Few studies have explored the effectiveness of short-term psychodynamic psychotherapy in children and adolescents. We aimed to investigate its efficacy in a heterogeneous group of young patients. We also wanted to check any relation between the improvement and patients’ age, sex, or diagnostic category.
We recruited a group of 123 patients (11 to 19 years old) with a diagnosis of psychiatric disorders confirmed by Kiddie Schedule for Affective Disorders and Schizophrenia (KSADS). All participants received eight sessions of psychodynamic psychotherapy (“Brief Individuation Psychotherapy” by Senise). They were assessed using the Clinical Global Impression (Severity at baseline, Improvement after treatment), and the Children’s Global Assessment Scale (C-GAS).
We found a clinically meaningful improvement in most patients (CGI-I 3 or lower; 79 out of 123, 64.2%) and a statistically significant improvement in the overall functioning (as measured by the C-GAS; p<0.001). We found no effect of age or sex of the patient on results obtained; patients with an externalizing disorder had significantly poorer results.
Our study, although lacking a control group, supports the possibility to use short-term psychodynamic psychotherapy in the treatment of psychiatric disorders in preadolescents and adolescents affected by psychiatric disorders.
Psychodynamic psychotherapy has been considered not to be an evidence-based treatment due to lack of studies confirming its utility and to its excessive duration; this in turn prevented it to be included as recommended treatment for quite a long time, although over the years it proved to be an effective therapy in the treatment of many disorders [
Only recently, strong scientific evidence of the success of psychodynamic psychotherapy in the treatment of depression in childhood and adolescence has led to the inclusion of psychodynamic therapy in the English NICE Guidelines as a recommended treatment for moderate to severe depression [
A problem which has been reported for years is the duration of original psychodynamic psychotherapy, which made it too long and expensive for the public health system. At present, a few studies support the effectiveness of short-term psychodynamic psychotherapy in the treatment of psychological disorders in adulthood [
Considering that psychopathological disorders in childhood and adolescence are increasingly recognized [
Given this framework, we aimed to investigate the efficacy of short-term psychodynamic psychotherapy in a heterogeneous group of young patients, using validated observational scales that measure the severity of disease, the overall functioning of patients and the improvement of their disease after the treatment. We also wanted to check if the improvement was related to patient’s age, sex, or diagnostic category.
We hypothesized that taking part in a cycle of psychodynamic psychotherapy, even of short duration, could produce an improvement in the overall functioning of preadolescent and adolescent patients and an improvement in their symptoms. Moreover, we would expect patients diagnosed with internalizing disorders to better respond to psychotherapeutic treatment, independently of age or sex [
We recruited 123 preadolescents and adolescents (61 females and 62 males; mean age=14.9 years, SD=1.79; SEM=0.16; age range: 11–19 years, extremes included) seen at the Child Neurology and Psychiatry Unit of the IRCCS Mondino Foundation in Pavia, Italy, between 2017 and 2018.
Patients younger than 11 years old or older than 19 years old, with insufficient comprehension of the Italian language or with an established diagnosis of intellectual disability were excluded. In accordance with guidelines and recent evidence, patients taking drug therapy were not excluded. In our sample, 3.33% assumed benzodiazepines, 3.33% antidepressants, 3.33% antipsychotic drugs, 0.8% mood stabilizers.
We collected data within a larger project named “Study of prognosis and possible predictors of outcome in a population of adolescent patients with psychosis, attenuated psychosis and not psychotic psychiatric disorders,” authorized in 2017 by the Ethical Committee of Policlinico San Matteo in Pavia, Italy (P20170028892). We followed the code of good ethical practice and the ethical standards of The Declaration of Helsinki (1964) and its later amendments. All patients and their families gave their written informed consent to participate in the study and were free to retreat in any moment. We informed participant that data would have been used for research purposes only and we would have anonymized them to protect privacy.
We started with an evaluation phase which included meetings with patient and his/her family, to collect family and medical history through clinical interviews and diagnostic analysis. At baseline (T0) clinician or psychotherapist compiled two scales to assess the severity of the disease (CGI-S) and the patient’s global functioning (C-GAS). After the assessment, every participant underwent a cycle of manualized psychotherapy based on the model of “Brief Individuation Psychotherapy” by Tommaso Senise [
To confirm the diagnosis, psychologists or child neuropsychiatrists conducted with both children/adolescents and their parents/caregivers the Kiddie Schedule for Affective Disorders and Schizophrenia (KSADS) [
To assess the progress of patients’ conditions, clinician or psychotherapist filled in the:
One of the most widely used rapid assessment scales in psychiatry, both in the field of research and clinic. It measures the severity of the disease (CGI-Severity), the improvement or overall change of the patient (CGI-Improvement), and the therapeutic response. The evaluation of severity of the patient’s conditions must be expressed at each visit, including the first one, assigning scores from 1 (normal, not at all ill) to 7 (among the most extremely ill patients). The improvement assessment must be made during every visit after baseline choosing a score from 1 (very much improved) to 7 (very much worse). Each section of this scale is assessed separately and does not have an overall score.
This is a useful scale for the evaluation of the patient’s overall functioning. It provides a measure of the overall severity coded in 10 ranges from the lowest 1–10 (need for constant supervision as a consequence of self-destructive behaviour or dominated by important aggression, or a serious impairment of reality analysis, communication, cognitive, emotional or personal hygiene level) to the highest 91–100 (superior functioning in every area of daily life, both at home and at school and in relations with peers, involvement in a wide range of activities, presence of numerous interests, daily concerns constantly under control, good school performance, absence of symptoms). This scale is simple to compile and is characterized by excellent psychometric properties [
Evaluators shared assessment results with clinician or psychotherapist prior to treatment. At T0 clinician or psychotherapist compiled CGI-Severity and CGAS. After eight sessions of psychotherapy [
Analyses were conducted using IBM SPSS Version 21 for Windows (IBM Corp., Armonk, NY, USA). After assessing descriptive statistics for each variable, a preliminary one-sample Kolmogorov-Smirnov test for normality was computed. Paired sample t-test was used to assess differences for normally distributed variables comparing the same subjects before and after treatment, while Spearman correlation coefficient was used to assess correlations involving ordinal variables.
The sample included 123 preadolescents and adolescents (49.59% females) from 11 to 19 years old, with a mean age of 14.9 (SD=1.79; SEM=0.16). No patient dropped out of research before the end.
The most frequent diagnosis within the sample was internalizing disorders, and most participants received an evaluation of disease severity from 3 to 5 at baseline (
There was a statistically significant improvement in the overall functioning of patients after psychotherapeutic treatment measured with C-GAS [t(122)=-6.79, p<0.001] (
We found no significant correlations between diagnosis and age or sex. In the same way, improvement score (CGI-I) did not correlate with age or sex. We found however a significant correlation between diagnostic category and improvement (r=0.185, p=0.041), as patients diagnosed with externalizing problems seemed to improve significantly less than the others (average CGI-I score 3.70±0.73 for externalizing disorders, versus an average of the other groups being 2.79±1.06 without statistically significant differences between the other diagnostic groups).
In our sample, internalizing disorders were, as also found in the Italian and international literature, those most diagnosed, followed by externalizing problems, mixed ones, and psychotic disorders [
Unlike other studies that found differences in prevalence due to age and gender [
Moreover, our first hypothesis was confirmed. A group of youth of various ages was considered so as not to deprive anyone of treatment. To address the inhomogeneity of the sample, statistical analyses were conducted for paired samples, and, according to our findings, most of participants had an improvement in their mental health condition from minimal to considerable after treatment. In line with this, the scale used to evaluate the global functioning of patients (C-GAS) showed a statistically significant improvement in the overall functioning, as previously proven in adult patients affected by common mental disorders [
Regarding the second hypothesis, despite some studies that stated that younger children [
This study has limitations, in fact future research could include participants from other regions and a control group in order to confirm our findings and to test their strength. In this study, we could not have a control group because the setting was that of a research-action study (i.e., we had to balance research with clinical practice). Furthermore, we hope that future studies could also compare the evidence collected by clinicians with the perception of change from the point of view of patients and their families, e.g., using self-report questionnaires. The fact that our sample was quite heterogeneous represents a limitation on one hand, but also a positive aspect as it resembles real-life clinical practice. Moreover, future research should include a longer follow up to assess stability of obtained changes.
The datasets generated or analyzed during the current study are available in the Zenodo repository, DOI: 10.5281/zenodo.4956736.
The authors have no potential conflicts of interest to disclose.
Conceptualization: Martina Maria Mensi, Matteo Chiappedi. Data curation: Marika Orlandi, Chiara Rogantini. Formal analysis: Matteo Chiappedi. Investigation: Marika Orlandi, Chiara Rogantini. Methodology: Martina Maria Mensi, Matteo Chiappedi, Renato Borgatti. Project administration: Marika Orlandi, Chiara Rogantini. Supervision: Martina Maria Mensi, Matteo Chiappedi, Renato Borgatti. Writing—original draft: Marika Orlandi, Chiara Rogantini. Writing—review & editing: Marika Orlandi, Chiara Rogantin, Matteo Chiappedi. All authors have read and agreed to the present version of the manuscript.
None
C-GAS scores improvement from T0 to T1. C-GAS, Children’s Global Assessment Scale.
Descriptive analysis for global functioning (at baseline and posttreatment) and severity of disease (at baseline and post-treatment)
C-GAS T0 | CGI-S T0 | C-GAS T1 | CGI-I T1 | |
---|---|---|---|---|
M | 56.41 | 3.98 | 62.78 | 2.94 |
SD | 17.05 | 1.32 | 17.30 | 1.09 |
SEM | 1.54 | 0.12 | 1.56 | 0.10 |
C-GAS, Children’s Global Assessment Scale; CGI-S, Clinical Global Impression-Status; CGI-I, Clinical Global Impression-Improvement; M, mean; SD, standard deviation; SEM, standard error of the mean
Frequencies and percentages of diagnosis and disease severity scores at T0
Frequency (N=123), % | |
---|---|
Diagnosis | |
0=No diagnoses | 0 (0) |
1=Psychotic disorders | 5 (4.1) |
2=Internalizing disorders | 70 (56.9) |
3=Externalizing disorders | 20 (16.3) |
4=Mixed disorders | 28 (22.8) |
CGI-S T0 | |
0=Not assessed | 0 (0) |
1=Normal, not at all ill | 4 (3.2) |
2=Borderline mentally ill | 13 (10.6) |
3=Mildly ill | 22 (17.9) |
4=Moderately ill | 46 (37.4) |
5=Markedly ill | 21 (17.1) |
6=Severely ill | 14 (11.4) |
7=Among the most extremely ill patients | 3 (2.4) |
CGI-S, Clinical Global Impression-Status
Frequencies and percentages of improvement scores at T1
Frequency (N=123), % | |
---|---|
CGI-I | |
1=Very much improved | 13 (10.6) |
2=Much improved | 26 (21.1) |
3=Minimally improved | 40 (32.5) |
4=No change | 39 (31.7) |
5=Minimally worse | 5 (4.1) |
6=Much worse | 0 (0) |
7=Very much worse | 0 (0) |
CGI-I, Clinical Global Impression-Improvement