Short-term, Intensive Psychodynamic Group Therapy Versus Cognitive-behavioral Group Therapy in the Day Treatment of Anxiety Disorders and Comorbid Depressive or Personality Disorders

Anxiety disorders are among the most prevalent mental disorders, with lifetime prevalence of 30% in US (Kessler et al., 2005) and only 9,9% in Poland (Moskalewicz, Wciórka, Kiejna, Wojtyniak, 2012), the study of the similar methodology, like in the U.S. Many studies suggest their strong comorbidity with personality disorders in some countries. Recent meta-analysis of 125 studies conducted by Friborg, Martinussen, Kaiser, Overgård and Rosenvinge (2013) has shown that a risk of comorbid anxiety disorders and personality disorders varies from 35% to 52%. Alongside anxiety disorders, the most frequently co-occurring are cluster C personality disorders. Epidemiologic studies also show high comorbidity rates for anxiety and depressive disorders, ranging from 40%-80% (Jacobi et al., 2004; Lamers et al., 2011). The data on relationships between comorbid mental disorders and treatment outcome is inconsistent. Reviews by Reich and Green (1991) and Reich and Vasile (1993) including 38 studies have shown that comorbid anxiety disorders and personality disorders are negatively related to treatment outcome. However, Dressen and Arntz (1997) after analyzing 15 studies do not share these conclusions.

Day treatment care is directed precisely to the patients who need treatment of a greater intensity and cannot be treated in outpatient care. Group psychotherapy (often used together with pharmacotherapy) is employed in day care since the 1940s (cf. Cameron 1947; Goldman, 1989). This form of therapy is chosen on economic basis. The treatment usually takes place a few days a week and lasts for several months. Different types of psychotherapy or different treatment methods (e.g. therapeutic community, psychodrama, art therapy, psycho-drawing, movie therapy, social skills training) are often applied together. In Poland, group psychotherapy is widely used in day care. Nowadays 300 such wards exist in Poland. Psychotherapy for anxiety disorders and personality disorders lasting for few months (most often three months) is provided for approximately 8000 patients a year (IPIN, 2009).

The effectiveness of day care is investigated to a very small degree, compared to its frequent usage (cf. Marshall et al 2001). However, difficulties in identifying the basic effective components of the treatment and a large diversity of treatment programs make it difficult to generalize the results.

Among a scarce number of published studies, only four were randomized controlled trials (RCT). Three of these studies compared psychotherapy in day care units to outpatient psychotherapy (Tyler et al., 1987; Dick et al., 1991; Arnevik et al., 2009) and one study used a waiting list control group (Piper, Rosie, Azim, & Joyce, 1993). Tyler et al. (1987) found no significant differences between day care and outpatient care for anxiety disorders. Dick et al. (1991) found a significant difference in the improvement of personality disorder pathology, in favor of day care. In the first study psychotherapy modality was not mentioned, in the second an eclectic psychotherapy was applied. In another study Arnevik et al. (2009), day care (18 week group psychodynamic and cognitive-behavioral psychotherapy) was compared to individual psychotherapy in patients with personality disorders and no significant differences in improvement were observed between the two groups. Piper et al. (1993) found that day care patients suffering from affective disorders and personality disorders experienced a significant improvement that continued in follow-up after 8 months (18 week group psychodynamic psychotherapy), compared to patients in a waiting list control group. Authors of a Cochrane review of day care versus outpatient care notice that because of a small number of existing studies: "there is only limited evidence to justify the provision of day treatment programs and transitional day hospital care, and no evidence to support the provision of day care centers" (Marshall et al. 2001). Existing data is therefore not sufficient to justify the use of group psychotherapy in day care, and more high quality research is needed. The question of which treatment of the two most widely used, psychodynamic or CBT, is more effective also awaits an answer. These questions are relevant in light of the large expenditures incurred by the national health funds financing the treatment. They are also important for the health care in Poland, where this type of treatment is very common.

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