Background
Depression is the largest contributor to the burden of disease in high-income countries, with further increase expected [
1]. Depression may not respond to outpatient treatment and may be so severe that hospital stay may be needed [
2,
3]. Patients with severe symptoms benefit more from acute inpatient treatment than from day-hospital care [
4]. Symptom improvement during first inpatient treatment is a significant predictor of the cumulative length of inpatient stay and the number of inpatient episodes over five years [
5]. Those results are consistent with more recent literature that recommends an intensive inpatient acute treatment of depression [
3,
6].
Due to the shift of locus of mental health care in most Western countries towards outpatient care, research on role and content of acute intensive inpatient psychiatric care have received limited attention [
7]. The vast majority of depressed inpatients receive pharmacotherapy, but receive psychotherapy less frequently [
8‐
10]. Several meta-analyses support the advantage of combining pharmacotherapy and psychotherapy to treat outpatients with severe or complex depressive disorders [
11‐
15]. The only review of combined therapy for depressed inpatients concluded that combined treatment appeared advantageous in therapy-resistant, chronic and severe forms of depressive disorders [
16]. Its generalizability is limited by relatively small sample sizes and heterogeneity in diagnosis of depression, though. The best well-controlled study available in this field of research compared interpersonal psychotherapy and pharmacotherapy vs. pharmacotherapy and clinical management for 124 inpatients with major depressive disorder. This randomized controlled trial showed that inpatient depression-specific psychotherapy augmented pharmacotherapy [
6].
Meta-analysis and mega-analysis findings support the efficacy of brief psychodynamic therapy for outpatient with depression [
17‐
19]. While yet unsufficient, research on efficacy and effectiveness of psychodynamic psychotherapy as a inpatient treatment of depression gives some indications to foster examination of its validity. In a review of 9 German studies, inpatient psychotherapy, mostly psychodynamic, demonstrated good efficacy (average effect size, d = 0.84). Depression and obsessive-compulsive disorders showed the best results, but usually for psychotherapies of longer duration [
20]. One cohort study on a sample of 83 consecutive inpatients examined the outcomes of short-term psychodynamic inpatient psychotherapy. Over the course of the 4 weeks of treatment, distress returned to normal range for 64% of patients and remained stable one year later [
21]. This study had two major limitations. It was a complete analysis and it did not compare the treatment to a valid comparator. Based on a randomized control trial with a two parallel group design, one study explored the efficacy of an interpersonal brief (5 weeks) and intensive (15 individual and 8 group sessions) psychotherapy program combined with pharmacotherapy compared to medication and clinical management. Response rate (70% vs 51%) and remission rate (49% vs. 34%) were higher for psychotherapeutic group at discharge; after the three-month follow-up the relapse rate (3% vs. 25%) also favored the psychotherapeutic group; finally between treatment effect sizes evolved from moderate (at discharge) to large during the follow-up period (3 and 12 months) [
6]. Results for a subsample of 45 patients with chronic depression revealed also a significantly greater reduction of depressive symptoms, as well as better global functioning [
6,
22].
Little systematic research has been conducted into the ideal dosage of brief psychotherapy. Evidence come from the outpatient setting. Between 12 and 18 sessions of therapy are required for 50% of patients to improve, according to a clinical significance perspective [
23]. The Second Sheffield Psychotherapy Project found that 16 sessions were significantly more effective than 8 sessions for patients with severe depression [
24]. The nature of the change aimed at should be taken into account, however [
23]. Recovery from maladaptive interpersonal patterns, for example, typically requires higher doses of psychotherapy than does recovery from symptoms of depression or broader distress [
25]. Changes at four weeks of inpatient psychotherapy are equivalent to a one-year follow-up for psychological distress but not for interpersonal problems [
6,
26].
Inpatient psychiatric treatment has been under great economic pressure to cut costs with the result of decrease in length of stay [
27,
28]. The brevity of inpatient stay has lead to discard psychotherapy and hindered examination of its potential cost-effectiveness. Research in outpatient care has found that although the cost of combination therapy in the initial treatment is substantially higher, these costs are in part offset by lower subsequent treatment costs [
29‐
31]. Improvement during the acute phase of treatment is important because it is associated with lower subsequent costs across the full range of mental health and general medical services [
32]. Currently there is no study done on the economicity of inpatient psychotherapy for depression.
In summary, current state of research support the need for well-controlled trials to examine the effectiveness and cost-effectiveness of inpatient acute treatment of depression, including adjunctive brief dynamic therapy to augment pharmacological treatment.
Objectives
The first purpose of the study is to estimate the relative efficacy of combined inpatient brief psychodynamic psychotherapy (IBPP) and pharmacotherapy compared to medication and clinical management on short- and long-term outcomes of inpatients with severe, recurrent or chronic depression (including so-called treatment-resistant) according to the DSM-IVTR. The second objective is to study the cost-effectiveness and the cost-utility of the IBPP. The third objective is to document the specific and the combined influence of the therapeutic alliance with the individual psychotherapist and with the clinical team as mediators of patient’s change.
Discussion
Despite the large number of studies on treatment of depression, there is a clear lack of controlled research in inpatient psychotherapy during the acute phase of a major depressive episode. Research on brief therapy is important to take into account current short lengths of stay in psychiatry. The current study has the potential to scientifically inform appropriate inpatient treatment. Psychodynamic psychotherapy has shown some promising signs of efficacy but more controlled studies are strongly needed in order to be empirically validated [
65]. This is a very important issue, at least for European countries like Switzerland, France or Germany where psychoanalytic psychotherapy remains the most practiced form of therapy. It may also provide indications of appropriate inpatient treatment to countries where inpatient psychiatric research has become difficult due to economic pressure. As for antidepressant drugs and various types of psychotherapy, psychodynamic psychotherapy is unlikely to be a universal therapy for depression and progress depends on identifying its most appropriate ecological niche [
66].
This study is the first to address the issue of the economic evaluation of inpatient psychotherapy. Psychotherapy is costly in time and money; thus evidence of the cost-effectiveness and cost-utility of a short adjunctive psychotherapy as an alternative treatment to longer hospitalization or outpatient aftercare would be an important healthcare finding.
The project has a direct impact on the functioning of the inpatient clinical unit. The implementation of a manualized practice (for psychotherapy and psychiatric treatment-as-usual) will help to improve the organization of the inpatient care and to better structure the clinicians’ training.
Strengths and limitations
This research has notable strength in its randomized controlled design. It compares the intervention to the state-of-the-art inpatient treatment of depression [
10]. Treatments are manualized and adherence to the psychotherapy is monitored. Most important potential confounders predicting depression outcome are assessed. Despite these strengths, this research has some important limitations. It doesn’t compare the intervention to another active treatment. The intervention is added to the treatment-as-usual. One might argue that patient in the intervention arm will get more therapeutic attention. However, from a quantitative point of view, 12 hours of therapy over 4 weeks of hospitalisation doesn’t add much of therapeutic attention. Furthermore, we believe it would be unethical to compare psychotherapy and clinical management to medication and clinical management. First, medication and clinical management is probably the most used treatment for inpatients with major depressive episode. Second, evidence suggest that a combined treatment is recommended for severe depression [
6,
18]. The 12-month follow-up is naturalistic. Most patients will benefit of ongoing pharmacological and/or psychotherapeutic treatment in both groups after hospital discharged.
Future research
Within a total health care delivery system, it is important to optimize the integration of inpatient and outpatient services. The next step in this project will be to select patients according to their response to the inpatient treatment and control for the outpatient psychotherapeutic after-care, as this has been neglected up till now [
21].
From a research perspective, if some evidence that IBPP is effective were to be found, it would then be interesting to have a better understanding of the processes by which IBPP achieves its results. The data gathered in this trial will constitute a “gold mine” for process-outcome studies in psychodynamic psychotherapy.
Acknowledgements
This study is funded by a grant of the Swiss National Science Foundation (Grant No 32003B-135098). The Foundation has peer-reviewed and approved the present protocol in the process of grant application. The funding is non-commercial. The funding body has no role in study design; the collection, analysis, and interpretation of data; the writing of the manuscript; or the decision to submit this manuscript for publication.
We acknowledge the dedicated psychotherapists, psychiatry residents and nursing staff for making this research possible. We thank the study participants for their involvement in the trial. We also thank the IBPP research team involved in the study: Ms Claudia Meystre, Ms Diana Ortega, Ms Christelle Gay, Mr Laurent Berthoud and the casual research staff. We especially thank Dr N. de Coulon whose involvement in supervision and in the development of the psychotherapy were invaluable.
Competing interests
All authors declare that: (1) No author has support for the submitted work; (2) Authors have no relationships that might have an interest in the submitted work in the previous 3 years; (3) their spouses, partners, or children have no financial relationships that may be relevant to the submitted work; and (4) Authors have no non-financial interests that may be relevant to the submitted work.
Authors’ contributions
JND had the idea of the research. YdR, JND and GA jointly formulated the research question. YdR, JND, GA and MP collaboratively developed the design and implemented the trial. JND and MP assured the strategic coordination of the project, while GA coordinated research and clinical teams. YdR wrote the research protocol and GA drafted the manuscript of this article. MP drafted the manual for pharmacotherapy. GA drafted the manual for psychotherapy. YdR defined the statistical methods. YdR supervised data collection and data entry. All authors read and approved the manuscript.