Chadwick Royal over at Brain Blogger asked the equivalent of “Where’s the beef?” in an entry this week commenting about the National Institute of Mental Health’s press release on the use of CBT after medications in teens reduces relapse. Royal asked why this is considered “news” when the fact that psychotherapy + medication = better outcomes is well known amongst most clinicians and researchers.
Here’s why — the general public (and many medical doctors) still don’t get the message, so it’s news to many. The National Institute of Mental Health serves not just researchers and clinicians, it also serves to help promote general information and news about mental health research. Especially with regards to what “works.”
In the U.S., consumers are constantly bombarded with pharmaceutical advertising describing the many benefits of different psychiatric medications (“Depression hurts…” No duh!). But consumers get no marketing about the benefits of psychotherapy, and often still have old, stigmatizing misconceptions about how it works and how expensive it is. (No, you don’t lie down on a couch and no, it doesn’t take 10 years before psychotherapy starts helping.)
Information about research that touts the benefits of psychotherapy (alone or when combined with an appropriate psychiatric medication) is ultimately helpful to the public, because knowledge is power. And while researchers and clinicians might take for granted that this approach — psychotherapy plus meds — is the most beneficial for most people with most mental health concerns, it’s a message that’s still not well-accepted or understood amongst the general public.
And I daresay it’s also not well-accepted among many primary care physicians and general practitioners, who rarely push psychotherapy treatment onto their patients, but have little problem prescribing a plethora of psychiatric medications.
Read the entry: Therapy and Medication – Where’s the Breaking News?
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Links to This Article
What is Depression? (1/24/2009)
Survivors News and Reviews » Blog Archive » Psychotherapy Works (1/24/2009)
7 Comments to
“‘Psychotherapy Works’ Is Still News to Many”
The Furious Seasons blog posted a similar type entry in 2007:
Prozac And CBT Help Treat Depression In Teens
Initially, combination therapy worked the best by a significant margin. But by week 36, here were the results:
86% for combination therapy, 81% for fluoxetine therapy, and 81% for CBT at week 36. Suicidal ideation was slightly less with CBT vs. combination therapy. And alot more with fluoxetine.
Anyway, I am just wondering if this study is typical in that the longer you go about, the closer CBT will come to combination therapy.
Great blog! I’d like to add that research on the effectivness of psychotherapy combined with medication does not always show a major benefit from adding medication to therapy. There are times that adjunctive medication does boost the overall outcome, but this benefit is often fairly small. This fact is surprising since the effects of medication and psychotherapy are both fairly large and you’d think that combining them would almost doubl the benefit.
For example, in the treatment of obsessive compulsive disorder, behavior therapy in the form of exposure and response prevention works at least as well as medication and does better at preventing relapse. I often recommend that clients try a thorough regimen of behavior therapy first and consider adding medication only if they don’t achieve the success they want.
Here is a recent publication by the same author, different study:
http://journals.lww.com/jaacap/Abstract/2009/02000/Remission_and_Recovery_in_the_Treatment_for.12.aspx
“At week 36, the estimated remission rates for intention-to-treat cases were as follows: combination, 60%; fluoxetine, 55%; cognitive-behavioral therapy, 64%; and overall, 60%.”
According to ClinicalTrials.gov, up to 432 subjects were to be enrolled. Where did the extra 7 subjects come from? As well, the data could be 4 – 10 years old:
http://www.clinicaltrials.gov/ct2/show/NCT00006286?term=emslie+tads&rank=1
Compare these results with a prior study:
http://www.nimh.nih.gov/science-news/2007/depressed-adolescents-respond-best-to-combination-treatment.shtml
NIMH has not posted a news release about this study on its Web site, yet.
And here is yet another recent publication by the same author—the “no harm done” study:
http://ajp.psychiatryonline.org/cgi/content/abstract/appi.ajp.2008.08040487v1
“At week 36, the response rate was 82% in the placebo/open group and 83% in the active treatment groups. The remission rate was 48% in the placebo/open group and 59% in the active treatment groups, a difference that approached statistical significance.
Remission rates at 9 months were lower in patients treated initially with placebo, but 3 months of placebo treatment was not associated with any harm or diminished response to subsequent treatment.”
Key words: “approached” statistical significance
Again, according to ClinicalTrials.gov, up to 432 subjects were to be enrolled. Where did the extra 7 subjects come from? And the data could be 4 – 10 years old:
http://www.clinicaltrials.gov/ct2/show/NCT00006286?term=emslie+tads&rank=1
Here are two news releases on the study:
http://www.utsouthwestern.edu/utsw/cda/dept353744/files/513040.html
The protocol and sample consent forms for the Treatment for Adolescents With Depression Study (TADS) may be found on the study Web site:
https://trialweb.dcri.duke.edu/tads/templates.html
For me I couldn’t fully participate in therapy & get benefit from it without being on medication to lift the depression (I tried for years with just therapy). I was just stuck in this deep depression that clouded my thinking & judgment to such an extent that I couldn’t seem to get any insight or implement any changes in my life that I should have gained from therapy & I tried several different therapists, too.
Once I got my thinking cleared & my depression lifted with medication, I was able to get so much benefit from individual therapy & dialectical behavioral therapy group. I am now in the process of discontinuing some of my medications & decreasing the dosages of others (I take quite a few for bipolar 1 disorder) as I have learned so many new coping skills from therapy & have actually been able to change some life-long negative thinking patterns & learned excellent techniques to help reduce stress & anxiety. Some meds I still need, but the therapy has given me tools to enable me to get off others that I needed initially to even function enough to benefit from therapy.
To take your point about primary car physicians not referring for psychotherapy, i would like to refer you to a study by Kravizt et al. (2006. They studied referral rates by primary care physcians for psychotherapy for patients diagnosed with adjustment disorder symptoms or major depression. Patients made 289 visits to various medical practices. Only 36% of physicians referred patients for mental health services. This referral rate is especially bad for those who suffer from chronic pain a population that has a high rate of depression. In a national survey, Bao, Sturm , and Croghan (2003) found that of those meeting criteria for major depression or dysthymia (N=1486), 63% had comorbid chronic pain conditions. These patients had 20% more primary care visits and were 20% less likely to see a mental health specialist than depressed, non-pain patients.
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Last reviewed: By John M. Grohol, Psy.D. on 23 Jan 2009
