Guideline-Based Psychotherapy of Children and Adolescents in Germany
Frequency, Treatment Modalities, and Duration of Treatment
; ; ; ;
The prevalence of emotional and behavioral disorders in children and adolescents (2 to 18 years old) is given as almost 18% in a meta-analysis of 34 studies for Germany (1). For almost all mental disorders in children and adolescents, psychotherapy based on guidelines (i.e., psychotherapy in accordance with the German Federal Joint Committee’s “Guideline on the Implementation of Psychotherapy”) is an essential component of guideline-based treatment (2). However, data on the use and duration of guideline-based psychotherapy (GPT) in children and adolescents are largely lacking or are only available in a generalized format (3).
This work is based on nationwide, contract physician billing data from the associations of statutory health insurance physicians in Germany according to Section 295 SGB V. Data were made available by the German Central Institute for Statutory Health Insurance Physicians (Zi). With regard to the use of GPT, persons aged 0 to 19 years with statutory health insurance and with at least one billing case in 2019 were considered (N = 13.37 million persons). A detailed account of the methodology is given in Jaite et al. (4), which examined the use of psychotherapeutic services in the broadest sense.
To determine the number of therapy hours, GPTs were considered that ended in 2019, had started in 2010 or later, for a patient younger than 20 years at the start of therapy, and that took place in an individual setting without a change in procedure. A total of 68,351 patients were examined (male, 42.9%; female, 56.0%; other/unknown, 1.1%).
Use of therapy
In 2019, 1.4% of all children/adolescents with statutory health insurance received GPT. Overall, only minor regional differences were found (new versus old federal states, 1.5% versus 1.4%; urban versus rural residential regions, 1.5% versus 1.3%). However, there were strong frequency differences between the individual districts (city of Suhl, 2.8%; district of Deggendorf, 0.6%). Among insured persons, the use of GPT was slightly higher for girls/female adolescents than for boys/male adolescents (1.6% versus 1.2%). The 15- to 19-year-olds received GPT the most frequently (2.5%), and 0- to 4-year-olds, the least frequently (0%). Children/adolescents with obsessive-compulsive disorders were most frequently treated with GPT (24.1% of all insured persons with this diagnosis), followed by children/adolescents with depressive disorders (18.2%) and adjustment disorders (14.2%) (Figure 1).
Therapy methods and service providers
For children/adolescents who received GPT, behavioral therapy was used most frequently (56.7%), followed by depth psychological psychotherapy (35.2%) and psychoanalysis (9.5%) (Figure 1). Most children/adolescents were treated by child and adolescent psychotherapists (total, 87.0%; behavioral therapy, 86.7%; depth psychology, 85.1%; psychoanalysis, 96.8%).
Duration of therapy
There were clear differences in the number of therapy hours depending on the respective psychotherapy method. By far the most therapy hours received were in the context of psychoanalytic GPT (mean value [mean]: 54.4 hours; standard deviation [SD]: 56.1), followed by depth psychology GPT (mean: 37.1; SD: 38.5) and behavioral therapy (mean, 27.1; SD: 22.7). Across all GPT procedures, the number of hours was highest in Berlin (mean: 40.1; SD: 39.0) and lowest in Mecklenburg-Western Pomerania (mean: 25.8; SD: 24.2) (Figure 2). Overall, only marginal gender differences in the number of therapy hours were observed. Irrespective of the therapy method, children aged 5 to 9 received the most therapy hours (mean: 36.6; SD: 36.2). With respect to diagnoses, children/adolescents with dissociative disorders (mean: 43.4; SD: 40.8), elimination disorders (mean: 41.4; SD: 41.0), and personality disorders (mean: 39.7; SD: 38.2) received the most therapy sessions.
The main results of this work are:
- The use of GPT is significantly below the prevalence of mental disorders in children and adolescents, which suggests an undersupply of GPT. Long GPT waiting times (17.8 weeks on average in 2018 ) support this perception. However, it must be taken into account that many other psychotherapeutic services are used in addition to GPT in everyday care (4); for these other methods, there is only little evidence of effectiveness.
- Overall, there are only minor regional differences in Germany in terms of GPT utilization. This can be seen as an indicator of a fundamentally balanced supply of care.
- The most frequent service providers were child and adolescent psychotherapists, which can also be attributed to the creation of new contract doctor offices for this professional group.
- Behavioral therapy was the most commonly used therapy method. This corresponds to the current body of evidence, which is strongest for behavioral therapy and comparatively weak for psychoanalysis/psychodynamic therapies (2). In this context, it is worth mentioning that psychoanalytic treatments have a higher number of hours than behavioral therapies, which is to be viewed critically in view of the weaker evidence base for them.
- The proportion of GPT was highest in children/adolescents with obsessive-compulsive disorder, which could be explained (at least in part) by the high risk of chronification of this disorder.
- In contrast to the distribution of its use, the average number of therapy hours showed significantly greater regional differences. Further analyses are necessary to analyze the influence of supply structures; however, that is out of the scope of this study.
The present study is based on secondary data, for which various limitations apply. The validity of the coded diagnoses cannot be checked; it is not possible to differentiate between main and secondary diagnoses; and information on possible pharmacotherapy is also missing. Conclusions on the appropriateness of psychotherapeutic care, especially in the case of adjustment disorders, are vague; this is also due to the fact that diagnoses of adjustment disorders are very heterogeneous in nature, and psychotherapeutic care is difficult to evaluate for such a collective category.
Charlotte Jaite*, Anja Seidel*, Falk Hoffmann, Fritz Mattejat, Christian J. Bachmann
*The authors share co-first authorship
Department of Child and Adolescent Psychiatry, University of Ulm, Ulm, Germany; Department of Child and Adolescent Psychiatry, Medical University of Vienna, Vienna, Austria; firstname.lastname@example.org
Department of Child and Adolescent Psychiatry, Psychosomatics and Psychotherapy, Charité – Universitätsmedizin Berlin, Berlin, Germany (Jaite)
Department “Data Science and Health Service Analysis”, Central Research Institute of Ambulatory Health Care in Germany (Zi), Berlin, Germany (Seidel)
Department of Health Services Research, School of Medicine and Health Sciences, Carl von Ossietzky University Oldenburg, Oldenburg, Germany (Hoffmann)
Institut für Verhaltenstherapie und Verhaltensmedizin (IVV), Philipps-University Marburg, Marburg, Germany (Mattejat)
Conflict of interest statement:
The authors declare that no conflict of interest exists.
Manuscript received on 22 November 2021, revised version accepted on 11 January 2022
Translated from the original German by Veronica A. Raker, PhD.
Cite this as:
Jaite C, Seidel A, Hoffmann F, Mattejat F, Bachmann CJ: Guideline-based psychotherapy of children and adolescents in Germany—frequency, treatment modalities, and duration of treatment. Dtsch Arztebl Int 2022; 119: 132–3. DOI: 10.3238/arztebl.m2022.0106
17 December 2021).
|1.||Barkmann C, Schulte-Markwort M: Prevalence of emotional and behavioural disorders in German children and adolescents: a meta-analysis. J Epidemiol Community Health 2012; 66: 194–203 CrossRefMEDLINE|
|2.||Midgley N, Mortimer R, Cirasola A, Batra P, Kennedy E: The evidence-base for psychodynamic psychotherapy with children and adolescents: a narrative synthesis. Front Psychol 2021; 12: 662671. DOI: 10.3389/fpsyg.2021.662671 CrossRef MEDLINE PubMed Central|
|3.||Steffen A, Akmatov MK, Holstiege J, Bätzing J: Diagnoseprävalenz psychischer Störungen bei Kindern und Jugendlichen in Deutschland: eine Analyse bundesweiter vertragsärztlicher Abrechnungsdaten der Jahre 2009 bis 2017. Zentralinstitut für die kassenärztliche Versorgung in Deutschland (Zi). Versorgungsatlas-Bericht Nr. 18/07. Berlin 2018.|
|4.||Jaite C, Hoffmann F, Seidel A, Mattejat F, Bachmann C: Ambulante psychotherapeutische Versorgung von Kindern und Jugendlichen in Deutschland: Status quo und Trends im Zeitraum 2009–2018. Psychiatr Prax 2021 (online ahead of print) CrossRef|
|5.||Bundespsychotherapeutenkammer: Ein Jahr nach der Reform der Psychotherapie-Richtlinie. Wartezeiten 2018. www.bptk.de/wp-content/uploads/2019/01/20180411_bptk_studie_wartezeiten_2018.pdf (last accessed on |
17 December 2021).