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Effects of treatment versus psychotherapy on mental health of transgender people

Effects of treatment versus psychotherapy on mental health of transgender people


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Has any reliable study been done to compare mental health (e.g. depression or suicide rate) of transgender people before and after procedures (hormone or surgery) intended to change their bodies to have characteristics that match their gender identity compared with psychological therapy intended to try and make them more comfortable with their biological sex?

I have heard some people claim that John's Hopkins used to perform sex-change procedures but stopped after failing to find it benefiting the mental health of those who they were performed on. But I have also heard people claim that these treatments really do cause a practical improvement in the mental health of transgender people. I'm not sure who, if either side or both, to trust.

Please avoid political discussion or debate on whether a transgender person can actually switch sexes or if it's a delusional disorder, even if your opinion on that might inform what you think the proper way of treating transgender people is. I'm just curious about reliable data on the psychological effects of the alternatives.


Johns Hopkins did stop doing gender reassignment surgery and one of their psychiatrists apparently says that

The suicide rate among transgendered people who had the surgery is 20 times higher

He also apparently says that

transgenderism is a “mental disorder” that merits treatment, that sex change is “biologically impossible,” and that people who promote sexual reassignment surgery are collaborating with and promoting a mental disorder.

According to this website, the Johns Hopkins psychiatrist involved has a history of speaking out against transgendered people.

On the flip side, the DSM-5 (5th Edition of the Diagnostics and Statistics Manual) in 2013 added Gender Dysphoria as the new term for Gender Identity Disorder in order to try and prevent stigma; and current case reports offer no evidence that psychotherapy offers total and long-standing change of gender dysphoria.


TL;DR: There's many studies which point to better mental health outcomes as a result of treatment, such as hormones and surgery, of transgender individuals.

It's also important to consider that there's a range of gender identities and a range of treatments which are tailored to the individual. There's a lot of factors to consider.


WPATH Standards of Care

The best place to start would be the WPATH Standards of Care, available from www.wpath.org. I'll quote from this:

Although Harry Benjamin already acknowledged a spectrum of gender nonconformity (Benjamin, 1966), the initial clinical approach largely focused on identifying who was an appropriate candidate for sex reassignment to facilitate a physical change from male to female or female to male as completely as possible (e.g., Green & Fleming, 1990; Hastings, 1974). This approach was extensively evaluated and proved to be highly effective. Satisfaction rates across studies ranged from 87% of MtF patients to 97% of FtM patients (Green & Fleming, 1990), and regrets were extremely rare (1-1.5% of MtF patients and <1% of FtM patients; Pfäfflin, 1993). Indeed, hormone therapy and surgery have been found to be medically necessary to alleviate gender dysphoria in many people (American Medical Association, 2008; Anton, 2009; The World Professional Association for Transgender Health, 2008).

It's also worth noting that there's a range of treatments which are individualized:

Treatment is individualized: What helps one person alleviate gender dysphoria might be very different from what helps another person. This process may or may not involve a change in gender expression or body modifications. Medical treatment options include, for example, feminization or masculinization of the body through hormone therapy and/or surgery, which are effective in alleviating gender dysphoria and are medically necessary for many people. Gender identities and expressions are diverse, and hormones and surgery are just two of many options available to assist people with achieving comfort with self and identity.


Example research papers

There's many research papers which compare mental health of transgender people before and after procedures. For example:

In a sample of 359 gender-dysphoric persons who completed "several psychometric measures":

… during [cross-sex hormonal treatment], [gender-dysphoric persons (GDs)] reported a significant reduction of general psychopathology, depressive symptoms, and subjective GD, whereas social and legal indicators of GD showed a significant increase across time
Fisher et al., Cross-Sex Hormone Treatment and Psychobiological Changes in Transsexual Persons: Two-Year Follow-Up Data, The Journal of Clinical Endocrinology & Metabolism, 2016.

In a sample of 61 participants who were surveyed:

The present study suggests a positive effect of hormone therapy on transsexuals' QoL after accounting for confounding factors. These results will be useful for healthcare providers of transgender persons but should be confirmed with larger samples using a prospective study design.
Gorin-Lazard et al., Is Hormonal Therapy Associated with Better Quality of Life in Transsexuals? A Cross‐Sectional Study, The Journal of Sexual Medicine, 2012.

Here, QoL = Quality of Life.

In a meta review for transgender men:

Multiple studies have shown the positive effect of gender affirming hormonal therapy and gender affirming surgery on quality of life of trans persons and several studies describe an increase in their psychological wellbeing. In addition, satisfaction rates after gender affirming surgery are high and surgery is rarely regretted. However, as only one study has addressed cost-effectiveness of gender affirming treatment in trans men, further research is necessary. Defreyne et al., Healthcare costs and quality of life outcomes following gender affirming surgery in trans men: a review, Expert Review of Pharmacoeconomics & Outcomes Research, 2017.

There's many more I haven't listed; they can be found by searching PubMed.


Johns Hopkins

Also note that Johns Hopkins have subsequently reaffirmed their stance:

We have committed to and will soon begin providing gender-affirming surgery as another important element of our overall care program, reflecting careful consideration over the past year of best practices and the appropriate provision of care for transgender individuals.
Johns Hopkins Medicine's Commitment to the LGBT Community, October 7, 2016.


Patients more likely to refuse drug therapy than psychotherapy for mental health

People seeking help for mental disorders are more likely to refuse or not complete the recommended treatment if it involves only psychotropic drugs, according to a review of research published by the American Psychological Association.

Researchers conducted a meta-analysis of 186 studies of patients seeking help for mental health issues that examined whether they accepted the treatment that was recommended and if they did, whether they completed it. Fifty-seven of the studies, comprising 6,693 patients, had a component that reported refusal of treatment recommendations, and 182 of the studies, comprising 17,891 patients, had a component reporting premature termination of treatment.

After diagnosis, patients in the studies were recommended to drug-only therapy (pharmacotherapy), talk therapy (psychotherapy) or a combination of the two.

"We found that rates of treatment refusal were about two times greater for pharmacotherapy alone compared with psychotherapy alone, particularly for the treatment of social anxiety disorder, depressive disorders and panic disorder," said lead researcher Joshua Swift, PhD, of Idaho State University. "Rates of premature termination of therapy were also higher for pharmacotherapy alone, compared with psychotherapy alone, particularly for anorexia/bulimia and depressive disorders."

The research was published in the APA journal Psychotherapy.

Across all the studies, the average treatment refusal rate was 8.2 percent. Patients who were offered pharmacotherapy alone were 1.76 times more likely to refuse treatment than patients who were offered psychotherapy alone. Once in treatment, the average premature termination rate was 21.9 percent, with patients on drug-only regimens 1.2 times more likely to drop out early. There was no significant difference for refusal or dropout rates between pharmacotherapy alone and combination treatments, or between psychotherapy alone and combination treatments.

While Swift said the findings overall were expected, the researchers were most surprised by how large the differences were for some disorders. For example, patients diagnosed with depressive disorders were 2.16 times more likely to refuse pharmacotherapy alone and patients with panic disorders were almost three times more likely to refuse pharmacotherapy alone.

The findings are especially interesting because, as a result of easier access, recent trends show that a greater percentage of mental health patients in the U.S. are engaging in pharmacotherapy than psychotherapy, according to co-author Roger Greenberg, PhD, SUNY Upstate Medical University.

Some experts have argued that psychotherapy should be the first treatment option for many mental health disorders. Those arguments have been largely based on good treatment outcomes for talk therapy with fewer side effects and lower relapse rates, said Greenberg. "Our findings support that argument, showing that clients are more likely to be willing to start and continue psychotherapy than pharmacotherapy."

Swift and Greenberg theorized that patients may be more willing to engage in psychotherapy because many individuals who experience mental health problems recognize that the source of their problems may not be entirely biological.

"Patients often desire an opportunity to talk with and work through their problems with a caring individual who might be able to help them better face their emotional experiences," said Greenberg. "Psychotropic medications may help a lot of people, and I think some do see them as a relatively easy and potentially quick fix, but I think others view their problems as more complex and worry that medications will only provide a temporary or surface level solution for the difficulties they are facing in their lives."

While the meta-analysis provides information on refusal and dropout rates, the studies did not report the patients' reasons for their actions, Swift noted. Going forward, research designed to identify these reasons could lead to additional strategies to improve initiation and completion rates for both therapies, he said. It is also important to note that participants in the research studies initially indicated they were willing to be assigned to any therapy, and therefore may not be representative of all consumers of treatment.


What is psychotherapy?

Psychotherapy can help treat challenges and symptoms relating to mental health and emotions.

Also known as talk therapy, psychotherapy aims to help a person understand their feelings and equip them to face new challenges, both in the present and the future.

Psychotherapy is similar to counseling, and the two can overlap. However, the former tends to look more deeply, addressing the underlying causes of a person’s problems as well as how to solve them.

To see positive results, a person will usually need to understand the need for change and be willing to follow the treatment plan as the specialist advises. They will also need to find a suitable therapist they can trust.

Psychotherapy can help when depression, low self-esteem, addiction, bereavement, or other factors leave a person feeling overwhelmed. It can also help treat bipolar disorder, schizophrenia, and certain other mental health conditions.

In this article, learn more about what psychotherapy involves.

There are many approaches to psychotherapy.

Some forms last for only a few sessions, while others may continue for months or years, depending on the person’s needs. Individual sessions usually last for around 45–90 minutes and follow a structured process.

Sessions may be one-to-one, in pairs, or in groups. Techniques can include talking and other forms of communication, such as drama, story-telling, or music.

  • a psychologist
  • a marriage and family therapist
  • a licensed clinical social worker
  • a licensed clinical professional counselor
  • a mental health counselor
  • a psychiatric nurse practitioner
  • a psychoanalyst
  • a psychiatrist

Psychotherapy can help people in a range of situations. For example, it may benefit someone who:

  • has overwhelming feelings of sadness or helplessness
  • feels anxious most of the time
  • has difficulty facing everyday challenges or focusing on work or studies
  • is using drugs or alcohol in a way that is not healthful
  • is at risk of harming themselves or others
  • feels that their situation will never improve, despite receiving help from friends and family
  • has experienced an abusive situation
  • has a mental health condition, such as schizophrenia, that affects their daily life

Some people attend psychotherapy after a doctor recommends it, but many seek help independently.

There are several styles of and approaches to psychotherapy. The sections below will outline these in more detail.

Cognitive behavioral therapy

Cognitive behavioral therapy (CBT) helps a person understand and change how their thoughts and behaviors can affect the way they feel and act.

CBT can help people with many issues, including:

Interpersonal therapy

Under this approach, a person learns new ways to communicate or express their feelings. It can help with building and maintaining healthy relationships.

For example, if someone who responds to feeling neglected by getting angry, this may trigger a negative reaction in others. This can lead to depression and isolation.

The individual will learn to understand and modify their approach to interpersonal problems and acquire ways of managing them more constructively.

Psychodynamic therapy

Psychodynamic therapy addresses the ways in which past experiences, such as those during childhood, can impact a person’s current thoughts and behaviors. Often, the person is unaware that this influence is even present.

Identifying these influences can help people understand the source of feelings such as distress and anxiety. Once they identify these sources, the psychotherapist can help the person address them. This can help an individual feel more in control of their life.

It is similar to psychoanalysis but less intense.

Family therapy

Family therapy can provide a safe space for family members to:

  • express their views
  • explore difficult feelings
  • understand each other
  • build on existing strengths
  • find solutions to problems

This form of psychotherapy can be useful when problems stem from family relationships, or when a child or young person is facing difficulties.

In fact, one 2019 article suggests that family therapy may help adolescents with mental health problems. It may also improve family cohesion and enhance parenting skills.

Relationship therapy is another type of psychotherapy. It is very similar to family therapy, but a person may instead wish to present to therapy with their partner to address issues within a relationship.

Group therapy

Group therapy sessions usually involve one therapist and around 5–15 participants with similar concerns, such as:

The group will usually meet for 1 or 2 hours each week, and individuals may also attend one-on-one therapy.

People can benefit from interacting with the therapist but also by interacting with others who are experiencing similar challenges. Group members can also support each other.

Although participating in a group may seem intimidating, it can help people realize that they are not alone with their problem.

Online therapy

Many people are now opting for online therapy, otherwise known as telehealth. This can have many benefits, especially for someone who:

  • has mobility problems
  • cannot find a suitable specialist in their area
  • has difficulty fitting therapy into their schedule
  • does not feel comfortable with face-to-face communication

Tools include video meetings and messaging services.

Although online services have helped “normalize” psychotherapy, making it easier to integrate into daily life, a person should check carefully before choosing a provider.

For example, they should consider:

  • the qualifications and experience of the therapist
  • the online and other security measures the provider has in place
  • using a company that psychologists run and that has links with professional associations

Other types

There are many other types of psychotherapy, including:

Each person’s experience of psychotherapy will be different, and the time it takes to see an improvement will also vary.

Some people will notice a difference after around six to 12 sessions, while others may need ongoing treatment for several years.

Psychotherapy can help a person by:

  • giving them someone to explore their problem with confidentially
  • enabling them to see things in a new way
  • helping them move toward a solution
  • learn more about themselves and their goals and values
  • identify causes of tension in relationships
  • develop skills for facing challenges
  • overcome specific problems, such as a phobia

To benefit from the process, a person needs to:

  • have a desire to participate
  • engage actively in treatment
  • attend appointments and complete any assignments between sessions
  • be honest when describing symptoms and situations

Effectiveness can also depend on:

  • the reason for seeking therapy
  • the skill of the practitioner
  • the relationship between the therapist and the individual
  • any support the person may have outside the therapy sessions

A trusting relationship between the individual and the therapist is also essential to the process.

According to the American Psychological Association (APA), the qualities of a good therapist include such factors as:

  • having a developed set of interpersonal skills
  • taking time to build trust with the individual
  • having a treatment plan in place and keeping it flexible
  • monitoring the person’s progress
  • offering hope and realistic optimism
  • relying on research evidence

Choosing a suitable therapist

People seek psychotherapy for a wide range of reasons, and each individual is different. Providers should have training in dealing with a wide range of situations, but some can meet more specific needs.

For example, a practitioner may specialize in counseling for survivors of sexual abuse.

A person who has experienced trauma due to race , sexual orientation, or human trafficking, for example, will need to find someone who understands where the person is starting from. They will also need appropriate training.

After identifying a therapist who seems suitable, the individual should ask plenty of questions before starting therapy to make sure that this is the person they want.

A doctor, online community, or local support group can often recommend a suitable therapist.

Psychotherapy can offer many benefits, but there are some cautions to be aware of before starting. The following sections will outline these in more detail.

Unexpected effects

During psychotherapy, some people may experience changes they had not expected or did not want.

Recalling past events can sometimes trigger unwanted emotions. Addressing and resolving these emotions is an integral part of therapy, but it can be challenging.

It is essential to find a trusted and qualified psychotherapist who is skilled at guiding people through these situations in a constructive way.

Unhelpful therapy

Most people feel better as a result of therapy, but it can take time to work — and sometimes, the approach the therapist takes is not suitable. In fact, according to some research, around 10% of people feel worse after starting therapy.

Some experts have expressed concerns about potentially harmful therapies. These could be techniques that leave a person feeling worse rather than better or approaches that may actually slow an individual’s progress.

Some approaches may not have enough research evidence to support their use. In some cases, the approach or “chemistry” between the individual and the therapist may not be suitable.

However, if the practitioner monitors the person’s progress regularly and asks for feedback, the risk of therapy not working or having a negative impact will be lower.

Using an interpreter

Not everyone can find a psychotherapist who speaks their primary language. This can pose a challenge for people who are already at a disadvantage in society.

One option is to find an interpreter, but it is essential to find someone who understands the complex issues that treatment is likely to involve.

Ideally, the person should also have the skills and training necessary for managing the specific dynamics the relationship will involve.

Cost in time and money

Psychotherapy can be expensive and time consuming. This is another reason that it is essential to find a qualified practitioner.

If a health professional considers treatment necessary, the Mental Health Parity Act requires that insurance companies pay for mental healthcare in a similar way to paying for physical medical care.

It is worth noting that the definitions of “reasonable and appropriate” or “medically necessary” may vary.


What are talking therapies?

Talking therapies are treatments which involve talking to a trained professional about your thoughts, feelings and behaviour. There are many different types of talking therapy, but they all aim to:

  • give you a safe time and place to talk to someone who won't judge you
  • help you make sense of things and understand yourself better
  • help you resolve complicated feelings, or find ways to live with them
  • help you recognise unhelpful patterns in the way you think or act, and find ways to change them (if you want to).

Is there a difference between 'therapy' and 'counselling'?

Throughout these pages we've chosen to use the term 'talking therapy'. But you might also hear people talk about:

  • counselling
  • therapy
  • psychotherapy
  • psychological therapy
  • talking treatment.

Usually there's very little difference between what's meant by these terms – they all broadly refer to talking therapy (as opposed to other types of treatment, such as drug therapy). But sometimes they might indicate differences in who your therapist is, or refer to a specific type of talking therapy.

"Sometimes it&rsquos hard to talk to family and friends and you just need that one person who takes the time to listen."

What can therapy help with?

Therapy can help you manage and cope with:

  • Difficult life events, such as bereavement (losing someone close to you), or losing your job.
  • Relationship problems.
  • Upsetting or traumatic experiences, whether it's something recent or something that happened a long time ago.
  • Difficult emotions, such as grief, guilt, sadness, confusion, anger and low self-esteem.
  • Depression and anxiety.
  • Other mental health problems. Talking therapies can help with a range of diagnoses, and specific talking treatments have been developed for some mental health problems.
  • Long-term physical health problems.

Some people think that therapy is an extreme option, and that unless things get really bad you should try to manage on your own. But this isn't true. It's ok to try therapy at any point in your life, whatever your background.

In fact getting support from a therapist when you're not at crisis point can be really helpful &ndash it might feel easier to reflect on what's going on, and could help you keep things from getting worse.

"For me, counselling was a lifesaver. I never used to talk to anyone. For years, I would keep things bottled up and then cry hysterically on my own as to not inconvenience anyone. I would hide it so I wouldn&rsquot have to confront my thoughts and fears."


Medication Vs. Psychotherapy

For far too long &ldquovs.&rdquo has designated a combative stance which has interfered with a useful combination of psychotherapy and medication.

Medication can be a vital aid when prescribed properly especially for severe depression, bi-polar disorders and psychosis. Of course each patient needs to be carefully evaluated but medication can help reduce some of the major symptoms that can be so disruptive.

Often medication can alleviate suicidal thoughts contain explosive and impulsive acts, calm panic, and regulate extreme mood swings.

Frequently severe problems necessitate the use of medication to assist in making psychotherapy productive. Since self exploration, for example, can and often does generate anxiety some medication on a short term basis may help someone stay with the process of psychotherapy long enough to gain beneficial results.

Medications are not silver bullets and can cause significant problems in therapy. For some people a recommendation to consider medication can leave them feeling hopeless and mentally ill. This reaction requires patience and skill to explore the personal meaning of taking any medication for emotional difficulties. Questions of side effects, family history, ineffectiveness or, on the other side, a belief that problems are beyond them and a pill will make all right with the world, are some of the areas that need discussion.

People can sometimes feel they must choose between psychotherapy and medication. It is unfortunate and ill advised for someone in the medical profession to state that all emotional problems are the result of a biochemical imbalance and that medication is all that is necessary. Some can be so convinced of this position that multiple &ldquohigh dose meds&rdquo are prescribed leaving patients feeling terrified, confused, &ldquonot themselves&rdquo and &ldquonumbed out&rdquo.

On the other side some therapists believe all problems are exclusively psychological/emotional and fail to make a timely referral, which could alleviate unnecessary suffering. Someone in the midst of a manic episode or immobilized by severe depression can benefit from all the help they can get, including medication in a number of cases.

When consulting with either a physician or psychotherapist about emotional struggles it is fair and necessary to ask each about their professional experience with and attitudes about medication and psychotherapy. It is also important to look for someone who has a reputation of respecting allied professionals in order to maximize the help you receive.

Finally, by all means question both your therapist and physician if you are unclear why medication has been prescribed and how your therapy might be affected. You deserve the best treatment available.


For me, the word ‘psychology’ means the science about humans, their behavior, and thought process. I also view psychology as a practical discipline that can be used by people in their daily lives and applied to the treatment of mental illnesses by certified practitioners. There is no denying that I am entering this course with a wide range of preconceived notions about psychology. For example, when conducting research for this paper, I have discovered that my long-standing belief about therapists being on-call crisis managers was not supported by reality (Finlay, 2015). In fact, therapists are obliged to maintain therapeutic boundaries both inside and outside their offices, thereby maintain healthy relationships with their clients.

Modern entertainment media has long been a major source of information about mental illness and psychotherapy for those who do not major in psychology. Fictional therapists in psychology shows such as In Treatment, Lie to Me, and Hoarders are extremely popular with TV audiences. Unfortunately, these shows often depict experts in psychology whose behavior would be harmful in real-life therapy, thereby creating skewed perceptions about help seeking (Jamieson, n.d.). There is ample evidence that people’s knowledge of schizophrenia, depression, and bipolar disorder is derived from television programs and movies (Fawcett, 2015). It means that inaccurate portrayals of these illnesses contribute to the development of social stigmas, which are extremely harmful to individuals requiring psychological help.

The media is rife with negative portrayals of therapists who cannot be trusted with secrets. A case in point is Dr. Arnold Wayne, a psychiatrist in a popular TV-series Mad Men who reported details of his sessions to a client’s husband (Mitchell, 2013). In reality, client confidentiality is a key requirement of therapy that has to be followed at all costs. Licensed mental health professionals operate within ethical and legal boundaries therefore, the contents of therapy are not discussed with external parties. A rare exception to the requirement of confidentiality is an imminent threat to either a patient or others, which might force a therapist “to testify against their clients” (Good Therapy, 2017, para. 4). It means that an image of self-serving and devious psychology practitioners cannot be further from the truth.

Many movies make people with mental disorders look either childish or threatening. Usual media stereotypes include, but are not limited to, disheveled hair and clothes, disorderly behavior, and unpleasant character quirks. Such visual signifiers are not only inaccurate but also extremely harmful. Fawcett (2015) argues that these images do not help to convey that “most people with serious mental illnesses are in pain” (para. 11). Maier, Gentile, and Vogel (2014) also state that the inaccurate construction of reality of mental disorders diminishes one’s willingness to ask for help, thereby undermining the well-being of individuals who are in need of mental health services. It follows that people’s beliefs about mental health issues are largely shaped by their portrayals in cinema and television, which are more harmful than helpful.


What is Psychotherapy?

Problems helped by psychotherapy include difficulties in coping with daily life the impact of trauma, medical illness or loss, like the death of a loved one and specific mental disorders, like depression or anxiety. There are several different types of psychotherapy and some types may work better with certain problems or issues. Psychotherapy may be used in combination with medication or other therapies.

Therapy Sessions

Therapy may be conducted in an individual, family, couple, or group setting, and can help both children and adults. Sessions are typically held once a week for about 30 to 50. Both patient and therapist need to be actively involved in psychotherapy. The trust and relationship between a person and his/her therapist is essential to working together effectively and benefiting from psychotherapy.

Psychotherapy can be short-term (a few sessions), dealing with immediate issues, or long-term (months or years), dealing with longstanding and complex issues. The goals of treatment and arrangements for how often and how long to meet are planned jointly by the patient and therapist.

Confidentiality is a basic requirement of psychotherapy. Also, although patients share personal feelings and thoughts, intimate physical contact with a therapist is never appropriate, acceptable, or useful.

Psychotherapy and Medication

Psychotherapy is often used in combination with medication to treat mental health conditions. In some circumstances medication may be clearly useful and in others psychotherapy may be the best option. For many people combined medication and psychotherapy treatment is better than either alone. Healthy lifestyle improvements, such as good nutrition, regular exercise and adequate sleep, can be important in supporting recovery and overall wellness.

Does Psychotherapy Work?

Research shows that most people who receive psychotherapy experience symptom relief and are better able to function in their lives. About 75 percent of people who enter psychotherapy show some benefit from it. 1 Psychotherapy has been shown to improve emotions and behaviors and to be linked with positive changes in the brain and body. The benefits also include fewer sick days, less disability, fewer medical problems, and increased work satisfaction.

With the use of brain imaging techniques researchers have been able to see changes in the brain after a person has undergone psychotherapy. Numerous studies have identified brain changes in people with mental illness (including depression, panic disorder, PTSD and other conditions) as a result of undergoing psychotherapy. In most cases the brain changes resulting from psychotherapy were similar to changes resulting from medication. 2

To help get the most out of psychotherapy, approach the therapy as a collaborative effort, be open and honest, and follow your agreed upon plan for treatment. Follow through with any assignments between sessions, such as writing in a journal or practicing what you&rsquove talked about.

Types of Psychotherapy

Psychiatrists and other mental health professionals use several types of therapy. The choice of therapy type depends on the patient&rsquos particular illness and circumstances and his/her preference. Therapists may combine elements from different approaches to best meet the needs of the person receiving treatment.

Cognitive behavioral therapy (CBT) helps people identify and change thinking and behavior patterns that are harmful or ineffective, replacing them with more accurate thoughts and functional behaviors. It can help a person focus on current problems and how to solve them. It often involves practicing new skills in the &ldquoreal world.&rdquo

CBT can be helpful in treating a variety of disorders, including depression, anxiety, trauma related disorders, and eating disorders. For example, CBT can help a person with depression recognize and change negative thought patterns or behaviors that are contributing to the depression.

Interpersonal therapy (IPT) is a short-term form of treatment. It helps patients understand underlying interpersonal issues that are troublesome, like unresolved grief, changes in social or work roles, conflicts with significant others, and problems relating to others. It can help people learn healthy ways to express emotions and ways to improve communication and how they relate to others. It is most often used to treat depression.

Dialectical behavior therapy is a specific type of CBT that helps regulate emotions. It is often used to treat people with chronic suicidal thoughts and people with borderline personality disorder, eating disorders and PTSD. It teaches new skills to help people take personal responsibility to change unhealthy or disruptive behavior. It involves both individual and group therapy.

Psychodynamic therapy is based on the idea that behavior and mental well-being are influenced by childhood experiences and inappropriate repetitive thoughts or feelings that are unconscious (outside of the person&rsquos awareness). A person works with the therapist to improve self-awareness and to change old patterns so he/she can more fully take charge of his/her life.

Psychoanalysis is a more intensive form of psychodynamic therapy. Sessions are typically conducted three or more times a week.

Supportive therapy uses guidance and encouragement to help patients develop their own resources. It helps build self-esteem, reduce anxiety, strengthen coping mechanisms, and improve social and community functioning. Supportive psychotherapy helps patients deal with issues related to their mental health conditions which in turn affect the rest of their lives.

Additional therapies sometimes used in combination with psychotherapy include:

  • Animal-assisted therapy &ndash working with dogs, horses or other animals to bring comfort, help with communication and help cope with trauma
  • Creative arts therapy &ndash use of art, dance, drama, music and poetry therapies
  • Play therapy &ndash to help children identify and talk about their emotions and feelings

More Information

  1. American Psychological Association. Understanding psychotherapy and how it works. 2016. http://www.apa.org/helpcenter/understanding-psychotherapy.aspx
  2. Karlsson, H. How Psychotherapy changes the Brain. Psychiatric Times. 2011.
  3. Wiswede D, et al. 2014. Tracking Functional Brain Changes in Patients with Depression under Psychodynamic Psychotherapy Using Individualized Stimuli. PLoS ONE. 2014. http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0109037

Physician Review By:
Ranna Parekh, M.D., M.P.H.
Lior Givon, M.D., PH.D.
January 2019

Finding and Choosing a Psychotherapist

Psychotherapy can be provided by a number of different types of professionals including psychiatrists, psychologists, licensed social workers, licensed professional counselors, licensed marriage and family therapists, psychiatric nurses, and others with specialized training in psychotherapy. Psychiatrists are also trained in medicine and are able to prescribe medications.

Finding a psychiatrist or other therapist with whom an individual can work well is important. Sources of referrals include primary care physicians, local psychiatric societies, medical schools, community health centers, workplace Employee Assistance Programs (EAP), and online resources (see links to online locators below).

Federal law requires that in most cases mental health services, including psychotherapy, be covered by health insurance similar to other medical care costs. (Read more about insurance coverage of mental health care)


Discussion

We conducted the most complete meta-analysis, to our knowledge, of trials on IPT to date and identified 90 randomized trials on IPT for mental health disorders. Two-thirds of these studies were aimed at prevention, treatment, and relapse prevention of depression, showing a moderate-to-large effect on depression compared with control groups, with smaller effects in older adults, in clinical samples, and in samples meeting diagnostic criteria for a depressive disorder. IPT was not significantly more or less effective than other psychotherapies for depression. There were some indications that pharmacotherapy may be somewhat more effective than IPT for acute-phase depression however, this finding was not robust and may have been influenced by the high risk of bias in many of these trials. Combined treatment was significantly more effective than IPT alone but not more effective than pharmacotherapy alone. This should be considered with caution, however, because of the relatively small number of trials. These results are comparable to our earlier meta-analysis of studies on IPT for depression (3).

We found indications that IPT may prevent the onset of depressive disorders in subthreshold depression, which is in line with meta-analyses of this field (6, 39). However, the finding that IPT may prevent the onset of depressive disorders has not been established in earlier meta-analyses. These findings should be considered with caution because the number of trials on prevention was small, risk of bias was considerable, and the confidence intervals were broad.

The trials examining the effects of maintenance IPT on recurrence and relapse also revealed significant effects of IPT. But again, these findings were limited by the small number of trials, considerable risk of bias, and broad confidence intervals.

We also found that the outcomes of IPT in depression were associated with the number of sessions, with 10 or more sessions resulting in an increase of the effect size with g=0.2. Although results of such metaregression analyses are not causal evidence, this may indicate that 16-session IPT is more effective than the shorter interpersonal counseling, a finding that needs confirmation in future research.

The applications of IPT to other disorders emerged in response to symptoms and morbidity (e.g., binge eating, social anxiety) being bidirectionally linked with interpersonal stressors and the importance of social supports and relationships to health and resilience (40–42).

In the treatment of eating disorders and anxiety disorders, IPT has been used in numerous studies as an active comparison group. No earlier meta-analysis has examined the effects of IPT in these disorders. Overall, these studies showed no convincing evidence that CBT is more effective than IPT in anxiety disorders. In eating disorders, a small but significant effect in favor of CBT was found for behavioral outcomes, but because the number of studies was small and risk of bias was high, this is uncertain, and longer-term effects are not clear.

IPT trials for other mental health problems, including addictions and distress from general medical disorders, showed some promising effects. However, this should be considered with caution because of the high risk of bias in most trials and the insufficient number of trials.

This meta-analysis examined a broad range of mental health problems in a large number of patients using one treatment method, IPT. There are, however, limitations to the conclusions that can be drawn. The number of trials for several comparisons was too small to make reliable estimates of the effects, and heterogeneity was considerable in several analyses. Furthermore, risk of bias was high in the majority of trials, reducing the strength of the evidence considerably. However, when we limited the analyses to studies with low risk of bias, the outcomes were very comparable to those found for all studies. In addition, because only a small number of studies examined long-term follow-up outcomes and these follow-up periods differed, these outcomes could not be examined. Finally, the results of randomized trials may not be generalized to patients who are treated in routine care because of the exclusion criteria used in the trials. Although this problem has not been found to affect the outcome of these trials (43), these limitations should be kept in mind when interpreting the outcomes of our study.

In conclusion, IPT is one of the best-examined treatments in mental health problems, and it is effective in depression and possibly in other disorders, such as eating and anxiety disorders. It is important to have more than one treatment option for patients, since no treatment works for everyone, and IPT, with its focus on salient relational and interpersonal experiences, provides an important alternative to pharmacotherapy or CBT. IPT has the potential to be used more broadly for endemic mental health problems, as a preventative treatment, and to address the concomitant interpersonal stressors associated with the onset or worsening of disorders.

Dr. Cuijpers has received royalties from Atheneum Publishers, HB Publishers, and Servier speaking fees from the NVGRT, the University of Trier, Vanderbilt University, and the VGCt and grant support from the European Commission, the NutsOhra Foundation, and ZonMw. Dr. Weissman receives royalties from Perseus Press and Oxford University Press. Dr. Ravitz receives royalties from WW Norton. All other authors report no financial relationships with commercial interests.

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Method

Data were drawn from the household component of the 1998 and the 2007 MEPS, which are subsamples of the National Health Interview Survey (NHIS) (10, 11). Both surveys were sponsored by the Agency for Healthcare Research and Quality to provide national estimates of the use of, expenditures on, and financing of health care services. These surveys were conducted as national probability samples of the U.S. noninstitutionalized civilian population and were designed to provide nationally representative estimates to be compared over time. All data elements in these analyses except the physician provider specialty variable were the same in the two surveys.

Samples

A total of 22,953 participants provided data for the entire 1998 survey year from two separate overlapping panels, each of which included three rounds of interviews. The full-year response rate was 67.9% after factoring in the effects of nonresponse to NHIS, nonresponse to the first round of MEPS, and survey attrition from both panels (10). A total of 29,730 participants provided data for the entire 2007 survey, the most recent available data, for a full-year response rate of 56.9% (11). For both surveys, a designated informant was queried about all related persons who lived in the household.

The Agency for Healthcare Research and Quality devised weights to adjust for the complex survey designs and yield unbiased national estimates. The sampling weights also adjust for non-response and poststratification to population totals based on U.S. census data. More detailed discussions of the design, sampling, and adjustment methods have been presented elsewhere (10, 11).

Structure of the Survey

The MEPS included a series of three in-person interviews during each study year. Respondents were asked to record medical events, as they occurred, in a calendar/diary that was reviewed in-person during each interview. Written permission was obtained from selected survey participants to contact the medical providers they mentioned during the survey to verify service use, charges, and sources and amounts of payments.

Mental health conditions.

The MEPS collected information on the diagnosis for each visit to hospital outpatient departments and office-based outpatient care. This information was coded in a manner that permitted classification according to ICD-9 categories by professional coders. The diagnoses associated with the psychotherapy visits were then grouped into the following mental health condition categories: schizophrenia and related disorders (codes 295, 297-299), depression and related mood disorders (codes 296.2, 296.3, 298.0, 300.4, 309.1, 311), anxiety disorders (codes 293.84, 300.0, 300.2, 300.3, 3008.3, 309.81), childhood disorders and mental retardation (codes 299, 312-315, 317-319, 307 [except 307.2 and 307.8]), adjustment disorders (codes 308 [except 308.3], 309.0, 309.1, 309.2, 309.4, 309.9), other mental disorders (codes 290-319 not specified above), and subsyndromal mental health-related conditions, including psychosocial circumstances (codes V40, V61, V62), sleep disturbance (780.5), malaise and fatigue (780.7), and nervousness (799.2). Separate variables classified emergency department visits and inpatient admissions with a diagnosis of a mental disorder (ICD-9-CM codes 290-319).

Psychotherapy.

The MEPS asked respondents what type of care was provided during each outpatient visit and whether it was from a mental health specialist or other health care provider, using a set of response categories that included “mental health counseling or psychotherapy.” Mental health counseling or psychotherapy is defined as “a treatment technique for certain forms of mental disorders relying principally on talk/conversation between the mental health professional and the patient.” It specifically includes “individual, family, and/or group therapies” (12). Visits for psychotherapy or mental health counseling are considered psychotherapy visits.

Psychotropic medications.

The MEPS surveys asked respondents about medications bought or otherwise obtained by survey participants during the survey year. Psychotropic medications were grouped by therapeutic class as antidepressants, antipsychotic medications, anxiolytics/hypnotics, stimulants, and mood stabilizers (the latter included lithium, lamotrigine, carbamaze-pine, and valproate or valproic acid for respondents who were not treated for seizure disorders [ICD-9-CM code 345]).

Providers.

The MEPS solicited information on the type of health care professionals providing treatment at each visit. We classified mental health providers of psychotherapy into three groups: social workers, psychologists, and psychiatrists. Information was not available in 1998 concerning psychotherapy visits provided by psychiatrists. A psychotherapy user was considered to have been treated by a given provider type if the user reported making one or more visits to that type during the survey year.

Expenditures and source of payment.

The MEPS data include sources of expenditures for each health care service. “Expenditures” refers to what is paid for the medical service and is defined as the sum of payments for each medical service that was obtained, including out-of-pocket payments and payments made by private insurance, Medicaid, Medicare, and other sources (10, 11). From these data, total expenditures were aggregated into outpatient medical care (outpatient visits and medications for all conditions), outpatient mental health care (outpatient visits and medications for mental health conditions), and outpatient psychotherapy. Summary variables were also constructed for six payment sources, including self-payment, private insurance, Medicaid, Medicare, other federal programs, and a residual group of other sources.

Analysis Plan

For each survey year, the percentage of persons using psychotherapy was computed overall and stratified by several sociodemographic characteristics. Trends were then examined by mental health condition group in the estimated national number of treated outpatients and their distribution with respect to treatment with psychotherapy but not psychotropic medication, psychotherapy and psychotropic medication, and psychotropic medication alone. The distributions of psychotherapy users were then examined by use of psychotropic medications, mental health provider groups, acute mental health service use, number of psychotherapy visits during the year, and self-assessed mental health status (excellent, very good, or good versus fair or poor). Among psychotherapy users, the mean number of psychotherapy visits in each survey year was compared overall and for psychotherapy users with and without psychotropic medication use as well as for those with good to excellent as compared with fair or poor self-rated mental health. In separate analyses, total national expenditures were estimated for all outpatient medical care, out-patient mental health care (outpatient visits for a mental disorder or condition), and psychotherapy. National psychotherapy expenditures were partitioned by payment source for the two survey years. The U.S. Consumer Price Index for medical care was used to adjust 1998 expenditures to 2007 dollars.

All statistical analyses were conducted using SAS, version 9.2 (SAS Institute, Cary, N.C.), using SURVEY procedures to accommodate the complex sample design and the weighting of observations. A series of logistic regressions, adjusted for age, sex, race/ethnicity, and insurance status, were performed to assess the strength of associations between year (with 1998 as the reference year) and psychotherapy use results are presented as adjusted odds ratios with 95% confidence intervals. Similar analyses were conducted with psychotherapy and psychotropic medication use as well as psycho-tropic medication use only as dependent variables. Linear regression was used to assess change in the number of psychotherapy visits per year among respondents reporting psychotherapy use, and z tests were used to evaluate changes in total national expenditures. All tests were two-sided, and alpha was set at 0.05.


Mental Health: Culture, Race, and Ethnicity: A Supplement to Mental Health: A Report of the Surgeon General.

To better understand what happens inside the clinical setting, this chapter looks outside. It reveals the diverse effects of culture and society on mental health, mental illness, and mental health services. This understanding is key to developing mental health services that are more responsive to the cultural and social contexts of racial and ethnic minorities.

With a seemingly endless range of subgroups and individual variations, culture is important because it bears upon what all people bring to the clinical setting. It can account for minor variations in how people communicate their symptoms and which ones they report. Some aspects of culture may also underlie culture-bound syndromes - sets of symptoms much more common in some societies than in others. More often, culture bears on whether people even seek help in the first place, what types of help they seek, what types of coping styles and social supports they have, and how much stigma they attach to mental illness. Culture also influences the meanings that people impart to their illness. Consumers of mental health services, whose cultures vary both between and within groups, naturally carry this diversity directly to the service setting.

The cultures of the clinician and the service system also factor into the clinical equation. Those cultures most visibly shape the interaction with the mental health consumer through diagnosis, treatment, and organization and financing of services. It is all too easy to lose sight of the importance of culture - until one leaves the country. Travelers from the United States, while visiting some distant frontier, may find themselves stranded in miscommunications and seemingly unorthodox treatments if they seek care for a sudden deterioration in their mental health.

Health and mental health care in the United States are embedded in Western science and medicine, which emphasize scientific inquiry and objective evidence. The self-correcting features of modern science - new methods, peer review, and openness to scrutiny through publication in professional journals - ensure that as knowledge is developed, it builds on, refines, and often replaces older theories and discoveries. The achievements of Western medicine have become the cornerstone of health care worldwide.

What follows are numerous examples of the ways in which culture influences mental health, mental illness, and mental health services. This chapter is meant to be illustrative, not exhaustive. It looks at the culture of the patient, the culture of the clinician, and the specialty in which the clinician works. With respect to the context of mental health services, the chapter deals with the organization, delivery, and financing of services, as well as with broader social issues - racism, discrimination, and poverty - which affect mental health.

Culture refers to a groups shared set of beliefs, norms, and values (Chapter 1). Because common social groupings (e.g., people who share a religion, youth who participate in the same sport, or adults trained in the same profession) have their own cultures, this chapter has separate sections on the culture of the patient as well as the culture of the clinician. Where cultural influences end and larger societal influences begin, there are contours not easily demarcated by social scientists. This chapter takes a broad view about the importance of both culture and society, yet recognizes that they overlap in ways that are difficult to disentangle through research.

What becomes clear is that culture and social contexts, while not the only determinants, shape the mental health of minorities and alter the types of mental health services they use. Cultural misunderstandings between patient and clinician, clinician bias, and the fragmentation of mental health services deter minorities from accessing and utilizing care and prevent them from receiving appropriate care. These possibilities intensify with the demographic trends highlighted at the end of the chapter.


What is Psychotherapy?

Problems helped by psychotherapy include difficulties in coping with daily life the impact of trauma, medical illness or loss, like the death of a loved one and specific mental disorders, like depression or anxiety. There are several different types of psychotherapy and some types may work better with certain problems or issues. Psychotherapy may be used in combination with medication or other therapies.

Therapy Sessions

Therapy may be conducted in an individual, family, couple, or group setting, and can help both children and adults. Sessions are typically held once a week for about 30 to 50. Both patient and therapist need to be actively involved in psychotherapy. The trust and relationship between a person and his/her therapist is essential to working together effectively and benefiting from psychotherapy.

Psychotherapy can be short-term (a few sessions), dealing with immediate issues, or long-term (months or years), dealing with longstanding and complex issues. The goals of treatment and arrangements for how often and how long to meet are planned jointly by the patient and therapist.

Confidentiality is a basic requirement of psychotherapy. Also, although patients share personal feelings and thoughts, intimate physical contact with a therapist is never appropriate, acceptable, or useful.

Psychotherapy and Medication

Psychotherapy is often used in combination with medication to treat mental health conditions. In some circumstances medication may be clearly useful and in others psychotherapy may be the best option. For many people combined medication and psychotherapy treatment is better than either alone. Healthy lifestyle improvements, such as good nutrition, regular exercise and adequate sleep, can be important in supporting recovery and overall wellness.

Does Psychotherapy Work?

Research shows that most people who receive psychotherapy experience symptom relief and are better able to function in their lives. About 75 percent of people who enter psychotherapy show some benefit from it. 1 Psychotherapy has been shown to improve emotions and behaviors and to be linked with positive changes in the brain and body. The benefits also include fewer sick days, less disability, fewer medical problems, and increased work satisfaction.

With the use of brain imaging techniques researchers have been able to see changes in the brain after a person has undergone psychotherapy. Numerous studies have identified brain changes in people with mental illness (including depression, panic disorder, PTSD and other conditions) as a result of undergoing psychotherapy. In most cases the brain changes resulting from psychotherapy were similar to changes resulting from medication. 2

To help get the most out of psychotherapy, approach the therapy as a collaborative effort, be open and honest, and follow your agreed upon plan for treatment. Follow through with any assignments between sessions, such as writing in a journal or practicing what you&rsquove talked about.

Types of Psychotherapy

Psychiatrists and other mental health professionals use several types of therapy. The choice of therapy type depends on the patient&rsquos particular illness and circumstances and his/her preference. Therapists may combine elements from different approaches to best meet the needs of the person receiving treatment.

Cognitive behavioral therapy (CBT) helps people identify and change thinking and behavior patterns that are harmful or ineffective, replacing them with more accurate thoughts and functional behaviors. It can help a person focus on current problems and how to solve them. It often involves practicing new skills in the &ldquoreal world.&rdquo

CBT can be helpful in treating a variety of disorders, including depression, anxiety, trauma related disorders, and eating disorders. For example, CBT can help a person with depression recognize and change negative thought patterns or behaviors that are contributing to the depression.

Interpersonal therapy (IPT) is a short-term form of treatment. It helps patients understand underlying interpersonal issues that are troublesome, like unresolved grief, changes in social or work roles, conflicts with significant others, and problems relating to others. It can help people learn healthy ways to express emotions and ways to improve communication and how they relate to others. It is most often used to treat depression.

Dialectical behavior therapy is a specific type of CBT that helps regulate emotions. It is often used to treat people with chronic suicidal thoughts and people with borderline personality disorder, eating disorders and PTSD. It teaches new skills to help people take personal responsibility to change unhealthy or disruptive behavior. It involves both individual and group therapy.

Psychodynamic therapy is based on the idea that behavior and mental well-being are influenced by childhood experiences and inappropriate repetitive thoughts or feelings that are unconscious (outside of the person&rsquos awareness). A person works with the therapist to improve self-awareness and to change old patterns so he/she can more fully take charge of his/her life.

Psychoanalysis is a more intensive form of psychodynamic therapy. Sessions are typically conducted three or more times a week.

Supportive therapy uses guidance and encouragement to help patients develop their own resources. It helps build self-esteem, reduce anxiety, strengthen coping mechanisms, and improve social and community functioning. Supportive psychotherapy helps patients deal with issues related to their mental health conditions which in turn affect the rest of their lives.

Additional therapies sometimes used in combination with psychotherapy include:

  • Animal-assisted therapy &ndash working with dogs, horses or other animals to bring comfort, help with communication and help cope with trauma
  • Creative arts therapy &ndash use of art, dance, drama, music and poetry therapies
  • Play therapy &ndash to help children identify and talk about their emotions and feelings

More Information

  1. American Psychological Association. Understanding psychotherapy and how it works. 2016. http://www.apa.org/helpcenter/understanding-psychotherapy.aspx
  2. Karlsson, H. How Psychotherapy changes the Brain. Psychiatric Times. 2011.
  3. Wiswede D, et al. 2014. Tracking Functional Brain Changes in Patients with Depression under Psychodynamic Psychotherapy Using Individualized Stimuli. PLoS ONE. 2014. http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0109037

Physician Review By:
Ranna Parekh, M.D., M.P.H.
Lior Givon, M.D., PH.D.
January 2019

Finding and Choosing a Psychotherapist

Psychotherapy can be provided by a number of different types of professionals including psychiatrists, psychologists, licensed social workers, licensed professional counselors, licensed marriage and family therapists, psychiatric nurses, and others with specialized training in psychotherapy. Psychiatrists are also trained in medicine and are able to prescribe medications.

Finding a psychiatrist or other therapist with whom an individual can work well is important. Sources of referrals include primary care physicians, local psychiatric societies, medical schools, community health centers, workplace Employee Assistance Programs (EAP), and online resources (see links to online locators below).

Federal law requires that in most cases mental health services, including psychotherapy, be covered by health insurance similar to other medical care costs. (Read more about insurance coverage of mental health care)


For me, the word ‘psychology’ means the science about humans, their behavior, and thought process. I also view psychology as a practical discipline that can be used by people in their daily lives and applied to the treatment of mental illnesses by certified practitioners. There is no denying that I am entering this course with a wide range of preconceived notions about psychology. For example, when conducting research for this paper, I have discovered that my long-standing belief about therapists being on-call crisis managers was not supported by reality (Finlay, 2015). In fact, therapists are obliged to maintain therapeutic boundaries both inside and outside their offices, thereby maintain healthy relationships with their clients.

Modern entertainment media has long been a major source of information about mental illness and psychotherapy for those who do not major in psychology. Fictional therapists in psychology shows such as In Treatment, Lie to Me, and Hoarders are extremely popular with TV audiences. Unfortunately, these shows often depict experts in psychology whose behavior would be harmful in real-life therapy, thereby creating skewed perceptions about help seeking (Jamieson, n.d.). There is ample evidence that people’s knowledge of schizophrenia, depression, and bipolar disorder is derived from television programs and movies (Fawcett, 2015). It means that inaccurate portrayals of these illnesses contribute to the development of social stigmas, which are extremely harmful to individuals requiring psychological help.

The media is rife with negative portrayals of therapists who cannot be trusted with secrets. A case in point is Dr. Arnold Wayne, a psychiatrist in a popular TV-series Mad Men who reported details of his sessions to a client’s husband (Mitchell, 2013). In reality, client confidentiality is a key requirement of therapy that has to be followed at all costs. Licensed mental health professionals operate within ethical and legal boundaries therefore, the contents of therapy are not discussed with external parties. A rare exception to the requirement of confidentiality is an imminent threat to either a patient or others, which might force a therapist “to testify against their clients” (Good Therapy, 2017, para. 4). It means that an image of self-serving and devious psychology practitioners cannot be further from the truth.

Many movies make people with mental disorders look either childish or threatening. Usual media stereotypes include, but are not limited to, disheveled hair and clothes, disorderly behavior, and unpleasant character quirks. Such visual signifiers are not only inaccurate but also extremely harmful. Fawcett (2015) argues that these images do not help to convey that “most people with serious mental illnesses are in pain” (para. 11). Maier, Gentile, and Vogel (2014) also state that the inaccurate construction of reality of mental disorders diminishes one’s willingness to ask for help, thereby undermining the well-being of individuals who are in need of mental health services. It follows that people’s beliefs about mental health issues are largely shaped by their portrayals in cinema and television, which are more harmful than helpful.


Medication Vs. Psychotherapy

For far too long &ldquovs.&rdquo has designated a combative stance which has interfered with a useful combination of psychotherapy and medication.

Medication can be a vital aid when prescribed properly especially for severe depression, bi-polar disorders and psychosis. Of course each patient needs to be carefully evaluated but medication can help reduce some of the major symptoms that can be so disruptive.

Often medication can alleviate suicidal thoughts contain explosive and impulsive acts, calm panic, and regulate extreme mood swings.

Frequently severe problems necessitate the use of medication to assist in making psychotherapy productive. Since self exploration, for example, can and often does generate anxiety some medication on a short term basis may help someone stay with the process of psychotherapy long enough to gain beneficial results.

Medications are not silver bullets and can cause significant problems in therapy. For some people a recommendation to consider medication can leave them feeling hopeless and mentally ill. This reaction requires patience and skill to explore the personal meaning of taking any medication for emotional difficulties. Questions of side effects, family history, ineffectiveness or, on the other side, a belief that problems are beyond them and a pill will make all right with the world, are some of the areas that need discussion.

People can sometimes feel they must choose between psychotherapy and medication. It is unfortunate and ill advised for someone in the medical profession to state that all emotional problems are the result of a biochemical imbalance and that medication is all that is necessary. Some can be so convinced of this position that multiple &ldquohigh dose meds&rdquo are prescribed leaving patients feeling terrified, confused, &ldquonot themselves&rdquo and &ldquonumbed out&rdquo.

On the other side some therapists believe all problems are exclusively psychological/emotional and fail to make a timely referral, which could alleviate unnecessary suffering. Someone in the midst of a manic episode or immobilized by severe depression can benefit from all the help they can get, including medication in a number of cases.

When consulting with either a physician or psychotherapist about emotional struggles it is fair and necessary to ask each about their professional experience with and attitudes about medication and psychotherapy. It is also important to look for someone who has a reputation of respecting allied professionals in order to maximize the help you receive.

Finally, by all means question both your therapist and physician if you are unclear why medication has been prescribed and how your therapy might be affected. You deserve the best treatment available.


What are talking therapies?

Talking therapies are treatments which involve talking to a trained professional about your thoughts, feelings and behaviour. There are many different types of talking therapy, but they all aim to:

  • give you a safe time and place to talk to someone who won't judge you
  • help you make sense of things and understand yourself better
  • help you resolve complicated feelings, or find ways to live with them
  • help you recognise unhelpful patterns in the way you think or act, and find ways to change them (if you want to).

Is there a difference between 'therapy' and 'counselling'?

Throughout these pages we've chosen to use the term 'talking therapy'. But you might also hear people talk about:

  • counselling
  • therapy
  • psychotherapy
  • psychological therapy
  • talking treatment.

Usually there's very little difference between what's meant by these terms – they all broadly refer to talking therapy (as opposed to other types of treatment, such as drug therapy). But sometimes they might indicate differences in who your therapist is, or refer to a specific type of talking therapy.

"Sometimes it&rsquos hard to talk to family and friends and you just need that one person who takes the time to listen."

What can therapy help with?

Therapy can help you manage and cope with:

  • Difficult life events, such as bereavement (losing someone close to you), or losing your job.
  • Relationship problems.
  • Upsetting or traumatic experiences, whether it's something recent or something that happened a long time ago.
  • Difficult emotions, such as grief, guilt, sadness, confusion, anger and low self-esteem.
  • Depression and anxiety.
  • Other mental health problems. Talking therapies can help with a range of diagnoses, and specific talking treatments have been developed for some mental health problems.
  • Long-term physical health problems.

Some people think that therapy is an extreme option, and that unless things get really bad you should try to manage on your own. But this isn't true. It's ok to try therapy at any point in your life, whatever your background.

In fact getting support from a therapist when you're not at crisis point can be really helpful &ndash it might feel easier to reflect on what's going on, and could help you keep things from getting worse.

"For me, counselling was a lifesaver. I never used to talk to anyone. For years, I would keep things bottled up and then cry hysterically on my own as to not inconvenience anyone. I would hide it so I wouldn&rsquot have to confront my thoughts and fears."


What is psychotherapy?

Psychotherapy can help treat challenges and symptoms relating to mental health and emotions.

Also known as talk therapy, psychotherapy aims to help a person understand their feelings and equip them to face new challenges, both in the present and the future.

Psychotherapy is similar to counseling, and the two can overlap. However, the former tends to look more deeply, addressing the underlying causes of a person’s problems as well as how to solve them.

To see positive results, a person will usually need to understand the need for change and be willing to follow the treatment plan as the specialist advises. They will also need to find a suitable therapist they can trust.

Psychotherapy can help when depression, low self-esteem, addiction, bereavement, or other factors leave a person feeling overwhelmed. It can also help treat bipolar disorder, schizophrenia, and certain other mental health conditions.

In this article, learn more about what psychotherapy involves.

There are many approaches to psychotherapy.

Some forms last for only a few sessions, while others may continue for months or years, depending on the person’s needs. Individual sessions usually last for around 45–90 minutes and follow a structured process.

Sessions may be one-to-one, in pairs, or in groups. Techniques can include talking and other forms of communication, such as drama, story-telling, or music.

  • a psychologist
  • a marriage and family therapist
  • a licensed clinical social worker
  • a licensed clinical professional counselor
  • a mental health counselor
  • a psychiatric nurse practitioner
  • a psychoanalyst
  • a psychiatrist

Psychotherapy can help people in a range of situations. For example, it may benefit someone who:

  • has overwhelming feelings of sadness or helplessness
  • feels anxious most of the time
  • has difficulty facing everyday challenges or focusing on work or studies
  • is using drugs or alcohol in a way that is not healthful
  • is at risk of harming themselves or others
  • feels that their situation will never improve, despite receiving help from friends and family
  • has experienced an abusive situation
  • has a mental health condition, such as schizophrenia, that affects their daily life

Some people attend psychotherapy after a doctor recommends it, but many seek help independently.

There are several styles of and approaches to psychotherapy. The sections below will outline these in more detail.

Cognitive behavioral therapy

Cognitive behavioral therapy (CBT) helps a person understand and change how their thoughts and behaviors can affect the way they feel and act.

CBT can help people with many issues, including:

Interpersonal therapy

Under this approach, a person learns new ways to communicate or express their feelings. It can help with building and maintaining healthy relationships.

For example, if someone who responds to feeling neglected by getting angry, this may trigger a negative reaction in others. This can lead to depression and isolation.

The individual will learn to understand and modify their approach to interpersonal problems and acquire ways of managing them more constructively.

Psychodynamic therapy

Psychodynamic therapy addresses the ways in which past experiences, such as those during childhood, can impact a person’s current thoughts and behaviors. Often, the person is unaware that this influence is even present.

Identifying these influences can help people understand the source of feelings such as distress and anxiety. Once they identify these sources, the psychotherapist can help the person address them. This can help an individual feel more in control of their life.

It is similar to psychoanalysis but less intense.

Family therapy

Family therapy can provide a safe space for family members to:

  • express their views
  • explore difficult feelings
  • understand each other
  • build on existing strengths
  • find solutions to problems

This form of psychotherapy can be useful when problems stem from family relationships, or when a child or young person is facing difficulties.

In fact, one 2019 article suggests that family therapy may help adolescents with mental health problems. It may also improve family cohesion and enhance parenting skills.

Relationship therapy is another type of psychotherapy. It is very similar to family therapy, but a person may instead wish to present to therapy with their partner to address issues within a relationship.

Group therapy

Group therapy sessions usually involve one therapist and around 5–15 participants with similar concerns, such as:

The group will usually meet for 1 or 2 hours each week, and individuals may also attend one-on-one therapy.

People can benefit from interacting with the therapist but also by interacting with others who are experiencing similar challenges. Group members can also support each other.

Although participating in a group may seem intimidating, it can help people realize that they are not alone with their problem.

Online therapy

Many people are now opting for online therapy, otherwise known as telehealth. This can have many benefits, especially for someone who:

  • has mobility problems
  • cannot find a suitable specialist in their area
  • has difficulty fitting therapy into their schedule
  • does not feel comfortable with face-to-face communication

Tools include video meetings and messaging services.

Although online services have helped “normalize” psychotherapy, making it easier to integrate into daily life, a person should check carefully before choosing a provider.

For example, they should consider:

  • the qualifications and experience of the therapist
  • the online and other security measures the provider has in place
  • using a company that psychologists run and that has links with professional associations

Other types

There are many other types of psychotherapy, including:

Each person’s experience of psychotherapy will be different, and the time it takes to see an improvement will also vary.

Some people will notice a difference after around six to 12 sessions, while others may need ongoing treatment for several years.

Psychotherapy can help a person by:

  • giving them someone to explore their problem with confidentially
  • enabling them to see things in a new way
  • helping them move toward a solution
  • learn more about themselves and their goals and values
  • identify causes of tension in relationships
  • develop skills for facing challenges
  • overcome specific problems, such as a phobia

To benefit from the process, a person needs to:

  • have a desire to participate
  • engage actively in treatment
  • attend appointments and complete any assignments between sessions
  • be honest when describing symptoms and situations

Effectiveness can also depend on:

  • the reason for seeking therapy
  • the skill of the practitioner
  • the relationship between the therapist and the individual
  • any support the person may have outside the therapy sessions

A trusting relationship between the individual and the therapist is also essential to the process.

According to the American Psychological Association (APA), the qualities of a good therapist include such factors as:

  • having a developed set of interpersonal skills
  • taking time to build trust with the individual
  • having a treatment plan in place and keeping it flexible
  • monitoring the person’s progress
  • offering hope and realistic optimism
  • relying on research evidence

Choosing a suitable therapist

People seek psychotherapy for a wide range of reasons, and each individual is different. Providers should have training in dealing with a wide range of situations, but some can meet more specific needs.

For example, a practitioner may specialize in counseling for survivors of sexual abuse.

A person who has experienced trauma due to race , sexual orientation, or human trafficking, for example, will need to find someone who understands where the person is starting from. They will also need appropriate training.

After identifying a therapist who seems suitable, the individual should ask plenty of questions before starting therapy to make sure that this is the person they want.

A doctor, online community, or local support group can often recommend a suitable therapist.

Psychotherapy can offer many benefits, but there are some cautions to be aware of before starting. The following sections will outline these in more detail.

Unexpected effects

During psychotherapy, some people may experience changes they had not expected or did not want.

Recalling past events can sometimes trigger unwanted emotions. Addressing and resolving these emotions is an integral part of therapy, but it can be challenging.

It is essential to find a trusted and qualified psychotherapist who is skilled at guiding people through these situations in a constructive way.

Unhelpful therapy

Most people feel better as a result of therapy, but it can take time to work — and sometimes, the approach the therapist takes is not suitable. In fact, according to some research, around 10% of people feel worse after starting therapy.

Some experts have expressed concerns about potentially harmful therapies. These could be techniques that leave a person feeling worse rather than better or approaches that may actually slow an individual’s progress.

Some approaches may not have enough research evidence to support their use. In some cases, the approach or “chemistry” between the individual and the therapist may not be suitable.

However, if the practitioner monitors the person’s progress regularly and asks for feedback, the risk of therapy not working or having a negative impact will be lower.

Using an interpreter

Not everyone can find a psychotherapist who speaks their primary language. This can pose a challenge for people who are already at a disadvantage in society.

One option is to find an interpreter, but it is essential to find someone who understands the complex issues that treatment is likely to involve.

Ideally, the person should also have the skills and training necessary for managing the specific dynamics the relationship will involve.

Cost in time and money

Psychotherapy can be expensive and time consuming. This is another reason that it is essential to find a qualified practitioner.

If a health professional considers treatment necessary, the Mental Health Parity Act requires that insurance companies pay for mental healthcare in a similar way to paying for physical medical care.

It is worth noting that the definitions of “reasonable and appropriate” or “medically necessary” may vary.


Method

Data were drawn from the household component of the 1998 and the 2007 MEPS, which are subsamples of the National Health Interview Survey (NHIS) (10, 11). Both surveys were sponsored by the Agency for Healthcare Research and Quality to provide national estimates of the use of, expenditures on, and financing of health care services. These surveys were conducted as national probability samples of the U.S. noninstitutionalized civilian population and were designed to provide nationally representative estimates to be compared over time. All data elements in these analyses except the physician provider specialty variable were the same in the two surveys.

Samples

A total of 22,953 participants provided data for the entire 1998 survey year from two separate overlapping panels, each of which included three rounds of interviews. The full-year response rate was 67.9% after factoring in the effects of nonresponse to NHIS, nonresponse to the first round of MEPS, and survey attrition from both panels (10). A total of 29,730 participants provided data for the entire 2007 survey, the most recent available data, for a full-year response rate of 56.9% (11). For both surveys, a designated informant was queried about all related persons who lived in the household.

The Agency for Healthcare Research and Quality devised weights to adjust for the complex survey designs and yield unbiased national estimates. The sampling weights also adjust for non-response and poststratification to population totals based on U.S. census data. More detailed discussions of the design, sampling, and adjustment methods have been presented elsewhere (10, 11).

Structure of the Survey

The MEPS included a series of three in-person interviews during each study year. Respondents were asked to record medical events, as they occurred, in a calendar/diary that was reviewed in-person during each interview. Written permission was obtained from selected survey participants to contact the medical providers they mentioned during the survey to verify service use, charges, and sources and amounts of payments.

Mental health conditions.

The MEPS collected information on the diagnosis for each visit to hospital outpatient departments and office-based outpatient care. This information was coded in a manner that permitted classification according to ICD-9 categories by professional coders. The diagnoses associated with the psychotherapy visits were then grouped into the following mental health condition categories: schizophrenia and related disorders (codes 295, 297-299), depression and related mood disorders (codes 296.2, 296.3, 298.0, 300.4, 309.1, 311), anxiety disorders (codes 293.84, 300.0, 300.2, 300.3, 3008.3, 309.81), childhood disorders and mental retardation (codes 299, 312-315, 317-319, 307 [except 307.2 and 307.8]), adjustment disorders (codes 308 [except 308.3], 309.0, 309.1, 309.2, 309.4, 309.9), other mental disorders (codes 290-319 not specified above), and subsyndromal mental health-related conditions, including psychosocial circumstances (codes V40, V61, V62), sleep disturbance (780.5), malaise and fatigue (780.7), and nervousness (799.2). Separate variables classified emergency department visits and inpatient admissions with a diagnosis of a mental disorder (ICD-9-CM codes 290-319).

Psychotherapy.

The MEPS asked respondents what type of care was provided during each outpatient visit and whether it was from a mental health specialist or other health care provider, using a set of response categories that included “mental health counseling or psychotherapy.” Mental health counseling or psychotherapy is defined as “a treatment technique for certain forms of mental disorders relying principally on talk/conversation between the mental health professional and the patient.” It specifically includes “individual, family, and/or group therapies” (12). Visits for psychotherapy or mental health counseling are considered psychotherapy visits.

Psychotropic medications.

The MEPS surveys asked respondents about medications bought or otherwise obtained by survey participants during the survey year. Psychotropic medications were grouped by therapeutic class as antidepressants, antipsychotic medications, anxiolytics/hypnotics, stimulants, and mood stabilizers (the latter included lithium, lamotrigine, carbamaze-pine, and valproate or valproic acid for respondents who were not treated for seizure disorders [ICD-9-CM code 345]).

Providers.

The MEPS solicited information on the type of health care professionals providing treatment at each visit. We classified mental health providers of psychotherapy into three groups: social workers, psychologists, and psychiatrists. Information was not available in 1998 concerning psychotherapy visits provided by psychiatrists. A psychotherapy user was considered to have been treated by a given provider type if the user reported making one or more visits to that type during the survey year.

Expenditures and source of payment.

The MEPS data include sources of expenditures for each health care service. “Expenditures” refers to what is paid for the medical service and is defined as the sum of payments for each medical service that was obtained, including out-of-pocket payments and payments made by private insurance, Medicaid, Medicare, and other sources (10, 11). From these data, total expenditures were aggregated into outpatient medical care (outpatient visits and medications for all conditions), outpatient mental health care (outpatient visits and medications for mental health conditions), and outpatient psychotherapy. Summary variables were also constructed for six payment sources, including self-payment, private insurance, Medicaid, Medicare, other federal programs, and a residual group of other sources.

Analysis Plan

For each survey year, the percentage of persons using psychotherapy was computed overall and stratified by several sociodemographic characteristics. Trends were then examined by mental health condition group in the estimated national number of treated outpatients and their distribution with respect to treatment with psychotherapy but not psychotropic medication, psychotherapy and psychotropic medication, and psychotropic medication alone. The distributions of psychotherapy users were then examined by use of psychotropic medications, mental health provider groups, acute mental health service use, number of psychotherapy visits during the year, and self-assessed mental health status (excellent, very good, or good versus fair or poor). Among psychotherapy users, the mean number of psychotherapy visits in each survey year was compared overall and for psychotherapy users with and without psychotropic medication use as well as for those with good to excellent as compared with fair or poor self-rated mental health. In separate analyses, total national expenditures were estimated for all outpatient medical care, out-patient mental health care (outpatient visits for a mental disorder or condition), and psychotherapy. National psychotherapy expenditures were partitioned by payment source for the two survey years. The U.S. Consumer Price Index for medical care was used to adjust 1998 expenditures to 2007 dollars.

All statistical analyses were conducted using SAS, version 9.2 (SAS Institute, Cary, N.C.), using SURVEY procedures to accommodate the complex sample design and the weighting of observations. A series of logistic regressions, adjusted for age, sex, race/ethnicity, and insurance status, were performed to assess the strength of associations between year (with 1998 as the reference year) and psychotherapy use results are presented as adjusted odds ratios with 95% confidence intervals. Similar analyses were conducted with psychotherapy and psychotropic medication use as well as psycho-tropic medication use only as dependent variables. Linear regression was used to assess change in the number of psychotherapy visits per year among respondents reporting psychotherapy use, and z tests were used to evaluate changes in total national expenditures. All tests were two-sided, and alpha was set at 0.05.


Mental Health: Culture, Race, and Ethnicity: A Supplement to Mental Health: A Report of the Surgeon General.

To better understand what happens inside the clinical setting, this chapter looks outside. It reveals the diverse effects of culture and society on mental health, mental illness, and mental health services. This understanding is key to developing mental health services that are more responsive to the cultural and social contexts of racial and ethnic minorities.

With a seemingly endless range of subgroups and individual variations, culture is important because it bears upon what all people bring to the clinical setting. It can account for minor variations in how people communicate their symptoms and which ones they report. Some aspects of culture may also underlie culture-bound syndromes - sets of symptoms much more common in some societies than in others. More often, culture bears on whether people even seek help in the first place, what types of help they seek, what types of coping styles and social supports they have, and how much stigma they attach to mental illness. Culture also influences the meanings that people impart to their illness. Consumers of mental health services, whose cultures vary both between and within groups, naturally carry this diversity directly to the service setting.

The cultures of the clinician and the service system also factor into the clinical equation. Those cultures most visibly shape the interaction with the mental health consumer through diagnosis, treatment, and organization and financing of services. It is all too easy to lose sight of the importance of culture - until one leaves the country. Travelers from the United States, while visiting some distant frontier, may find themselves stranded in miscommunications and seemingly unorthodox treatments if they seek care for a sudden deterioration in their mental health.

Health and mental health care in the United States are embedded in Western science and medicine, which emphasize scientific inquiry and objective evidence. The self-correcting features of modern science - new methods, peer review, and openness to scrutiny through publication in professional journals - ensure that as knowledge is developed, it builds on, refines, and often replaces older theories and discoveries. The achievements of Western medicine have become the cornerstone of health care worldwide.

What follows are numerous examples of the ways in which culture influences mental health, mental illness, and mental health services. This chapter is meant to be illustrative, not exhaustive. It looks at the culture of the patient, the culture of the clinician, and the specialty in which the clinician works. With respect to the context of mental health services, the chapter deals with the organization, delivery, and financing of services, as well as with broader social issues - racism, discrimination, and poverty - which affect mental health.

Culture refers to a groups shared set of beliefs, norms, and values (Chapter 1). Because common social groupings (e.g., people who share a religion, youth who participate in the same sport, or adults trained in the same profession) have their own cultures, this chapter has separate sections on the culture of the patient as well as the culture of the clinician. Where cultural influences end and larger societal influences begin, there are contours not easily demarcated by social scientists. This chapter takes a broad view about the importance of both culture and society, yet recognizes that they overlap in ways that are difficult to disentangle through research.

What becomes clear is that culture and social contexts, while not the only determinants, shape the mental health of minorities and alter the types of mental health services they use. Cultural misunderstandings between patient and clinician, clinician bias, and the fragmentation of mental health services deter minorities from accessing and utilizing care and prevent them from receiving appropriate care. These possibilities intensify with the demographic trends highlighted at the end of the chapter.


Patients more likely to refuse drug therapy than psychotherapy for mental health

People seeking help for mental disorders are more likely to refuse or not complete the recommended treatment if it involves only psychotropic drugs, according to a review of research published by the American Psychological Association.

Researchers conducted a meta-analysis of 186 studies of patients seeking help for mental health issues that examined whether they accepted the treatment that was recommended and if they did, whether they completed it. Fifty-seven of the studies, comprising 6,693 patients, had a component that reported refusal of treatment recommendations, and 182 of the studies, comprising 17,891 patients, had a component reporting premature termination of treatment.

After diagnosis, patients in the studies were recommended to drug-only therapy (pharmacotherapy), talk therapy (psychotherapy) or a combination of the two.

"We found that rates of treatment refusal were about two times greater for pharmacotherapy alone compared with psychotherapy alone, particularly for the treatment of social anxiety disorder, depressive disorders and panic disorder," said lead researcher Joshua Swift, PhD, of Idaho State University. "Rates of premature termination of therapy were also higher for pharmacotherapy alone, compared with psychotherapy alone, particularly for anorexia/bulimia and depressive disorders."

The research was published in the APA journal Psychotherapy.

Across all the studies, the average treatment refusal rate was 8.2 percent. Patients who were offered pharmacotherapy alone were 1.76 times more likely to refuse treatment than patients who were offered psychotherapy alone. Once in treatment, the average premature termination rate was 21.9 percent, with patients on drug-only regimens 1.2 times more likely to drop out early. There was no significant difference for refusal or dropout rates between pharmacotherapy alone and combination treatments, or between psychotherapy alone and combination treatments.

While Swift said the findings overall were expected, the researchers were most surprised by how large the differences were for some disorders. For example, patients diagnosed with depressive disorders were 2.16 times more likely to refuse pharmacotherapy alone and patients with panic disorders were almost three times more likely to refuse pharmacotherapy alone.

The findings are especially interesting because, as a result of easier access, recent trends show that a greater percentage of mental health patients in the U.S. are engaging in pharmacotherapy than psychotherapy, according to co-author Roger Greenberg, PhD, SUNY Upstate Medical University.

Some experts have argued that psychotherapy should be the first treatment option for many mental health disorders. Those arguments have been largely based on good treatment outcomes for talk therapy with fewer side effects and lower relapse rates, said Greenberg. "Our findings support that argument, showing that clients are more likely to be willing to start and continue psychotherapy than pharmacotherapy."

Swift and Greenberg theorized that patients may be more willing to engage in psychotherapy because many individuals who experience mental health problems recognize that the source of their problems may not be entirely biological.

"Patients often desire an opportunity to talk with and work through their problems with a caring individual who might be able to help them better face their emotional experiences," said Greenberg. "Psychotropic medications may help a lot of people, and I think some do see them as a relatively easy and potentially quick fix, but I think others view their problems as more complex and worry that medications will only provide a temporary or surface level solution for the difficulties they are facing in their lives."

While the meta-analysis provides information on refusal and dropout rates, the studies did not report the patients' reasons for their actions, Swift noted. Going forward, research designed to identify these reasons could lead to additional strategies to improve initiation and completion rates for both therapies, he said. It is also important to note that participants in the research studies initially indicated they were willing to be assigned to any therapy, and therefore may not be representative of all consumers of treatment.


Discussion

We conducted the most complete meta-analysis, to our knowledge, of trials on IPT to date and identified 90 randomized trials on IPT for mental health disorders. Two-thirds of these studies were aimed at prevention, treatment, and relapse prevention of depression, showing a moderate-to-large effect on depression compared with control groups, with smaller effects in older adults, in clinical samples, and in samples meeting diagnostic criteria for a depressive disorder. IPT was not significantly more or less effective than other psychotherapies for depression. There were some indications that pharmacotherapy may be somewhat more effective than IPT for acute-phase depression however, this finding was not robust and may have been influenced by the high risk of bias in many of these trials. Combined treatment was significantly more effective than IPT alone but not more effective than pharmacotherapy alone. This should be considered with caution, however, because of the relatively small number of trials. These results are comparable to our earlier meta-analysis of studies on IPT for depression (3).

We found indications that IPT may prevent the onset of depressive disorders in subthreshold depression, which is in line with meta-analyses of this field (6, 39). However, the finding that IPT may prevent the onset of depressive disorders has not been established in earlier meta-analyses. These findings should be considered with caution because the number of trials on prevention was small, risk of bias was considerable, and the confidence intervals were broad.

The trials examining the effects of maintenance IPT on recurrence and relapse also revealed significant effects of IPT. But again, these findings were limited by the small number of trials, considerable risk of bias, and broad confidence intervals.

We also found that the outcomes of IPT in depression were associated with the number of sessions, with 10 or more sessions resulting in an increase of the effect size with g=0.2. Although results of such metaregression analyses are not causal evidence, this may indicate that 16-session IPT is more effective than the shorter interpersonal counseling, a finding that needs confirmation in future research.

The applications of IPT to other disorders emerged in response to symptoms and morbidity (e.g., binge eating, social anxiety) being bidirectionally linked with interpersonal stressors and the importance of social supports and relationships to health and resilience (40–42).

In the treatment of eating disorders and anxiety disorders, IPT has been used in numerous studies as an active comparison group. No earlier meta-analysis has examined the effects of IPT in these disorders. Overall, these studies showed no convincing evidence that CBT is more effective than IPT in anxiety disorders. In eating disorders, a small but significant effect in favor of CBT was found for behavioral outcomes, but because the number of studies was small and risk of bias was high, this is uncertain, and longer-term effects are not clear.

IPT trials for other mental health problems, including addictions and distress from general medical disorders, showed some promising effects. However, this should be considered with caution because of the high risk of bias in most trials and the insufficient number of trials.

This meta-analysis examined a broad range of mental health problems in a large number of patients using one treatment method, IPT. There are, however, limitations to the conclusions that can be drawn. The number of trials for several comparisons was too small to make reliable estimates of the effects, and heterogeneity was considerable in several analyses. Furthermore, risk of bias was high in the majority of trials, reducing the strength of the evidence considerably. However, when we limited the analyses to studies with low risk of bias, the outcomes were very comparable to those found for all studies. In addition, because only a small number of studies examined long-term follow-up outcomes and these follow-up periods differed, these outcomes could not be examined. Finally, the results of randomized trials may not be generalized to patients who are treated in routine care because of the exclusion criteria used in the trials. Although this problem has not been found to affect the outcome of these trials (43), these limitations should be kept in mind when interpreting the outcomes of our study.

In conclusion, IPT is one of the best-examined treatments in mental health problems, and it is effective in depression and possibly in other disorders, such as eating and anxiety disorders. It is important to have more than one treatment option for patients, since no treatment works for everyone, and IPT, with its focus on salient relational and interpersonal experiences, provides an important alternative to pharmacotherapy or CBT. IPT has the potential to be used more broadly for endemic mental health problems, as a preventative treatment, and to address the concomitant interpersonal stressors associated with the onset or worsening of disorders.

Dr. Cuijpers has received royalties from Atheneum Publishers, HB Publishers, and Servier speaking fees from the NVGRT, the University of Trier, Vanderbilt University, and the VGCt and grant support from the European Commission, the NutsOhra Foundation, and ZonMw. Dr. Weissman receives royalties from Perseus Press and Oxford University Press. Dr. Ravitz receives royalties from WW Norton. All other authors report no financial relationships with commercial interests.

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