Posts tagged: psychotherapy

Medication

The use of legal psychoactive drugs has increased twenty two percent in the nine years between 2001 and 2010.  This is a truly staggering increase.  Most of the increased prescribing is performed by general practitioners-not psychiatric physicians.  Most people do not realize that psychiatrists attend medical school like other physicians.  After they graduate, psychiatrists receive special training within the field of mental health.  Non-psychiatric physicians have a few months of study and clinical training in mental health.  This is not intended to demean medically oriented physicians.  One can master only so much in a limited amount of time.  Most of the problem is not the limited training of physicians, rather it is the beliefs held by the public at large.

Many medically-oriented physicians believe particular patients would gain more from psychotherapy than medication; however, most patients are taken aback by a psychology referral.  Patients may believe that the doctor secretly thinks they are crazy or beyond the help of medication(s).  In addition, most people believe that psychotherapy takes years, or even a lifetime, to be effective.  It evokes images of the psychoanalytic couch, or worse, the snake pit of inpatient treatment.  Perhaps the psychologist will discover a hidden psychosis; a primal fear of many normal people.  Perhaps the psychologist seeks to relive one’s horrid memories until they are no longer able to function.  What about the fear of entrusted secrets to a near stranger?  Perhaps the psychologist discusses their crazy patients as entertainment.  Once the information is poured out of the bottle, who can say where all the drops will collect.

The beliefs of many psychologists may also interfere with the use of psychotherapy over medications.  A lauded professor of psychology, as well as practicing clinician, bemoaned the invention of Prozac as the death of psychotherapy.  This was bemoaned in 1990, long before the limitations and risks of the new antidepressants became known.  It is often difficult for the clinician to see progress in some patients, such that the use of a magic substance is very attractive.  The doctor would feel more secure and effective with something that promises to accelerate  the relief experienced in the office.  Early research suggested that psychotherapy is only effective for mild cases of anxiety or depression, and many clinicians still believe this to be true.  If medication was truly more effective than psychotherapy, psychologists would be guilty of misleading the public at large.  The outpatient practice of psychotherapy would effectively be a conspiracy against the public.
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Perhaps the easiest explanation for the rise of drug treatment is that insurance reimbursement for psychotherapy is lower and harder to obtain than that for drugs.  From the mid 1990’s to the mid 2000’s, the drug companies tripled their marketing of psychoactive drugs.  It has shaped the perceptions of the American public, and likely many professionals as well.  The drug companies do not have to make deceitful claims about their products.  Saturating the airwaves with pictures of happy attractive people taking their medications is sufficient to mold the unconscious mind.  Saturating the airwaves with happy attractive psychotherapy patients is not likely to occur in the near or distant future.  No one individual or company would profit from the endeavor.  There is no market pressure to push psychotherapy, such that it is shoved to the sidelines.

Convincing people to buy what they don’t need is at the center of American marketing genius.  The public apprehension regarding psychotherapy and psychologists energizes and assists the marketing of drugs.  Few patients weigh the benefits of psychotherapy over medication, since they are not presented with useful information.  Just as the nation woke from a Valium haze in the 80’s, the public is beginning to realize it has been oversold.  Wake up and evaluate the options for mental health treatment-you may be pleasantly surprised.

Sixty Minutes of Placebo

Recently, the news magazine 60 Minutes offered a piece on the role of placebos in the treatment of depression.  If held to the usual standards of broadcast journalism, the piece would not be particularly disturbing.  The 60 Minutes news magazine, however, has a strong track record of breaking news stories in an accurate and reliable fashion.  Historically, 60 Minutes held a higher standard for the subject matter examined, and the depth of its reportage.  Lesley Stahl’s piece on placebos was a break in this chain.  It tended to confuse the issue, rather than draw a conclusion from the evidence.  The confusion was not limited to the role of placebos, but the role of antidepressants in general.

Lesley Stahl’s piece made the assertion that antidepressant effectiveness is largely due to the placebo effect.  This is not news.  The fact that drug companies only select those studies that are favorable to their drug, suppressing the unfavorable studies, is also not news.  A number of detailed and accurate books have been published on this exact topic-even a critique by a former director of the American Medical Association.  It may have been news if Mrs. Stahl focused on the consequences of suppressing unfavorable studies.  Instead, Mrs. Stahl attempted to appear impartial by berating the Harvard professor whose research has reinforced the role of the placebo.  It may have been news if Mrs. Stahl found that the professor’s research was flawed.  She cast doubt on his conclusions without ever achieving some conclusion of her own.  She appealed to psychiatrists, paid by drug companies, as experts to evaluate the research of an unbiased academic.  At no time in the piece did Mrs. Stahl refer to the professor by his correct title, though she unfailingly referred to drug company psychiatrists by their professional titles.  The end result was to cast doubt on both placebos and antidepressants.

The first fact to consider is that most competent psychiatrists are just as concerned with side-effects as the intended effect.  A patient who cannot sleep is given a sedating antidepressant over one that is activating.  A patient who sleeps too much and can’t wake in the morning is prescribed an activating antidepressant.  Patients who are overweight are prescribed antidepressants that cause minimal weight gain, while those who have lost their appetite and are losing weight are given antidepressants that increase appetite.  The side-effect of medication is often as important in the treatment of depression as the main intended effect.  The only difference between a medication’s side-effect and main effect is the intention of the humans that formulate the drug.  The human body does not know the difference between side and main effects of medications.  This very important feature of antidepressant medication treatment was never mentioned in Mrs. Stahl’s report.

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The third and last fact to consider is that placebos have been researched for over fifty years.  This is far from being newsworthy.  It is like breaking news on the value of soap and water.  The brain’s response to placebos and antidepressant drugs is nearly identical.  Using brain scans that take snapshots of brain metabolism and activation (PET), researchers have discovered that placebos cause a similar increase in brain activation (glucose uptake) as antidepressant medication.  Placebo treatment is not known to cause an increase in brain neurogensis, but this appears to be an artifact of scant research, rather than from actually being disproved.  Well-controlled studies may yet reveal that placebos cause neurogensis, but there is little economic motivation to perform this study.  If Mrs. Stahl questioned why drug companies decline to research placebos, that may have been newsworthy as well.

In summary, Lesley Stahl danced around the relevant issues regarding antidepressant medications.  Perhaps she was unaware that the side-effects of drugs may be therapeutic, that SSRIs potentiate neurogenesis, and that both placebos and drugs affect glucose metabolism in a similar fashion.  Mrs. Stahl fell short of asking relevant questions; for example, should antidepressant medication be used primarily for its side effect(s), should physicians continue to recommend drug treatment over psychotherapy, and should drug companies market psychotherapy in combination with placebos or antidepressants?  Any one of these questions may have received an answer that could have changed the future of depression treatment.  Important aspects of depression treatment were ignored, while well-proven old information was touted as breaking news.  Lesley Stahl’s piece failed to arrive at a conclusion, let alone a call to action.  It is unfortunate that the net effect of Mrs. Stahl’s piece will be to further confuse the issues surrounding the current treatment of clinical depression.  It was not 60 Minutes‘ finest hour; certainly not their finest fifteen minutes.