Large improvement of mental health during in outpatient short-term group psychotherapy treatment—a naturalistic pre-/post-observational study

One of the most critical current public health challenges is to provide mental health interventions in ways that are effective, affordable, and have the potential for large-scale applications. The current World Health Organization “Mental Health Action Plan 2013–2030” highlights the central role of mental health in achieving health and equity for all people by providing universal health coverage. This agenda has to compete with high prevalence rates. For example, in EU countries, the latest estimates of the prevalence of mental disorders indicated having 17% of EU citizens suffer from mental disorders each year [1]. A recently published epidemiological survey of the adult population in Austria reported a 4.3–9.9% (2-week prevalence) and 15.6% (10-year prevalence) for depression, and 6.5% of anxiety disorders [2, 3]. In addition to the suffering mental impairment causes for those affected and their families, it also imposes economic and societal burden. It was estimated that in 2010 a total of up to 8.5 trillion US dollars in lost output could be attributed to mental health issues [4] and that anxiety and depression alone lead to a worldwide loss of more than 12 billion days of productivity each year [5]. A study published in 2020 reported 37% higher healthcare costs and twice as high total costs among individuals with major depressive disorder (MDD) compared to individuals without MDD in Austria, and lost productivity costs over 2.5-times higher for those with MDDs [6].

Psychotherapy has become a widely approved treatment intervention for mental disorders [7] and research in recent years has demonstrated the efficacy and efficiency of psychotherapy in multiple studies [8, 9]. The National Institute for Health and Care Excellence (NICE) guidelines consider psychotherapy even as less intrusive than psychopharmaceuticals and, thus, recommend it as the treatment of choice for anxiety disorders [10]. As for depression in outpatients, psychotherapy and pharmacotherapy were found to be equally efficacious in the short term, while psychotherapy showed superior outcomes in the long term [11]. Thus, psychotherapy is considered a key element in the treatment of mental health issues and is recommended as treatment in several treatment guidelines [12, 13].

Psychotherapeutic treatment usually consists of individual treatment based on cognitive–behavioral, interpersonal or psychodynamic approaches. Besides individual psychotherapy, several conceptualizations and manuals for group therapies have been developed over the last few decades. Psychotherapeutic group therapy usually includes six to twelve participants and either one or two psychotherapists. The groups can either have a closed format, i.e., a fixed number of participants and sessions or an open format, i.e., and ongoing group where patients can join at predefined timepoints [14]. Despite organizational challenges around group therapy, such as a difficulty to find appropriate rooms or, especially in rural areas, of finding a sufficient number of patients who want to participate, group psychotherapy has several advantages over individual therapy. For one, patients often find a sense of cohesion when sharing their experiences with others who are facing similar problems. In addition, the group setting offers more interpersonal feedback and allows an easier understanding of the relational problems patients often have to face outside the therapy setting too [14]. Research has shown that group therapy is an effective treatment for different mental health issues, including anxiety and depression [15‐17]. A recent review suggested that group psychotherapy was equally effective in reducing a patient’s psychological distress and symptoms than individual psychotherapy [18].

In Austria, group therapy is most frequently applied in inpatient settings, e.g., inpatient psychotherapy wards or inpatient rehabilitation centers, while outpatients usually receive psychotherapy in the individual setting. In contrast to Germany, psychotherapy is usually not covered by the general health insurance in Austria [19]. However, the local health insurance providers in each federal state have developed financial support systems for patients in their region. As these models are largely underfunded, patients have long waiting periods or must pay for their psychotherapy out of pocket [20]. A recent study of > 6000 patients from a psychosomatic rehabilitation center in Austria showed that less than half of the patients had received funding from their health insurance. The majority of patients who self-financed psychotherapy paid more than 50–100 € per session, while a third of this sample earned less than 1000 € a month [20]. This clearly shows that psychotherapy is still a scarce good for many patients in need in Austria. To meet this demand, the regional health care provider of the federal state of Tyrol (ÖGK Tirol) launched a pilot project for cost-free group therapy in association with the Tyrolean Regional Association of Psychotherapy (TLP) starting in spring 2018. The present study aims to provide data on the effectiveness of the group therapy project in improving mental health of participating patients.

A total of 98 patients completed the questionnaires at T0 and were thus included in the study. A mean number of 8 patients (range 5–12 patients) per group participated in therapy. The vast majority of patients were female (> 70%), between 40–60 years, and living with their partner and/or children. Most patients were assigned to the group psychotherapy treatment by a psychotherapist (n = 37; 37.8%), a hospital (n = 21; 21.4%), or a psychiatrist (n = 19; 19.4%) and about two thirds had a pre-existing psychiatric diagnosis (n = 67; 68.4%). While 70 (71.4%) patients had experiences with individual psychotherapy, only 39 (39.8%) had previously taken part in group psychotherapy. For details see Table 1.

In this naturalistic study based on real-world data, we aimed to investigate to what extent short-term group psychotherapy reduced psychological distress in outpatients with various mental health problems. In line with previous research, we found improvements with large effect sizes for depression, anxiety, and somatization.

At baseline, almost 60% of the patients fulfilled the criteria for a depressive disorder and almost 50% for somatization and alcohol abuse. These findings are consistent with epidemiological research in Austria, which found especially depression and alcohol abuse to be highly prevalent in the general population [3]. Depression is a major health risk and has been associated with decreased quality of life [24] and quality-adjusted life years (QALYs) [25], and even higher mortality [26]. Depression is also strongly linked to substance abuse and drinking patterns [27]. The consumption of alcohol is culturally broadly accepted in Austria, and there is a tendency to belittle the multiple toxic side effects of alcohol abuse. These include an increased risk for physical comorbidities such as infectious diseases, cancer, diabetes or cardiovascular disease, problems in interpersonal relationships and the workplace, lower capacity to deal with aggression, and an increased risk for economic and legal problems [28].

We could observe a substantially reduced level of anxiety, depression, and somatization in our sample by the end of the group therapy. While before treatment, about two-thirds of the sample reported moderate to severe symptoms of depression, by the end of treatment, the rates were inversed, with two-thirds of patients reporting none or only mild symptoms of depression. Our results align with previous research that found large effect sizes for major symptom clusters such as anxiety or depression [18]. In contrast to previous findings [29], group size was not associated with treatment outcome, i.e., indicating that patients in smaller and larger groups benefitted equally from the treatment. Since the treatment duration was slightly longer for larger groups, this could possibly have compensated the group size effect. However, it has to be mentioned that no substantial changes in substance abuse were observed in our sample. A probable explanation might be that substance abuse was often a secondary problem resulting from other issues—such as depression or anxiety—and patients focused on their primary burden in the treatment. It might be worthwhile to offer separate groups addressing substance abuse in the future to achieve better outcomes in this clinical population.

In our sample, a substantially larger proportion of female patients participated in group therapy. This is in line with previous studies which reported gender differences in the prevalence of various mental disorders [30, 31]. In addition, men are less likely to seek psychological help than women and are less open to report problems or feelings of insufficiency than women [32]. Ogrodniczuk and Oliffe [33] point out that men may often face challenges in overcoming their cultural norms that prevent them from revealing themselves, which can lead to isolation, distress, and diminished self-awareness. While this may be especially true for psychotherapeutic groups, the evidence on gender-related differences in uptake of group therapy is scarce and merits further research. In contrast to previous research [34], in our study gender was not associated with therapy outcome, neither for anxiety, depression nor somatization, indicating that both men and women equally profited from group psychotherapy.

Patients also reported a significantly improved subjective working ability. While there is some indication that psychotherapy can lead to long-term improvement of patients’ working ability [35], to our knowledge, no study has investigated this for short-term group psychotherapy. Our results thus indicate that group psychotherapy effectively decreases mental health problems and increases the patient’s quality of life, while being relatively cost effective [15]. While cost-saving should never be the leading argument in patient care, is undeniable an important variable to argue for the implementation of therapeutic interventions into clinical practice.

In this naturalistic observational study, large improvements in anxiety, depression, and somatization were observed during a short-term group psychotherapy treatment for patients with mixed mental health issues. Group psychotherapy is an effective and cost-efficient way to improve the quality of life of individuals with mental health issues. Based on our findings, we consider group psychotherapy an essential and valuable treatment and strongly recommend providing free access to group therapy for people with mental health problems.