Targets and outcomes of psychotherapies for mental disorders: an overview

Abstract

It is not yet clear what mental disorders are and what are the causal pathways that lead to them. That makes it difficult to decide what the targets and outcomes of psychotherapies should be. In this paper, the main types of targets and outcomes of psychotherapies are described, and a brief overview is provided of some of the main results of research on these types. These include symptom reduction, personal targets and outcomes from the patient's perspective, improvement of quality of life, intermediate outcomes depending on the theoretical framework of the therapist, negative outcomes to be avoided, and economic outcomes. In line with the dominance of the DSM and ICD systems for diagnoses, most research has been focused on symptom reduction. This considerable body of research, with hundreds of randomized trials, has shown that for most mental disorders effective psychotherapies are available. There is also research showing that psychotherapies can result in improvement of quality of life in most mental disorders. However, relatively little research is available on patient‐defined outcomes, intermediate outcomes, negative outcomes and economic outcomes. Patients, relatives, therapists, employers, health care providers and society at large each have their own perspectives on targets and outcomes of psychotherapies. The perspective of patients should have more priority in research, and a standardization of outcome measures across trials is much needed.

Moderation, mediation, and moderated mediation

“…P. Cuijpers links a focus on symptom reduction in psychotherapy research to the omnipresence of diagnostic systems such as DSM and ICD that are based on symptom clusters. However, diagnostic systems come and go, usually in an upward spiral.…”

What is “evidence” in psychotherapies?

“…Evidence‐based psychotherapies are commonly conceptualized as a three‐legged stool. One leg comprises the best available evidence bearing on the efficacy (beneficial effects in rigorously controlled conditions) and effectiveness (beneficial effects in real‐world conditions); the other two comprise clinical expertise and patient preferences/values (see Cuijpers in this issue of the journal).…”

“…Nevertheless, most evidence‐based guidelines, including those for ESTs, overlook the possibility of harm. One challenge to addressing this omission is that many psychotherapy studies rely on unipolar outcome measures, which range from no improvement to substantial improvement; they must instead administer bipolar outcome measures, which can detect patient deterioration during and after treatment.…”

Outcomes help map out evidence in an uncertain terrain, but they are relative

“…It is a testament to P. Cuijpers' intellectual courage that he opens his paper by stating that we do not really know what we mean by “mental disorder” , and that we are not sure about what really constitutes a psychological treatment or underpins its effectiveness. He ends by pointing out that the outcomes of whatever we are treating with whatever means we have all depend upon the perspective we take, whether we are a patient, a clinician or anyone else.…”

“…Although the goal of treatment is to make patients “better” (or to help them cope with their problems), precisely what “better” means, and when we can reliably claim we have achieved this, is definitely less clear. This is partly because the “nature and causes of [mental] disorders are unclear”; and partly, I would add, because, like beauty, getting “better” is in the eye of the beholder.…”