Talking Therapy - The Evidence
We know talking therapy works. Now we're starting to learn why and how.
Talking therapy and depression and bipolar. In an editorial in the May 2007 American 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.
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Dr Weissman also noted that, for a change, 2007 had been a good year for psychotherapy. Exhibit A was 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 dogma with no scientific support 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, who headed up the NIMH-underwritten STAR*D series of real world depression trials during the mid-2000s. In the first round, patients were tried on the antidepressant Celexa, then put on different options if they failed to achieve satisfactory results. One set of options was adding cognitive therapy to their antidepressant or trying cognitive therapy alone.
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. 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.
An earlier study published in the New England Journal of Medicine in 2000 found an unexpected turbocharge effect: The chronic depression patients in the study posted similar responses rates (about 50 percent) to either a form of cognitive therapy or an antidepressant, but for those on both the antidepressant and cognitive therapy, the results were an eye-popping 85 percent.
When measured for remission, 42 percent in the combination group achieved this higher standard vs about 20 percent in the antidepressant-alone and the cognitive therapy-alone groups.
Three years later, another look at the study data found that those who had lost their parents at an early age, been physically or sexually abused, and/or neglected fared significantly better on talking therapy than on an antidepressant.
Commenting on the STAR*D findings, plus other studies such as this one, Dr Weissman in her editorial made a case for having psychotherapy offered as the first option in the next STAR*D-like study. The same issue of the American Journal of Psychiatry could not quite find a study that fit the order, but nevertheless did its best to oblige …
Interpersonal 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.
In the study published in the AJP, 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.
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. The same AJP dialed up a new brain scan study of hers 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.
In other words, 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 may provide the necessary chemical boot up.
Meanwhile, Over in Bipolar Land
At the same time STAR*D got rolling, its sister study STEP-BD tested three different talking therapies - cognitive therapy, interpersonal and social rhythm therapy (IPSRT), and family-focused therapy (FFT) - on bipolar patients.
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 explained to me in a 2004 interview, "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," David Miklowitz, originator of the therapy, 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 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. 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 a standard form of psychoeducation with their meds.
Yes, 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 fairly easily be 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 The Bipolar Workbook, Dr Basco goes into considerable detail on how patients can accomplish this.
Wrapping It Up
The last word goes to Dr Weissman. from her AJP editorial:
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.
Feb 10, 2008, revised Jan 12, 2011
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