Objective: Anger control has been seen as a set of learnable skills. How much time is necessary for such learning? Comparisons with time requirements for other skills make it plausible that for many people, learning anger control may require well over 100 hours of time on task. Research interventions have been shorter - a mean of 9 sessions was reported in one meta-analysis. In this study, our goal was to examine how much psychotherapeutic intervention is being delivered in the "real world" to patients with Intermittent Explosive Disorder. Method: We studied a de-identified electronic health record data from TriNetX, collected from 87 medical institutions. We studied 32,322 individuals with Intermittent Explosive Disorder. We examined the distribution of the number of individuals across numbers of sessions received. Results: The distribution for the numbers of sessions is highly skewed, resembling a curve of inverse proportion, or a Pareto function. The mode and the median were zero. Only about 25% of patients received any psychotherapy. For that subset, the median was 5 sessions, and the mean was 16. Approximately 10% received 9 visits or more; 5% 30 or more; 2% 50 or more. A large fraction of the psychotherapeutic labor was devoted to a small fraction of the patients: 80% of the sessions went to 7.5% of the patients. Conclusions: The ability of health care systems to reduce the societal problem of aggression, at least by psychotherapeutic intervention, appears limited by the factors leading to low, or no, time on task.

Stephen Faraone in the past 36 months received income, potential income, travel expenses continuing education support and/or research support from Arbor, Aardvark, Aardwolf, AIMH, Akili, Atentiv, Axsome, Genomind, Ironshore, Johnson & Johnson/Kenvue, Kanjo, KemPharm/Corium, Medice, Noven, Ondosis, Otsuka, Rhodes, Sky Therapeutics, Sandoz, Supernus, Takeda, Tris, and Vallon. With his institution, he has US patent US20130217707 A1 for the use of sodium-hydrogen exchange inhibitors in the treatment of ADHD. He also receives royalties from books published by Guilford Press: Straight Talk about Your Child's Mental Health, Oxford University Press: Schizophrenia: The Facts and Elsevier: ADHD: Non-Pharmacologic Interventions. He is Program Director of www.ADHDEvidence.org and www.ADHDinAdults.com. Dr. Faraone's research is supported by the Upstate Foundation, the European Union's Horizon 2020 research and innovation programme under grant agreement 965381; NIH/NIMH grants U01AR076092-01A1, 1R21MH1264940, U01AR076092, R01MH116037, 1R01NS128535, R01MH131685, 1R01MH130899, U01MH135970, and Supernus Pharmaceuticals. His continuing medical education programs are supported by The Upstate Foundation, Corium Pharmaceuticals, Oregon Health & Science University, Tris Pharmaceuticals and Supernus Pharmaceuticals. Yanli Zhang-James and Joseph Strayhorn has no disclosures to report.

The study did not receive any funding.

I confirm all relevant ethical guidelines have been followed, and any necessary IRB and/or ethics committee approvals have been obtained.

Yes

The details of the IRB/oversight body that provided approval or exemption for the research described are given below:

Because only de-identified medical records were used, the study was determined to be non-human study by the State University of New York Upstate Medical University Institutional Review Board.

I confirm that all necessary patient/participant consent has been obtained and the appropriate institutional forms have been archived, and that any patient/participant/sample identifiers included were not known to anyone (e.g., hospital staff, patients or participants themselves) outside the research group so cannot be used to identify individuals.

Yes

I understand that all clinical trials and any other prospective interventional studies must be registered with an ICMJE-approved registry, such as ClinicalTrials.gov. I confirm that any such study reported in the manuscript has been registered and the trial registration ID is provided (note: if posting a prospective study registered retrospectively, please provide a statement in the trial ID field explaining why the study was not registered in advance).

Yes

I have followed all appropriate research reporting guidelines, such as any relevant EQUATOR Network research reporting checklist(s) and other pertinent material, if applicable.

Yes

All data produced in the present work are contained in the manuscript, and available online at MedRxiv. De-identified medical records are only available directly from TriNetX.