Long-term Psychodynamic Psychotherapy Research Articles

Therapeutic immediacy across long-term psychodynamic psychotherapy: An evidence-based case study.

C. E. Hill (2004) recently developed the concept of therapist immediacy to capture discussion by the therapist about the therapeutic relationship that occurs in the here-and-now of a therapy session. This concept has been expanded to include discussion about the therapeutic relationship by both the client and therapist, captured by the term therapeutic immediacy (K. Kuutmann & M. Hilsenroth, 2011). Although prior research has examined the use of therapeutic immediacy across short-term treatment, the present study is the first to examine the use of immediacy across a long-term (4 years) psychotherapy. Also, this is the first study to assess the interrater reliability of therapeutic immediacy, which was found to achieve good to excellent levels across raters. The most frequently used categories of client and therapist immediacy are presented. Finally, the authors provide an in-depth qualitative examination of 5 therapeutic immediacy segments across the treatment judged by the raters to have high levels of depth/intensity (4.5 or higher out of 5) to examine the role of therapeutic immediacy in exploring meaningful treatment issues. Clinical utility, potential limitations, and future research on therapeutic immediacy are discussed.

P-1153 - The effectiveness of short- and long-term psychotherapy during a 7-year follow-up

Introduction The majority of studies on the effectiveness of psychotherapy have reported results for relatively short follow-up times. Aims In this study the effectiveness of short- and long-term psychotherapy was compared during a very long follow-up. Methods A total of 326 psychiatric outpatients with mood or anxiety disorder were randomly assigned to solution-focused therapy (12 sessions), short-term psychodynamic (20 sessions) and long-term psychodynamic psychotherapy (240 sessions) in Helsinki Psychotherapy Study. The patients were followed from start of treatment and assessed 11 times during a 7-year follow-up. Symptom Check List (anxiety, depression, and general symptom scale), Work-subscale of the Social Adjustment Scale, and use of auxiliary treatment (psychotherapy, psychotropic medication, and psychiatric hospitalization) were used as outcome measures. Results A reduction in psychiatric symptoms and improvement in work ability and functional capacity was noted in all treatment groups. The short-term therapies were more effective than long-term psychotherapy during the first year, whereas the long-term therapy was more effective after 3 years of follow-up. No significant differences were observed between long- and short-term therapies during the 4 last years of follow-up.A total of 80% of the patients in the short-term therapy groups and 60% in the long-term therapy group used auxiliary treatment. Conclusions Short-term psychotherapy gives faster benefits than long-term psychotherapy, but in the long run no notable differences in symptoms or working ability are seen. Considerably auxiliary treatments are taken after the end of the intervention implying further need of treatment. These findings should be repeated in other populations.

Supervised team management, with or without structured psychotherapy, in heavy users of a mental health service with borderline personality disorder: a two-year follow-up preliminary randomized study

BackgroundIndividuals affected by severe Borderline Personality Disorder (BPD) are often heavy users of Mental Health Services (MHS). Short-term treatments currently used in BPD therapy are useful to target disruptive behaviors but they are less effective in reducing heavy MHS use. Therefore, alternative short-term treatments, less complex than long-term psychodynamic psychotherapies but specifically oriented to BPD core problems, need to be developed to reduce MHS overuse. This study aimed to evaluate the efficacy of adding Sequential Brief Adlerian Psychodynamic Psychotherapy (SB-APP) to Supervised Team Management (STM) in BPD treatment compared to STM alone in a naturalistic group of heavy MHS users with BPD. Effectiveness was evaluated 6 times along a two-year follow-up.MethodsThirty-five outpatients who met inclusion criteria were randomly assigned to two treatment groups (STM = 17; SB-APP = 18) and then compared. Clinical Global Impression (CGI) and CGI-modified (CGI-M) for BPD, Global Assessment of Functioning (GAF), State-Trait Anger Expression Inventory (STAXI), and Symptom Checklist-90 Revised (SCL-90-R) were administered at T1, T3, T6, T12, T18 and T24. At T12 the Working Alliance Inventory-Short Form (WAI-S) was also completed. At the one-year follow-up, SB-APP group did not receive any additional individual psychological support. MHS team was specifically trained in BPD treatment and had regular supervisions.ResultsAll patients improved on CGI, GAF, and STAXI scores after 6 and 12 months, independently of treatment received. SB-APP group showed better outcome on impulsivity, suicide attempts, chronic feelings of emptiness, and disturbed relationships. We found a good stabilization at the one year follow-up, even after the interruption of brief psychotherapy in the SB-APP group.ConclusionsAlthough STM for BPD applied to heavy MHS users was effective in reducing symptoms and improving their global functioning, adding a time-limited and focused psychotherapy was found to achieve a better outcome. In particular, focusing treatment on patients' personality with a specific psychotherapeutic approach (i.e. SB-APP) seemed to be more effective than STM alone.Trial RegistrationClinicalTrials.gov: NCT1356069

Use of auxiliary psychiatric treatment during a 5-year follow-up among patients receiving short- or long-term psychotherapy

The need for treatment is, despite of its obvious usefulness, a scarcely used measure of effectiveness in psychotherapy trials. This study considers changes in the need for auxiliary psychiatric treatment after starting short- and long-term psychotherapy and psychoanalysis. Altogether 326 psychiatric outpatients with mood or anxiety disorder were randomly assigned to solution-focused therapy (SFT), short-term psychodynamic psychotherapy (SPP), or long-term psychodynamic psychotherapy (LPP) while 41 self-selected patients were allocated to psychoanalysis (PA). The patients were followed for 5 years from start of treatment. Outcome measures were use of auxiliary psychotherapy, psychotropic medication, and hospitalization for mental reasons. About 60% of the patients used auxiliary treatment during the follow-up. It was most common in the short-term therapy groups and its incidence was highest during the first year after the start of therapy. The average numbers of all therapy sessions among patients starting the therapy were 60, 70, 240, and 670 in SFT, SPP, LPP, and PA, respectively, whereas the corresponding average numbers of study therapy sessions alone were 10, 19, 232, and 646. Over 50% of the patients receiving short-term therapy received on average 4-6 times more therapy sessions than initially assigned. Post-randomization withdrawal was uneven. Auxiliary treatment is usual among patients receiving short- and long-term therapies, and apparently becomes common shortly after the start of treatment. Auxiliary treatment can be used as an outcome measure indicating the need for treatment, should be monitored clinically and considered when interpreting the results of effectiveness studies.

Clinical Social Work and Evidence-Based Practice: An Introduction to the Special Issue

We are very pleased to have been asked to coordinate this special issue of the Clinical Social Work Journal, oriented around the general topic of evidence-based practice (EBP). EBP has aroused considerable interest, optimism, and some controversy within our field since it was first introduced into social work by Gambrill (1999). A PsycINFO search we completed in June 2011, using ‘‘social work’’ AND ‘‘evidence-based practice’’, appearing in abstracts published during the past 5 years (2006–2010), found twice as many citations than a similar search using ‘‘social work’’ AND ‘‘psychotherapy’’ as key words. This suggests the remarkable influence the EBP process has exerted within our disciplinary literature in recent years. Working closely with this journal’s Editor, Dr. Carol Tosone, we were able to solicit the collection of papers you now find within these pages, some from proponents of EBP and others from individuals more cautious about this relatively new approach. We are grateful to these authors for providing their contributions to this topic and to Dr. Tosone for supporting this project. The impetus for our undertaking this special issue was the publication of Leichsenring and Rabung’s (2008) metaanalysis of the effectiveness of long term psychodynamic psychotherapy (LTPP) in the prestigious journal JAMA (formerly known as the Journal of the American Medical Association). These authors examined 23 different psychotherapy outcome studies that involved the provision of psychodynamic psychotherapy for at least 1 year, in the context of a published quasi-experimental or randomized clinical trial. These studies included a total over 1,000 patients who received LTPP, and the major finding was said that LTPP was significantly superior to shorter-term methods of psychotherapy. Subsequent reader responses in Letters to the Editor published in JAMA and a critical analysis (Bhar et al. 2010) indicate that this article generated considerable controversy and some of its findings were called into question. In some ways however, the accuracy of Leichsenring and Rabung’s (2008) conclusions are not as significant as is the very fact that LTPP proved to be amenable to meta-analysis, however imperfect. Coupled with the publication of a related randomized controlled trial on psychoanalytic psychotherapy for panic disorder (Milrod et al. 2007) and a systematic review on the effectiveness of long-term psychoanalytic therapy (De Maat et al. 2009), such studies put to rest the oft-heard contention that the methodological tools of outcome studies and clinical trials are inherently deficient tools to dissect and isolate the presumptively subtle effects of relationship-oriented psychotherapies (e.g., Thorpe and Baker 1959; Pharis 1976; Richardson 2001). Such outcome studies can be done well and there is a rather substantial literature in this area, studies of gradually increasing rigor and methodological sophistication. Clearly, psychodynamic psychotherapy is amenable to credible scientific appraisal, in terms of its effects, and ultimately, mechanisms of action. Any therapy that is contended to help improve client well-being is fair game for scientific investigation, to the extent it makes testable claims relating to outcomes and enhanced functioning. Of course findings obtained under carefully controlled trial conditions need to replicated under clinically representative circumstances, with heterogeneous clients and clinicians of diverse backgrounds, and steps are also being undertaken in this direction, by social workers (e.g., Roseborough 2006; B. A. Thyer (&) M. Pignotti College of Social Work, Florida State University, 296 Champions Way, Tallahassee, FL 32306, USA e-mail: Bthyer@fsu.edu

Long-term psychodynamic psychotherapy in complex mental disorders: update of a meta-analysis

Dose-effect relationship data suggest that short-term psychotherapy is insufficient for many patients with chronic distress or personality disorders (complex mental disorders). To examine the comparative efficacy of long-term psychodynamic psychotherapy (LTPP) in complex mental disorders. We conducted a meta-analysis of controlled trials of LTPP fulfilling the following inclusion criteria: therapy lasting for at least a year or 50 sessions; active comparison conditions; prospective design; reliable and valid outcome measures; treatments terminated. Ten studies with 971 patients were included. Between-group effect sizes in favour of LTPP compared with less intensive (lower dose) forms of psychotherapy ranged between 0.44 and 0.68. Results suggest that LTPP is superior to less intensive forms of psychotherapy in complex mental disorders. Further research on long-term psychotherapy is needed, not only for psychodynamic psychotherapy, but also for other therapies.

Changes in self and object representations following psychotherapy measured by a theory-free, computational, semantic space method

We propose a theory-neutral, computational and data-driven method for assessing changes in semantic content of object representations following long-term psychodynamic psychotherapy. Young adults in psychotherapy are compared with an age-matched, non-clinical sample at three time points. Verbatim transcripts of descriptions of the self and parents were quantified in a semantic space constructed by Latent Semantic Analysis. In the psychotherapy group, all representations changed from baseline to follow-up, whereas no comparable changes could be observed in the comparison group. The semantic space method supports the hypothesis that long-term psychodynamic psychotherapy contributes to sustained change of affective-cognitive schemas of self and others.

A Clinician-Researcher’s Understanding of “The Effectiveness of Long-Term Psychodynamic Psychotherapy”

Leichsenring and Rabung’s meta-analysis of long-term psychodynamic psychotherapy offers a useful summary of available research data. Their adaptation of meta-analysis has many merits as well as some important limitations. Their work provides preliminary support for the effectiveness of this therapy, a widely used method of treatment that also has detractors. The article also sets the stage for reviewing how the research ideology of evidence-based practice (EBP), and the economic forces behinds EBP, may limit research on several therapeutic methods of interest to clinical social workers and our clients. A call is made for additional high quality research on many therapies with considerable research support that may not (yet) meet the standards of EBP.

Psychodynamic Group Psychotherapy: Impact of Group Length and Therapist Professional Characteristics on Development of Therapeutic Alliance

Little research has been done on therapeutic alliance in group psychotherapy, especially the impact of treatment duration and therapist professional characteristics. Therapeutic alliance was rated by patients on the Working Alliance Inventory-Short Form at three time points (sessions 3, 10 and 17) in a randomized controlled trial of short-term and long-term psychodynamic group psychotherapy. As predictors we selected therapist clinical experience and length of didactic training, which have demonstrated ambiguous results in previous research. Linear latent variable growth curve models (structural equation modeling) were developed for the three Working Alliance Inventory-Short Form subscales bond, task and goal. We found a significant variance in individual growth curves (intercepts and slopes) but no differential development due to group length. Longer therapist formal training had a negative impact on early values of subscale task in both treatments. There was an interaction between length of the therapists' clinical experience and group length on early bond, task and goal: therapists with longer clinical experience were rated lower on initial bond in the long-term group but less so in the short-term group. Longer clinical experience influenced initial task and goal positively in the short-term group but was unimportant for task or significantly negative for goal in the long-term group. There was no mean development of alliance, and group length did not differentially impact the alliance during 6 months. Early ratings of the three Working Alliance Inventory-Short Form subscales partly reflected different preparations of patients in the two group formats, partly therapist characteristics, but more research is needed to see how these aspects impact alliance development and outcome. Therapists should pay attention to all three aspects of the alliance, when they prepare patients for group therapy. In psychodynamic groups, length of therapy does not differentiate the overall level or the development of member-leader alliance. Within psychodynamic groups, each individual appear to have their unique perception of the member-leader alliance. Therapists with longer formal psychotherapy training may be less successful in establishing early agreement with patients on the tasks of psychodynamic group psychotherapy. Patients perceive a somewhat lower degree of early emotional bonding with the more clinically experienced therapists in long-term psychodynamics groups. Therapists with more clinical experience may contribute to a stronger degree of initial agreement with patients on the tasks and goals of short-term group psychotherapy.

Outcomes of psychotherapy from the perspective of the users

Psychotherapy is widely held to be an effective means to decrease depression. It seems, however, that not everyone benefits from every kind of therapy, and the relevant outcomes vary from person to person. In this article, the pre-therapy views and post-therapy experiences of 14 users of either long-term psychodynamic psychotherapy or short-term solution-focused therapy are analyzed. The interviewees’ personal views about their depression and therapy are approached with the concept of inner narrative. Three “basic stories” or orientations were found: life historical, situational and moral. These offered people different contexts from which to evaluate the outcomes of their therapy. The findings suggest that a person's expectations, hopes and values are worth taking into account to ensure positive therapy outcomes.

Quasi-experimental study on the effectiveness of psychoanalysis, long-term and short-term psychotherapy on psychiatric symptoms, work ability and functional capacity during a 5-year follow-up

BackgroundPsychotherapy is apparently an insufficient treatment for some patients with mood or anxiety disorder. In this study the effectiveness of short-term and long-term psychotherapies was compared with that of psychoanalysis. MethodsA total of 326 psychiatric outpatients with mood or anxiety disorder were randomly assigned to solution-focused therapy, short-term psychodynamic and long-term psychodynamic psychotherapies. Additionally, 41 patients suitable for psychoanalysis were included in the study. The patients were followed from the start of the treatment and assessed 9 times during a 5-year follow-up. The primary outcome measures on symptoms were the Beck Depression Inventory, the Hamilton Depression and Anxiety Rating Scales, and the Symptom Check List, anxiety scale. Primary work ability and functional capacity measures were the Work Ability Index, the Work-subscale of the Social Adjustment Scale, and the Perceived Psychological Functioning Scale. ResultsA reduction in psychiatric symptoms and improvement in work ability and functional capacity was noted in all treatment groups during the 5-year follow-up. The short-term therapies were more effective than psychoanalysis during the first year, whereas the long-term therapy was more effective after 3years of follow-up. Psychoanalysis was most effective at the 5-year follow-up, which also marked the end of the psychoanalysis. ConclusionsPsychotherapy gives faster benefits than psychoanalysis, but in the long run psychoanalysis seems to be more effective. Results from trials, among patients suitable for psychoanalysis and with longer follow-up, are needed before firm conclusions about the relative effectiveness of psychoanalysis and psychotherapy in the treatment of mood and anxiety disorders can be drawn.

Psychoanalysis for Depression and Anxiety in the Long Run

The effectiveness of psychoanalysis is less studied than that of other psychotherapies. These researchers randomized 326 outpatients with depressive or anxiety disorders (86% with mood disorders) to solution-focused therapy (SFT; every 2–3 weeks; maximum, 12 sessions), short-term psychodynamic psychotherapy (SPP; 20 weekly sessions), or long-term psychodynamic psychotherapy (LPP; 2–3 sessions weekly for 3 years). The investigators examined symptoms and ability …

Is there room for criticism of studies of psychodynamic psychotherapy?

Comments on the original article, "The efficacy of psychodynamic psychotherapy," by J. Shedler (see record 2010-02208-012). Shedler declared unequivocally that "empirical evidence supports the efficacy of psychodynamic therapy" (p. 98). He did not mention any specific criticisms that have been made of evidence on psychodynamic psychotherapies or address possible distinctions between evidence for short-term versus long-term psychodynamic psychotherapies. Instead, he attributed dissenting views to biases in evidence dissemination and review, which he suggested are rooted in a "lingering distaste in the mental health professions professions for past psychoanalytic arrogance and authority" related to a "hierarchical medical establishment that denied training to non-MDs and adopted a dismissive stance toward research" (Shedler, 2010, p. 98). Shedler (2010) justified his blanket dismissal of criticisms of evidence supporting psychodynamic psychotherapy on the basis of several published meta-analyses. The validity of conclusions from metaanalyses depends on the quality of the evidence synthesized, the nature of the studies included, and the rigor of the statistical analyses employed. Many meta-analyses, however, are not performed rigorously, which can result in treatment efficacy estimates that obscure important intertrial differences and that are unlikely to be replicated in clinical practice.

Making Sense of Meta-Analysis: A Critique of “Effectiveness of Long-Term Psychodynamic Psychotherapy”

Evidence-based practice depends in part on knowledge derived from relevant research. For any given topic, there are likely to be many, potentially relevant studies; a careful appraisal and synthesis of the results of these studies is needed to understand the state of the empirical evidence. Meta-analysis is widely used to combine results of quantitative studies; yet this method is unfamiliar to many people and, as a result, meta-analyses are often uncritically accepted. In this article, we argue that meta-analysis is only one component of a good research synthesis. We critique a recent metaanalysis on the effectiveness of long-term psychodynamic psychotherapy, showing that this metaanalysis failed to meet current standards for the conduct and reporting of systematic research reviews and meta-analyses. We demonstrate the use of AMSTAR, a straightforward tool for assessing the quality of systematic reviews and meta-analyses.

Mixing Apples and Oranges and Other Methodological Problems with a Meta-Analysis of Long Term Psychodynamic Psychotherapy

Current trends in mental health practice indicate that mental health practitioners, including clinical social workers, are tending to move away from psychodynamic approaches and are favoring short-term empirically supported approaches such as cognitive-behavioral therapy (CBT). Recently, the presumption that long-term psychodynamic psychotherapy (LTPP) approaches lack empirical support has been challenged, however, with the publication in major peer reviewed journals of meta-analyses that are claimed to demonstrate its equality to or superiority over empirically supported short-term therapies for some conditions. The present article examines the methodology employed in one particular meta-analysis which compared LTPP to short term therapies and the studies upon which the analysis was based. We found that major methodological and statistical flaws with the meta-analysis and with the individual studies preclude drawing any conclusions regarding the efficacy of LTPP.

P03-111 - Influence of psychodynamic group oriented psychotherapy on quality of life in patients with psychotic disorders

ObjectivesGroup psychotherapy along with psychopharmacological therapy and sociotherapy is an important and frequently applied therapeutic method. Numerous studies indicate that group psychotherapy affects the functioning in patients with psychotic disorders in terms of improving the cognitive, emotional and social functioning and generally contributes to a better quality of life (Kanas, 1996).The aim of this study was to assess the impact of psychodynamic oriented group psychotherapy on the quality of life in patients with psychotic disorders and to compare the obtained results with the results of patients with psychotic disorders who did not participate in psychodynamic group psychotherapy.MethodPatients included in this study have completed psychotherapy group five years ago and were in regular outpatient treatment together with regular application of medication therapy. The applied method was Quality of Life Scale (Krizmanić, Kolesarić). Answers were analyzed qualitatively and quantitatively.ResultsThe quality of life in the group of patients who completed long-term psychodynamic group psychotherapy was better than in the group of patients who were not treated in that manner, although there are no statistically significant differences. The most important differences were in the area of intimacy, professional occupation and in the area of family relations.ConclusionIt can be concluded that long-term psychodynamic group psychotherapy has a positive influence on quality of life of patients with psychotic disorders.

P02-363 - Changes in cognitive functioning during group psychodynamic psychotherapy with young psychotic patients

ObjectivesCognitive impairment is considered to be one of the central features of schizophrenia and it has been so since original descriptions of illness by Kraepelin and Bleuler. Deficits are already present at the first-episode of illness. Some researches conclude that deficits do not change over time, while others suggest that deficits can be reduced. The objective of this research is comparison of cognitive functions of psychotic patients who participated group psychotherapy with those ho did not.MethodIn this paper, by means of Revised Beta Examination (measure of non-verbal intellectual ability) we observe changes in cognitive functioning of 29 psychotic patients who participated in the psychodynamic group psychotherapy within the Early Interventions Program and compare their cognitive achievements with results of matched 32 psychotic patients who received “treatment as usual”. Answers were analyzed qualitatively and quantitatively.ResultsImprovement in cognitive functions was observed in both investigated and control group, but improvement in patients who are participants of long-term psychodynamic group psychotherapy was better than in the group of patients who were not treated in that manner with statistical significance.ConclusionsPsychiatric hospital “Sveti Ivan” offers an extensive outpatient Early Intervention Program for psychotic patients in the critical period of their illness - up to five years from onset. The program includes psychoeducation workshops for the patients and their family members together, group psychodynamic psychotherapy for the patients and group psychotherapy for the family members. Our results indicate better effectiveness of Program when compared to “treatment as usual”.

Schlusswort: Wie müsste eine aussagekräftige Metaanalyse zur psychodynamischen Langzeittherapie gestaltet sein?

In their answer to our critical evaluation of their meta-analysis about long-term psychodynamic psychotherapy (LTPP), Leichsenring and Rabung claim that all our critical points could be rejected. This is surprising, as the authors already confirmed different shortcomings of their analysis. Our major criticism is that the meta-analysis is based on very few high-quality studies (including follow-up assessments), but on many studies with poor quality and/or observational studies resulting in serious publication bias. Neither the treatment of interest (LTPP) nor the target group is sufficiently circumscribed, but the very few studies are misinterpreted as if confirming efficacy of all psychodynamic interventions for nearly all psychiatric groups. Superior efficacy over other effective psychological interventions is mentioned, although not justified by data. Patient selection bias which is a major issue in long-term treatments is not addressed adequately and led to erroneous conclusions that the more treatment people receive, the higher the benefit. To conclude, the authors try to suggest far-reaching conclusions which are only based on a few studies with poor data quality.

Zur Wirksamkeit psychodynamischer Langzeittherapie bei komplexen psychischen Störungen

Rief and Hofmann (Nervenarzt 80:593-597) criticize in a very detailed comment our meta-analysis of long-term psychodynamic psychotherapy (JAMA 300:1551-1565). Although our article clearly included information that our meta-analysis addressed long-term psychodynamic psychotherapy of at least 50 sessions or at least 1 year duration, Rief and Hofmann allege that we studied "psychoanalysis" or "long-term psychoanalysis". Then they "show" for some of the studies we included that these studies did not address "psychoanalysis" or "long-term psychoanalysis" - which they did indeed not, but had never been claimed by us. For all other points of criticism put forward by the authors we show that they are not tenable as well. In addition, we show that Rief and Hofmann use omissions and allegations that give the impression that we deliberately violated principles of good scientific practice. This is reputation-damaging behaviour that clearly goes beyond a scientific discussion among researchers and constitutes a special act which itself violates the principles of good scientific practice.

Changes in lifestyle for psychiatric patients three years after the start of short- and long-term psychodynamic psychotherapy and solution-focused therapy

Objectives Lifestyle is less favourable among individuals suffering from psychiatric disorders. We studied whether psychotherapy brings along changes in lifestyle and whether these changes differ between short-term and long-term psychodynamic psychotherapy (SPP and LPP) and solution-focused therapy (SFT). Methods A total of 326 outpatients, 20–46 years of age, with mood or anxiety disorder were randomly assigned to LPP, SPP and SFT. The lifestyle variables considered were alcohol consumption, smoking, body mass index (BMI), leisure time exercise and serum cholesterol. The patients were monitored for three years from the start of treatment. Results During the three-year follow-up, BMI and serum cholesterol rose statistically significantly although no statistically significant trends were shown for alcohol consumption, smoking or exercise. SPP showed a disadvantage of increased alcohol consumption and serum cholesterol level when compared with LPP. SFT showed an advantage of reduced smoking in comparison with SPP. Discussion Small therapy-specific changes in lifestyle may be a result from psychotherapy treatment. These lifestyle changes are apparently more common in short-term therapy. More studies are needed to verify these findings.