatric symptoms (BDI, SCL-90-Anx, and SCL-90-GSI), working ability (WAI), and recovery (based on changes in psychiatric symptoms and use of auxiliary treatment) were used as outcome measures.
For patients with depressive disorder LPP was more effective than SPP or SFT in reducing symptoms, improving work ability and leading to recovery during the 3 last years of follow-up. For patients with anxiety disorder effectiveness of LPP was less pronounced with no differences between short-term and long-term therapy in recovery from anxiety symptoms. No differences were found between the effectiveness of the short-term therapies.
Long-term psychotherapy is more effective than short-term therapy during a long follow-up especially in the treatment of depressive disorder. More research especially considering different anxiety disorders is still needed.
The majority of studies on the effectiveness of psychotherapy have reported results for relatively short follow-up times.
In this study the effectiveness of short- and long-term psychotherapy was compared during a very long follow-up.
A total of 326 psychiatric outpatients with mood or anxiety disorder were randomly assigned to solution-focused therapy (12 sessions), short-term psychodynamic (20 sessions) and long-term psychodynamic psychotherapy (240 sessions) in Helsinki Psychotherapy Study. The patients were followed from start of treatment and assessed 11 times during a 7-year follow-up. Symptom Check List (anxiety, depression, and general symptom scale), Work-subscale of the Social Adjustment Scale, and use of auxiliary treatment (psychotherapy, psychotropic medication, and psychiatric hospitalization) were used as outcome measures.
A reduction in psychiatric symptoms and improvement in work ability and functional capacity was noted in all treatment groups. The short-term therapies were more effective than long-term psychotherapy during the first year, whereas the long-term therapy was more effective after 3 years of follow-up. No significant differences were observed between long- and short-term therapies during the 4 last years of follow-up.A total of 80% of the patients in the short-term therapy groups and 60% in the long-term therapy group used auxiliary treatment.
Short-term psychotherapy gives faster benefits than long-term psychotherapy, but in the long run no notable differences in symptoms or working ability are seen. Considerably auxiliary treatments are taken after the end of the intervention implying further need of treatment. These findings should be repeated in other populations.
The effect of mental disorders may be particularly detrimental in early adulthood, and information on mental disorders and their correlates in this age group is important.
A questionnaire focusing on mental health was sent to a nationally representative two-stage cluster sample of 1863 Finns aged 19 to 34 years. Based on a mental health screen, all screen-positives and a random sample of screen-negatives were asked to participate in a mental health assessment, consisting of the Structured Clinical Interview for DSM-IV (SCID-I) interview and neuropsychological assessment. We also obtained case-notes from all lifetime mental health treatments. This paper presents prevalences, sociodemographic associations and treatment contacts for current and lifetime mental disorders.
Forty percent of these young Finnish adults had at least one lifetime DSM-IV Axis I disorder, and 15% had a current disorder. The most common lifetime disorders were depressive disorders (17.7%) followed by substance abuse or dependence (14.2%) and anxiety disorders (12.6%). Of persons with any lifetime Axis I disorder, 59.2% had more than one disorder. Lower education and unemployment were strongly associated with current and lifetime disorders, particularly involving substance use. Although 58.3% of persons with a current Axis I disorder had received treatment at some point, only 24.2% had current treatment contact. However, 77.1% of persons with a current Axis I disorder who felt in need of treatment for mental health problems had current treatment contact.
Mental disorders in young adulthood are common and often co-morbid, and they may be particularly harmful for education and employment in this age group.
Insufficient evidence exists for a viable choice between long- and short-term psychotherapies in the treatment of psychiatric disorders. The present trial compares the effectiveness of one long-term therapy and two short-term therapies in the treatment of mood and anxiety disorders.
In the Helsinki Psychotherapy Study, 326 out-patients with mood (84.7%) or anxiety disorder (43.6%) were randomly assigned to three treatment groups (long-term psychodynamic psychotherapy, short-term psychodynamic psychotherapy, and solution-focused therapy) and were followed up for 3 years from start of treatment. Primary outcome measures were depressive symptoms measured by self-report Beck Depression Inventory (BDI) and observer-rated Hamilton Depression Rating Scale (HAMD), and anxiety symptoms measured by self-report Symptom Check List Anxiety Scale (SCL-90-Anx) and observer-rated Hamilton Anxiety Rating Scale (HAMA).
A statistically significant reduction of symptoms was noted for BDI (51%), HAMD (36%), SCL-90-Anx (41%) and HAMA (38%) during the 3-year follow-up. Short-term psychodynamic psychotherapy was more effective than long-term psychodynamic psychotherapy during the first year, showing 15–27% lower scores for the four outcome measures. During the second year of follow-up no significant differences were found between the short-term and long-term therapies, and after 3 years of follow-up long-term psychodynamic psychotherapy was more effective with 14–37% lower scores for the outcome variables. No statistically significant differences were found in the effectiveness of the short-term therapies.
Short-term therapies produce benefits more quickly than long-term psychodynamic psychotherapy but in the long run long-term psychodynamic psychotherapy is superior to short-term therapies. However, more research is needed to determine which patients should be given long-term psychotherapy for the treatment of mood or anxiety disorders.
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