August 16, 2017
The CDC’s National Center for Health Statistics just put out a report about the increasing use of antidepressants. As a psychologist (as opposed to a psychiatrist), I have mixed feelings about this. On the one hand, there have been many studies that have demonstrated the superior or at least matched efficacy of psychotherapy over medication to treat depression and anxiety, so I find this trend concerning. But on the other hand, when I recommend that some of my patients should consider consulting with their primary care provider or a psychiatrist and they express concerns about stigma, weakness or other reasons not to consider this treatment option, I attempt to reassure them that “antidepressants are one of the three most commonly used therapeutic drug classes in the United States” according to the report, and thus they should not feel self-conscious about taking such medications.
The report noted that there has been a progressive increase in antidepressant use since 1999, and that during the time of the study, nearly 13% of people over the age of 12 in the US have reported taking antidepressants in the past month. Women take antidepressants at double the rate of men. A quarter of those who reported using antidepressants have taken them for at least ten years.
It’s reassuring that those who need to take medication are in good company, but it is important to explore non-medical treatment of depression and anxiety, as the beneficial effects tend to be of a much longer-lasting duration.
December 19, 2016
A recently published meta-analysis of over 3000 studies suggested that switching antidepressants after the first drug doesn’t produce the desired results is not better than staying the course and/or exploring options other than trying a different drug. This is a very interesting finding as most prescribing clinicians tend to give one antidepressant a “trial” of about 6-12 weeks. If things aren’t better then often scrap that medication and start another 6-12 week trial of another one. The authors of this article reviewed 3234 relevant studies and concluded that it is generally wiser to explore alternatives other than a medication change.
July 19, 2016
A recent article in The Wall Street Journal summarizes some of the explanations about how we think placebos work. If you read an earlier blog post I wrote about placebos, what I find so fascinating about all this is that even when subjects/patients are told they are receiving a placebo (either in the form of a sub-therapeutic dosage of a real medication or just a sugar pill), they often still show the suggested effects of that “treatment.” If people expect something to happen when they take a pill, it often does. For example, this self-confirming bias occurs with medication side effects: you read that horrible insert from the pharmacist that lists every possible side effect that has been reported for the drug and sure enough you start to experience some of the effects… right away, before it’s really physiologically possible for the medication to have caused them.
Though some of my colleagues may not like this, I’d imagine that a nice chunk of what happens in psychotherapy is related to the placebo effect. We might call it a safe holding environment, positive future orientation or something like that, but the fact of the matter is that when a patient comes into therapy expecting a positive outcome, they typically experience that. (Similarly, when patients initiate treatment with negative expectations, they often don’t get much from treatment.) Clearly, a difference between psychotherapy and placebo is that actual treatment is being provided with psychotherapy, but patient expectation, therapist suggestions and patient suggestibility all play a significant role in therapy and should not be underestimated.
March 15, 2016
In a recent presentation, US Surgeon General Vivek H. Murthy said, “If there was a factor in your life that could reduce your risk of having a heart attack or a stroke, that could increase your chances of living longer, and would make your children less likely to engage in crime or use drugs, and that would even increase your success with losing weight, what would that factor be? It turns out, it would be happiness.”
Happiness is a realistic goal for most people; it is not a luxury and need not be a distant fantasy. People often have psychological road blocks to achieving true happiness, and psychotherapy can often help knock down or work around these obstacles.
February 10, 2016
The American College of Physicians has released a new clinical guideline on the treatment of depression in the Annals of Internal Medicine. They suggested that psychotherapy is as effective for treating depression as antidepressants, and “given its relative lack of potential harms, should be strongly considered as the first-line treatment.” This is consistent with the American Psychiatric Association guidelines on major depressive disorder from 2010, which show therapy and antidepressant medications as being similarly effective.
The two issues that I, personally, have with this are: 1) that the guidelines specifically mention CBT and do not adequately discuss the benefits of other modalities of psychotherapy which may lead health care providers and patients to assume that CBT is the only mode of treatment that is so effective, and 2) the suggestion that psychotherapy has a “relative lack of potential harms.” The word “relative” is key here: psychotherapy has significant fewer potential side effects than medication, but this does not mean that psychotherapy is side effect-free. Therapy can be difficult for many patients at different times along the course of treatment and patients should be aware of this from the outset.
January 27, 2016
The US Preventive Services Task Force (USPSTF) now officially recommends that primary care health clinicians screen all of their patients for depression. Though this is wonderful, this is very, very long overdue. The costs associated with depression and other mental health screen are insignificant relative to the potential gains of “catching” otherwise unrecognized suffering patients. Physicians and other front-line, primary care providers are offered screening guidelines by the AMA via this JAMA article.
Hopefully with more patients being routinely screened, including pregnant and post-partum women – – an often overlooked depressed population, more people will receive quality treatment consisting of psychotherapy and/or antidepressant medications.
November 18, 2015
I teach a great professional development and clinical consultation class at Loyola University Maryland. Yesterday morning my doctoral students and I had a great discussion about what makes psychotherapy work (among some other very stimulating discussions). This morning I received an email with a link to an article entitled, Revival of psychotherapy? How “talk” therapy changes our brains and genes. This short piece reviews some of the recent literature about the effectiveness of psychotherapy, including referencing statements from the American Psychiatric Association and the American Psychological Association. But the article gets even better when it approaches some newer thinking including the possibility that psychotherapy may actually make structural changes in our brains. Scientists have long known that repeated exposures to stimuli (aka, learning) can create new and more efficient neural pathways in the brain. We are now more confidently hypothesizing that the same thing occurs when patients “vent” in therapy… but instead of just venting, what may be happening is that the patient is packaging her thoughts into a narrative that the psychologist can understand, and that in the process of this processing she is starting to think her thoughts differently, to appreciate new facets of her history and to consider alternate perspectives about all this. In other words, she is being exposed to new “stimuli.” And in doing this multiple times (patients often tell the same or similar stories many times over the course of psychotherapy – – and this is a good thing), she may actually be forming new “connections” in her brain and this might be part of why talk therapy does, in fact, work for so many people.
June 30, 2015
I stumbled upon this brief piece in the Huffington Post about when patients should consider doing psychotherapy, trying medication, doing both at the same time or not doing anything at all. I liked this article because it was short and to the point while giving some nice examples behind the answer to the question: “it depends.”
As a psychologist I have many patients ask for medications and I have many patients refuse my suggestion that they consider medications. I work with only a handful of psychiatrists who I trust, and one of the things that I really like about them is that they don’t always prescribe medication on the first visit and sometimes they don’t prescribe at all. Now days many psychiatrists have defaulted to the role of “prescription mill” and they just see patients on the quarter hour, back to back, writing scripts as quickly as they can. I feel fortunate that I have good relationships with some very thoughtful and knowledgeable psychiatrists.
I also feel fortunate that as a psychologist I have the luxury of time to get to really know my patients, develop a strong therapeutic relationship with them and then help them improve various aspects of their lives. One of my favorite things to do in therapy is to review my clinical notes with a patient when we’re close to terminating treatment. I have found that when people are feeling better they often forget just how bad things were when they first came to me. When we read through the chart together they are reminded of the incredible progress they made.
June 24, 2015
Over the years of doing psychotherapy with individuals and couples I have often observed a thematic trend from patient to patient. Sometimes I get a bunch of calls about relationship problems or several existing patients will bring up similar issues in the same week or even the same day. Lately I have noticed that I am talking with a bunch of folks about forgiveness. Often the historical issue that my patient is struggling with is an “unforgivable” event but we still find ourselves discussing what forgiveness means or what it looks like. I like to think about forgiveness as being a selfish – rather than a selfless – process. Sometimes we forgive people, not for them but, for ourselves.
Think about the amount of time, energy and emotion you devote (and continue to allocate) toward maintaining resentments, being angry and keeping hatred alive. Now imagine how liberating it would be to be able to let go of that and how you might reallocate that time, energy and emotion. I’m sorry, but I don’t have any magical answers about how this process unfolds other than to say that it is just that: a process, and it begins by talking about the transgression against you. Eventually you may or may not opt to have a conversation, write a letter or engage in some sort of symbolic gesture to “interpersonally” forgive your transgressor. I recently read an interesting article in the Huffington Post about forgiveness but the most inspiring thing I’ve come across regarding the concept of forgiveness was a great story on NPR’s The Story (scroll down to the second story and if you want to listen to the show, you can skip the first third of the mp3 file).
November 25, 2014
An article was recently published in The Lancet Psychiatry and nicely summarized in Forbes describing the benefits of even short-term psychotherapy on repeated suicide attempts and suicide related deaths. Not surprisingly, the data suggest that talk therapy serves to significantly reduce the frequency of suicide following a previous suicide attempt. The Forbes article also very briefly summarized several recent studies on the efficacy of psychotherapy as an adjunct to or instead of psychiatric medication.