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Background Childhood adversities are frequent among adults who seek treatment for depression or anxiety. These disorders are commonly treated by psychotherapy. Yet it is not known if specific types or durations of psychotherapy are particularly suited for patients who have suffered various early adversities. Methods 221 depressed and anxious adult outpatients from community, student, occupational, and private healthcare services filled the Childhood Family Atmosphere Questionnaire. They were randomly assigned to short- (solution-focused or psychodynamic) or long-term (psychodynamic) psychotherapy. Outcome was assessed via patient questionnaires and clinician interviews of psychiatric symptoms and global functioning during a 5-year follow-up. Linear regression analyses were conducted. Results Less separations from caregivers expectedly predicted better outcomes in all therapies; unexpectedly, so did greater abuse. Family unhappiness and parental problems predicted faster or greater improvement when patients were assigned to a short- or long-term psychodynamic therapy model. Limitations As patients with psychotic, substance abuse, and severe personality disorders were screened out, findings might not generalize to these patient groups. Conclusions Patients with certain childhood adversities appear to respond with faster or greater improvement when the psychotherapy model is explicitly focused on working through the potential connections between past and current problems. If confirmed by in-depth studies, the findings may help match psychotherapeutic models with given patient complaints, as well as fine-tune different psychosocial interventions to individual needs for optimizing treatment outcomes.

Childhood adversities frequently precede adulthood depression and anxiety. Yet, how they impact needed treatment duration, type or focus in these common disorders, is unclear. For developing more individualized and precise interventions, we investigated whether specific early adversities associate with patients' distinct psychiatric problems, psychological vulnerabilities, and suitability for psychotherapy. A total of 221 depressed and anxious adult outpatients (excluding psychotic, severe personality, bipolar, and substance abuse disorders) referred from community, student, occupational, and private healthcare services filled the Childhood Family Atmosphere Questionnaire (CFAQ). They also filled self-reports on interpersonal behavior and problems, perceived competence, dispositional optimism, sense of coherence, defenses, and psychiatric history. Clinicians assessed the patients' symptomatology, personality, object relations, cognitive performance, and psychotherapy suitability. Regression analyses were conducted. Childhood adversities predicted both worse current psychological functioning (e.g., interpersonal problems), and better clinician-rated capacities for benefiting from psychotherapy (e.g. self-reflection, capacity for interaction). Parental problems had the most numerous negative associations to psychological functioning. Best capacities for psychotherapy were predicted by recollected family unhappiness. Associations with psychiatric criteria were, however, largely non-significant. In conclusion, for psychosocial treatment planning, patients' early adversities may indicate both vulnerability and resources. As childhood adversities are frequent among treatment-seekers, further studies examining how early adversities predict psychotherapy outcome are needed.

Objectives How level of personality organization (LPO) predicts psychiatric symptoms and work ability in short- versus long-term psychotherapies is poorly known. We investigated the importance of the LPO on the benefits of short-term versus long-term psychotherapies. Design A cohort study based on 326 outpatients with mood or anxiety disorder was allocated to long-term (LPP) and short-term (SPP) psychodynamic psychotherapy, and solution-focused therapy (SFT). Methods The LPO was assessed by interview at baseline and categorized into neuroses and higher level borderline. Outcome was assessed at baseline and 4–9 times during a 5-year follow-up, using self-report and interview-based measures of symptoms and work ability. Results For patients receiving SPP, improvement in work ability, symptom reduction, and the remission rate were more considerable in patients with neuroses than in higher level borderline patients, whereas LPP or SFT showed no notable differences in effectiveness in the two LPO groups. In patients with neuroses, improvement was more considerable in the short-term therapy groups during the first year of follow-up, and in higher level borderline patients LPP was more effective after 3 years of follow-up. The remission rate, defined as both symptom reduction and lack of auxiliary treatment, was higher in LPP than in SPP for both the LPO groups considered. Conclusions In neuroses, short-term psychotherapy was associated with a more rapid reduction of symptoms and increase in work ability, whereas LPP was more effective for longer follow-ups in both LPO groups. Further large-scale studies are needed. Practitioner points Level of personality organization is relevant for selection between short- and long-term psychotherapies. Short-term therapy gives faster benefits for neurotic patients but not for patients with higher level borderline personality organization. Sustained remission from symptoms is more probable after long-term than short-term therapy.

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.

BackgroundEmpirical 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.MethodIn 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.ResultsAt 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.ConclusionsAfter 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.

Aims The role of the serotonin transporter (SERT) in the pathophysiology of depression is unclear and only a few follow-up studies exist. Our aim was to measure changes in SERT availability during psychodynamic psychotherapy in patients with major depression over a follow-up time of 12 or 18 months. Methods The patients were studied with iodine-123 labelled 2β-carbomethoxy-3β-(4-iodophenyl) serial single-photon emission tomography imaging and clinical rating scales of symptoms. Results Changes in SERT availability had no correlation with the change of symptoms, but the change of SERT availability during psychotherapy in the midbrain was predicted by the baseline severity of the clinical symptoms measured by the Symptom Checklist Depression Scale and the Symptom Checklist Global Severity Index. With cut-off values applied, it was found that SERT availabilities increased in patients with high baseline symptoms, and decreased in patients with low baseline symptoms. Conclusions Together with our earlier finding of decreased SERT in patients with depression, these results indicate a state-dependent and possibly a compensatory role of decreased SERT availability in depression.

Background Only few randomized trials comparing sustained effects of short- and long-term psychotherapies in personality functioning are available. In this study we compared the effects of two short-term therapies and long-term psychodynamic psychotherapy on patients’ personality functioning during a 5-year follow-up. Methods Altogether 326 patients of the Helsinki Psychotherapy Study, with anxiety or mood disorder, were randomly assigned to either short-term psychotherapy of about six months (solution-focused therapy (SFT, n =97) or short-term psychodynamic psychotherapy (SPP, n =101)), or to long-term psychodynamic psychotherapy (LPP, n =128), lasting on average three years. Outcomes in personality functioning (i.e., self-concept, defense style, interpersonal problems, and level of personality organization) were assessed five to seven times using, respectively, questionnaires (SASB, DSQ, IIP) and interview (LPO) during the 5-year follow-up from randomization. Results Personality functioning improved in all therapy groups. Both short-term therapies fared better than LPP during the first year of follow-up, by faster improvement in self-concept and decrease in immature defense style. SFT also showed more early reduction of interpersonal problems. However, LPP thereafter showed larger and more sustained benefits than SFT and SPP, through greater changes in self-concept. Additionally, LPP outperformed SFT at the end of the follow-up in IIP and LPO, after adjustment for auxiliary treatment. No differences were noted between the short-term therapies at any measurement point. Limitations Auxiliary treatment was used relatively widely which limits generalization to exclusive use of short- or long-term therapy. Conclusions LPP seems to be somewhat more effective than short-term therapies in facilitating longterm changes in personality functioning.

Background: Various psychotherapies are used extensively in treating different mental disorders, but still relatively little is known about the long-term health and cost effects of different therapies. The aim of this study is to compare the cost-effectiveness of short-term psychodynamic psychotherapy (SPP) and solution-focused therapy (SFT) in the treatment of depressive and anxiety disorders during a three-year follow-up. Methods: A total of 198 outpatients suffering from mood or anxiety disorder were randomized to SPP or SFT. Symptoms were assessed using the Beck Depression Inventory, the Hamilton Depression Rating Scale, the Symptom Check List Anxiety Scale, the Hamilton Anxiety Rating Scale, and the Symptom Check List Global Severity Index. Both direct and indirect costs due to mental health problems were measured. Results: The symptoms of depression and anxiety were reduced statistically significantly according to all 5 psychiatric outcome measures during the first 7 months, after which only minor changes were observed. The differences between the two groups were small and not statistically significant. The direct costs were about equal in both groups but the indirect costs were somewhat higher in the SPP group, although not statistically significantly. The costs of auxiliary treatments were much higher than the cost of SPP or SFT. Conclusions: With regard to cost-effectiveness, there is little difference between SPP and SFT.

The quality of object relations affects interpersonal behaviour, but it is not known whether it modifies effectiveness on personality functioning in psychotherapies of different mode and length. In this study we estimated the modifying effect of the quality of object relations on the effect of solution-focused therapy (SFT) and shortand long-term psychodynamic psychotherapy (SPP and LPP) on self-concept. A total of 326 patients were assessed at baseline with the Quality of Object Relations Scale (QORS) and 4 times during a 3-year follow-up with the Structural Analysis of Social Behavior self-concept questionnaire, comprising altogether 10 scores on different aspects of self-concept pathology. The effectiveness of SFT, but not SPP, was significantly poorer in several domains (5/10) of self-concept for patients with low QORS, i.e. those with less mature relational patterns, than for patients with high QORS, while the reversal occurred in some (3/10) self-concept domains in LPP. The results suggest that the quality of object relations has significance for treatment selection in therapies with different mode and length.

The role of nonspecific factors in the outcome of psychotherapy is poorly understood. To study the effects of pretreatment expectancy of scheduled psychotherapy, we examined the effects of an agreed waiting time on the outcome of psychodynamic psychotherapy. Thirty-three treatment-naive outpatients with major depressive disorder were randomly selected to start psychotherapy either directly (DG; n = 17) or after waiting for 6 months (WG; n = 16). In WG, 18% to 60% of the total decline in symptoms took place during the waiting time. After 1 year of active psychotherapy, the anxiety score declined significantly only in WG, and the total length of treatment needed was shorter in WG. No other outcome differences between WG and DG were found. We conclude that scheduled waiting associates with a significant decline in depressive symptoms. Scheduled waiting should be regarded as a preparatory treatment and not as an inert nontreatment control.

This study compares the effectiveness of solution-focused therapy (SFT) and short- and long-term psychodynamic psychotherapy (SPP and LPP) on self-concept during a 3-year follow-up. Altogether, 326 patients with mood or anxiety disorder were randomized to SFT, SPP, and LPP in the Helsinki Psychotherapy Study. Outcome was assessed using the Structural Analysis of Social Behavior questionnaire at baseline and 7, 12, 24, and 36 months after. Overall, during the first year of follow-up, self-concept improved more in both SFT and SPP than in LPP, indicated by the primary outcome indicators self-directed affiliation (AF) and self-directed autonomy, as well as by most of the eight secondary cluster scores. After the 3-year follow-up, LPP was more effective than SFT in AF and in the cluster scores self-affirm, self-blame, and self-neglect, whereas no difference was noted between LPP and SPP. Long duration and psychodynamic orientation of therapy may be beneficial for self-concept improvement.

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.The present study addresses this question in a clinical trial with an exceptionally long follow-up.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.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.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.

Background The need for treatment is, despite of its obvious usefulness, a scarcely used measure of effectiveness in psychotherapy trials. This study considers changes in the need for auxiliary psychiatric treatment after starting short- and long-term psychotherapy and psychoanalysis. Methods Altogether 326 psychiatric outpatients with mood or anxiety disorder were randomly assigned to solution-focused therapy (SFT), short-term psychodynamic psychotherapy (SPP), or long-term psychodynamic psychotherapy (LPP) while 41 self-selected patients were allocated to psychoanalysis (PA). The patients were followed for 5 years from start of treatment. Outcome measures were use of auxiliary psychotherapy, psychotropic medication, and hospitalization for mental reasons. Results About 60% of the patients used auxiliary treatment during the follow-up. It was most common in the short-term therapy groups and its incidence was highest during the first year after the start of therapy. The average numbers of all therapy sessions among patients starting the therapy were 60, 70, 240, and 670 in SFT, SPP, LPP, and PA, respectively, whereas the corresponding average numbers of study therapy sessions alone were 10, 19, 232, and 646. Over 50% of the patients receiving short-term therapy received on average 4–6 times more therapy sessions than initially assigned. Limitations Post-randomization withdrawal was uneven. Conclusions Auxiliary treatment is usual among patients receiving short- and long-term therapies, and apparently becomes common shortly after the start of treatment. Auxiliary treatment can be used as an outcome measure indicating the need for treatment, should be monitored clinically and considered when interpreting the results of effectiveness studies.

Quantification of the impact of exposure to modifiable risk factors on a particular outcome at the population level is a fundamental public health issue. In cohort studies, the population attributable fraction (PAF) is used to assess the proportion of the outcome that is attributable to exposure to certain risk factors in a given population during a certain time interval. This is done by combining information about the prevalence of the risk factor in the population with estimates of the strength of the association between the risk factor and the outcome. In case of mortality, the PAF demonstrates what proportion of mortality can be delayed during the given follow-up time. However, literature on carrying out model-based estimation of PAF and its variance in cohort studies while properly taking follow-up time into account is still scarce. In this article, the authors present formulas for estimation of PAF, its variance, and its confidence interval using the piecewise constant hazards model and apply a SAS macro created for the estimation of PAF (SAS Institute Inc., Cary, North Carolina) to estimate the mortality attributable to some common risk factors.

Lifestyle factors predict type 2 diabetes occurrence, but their effect in high- and low-risk populations is poorly known. This study determines the prediction of low-risk lifestyle on type 2 diabetes in those with and without metabolic syndrome in a pooled sample of two representative Finnish cohorts, collected in 1978-1980 and 2000-2001. Altogether 8,627 individuals, aged 40-79 years, and free of diabetes and cardiovascular disease at baseline were included in this study. A low-risk lifestyle was defined based on body mass index, exercise, alcohol consumption, smoking, and serum vitamin D concentration. The metabolic syndrome was defined according to the International Diabetes Federation including obesity, blood pressure, serum HDL cholesterol, serum triglycerides, and fasting glucose. During a 10-year follow-up, altogether 226 type 2 diabetes cases occurred. Overweight was the strongest predictor of type 2 diabetes (population attributable fraction (PAF) = 77%, 95% confidence interval (CI): 53, 88%). Together with lack of exercise, unsatisfactory alcohol consumption, smoking, and low vitamin D concentration it explained 82% of the cases. Altogether 62% (CI: 47, 73%) of the cases were attributable to the metabolic syndrome and 92% (CI: 67, 98%) to the most unfavourable combination of its components. The metabolic syndrome did not modify the prediction of lifestyle factors but persons with normal blood pressure benefited more from positive changes in exercise, alcohol consumption, and smoking than those with elevated blood pressure (P for interaction = 0.01). In conclusion, modification of lifestyle factors apparently reduces type 2 diabetes risk, especially in persons with normal blood pressure.

IntroductionThe evidence of potentially greater long-term benefits of psychoanalysis (PA) in comparison to long-term psychodynamic psychotherapy (LPP) is scarce.AimsThis study aimed to compare the effectiveness of PA and LPP on different aspects of functioning and wellbeing during a 10-year follow-up from the beginning of the treatments.MethodsAltogether 169 patients were included in the study: 41 patients self-selected for PA and 128 patients assigned to LPP in the Helsinki Psychotherapy Study. The eligible patients were 20–45 years of age and had a long-standing anxiety or mood disorder causing work dysfunction. Potential confounding factors were assessed at baseline and acknowledged in analyzing outcomes in personality (LPO, IIP-64, DSQ, SASB) and social functioning (SAS-SR, SOC, Perceived competence, LSS), psychiatric diagnoses (DSM-IV), symptoms (SCL-90, HDRS, HARS), work ability (SAS-work, WAI, PPF, GAF, work status), and remission, including the use of additional psychiatric treatment, measured 5 to 14 times during the 10-year follow-up.ResultsFrom the 5-year to the 7-year follow-up personality and social functioning improved significantly more in the PA than in the LPP group. In the domain of psychiatric symptoms and work ability practically no differences were found beyond the 5-year follow-up and at the final 10-year measurement, when psychiatric and work status was relatively good in both treatment groups.ConclusionsPA may give additional benefits especially when personality-related long-term aims are essential and less intensive treatments are not considered to be sufficient.Disclosure of interestThe authors have not supplied their declaration of competing interest.

The role of the serotonin transporter (SERT) in the pathophysiology of depression is unclear and only a few follow-up studies exist. Our aim was to measure changes in SERT availability during psychodynamic psychotherapy in patients with major depression over a follow-up time of 12 or 18 months.The patients were studied with iodine-123 labelled 2β-carbomethoxy-3β-(4-iodophenyl) serial single-photon emission tomography imaging and clinical rating scales of symptoms.Changes in SERT availability had no correlation with the change of symptoms, but the change of SERT availability during psychotherapy in the midbrain was predicted by the baseline severity of the clinical symptoms measured by the Symptom Checklist Depression Scale and the Symptom Checklist Global Severity Index. With cut-off values applied, it was found that SERT availabilities increased in patients with high baseline symptoms, and decreased in patients with low baseline symptoms.Together with our earlier finding of decreased SERT in patients with depression, these results indicate a state-dependent and possibly a compensatory role of decreased SERT availability in depression.

Background To assess the nonresponse rates in a questionnaire survey with respect to administrative register data, and to correct the bias statistically. Methods The Finnish Regional Health and Well-being Study (ATH) in 2010 was based on a national sample and several regional samples. Missing data analysis was based on socio-demographic register data covering the whole sample. Inverse probability weighting (IPW) and doubly robust (DR) methods were estimated using the logistic regression model, which was selected using the Bayesian information criteria. The crude, weighted and true self-reported turnout in the 2008 municipal election and prevalences of entitlements to specially reimbursed medication, and the crude and weighted body mass index (BMI) means were compared. Results The IPW method appeared to remove a relatively large proportion of the bias compared to the crude prevalence estimates of the turnout and the entitlements to specially reimbursed medication. Several demographic factors were shown to be associated with missing data, but few interactions were found. Conclusions Our results suggest that the IPW method can improve the accuracy of results of a population survey, and the model selection provides insight into the structure of missing data. However, health-related missing data mechanisms are beyond the scope of statistical methods, which mainly rely on socio-demographic information to correct the results.

Knowledge is incomplete on whether long-term psychotherapy is more effective than short-term therapy in treating mood and anxiety disorder, when measured by improvements in psychosocial functioning and life quality. In the Helsinki Psychotherapy Study, 326 outpatients with mood or anxiety disorder were randomized to solution-focused therapy (SFT), short-term psychodynamic psychotherapy (SPP), or long-term psychodynamic psychotherapy (LPP), and followed up for 5 years from the start of treatment. The outcome measures comprised 4 questionnaires on psychosocial functioning, assessing global social functioning (Social Adjustment Scale (SAS-SR), sense of coherence (Sense of Coherence Scale (SOC)), perceived competence (Self-Performance Survey), dispositional optimism (Life Orientation Test (LOT)), and 1 questionnaire assessing quality of life (Life Situation Survey (LSS)). Short-term therapies improved psychosocial functioning and quality of life more than LPP during the first year. The only exceptions were LOT and perceived competence, which did not differ between SPP and LPP. Later in the follow-up, SOC and perceived competence showed significantly more improvement in LPP than in the short-term therapy groups. No direct differences between SFT and SPP were noted. Short-term therapy has consistently more short-term effects on psychosocial functioning and quality of life than LPP, whereas LPP has some additional long-term benefits on psychosocial functioning.

The regional pattern of insulin-dependent diabetes mellitus (IDDM) incidence among children in Finland was analysed applying several methods attempting to describe the geographical variation in occurrence of IDDM. From 1987 to 1991 the number of newly diagnosed cases aged 14 years or less at diagnosis was 1728. The incidence, the incidence rate ratio and the Bayes relative risk (RR) for IDDM were calculated by municipality, by functional area (an urban centre with a subordinated surrounding area) and by area with a population of equal size at risk employing the Geographical Information Systems. The association of IDDM incidence with the degree of urbanization was assessed using the population density as a criterion for the degree of urbanization. The overall mean of the IDDM incidence was 35 per 100000 persons per year. Between municipalities the incidence varied from 4 to 245 per 100000 persons per year, whereas a clear regional pattern was seen among the functional areas and the incidence varied from 26...

To investigate the determinants of the therapeutic working relationship and better understand its intrapersonal and interpersonal nature, this study investigated therapist characteristics as predictors of the formation and development of patient-rated and therapist-rated working alliances within a clinical trial of short-term versus long-term therapies. Short-term (solution-focused and short-term psychodynamic) and long-term (long-term psychodynamic therapy and psychoanalysis) therapies were provided by 70 volunteering, experienced therapists to 333 patients suffering from depressive and/or anxiety disorders. Therapists' professional and personal characteristics, measured prior to the start of the treatments, were assessed with the comprehensive self-report instrument, Development of Psychotherapists Common Core Questionnaire. The Working Alliance Inventory was rated by both therapists and patients at the third session and at the 7 months' follow-up point from the initiation of therapy. Therapists' self-rated basic interpersonal skills were found to predict the formation of better patient-rated alliances in both short-term and long-term therapies. Engaging, encouraging relational style fostered improvement of patients' working alliances especially in the course of short-term therapies. However, it led to patient alliance deterioration in long-term therapies, where constructive coping techniques proved more beneficial. Therapists' professional self-confidence and work enjoyment, along with their self-experiences in personal life, consistently predicted their alliances, but were less salient for patient ratings of alliance. The divergence of therapist and patient viewpoints has implications for therapist training and supervision, as characteristics found detrimental or helpful for the working relationship rated from the perspective of one party may not be predictive of the other therapy participant's experience. Copyright © 2013 John Wiley & Sons, Ltd. Key Practitioner Message In both short-term and long-term therapies, patients form more positively evaluated working alliances with those therapists who experience their overall basic relational skills as better. However, as patients' experience of alliance also develops during the course of therapy, it seems that briefer treatments may benefit more from a therapist's engaging and affirming relational style than long-term therapy. Practitioners' professional lack of confidence and enjoyment in therapy work predict poorer working alliances as rated by themselves, but therapists generally seem to be able to contain these difficult experiences, so that they do not predict worse patient-rated alliances. Therapists' self-experiences in their close personal relationships, such as how open, forceful or private they experience themselves, predict how they will experience the working relationships with their patients. Practitioners should be aware that how they evaluate their working relationships with specific patients may be notably influenced by their overall experiences of their professional and private selves and also that many of these self-experienced qualities have less strong or direct bearing on their patients' experiences.

Background Quality of object relations and self-concept reflect clinically relevant aspects of personality functioning, but their prediction as suitability factors for psychotherapies of different lengths has not been compared. This study compared their prediction on psychiatric symptoms and work ability in short- and long-term psychotherapy. Methods Altogether 326 patients, 20–46 years of age, with mood and/or anxiety disorder, were randomized to short-term (solution-focused or short-term psychodynamic) psychotherapy and long-term psychodynamic psychotherapy. The Quality of Object Relations Scale (QORS) and the Structural Analysis of Social Behavior (SASB) self-concept questionnaire were measured at baseline, and their prediction on outcome during the 3-year follow-up was assessed by the Symptom Check List Global Severity Index and the Anxiety Scale, the Beck Depression Inventory and by the Work Ability Index, Social Adjustment Scale work subscale and the Perceived Psychological Functioning scale. Results Negative self-concept strongly and self-controlling characteristics modestly predicted better 3-year outcomes in long-term therapy, after faster early gains in short-term therapy. Patients with a more positive or self-emancipating self-concept, or more mature object relations, experienced more extensive benefits after long-term psychotherapy. Limitations The importance of length vs. long-term therapy technique on the differences found is not known. Conclusions Patients with mild to moderate personality pathology, indicated by poor self-concept, seem to benefit more from long-term than short-term psychotherapy, in reducing risk of depression. Long-term therapy may also be indicated for patients with relatively good psychological functioning. More research is needed on the relative importance of these characteristics in comparison with other patient-related factors.

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

We developed a test statistic based on an approach of Whittemore et al. (1987) to detect space-time clustering for non-infectious diseases. We extended the spatial test of Whittemore et al. by deriving conditional probabilities for Poisson distributed random variables. To combine spatial and time distances we defined a distance matrix D, where dij is the distance between the ith and jth cell in a three-dimensional space-time grid. Spatial and temporal components are controlled by a weight. By altering the weight, both marginal tests and the intermediate test can be reached. Allowing a continuum from a pure spatial to a pure temporal test, the best result will be gained by trying different weights, because the occurrence of a disease might show some temporal and some spatial tendency to cluster. We examined the behaviour of the test statistic by simulating different distributions for cases and the population. The test was applied to the incidence data of insulin-dependent diabetes mellitus in Finland. This test could be used in the analysis of data which are localized according to map co-ordinates, by addresses or postcodes. This information is important when using the Geographical Information System (GIS) technology to compute the pairwise distances needed for the proposed test.

Seasonal patterns in the incidence of insulin-dependent diabetes based on 2,062 cases diagnosed at age 14 years or under in Finland are described for the years 1987-1992. Seasonal patterns were estimated presenting the data as short Fourier series up to three harmonics together with a possible linear trend. This method allows an arbitrary shape for the seasonal effect. Likelihood ratio tests and Akaike's information criterion were used to determine the number of harmonics necessary to model the seasonal pattern and to test differences among age- and sex-specific subgroups in the population. Seasonal patterns in incidence were compared between sexes and between the three 5-year age groups with each controlling for the other's effect. A significant seasonal pattern in the incidence of insulin-dependent diabetes was found for the sexes combined and for two age groups (0-9 and 10-14 years). A statistically significant seasonal pattern could be confirmed for males, but not for females. During a calendar year, one cycle with a decreased incidence of insulin-dependent diabetes in June was found among younger boys. Among older boys, there were two distinct cycles with a decreased incidence, the first in June and the second during November-December. The most visible seasonal pattern was a lower number of cases diagnosed in June, while during the rest of the year the incidence remained relatively stable and high. The average annual incidence was 35.6 per 100,000 persons without any upward peaks.

To investigate the determinants of the therapeutic working relationship and better understand its intrapersonal and interpersonal nature, this study investigated therapist characteristics as predictors of the formation and development of patient-rated and therapist-rated working alliances within a clinical trial of short-term versus long-term therapies. Short-term (solution-focused and short-term psychodynamic) and long-term (long-term psychodynamic therapy and psychoanalysis) therapies were provided by 70 volunteering, experienced therapists to 333 patients suffering from depressive and/or anxiety disorders. Therapists' professional and personal characteristics, measured prior to the start of the treatments, were assessed with the comprehensive self-report instrument, Development of Psychotherapists Common Core Questionnaire. The Working Alliance Inventory was rated by both therapists and patients at the third session and at the 7 months' follow-up point from the initiation of therapy. Therapists' self-rated basic interpersonal skills were found to predict the formation of better patient-rated alliances in both short-term and long-term therapies. Engaging, encouraging relational style fostered improvement of patients' working alliances especially in the course of short-term therapies. However, it led to patient alliance deterioration in long-term therapies, where constructive coping techniques proved more beneficial. Therapists' professional self-confidence and work enjoyment, along with their self-experiences in personal life, consistently predicted their alliances, but were less salient for patient ratings of alliance. The divergence of therapist and patient viewpoints has implications for therapist training and supervision, as characteristics found detrimental or helpful for the working relationship rated from the perspective of one party may not be predictive of the other therapy participant's experience.

Background/Aims: Clinical assessment of object relations is essential when evaluating treatability by different types of psychotherapy. The Quality of Object Relations Scale (QORS) is an established interview measure used for assessing object relations, but the validity of the QORS in relation to its theoretical constituents has not been examined. Our aim was to study the concurrent validity of the QORS. Methods: Trained interviewers assessed 263 outpatients seeking psychotherapy due to mood or anxiety disorder, with the QORS and with selected proxy criterion measures representing constituents of object-relational maturity. Results: Discontinuity in relationships and the use of devaluation in relationships were the main determinants of low Quality of Object Relations (low-QOR). Patients with discontinuity in relationships had a four-fold and patients with devaluation in relationships a three-fold risk of belonging to the low-QOR group (p = 0.001) in comparison to those without these relational characteristics. Also poor self-confidence and major separations in childhood predicted the low- versus high-QOR category. Conclusion: The results indicate adequate concurrent validity of the QORS and support its credibility in assessing personality pathology, beyond axis II diagnosis, by trained clinicians.

Background Psychotherapy is apparently an insufficient treatment for some patients with mood or anxiety disorder. In this study the effectiveness of short-term and long-term psychotherapies was compared with that of psychoanalysis. Methods A total of 326 psychiatric outpatients with mood or anxiety disorder were randomly assigned to solution-focused therapy, short-term psychodynamic and long-term psychodynamic psychotherapies. Additionally, 41 patients suitable for psychoanalysis were included in the study. The patients were followed from the start of the treatment and assessed 9 times during a 5-year follow-up. The primary outcome measures on symptoms were the Beck Depression Inventory, the Hamilton Depression and Anxiety Rating Scales, and the Symptom Check List, anxiety scale. Primary work ability and functional capacity measures were the Work Ability Index, the Work-subscale of the Social Adjustment Scale, and the Perceived Psychological Functioning Scale. Results A reduction in psychiatric symptoms and improvement in work ability and functional capacity was noted in all treatment groups during the 5-year follow-up. The short-term therapies were more effective than psychoanalysis during the first year, whereas the long-term therapy was more effective after 3 years of follow-up. Psychoanalysis was most effective at the 5-year follow-up, which also marked the end of the psychoanalysis. Conclusions Psychotherapy gives faster benefits than psychoanalysis, but in the long run psychoanalysis seems to be more effective. Results from trials, among patients suitable for psychoanalysis and with longer follow-up, are needed before firm conclusions about the relative effectiveness of psychoanalysis and psychotherapy in the treatment of mood and anxiety disorders can be drawn.

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.To compare the cost-effectiveness of two short-term psychotherapies in the treatment of depressive and anxiety disorders during a one-year follow-up.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.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.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.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.

The population attributable fraction (PAF) is a useful measure for describing the expected change in an outcome if its risk factors are modified. Cohort studies allow researchers to assess the predictive value of the risk factor modification on the incidence of the outcome during a certain follow-up. Estimation of PAF for both mortality and morbidity in cohort studies with censored survival data has been developed in the recent years. So far, however, censoring due to death in the estimation of PAF for morbidity has been ignored, resulting in estimation of a quantity which is not relevant in practice as some people are likely to die during the follow-up. The risk factors related to the disease incidence may also be related to mortality, and modification of these risk factors is likely to delay the occurrence of both events. Thus, censoring due to death and the impact of risk factor modification must be considered when estimating PAF for disease incidence. We consider both and introduce two measures of disease burden: PAF for the incidence of disease during lifetime and PAF for the prevalence of disease in the population at a certain time. We demonstrate how consideration of censoring due to death changes the estimated PAF for disease incidence and its confidence interval. This underlines the importance of choosing a correct PAF measure depending on the outcome of interest and the risk factors of interest to obtain accurate and interpretable results.

Introduction Little is known about long-term effects of psychotherapy on depressive or anxiety disorders. Aims To compare the effectiveness of three psychotherapies of different length in a clinical trial with a 5-year follow-up. Methods 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. Results 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. Conclusions 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.

Introduction The majority of studies on the effectiveness of psychotherapy have reported results for relatively short follow-up times. Aims In this study the effectiveness of short- and long-term psychotherapy was compared during a very long follow-up. Methods 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. Results 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. Conclusions 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.

A cross-sectional population survey was carried out in 15 population groups (ethnicity includes Melanesian, Polynesian, Micronesian, Asian Indian and Chinese) in 9 developing countries: Fiji, Nauru, Kiribati, Cook Island, Niue, Western Samoa, New Caledonia, Mauritius and China (Beijing) in 1978–1987. The total sample included 4594 men and 4988 women aged 35–59 years. The aim of study is to report the prevalence of coronary heart disease (CHD) as indicated by ECG Minnesota coding, and risk factor levels and to describe the individual and ecological relationship between CHD prevalence and CHD risk factors among different ethnic groups in developing countries. Mauritians had the highest prevalence of CHD of these countries. Total serum cholesterol concentration and the prevalence of CHD were higher in Mauritius Chinese than in Beijing Chinese. Mean total cholesterol was lower than or equal to 5.2 mmol/l (200 mg/dl) in all population groups, except in Mauritians. Hypertensive subjects in most populations had a low cholesterol concentration. The prevalence of hypertension varied from 7 to 35% and mean body mass index (BMI) from 22.9 to 37.0 kg/m 2 . Smoking was more common in men (36–82%) than women (0.8–65%). Multiple logistic regression analysis using individuals as a unit of analysis showed that cholesterol and systolic blood pressure were significant independent predictors of CHD prevalence. When fasting or 2 hr post-load blood glucose was included in the model total cholesterol was no longer significant in men but remained significant in women. Ecological analysis using populations as units of analysis showed that the combination of several CHD risk factors could explain about 90% of the interpopulations variance of the CHD prevalence in women. The best models were those where 2 hr post-load glucose was included. Our study has demonstrated that the total cholesterol concentration of the population was consistent with the prevalence of CHD in the population. A considerable proportion of the variation in CHD prevalence across populations in developing countries can be explained by well-known risk factors. These data support the concept that retaining traditional balanced dietary habits and limiting salt intake together with avoiding smoking use are important activities for the prevention of cardiovascular disease (CVD) in developing countries.