Treatment

Talking Therapy - The Evidence

We know talking therapy works. Now we are starting to learn when and why and how.

In an editorial in the May 2007American Journal of Psychiatry, Myrna Weissman PhD of Columbia University writes:

"Unlike medication, few psychotherapies for depression have undergone extensive testing in clinical trials. Psychotherapy has been a cottage industry, without any pharmaceutical company-like support for developing and testing new psychotherapies or new indications for old ones. Many excellent widely used psychotherapies remain untested, and tests directly comparing psychotherapies are rare. Thirty years after cognitive therapy and IPT were conceived, we are still looking at dose, effectiveness, and new indications. If these two psychotherapies were medications, by now there would be off-label uses, generic versions, and numerous other second- and third-generation psychotherapies in trials."

Dr Weissman also notes that, for a change, this has been a good year for psychotherapy. Exhibit A is Aaron Beck MD of the University of Pennsylvania, who received the prestigious Albert Lasker Award for Clinical Medical Research for the development of cognitive therapy.

Cognitive therapy teaches patients to catch their irrational self-defeating automatic thoughts as they are occurring and substitute more rational constructive ones. Thus, in an impending work deadline situation, it is possible to turn an "it’s the end of the world" train of thought into one of "let’s work on a solution" (though some of us do require our standard allotment of cathartic mad scene time, or at least I do). Someone who is working on a solution is in far more control than someone freaking out. And how does it "feel" to be in control? A lot better than freaking out, thank you very much.

Great theory, but what would Freud think?

Flashback to the young Dr Beck, who was working as a psychoanalyst. One afternoon, Dr Beck was treating a young woman who was having difficulties with men. As she lay on the couch describing her sexual encounters, Dr Beck suddenly asked her: "how does talking about this make you feel"?

It has been said that the seismic effects of Freud rolling over in his grave were felt in remote villages throughout the globe.

Not only that, Dr Beck broke another cardinal rule of psychoanalysis and asked the patient to sit up and face him. Dr Beck merely wanted to show his patient that he was not disapproving of her behavior. But his patient surprised him by confessing that she thought that she was boring him.

It was here that Dr Beck’s Eureka! moment occurred. If the patient were experiencing anxiety over what her shrink may or may not be thinking, then there could be no unrestricted bubbling up of her thoughts from the unconscious, which was the basis of psychoanalysis.

As Huda Zoghbi MD of the Howard Hughes Medical Institute, in presenting Dr Beck with the Lasker Award described it: "He abandoned probing for unconscious sexual conflicts and began focusing on the patterns of thoughts that made his patients depressed or anxious. Thus was born a new type of treatment …"

In his Lasker Award acceptance remarks, Dr Beck recalled how his wife thought that there was some merit to his bright idea. Not only that, his theory passed the teen-age daughter test, which is highly encouraging news to any parent. But a brash young postdoc student of his laid it on the line: "You've got a new therapy Tim, but nobody will believe it until you conduct a clinical trial."

In other words, the Freudian establishment - who operated out of a system of beliefs with absolutely no scientific validity and who practiced a therapy that demonstrably failed to produce results - would be demanding in Dr Beck both hard science and proof of efficacy. And you thought Galileo had it bad …

STAR*D Tests Cognitive Therapy

Dr Beck’s postdoc student was none other than A John Rush MD, now a professor at the University of Texas Southwestern Medical Center at Dallas, with more than 300 articles and ten books to his credit. He also heads up the NIMH-underwritten Sequenced Treatment Alternatives to Relieve Depression (STAR*D) series of real world trials. Beginning in 2001, STAR*D enrolled 4,000 patients with major depression in 23 locations throughout the US. The patients were first treated with Celexa, and then tried on different options if they failed to achieve satisfactory results on this medication.

Last year, STAR*D published the first of its findings on how these patients fared. As expected, slightly less than half of the patients responded to the initial medication. The patients who did not do well on Celexa and who elected to remain in the study were then tried on either one of three antidepressants or on different combinations of antidepressants. About a quarter to a third remitted. The third and fourth round results were totally discouraging, but taken together with the second round, the cumulative findings pointed out the wisdom in sticking with treatment – namely that 67 percent of the patients who chose to remain in the study did remit.

In this month’s AJP, STAR*D released its latest findings (Michael Thase MD of the University of Pittsburgh as lead author). In the second round of the study, patients who failed on their Celexa were given yet another option of going with cognitive therapy, either as monotherapy or with meds. Since the patients were already started on an antidepressant (together with the fact that there was no reimbursement for cognitive therapy, plus other considerations), not surprisingly only 26 percent of those who remained in the study chose trying cognitive therapy.

Those who added cognitive therapy to their Celexa did as well as those who added a different antidepressant to their Celexa, though the meds augmentation route produced faster results. Unexpectedly, both augmentation groups fared about the same in side effects. Those who switched from their Celexa to cognitive therapy alone did as well as those who switched from the Celexa to a different antidepressant, again with slower results but this time with no meds side effects.

Commenting on the latest STAR*D findings, plus other studies, Dr Weissman in her editorial made a case for having psychotherapy offered as the first option in the next STAR*D-like study. This month’s American Journal of Psychiatry could not quite find a study that fit the order, but nevertheless did its best to oblige …

Talking Therapy or Meds?

Interpersonal therapy (IPT) assists patients through life's transitions and in overcoming deficits in social skills. At the 2002 American Psychiatric Association annual meeting, Ellen Frank PhD of the University of Pittsburgh recounted the case of a 28-year-old graduate student having to deal with the sudden death of her mother, a conflict with her thesis advisor, and a shift in her relationship with her father as a result of her mother's death. Using the skills she learned from interpersonal therapy, the student was able to resolve her dispute with her father, and her depression subsequently remitted.

A study in this month’s AJP by Dr Frank and her colleagues investigated a group of women with recurrent major depression. During the initial phase of treatment, the women were started on IPT alone. Those who failed to remit on IPT were put on an adjunctive antidepressant.

Now the real part of the study could begin. Following remission, all the women still in the study received maintenance IPT with no meds over two years or until a recurrence. The treatment was the same, but the two groups of women in the trial were different. One group had required an antidepressant to get them well, the other had not. Did that matter? It turns out that those in need of an initial medications assist were twice as likely to relapse over two years as those only requiring IPT (50 percent vs 26 percent). In other words, if IPT got you well, more of the same was likely to keep you well. Conversely, for those in need of an antidepressant, it is advisable to stick with that medication for some time.

Significantly, the frequency of the IPT did not matter. Those on one maintenance session a month did as well as those attending weekly and twice-monthly.

IPT for Inpatients

In what amounts to an AJP double-feature, a German study (Elisabeth Schramm PhD lead author) tested IPT on a whole new group of patients – inpatients with severe depression. These patients were given three individual sessions a week for five weeks, plus eight group sessions over the same period, together with medications. The study found that those on the intensive IPT achieved higher response and remission rates (70 percent and 49 percent, respectively) than those with the usual clinical management augmenting their meds (50 percent and 34 percent). Nearly all the IPT patients were able to sustain their remission over three months vs 75 percent of the clinical management patients

A Little Brain Science

In case you are wondering what goes on in the brain as psychotherapy kicks in, the person to talk to is Helen Mayberg MD of Emory University. This month’s AJP dialed up a new brain scan study of hers (Sidney Kennedy MD of the University of Toronto lead author) that found that "consistent with earlier reports, response to cognitive-behavioral therapy was associated with a reciprocal modulation of cortical-limbic connectivity, while [Effexor] engaged additional cortical and striatal regions previously unreported in neuroimaging investigations."

Suffice to say, talking therapy, like meds therapy, induces physical changes in the brain consistent with the brain scans of healthy individuals. Meds and talking therapy act in large part on the same areas of the brain, but there are also crucial differences.

It all comes down to the proposition that if we can think our way into depression, it is also possible to think our way out of it. Psychotherapy can literally download the requisite software and software patches. Antidepressants can provide the necessary chemical kickstart and long-term protection. What we already know is that either approach is about as effective as the other. What we’re only beginning to learn is in what circumstances and in which populations we need to use one or the other or both.

Lots more studies, please.

Meanwhile, Over in Bipolar Land

At the same time STAR*D was getting underway, its sister NIMH study, the Systematic Treatment Enhancement Program for Bipolar Disorder (STEP-BD), was recruiting 5,000 patients in 18 centers across the US. STEP-BD was headed up by Gary Sachs MD of Harvard. Last month, STEP-BD published one of its initial findings in the Archives of General Psychiatry, with David Miklowitz PhD of the University of Colorado, who has developed family-focused therapy (FFT) for bipolar disorder, as the study’s lead author.

STEP-BD tested the efficacy of a minimal psychosocial intervention involving collaborative care (consisting of three educational sessions) against three intensive psychotherapies of up to 30 sessions, including cognitive therapy, interpersonal and social rhythm therapy (IPSRT), and FFT.

IPSRT, which was developed by Dr Frank out of interpersonal therapy, is aimed at helping individuals normalize their routines. "The treatment is all about developing strategies first to get oneself regular," Dr Frank explained in Newsletter 6#20, "and then to be able to maintain strategies to maintain that regularity."

Part of the therapy involves getting patients to compile a life chart. This helps patients make the connection between many of their bipolar episodes and major life events that lead to marked changes in routine, such as the birth of a child. The therapist will work with the patient in finding the most unstable lifetime rhythms (such as sleep-wake cycles) and setting goals (with reasonable expectations) for change, meanwhile searching for triggers likely to cause any disruptions.

FFT emphasizes creating a stable family environment that promotes recovery and encourages medication adherence. In his book, "The Bipolar Disorder Survival Guide: What You and Your Family Need to Know," Dr Miklowitz, writes: "Sometimes bipolar disorder is best treated in a family or couple context. The advantage of therapy with your close relatives is that they can be educated about your disorder and taught coping skills for managing stress the same time as you. People with bipolar disorder often have significant family or relationship problems. Family treatments can provide ways of improving your communication with your spouse, parents, or kids."

Nearly all the patients in this phase of the study were already on mood stabilizers. The 293 participants formed a subset of patients in the study assigned to experimental treatments for acute (initial phase) depression.

Now to the STEP-BD results ...

Within one year, 76.9 percent of the patients in FFT, 64.5 percent in IPSRT, and 60 percent in cognitive therapy recovered from their depression. This contrasted with a 51 percent recovery rate for patients in collaborative care. Within any particular month, the patients on one of the three psychotherapies were 1.58 times more likely to be well than those who had merely received collaborative care with their meds.

But What About Mania?

Have no fear, none other than Dr Rush is on the case. We may not have the definitive studies, but the basic techniques of cognitive therapy can be fairly easily applied to helping prevent mania. In their book "Cognitive-Behavioral Therapy for Bipolar Disorder," Dr Rush and his university colleague Monica Basco PhD talk about "feeling a little too good" as a flag for a possible oncoming episode. Then, among other things, clinicians can help their patients "choose a limited number of activities from their plethora of ideas and pursue those that have the highest probability of success and the lowest probability of negative consequences."

Of course, this depends upon the patient spotting the warning signs and recognizing the danger well before his or her clinician. In her recent book, "The Bipolar Workbook: Tools for Controlling Your Mood Swings," Dr Basco goes into considerable detail on how patients can accomplish this.

Of course, way back in 2000, at a DBSA Conference, I had to challenge Dr Basco on some of this. Her reply was, "I do not believe you should be a passive recipient of care." Fittingly, it is appropriate to conclude with something I wrote from around that era:

"And this, perhaps, is [psycho]therapy's greatest asset: the simple knowledge that we are not helpless bystanders, that in the unending battle for control of our own brains there is still an ‘I’ that can put up a fight. And where there is ‘I’ there is hope."

Feb 10, 2008