When a person is prescribed a medication, he or she receives instructions about how much to take (dose) and how often to take it. Dose and frequency may vary depending on the severity of the condition being treated. The length of time a person takes the medicine also depends on the condition and its severity. Should we think about psychotherapy the same way in terms of dose and frequency of administration? Rigorous studies have shown that specific psychotherapies are beneficial in treating specific conditions. Should the dosing parameters of such psychotherapies be studied? Would some therapies be just as effective when administered at high doses over short periods of time as with the more common regimen of weekly sessions over 3 to 4 months or longer?
A recent study by Anke Ehlers and colleagues in the American Journal of Psychiatry demonstrates that intensive (high-dose, short-term) cognitive therapy (CT) is as effective as lower-dose, longer-term CT in treating patients with post-traumatic stress disorder (PTSD). CT is an evidenced-based psychotherapy that focuses on teaching patients how to modify dysfunctional thoughts.
In this study, intensive CT consisted of approximately 18 hours of treatment administered over 5 to 7 days. Up to 2 additional sessions were conducted one week and one month later in order to go over homework assignments and discuss progress. Standard CT therapy involved weekly sessions for about 3 months. Booster sessions after 3, 4, and 5 months were an option for both the intensive CT and standard CT groups. By the end of the study, about the same number of sessions had been administered in the 2 CT groups (10 regular and 2 booster sessions).
Participants in the study included 121 patients suffering from PTSD. The study was restricted to people whose PTSD was linked to 1 or 2 discrete traumatic events experienced during adulthood. The most common of these events involved interpersonal violence, accidents, or disasters. The investigators assessed improvement of PTSD symptoms with standardized interview instruments and self-report assessments. In addition, changes in anxiety and depression symptoms were examined along with changes in disability and quality of life.
The results of this study demonstrated that intensive, short-term CT for PTSD worked as well as the more standard course of therapy. The amount of improvement was similar for both groups and persisted at least until the end of the 40-week study period. The intensive treatment led to more rapid improvement. Both forms of CT worked substantially better than weekly sessions of emotion-focused supportive treatment, and all three forms of therapy were better in reducing symptoms than no treatment at all.
If these results are replicated by other investigators, this work would have important implications. Many people with PTSD might prefer short-term, intensive therapy. Those with jobs might find it easier to take a week off for an intensive course of therapy, especially if this would lead to more rapid improvement. Also, intensive, short-term therapy might be more efficient and, therefore, less expensive. Would intensive therapy help military personnel with PTSD? Would it be more effective to administer an intense brief course of therapy closer to the time of the stressor? These are important questions that deserve study.
CT is effective for a large number of psychiatric conditions. Would other psychiatric conditions that have been shown to respond to conventional CT also respond to brief, intensive therapy? Patients with such conditions might find it more acceptable to receive intense treatment over a shorter period of time.
If treatment response to intense therapy is more rapid, would such an approach complement medications in those patients with conditions that would benefit from a combination of CT and medications? Would a week of intensive therapy help a person improve more rapidly than medication alone?
Some might feel that talking about psychotherapies in terms of dose and frequency detracts from the nature of therapy. We believe that it is important to take advantage of current clinical research data in order to best implement effective therapeutic approaches. This becomes even more important in an era of constrained health care reimbursement and substantial psychiatric need in the population.
This column was written by Eugene Rubin MD, PhD and Charles Zorumski MD.