Changing Thoughts May Be Better Than Changing Behavior in the Early Stage of Psychotherapy for Severe Depression

Posted on 2010-05-16 by Andrew Gottlieb, Ph.D.

A recent study took a close look at what predicts improvement in depression in the first five sessions of cognitive behavioral therapy. They looked at the degree to which the therapists used either cognitive therapy methods, practiced structuring the sessions clearly, and how much they used behavioral methods/homework. They also examined whether the patients cooperated with these parts of cognitive behavioral therapy. They also measured the strength of the therapeutic alliance.

Sixty patients with major depression participated in the study. Their sessions were videotaped and trained raters rated how much the therapists used cognitive versus behavioral methods.

What they found was only two aspects of therapist behavior predicted improvement between sessions. Depression was measured after every session, and these measurements showed that patients felt better when therapists used cognitive techniques, but didn’t improve when the therapists focused on behavioral techniques.

Patients also showed greater improvement when they adhered to suggestions made by the therapist, which is not surprising.

The behavioral methods used were techniques such as having patients schedule their activities to become more active, and tracking how they actually spent their time. This is called behavioral activation, and previous studies have suggested it is an effective approach to treating depression. The behavioral activation model is that depressed patients tend to do very little, and this leads to further depression. Patients are encouraged to schedule activities that are fun, or activities that provide a sense of mastery or success. This leads to a lessening of depressive feelings.

The cognitive methods were techniques such as writing down what your thoughts are, and using cognitive therapy to challenge or modify distorted thinking.

So how to interpret the results of this study?

It’s only one small study and I would be cautious about taking too much from it. It does suggest that at least in the early sessions of therapy, cognitive methods may be superior to behavioral methods. This makes sense to me because early in therapy depressed patients feel a lot of pain and lethargy, and getting them to suddenly increase their activity can be very challenging and perhaps too difficult. This may lead to a sense of failure which increases depression rather than reducing it. On the other hand, using cognitive methods may lead to more immediate sense of control and relief, which would tend to reduce depression levels.

My sense is that later in therapy behavioral activation techniques are very useful. But typically in order to get patients to cooperate with these techniques there needs to be a strong alliance with the therapist. This takes some time to build.

It would have been interesting if they had continued the study beyond the first five sessions, and looked at whether over time the relative importance of the cognitive versus behavioral techniques would have shifted.

The study shows that therapist behavior in sessions does matter. This is one of my pet peeves. Many psychotherapists claim to use cognitive behavioral therapy, yet fail to actually use any cognitive behavioral techniques on a regular basis in sessions. This study shows that therapist adherence to structuring sessions and using cognitive techniques matters.

So from a consumer point of view there are a few take-home lessons.

1. If you are seeking cognitive behavioral therapy, make sure your therapist actually does cognitive behavioral therapy during sessions. This means they should structure the sessions clearly, as opposed to simply letting you talk about whatever is on your mind. It also means they should be asking you to track your self talk in written form, during sessions go over those thoughts, helping you learn to identify and correct distortions in the thoughts. If they don’t do these behaviors, and therapy feels free-form, then you’re probably not getting cognitive behavioral therapy, and you might want to look elsewhere. If you don’t regularly get homework to do between tasks, you aren’t receiving cognitive behavioral therapy.

2. At least in the early part of therapy pure cognitive therapy techniques may be more effective than behavioral techniques. You may want to focus your own homework more on identifying and changing your inner thoughts, rather than trying to increase positive behaviors. This probably will yield more relief of depression.

3. The study also confirmed that when clients cooperate and are more involved using cognitive therapy techniques, they improve faster. So even if you’re feeling skeptical, try to fully participate during sessions and in between sessions, as that provides you the best chance of more rapid relief.

Your off to analyze his thoughts psychologist,

Andrew Gottlieb, Ph.D.

New Study Shows Antidepressant Medication Fails to Help Most Depressed Patients

Posted on 2010-01-22 by Andrew Gottlieb, Ph.D.

A very interesting study recently published in the Journal of the American Medical Association (JAMA) demonstrated very clearly that when it comes to antidepressant medication, the Emperor is wearing few if any clothes! The researchers did what is called a meta-study or meta-analysis. They searched the research literature for all studies that were placebo-controlled studies of antidepressants when used for depression. That means the studies had to include random assignment to either a medication group or a placebo (sugar pill) group. They eliminated some studies which use a placebo washout condition. (This means the studies first gave patients a placebo, and then eliminated all patients who had a 20% or greater improvement while taking placebo.) When they eliminated all studies that didn’t meet their criteria, they were left with 6 studies of 738 people.

Based on scores on the Hamilton Depression Rating Scale (HDRS), the researchers divided the patients into mild to moderately depressed, severely depressed, and very severely depressed. This is a 17 item scale that is filled out by a psychologist or psychiatrist, and measures various aspects of depression. It is used in most studies of depression. They then analyzed the response to antidepressant medication based on how severe the initial depression was.

The two antidepressants studied were imipramine and paroxetine (Paxil). Imipramine is an older, tricyclic antidepressant, and Paxil is a more modern SSRI antidepressant.

What did they find? They were looking at the size of the difference between the medication groups and the placebo groups. Rather than do the typical thing of just looking at statistical significance, which is simply a measure of whether the difference could be explained by chance, they looked at clinical significance. They used the definition used by NICE (National Institute of Clinical Excellence in England), which was an effect size of 0.50 or a difference of 3 points on the HDRS. This is defined as a medium effect size.

What they found was very disheartening to those who use antidepressant medications in their practices. They divided the patients into three groups based on their initial HDRS scores: mild to moderate depression (HDRS 18 or less), severe depression (HDRS 19 to 22), and very severe depression (HDRS 23 or greater).

For the mild to moderately depressed patients, the effect size was d=0.11, and for severely depressed patients the effect size was d = 0.17. Both of these effect sizes are below the standard description of a small effect which is 0.20. For the patients in the very severe group, the effect size was 0.47 which is just below the accepted value of 0.50 for a medium effect size.

When they did further statistical analysis, they found that in order to meet the NICE criteria of effect size of a 3 points difference, patients had to have an initial HDRS score of 25 or above. To meet the criteria of an effect size of .50, or medium effect size, they had to have a score of 25 or above, and to have a large effect size, 27 or above.

What does this all mean for patient care? It means that for the vast majority of clinically depressed patients who fall below the very severely depressed range, antidepressant medications most likely won’t help. The sadder news is that even for the very severely depressed, medications have a very modest effect. Looking at the scoring of the HDRS, the normal, undepressed range is 0 to 7. The very severely depressed patients had scores of 25 or above, and a medium effect size was a drop in scores of 3 or more points compared to placebo patients. Looking at the one graph in the paper that show the actual drops in HDRS scores, the medication group had a mean drop of 12 points when their initial score was 25. That means they went from 25 to 13, which is still in the depressed range, although only mildly depressed. Patients who initially were at 38 dropped by roughly 20 points, ending at 18, which is still pretty depressed. And the placebo group had only slightly worse results.

One interesting thing is how strong the placebo effects are in these studies. It seems that for depressions less serious than very severe, placebo pills work as well as antidepressant medication. Is this because antidepressants don’t work very well, or because placebos work too well? It’s hard to know. Maybe doctors should give their patients sugar pills, and call the new drug Eliftimood!

So in summary, here are the main observations I make from this study.

If you are very severely depressed, antidepressants may help, and are worth trying.
If you are mildly, moderately, or even severely depressed, there is little evidence that antidepressants will help better than a placebo. You would be better off with CBT (Cognitive Behavioral Therapy), which has a proven track record with less severe depressions, and which has no side effects.
Interestingly, CBT is less effective for the most severe depressions, so for these kinds of depressions medication treatment makes a lot of sense.
If you are taking antidepressants and having good results, don’t change what you are doing. You may be wired in such a way that you are a good responder to antidepressants.
If you have been taking antidepressants for mild to severe (but not very severe) depression, and not getting very good results, this is consistent with the research, and you might want to discuss alternative treatments such as CBT with your doctor. Don’t just stop the medications, as this can produce withdrawal symptoms, work with your doctor to taper off them.
Even in very severely depressed patients, for whom antidepressants have some effects, they may only get the patient to a state of moderate depression, but not to “cure”. To get to an undepressed, normal state, behavioral therapy may be necessary in addition to medications.
How do you find out how depressed you are? Unfortunately there is no online version of the HDRS for direct comparison. You may want to see a professional psychologist or psychiatrist if you think you might be depressed, and ask them to administer the HDRS to you. There are also online depression tests, such as here and here. If you score in the highest ranges you might want to consider trying antidepressant medications, if you score lower you might want to first try CBT.
The most important thing is not to ignore depression, as it tends to get worse over time. Get some help, talk to a professional.

I’m off to take my Obecalp pills now, as it’s been raining here in Northern California for more than a week, and I need a boost in my mood. (Hint: what does Obecalp spell backwards?)

New Study Finds the Best Pharmacological Stop Smoking Solution: (Hint, it’s not what you’d think)

Posted on 2009-11-23 by Andrew Gottlieb, Ph.D.

A new study at the Center for Tobacco Research and Intervention, School of Medicine and Public Health, University of Wisconsin, Madison, compared all except one of the current drug treatments that help with quitting smoking. They looked at the following treatments and combined treatments:

“bupropion SR (sustained release; Zyban, GlaxoSmithKline), 150 mg twice daily for 1 week before a target quit date and 8 weeks after the quit date;
nicotine lozenge (2 or 4 mg) for 12 weeks after the quit date;
nicotine patch (24-hour, 21, 14, and 7 mg titrated down during 8 weeks after quitting;
nicotine patch plus nicotine lozenge;
bupropion SR plus nicotine lozenge; or
placebo (1 matched to each of the 5 treatments).”

Everyone received six 10- to 20-minute individual counseling sessions, with the first 2 sessions scheduled before quitting.

What were the results?

Three treatments worked better than placebo during the immediate quit period: the patch, bupropion plus lozenge, and patch plus lozenge.

At six months, only one treatment was effective; the nicotine patch plus nicotine lozenge. The exact numbers , as confirmed by carbon monoxide tests, were: “40.1% for the patch plus lozenge, 34.4% for the patch alone, 33.5% for the lozenge alone, 33.2% for bupropion plus lozenge, 31.8% for bupropion alone, and 22.2% for placebo.”

So we see that the combined nicotine substitution therapy worked best, followed closely by either nicotine substitute alone. Zyban or Welbutrin (bupropion) was a bust, no more effective than the simple nicotine lozenge. The only advantage to Zyban would be if one prefers not to use nicotine substitutes.

Now I mentioned that they omitted one drug treatment, which is the drug Chantix (varenicline). This is probably because the drug is a nicotine receptor blocker, so wouldn’t have made sense to combine with nicotine substitutes. Also, there have been some disturbing case reports of people having severe depressive reactions to Chantrix.

Of course, there was one glaring omission that any card-carrying psychologist would spot in a moment–the lack of a behavior therapy component. Giving 6 ten minute sessions is hardly therapy. I would have liked to see true smoking cessation behavior therapy combined with the drug treatments.

So, if you’re trying to quit smoking, combine nicotine patches with nicotine lozenges, sold in any pharmacy. If you do, you have a 40 percent chance of succeeding at 6 months.

Now I am off to have a cigarette….just kidding.

Study: http://cme.medscape.com/viewarticle/712074_print

Why do Most Psychologists Ignore Science Based Therapy? Evidence Based Psychotherapy and the Failure of Practicioners

Posted on 2009-10-09 by Andrew Gottlieb, Ph.D.

A new article in Newsweek magazine titled Ignoring the Evidence documents how most psychologists ignore scientific evidence about treatments such as cognitive behavioral therapy which have been proven to be effective.

A two-year study which is going to be published in November in Psychological Science in the Public Interest, found that most psychologists “give more weight to their personal experiences then to science.”

The Newsweek article has a wonderful quote,

“Thanks to clinical trials as rigorous as those for, say, cardiology, we now know that cognitive and cognitive-behavior therapy (teaching patients to think about their thoughts in new, healthier ways and to act on those new ways of thinking) are effective against depression, panic disorder, bulimia nervosa, obsessive-compulsive disorder, and -posttraumatic-stress disorder, with multiple trials showing that these treatments-the tools of psychology-bring more durable benefits with lower relapse rates than drugs, which non-M.D. psychologists cannot prescribe. Studies have also shown that behavioral couples therapy helps alcoholics stay on the wagon, and that family therapy can help schizophrenics function. “

The article documents how most psychologists fail to provide empirically proven treatment approaches and instead use methods which are often ineffective. The truth is there is very little evidence for most of the types of therapy commonly performed in private practices by psychologists and by Masters level therapists. If you are shopping for the most effective types of therapy you need to find a practitioner who is skilled at cognitive behavioral therapy (CBT) which is one of the few psychotherapy approaches that has been proven to work on a variety of problems.

Another interesting article in Newsweek about evidence-based treatment discussed bulimia. Here’s the summary:

“On bulimia (which affects about 1 percent of women) and binge eating disorders (2 to 5 percent), the verdict is more optimistic: psychological treatment can help a lot, and cognitive behavioral therapy (CBT) is the most effective talk therapy. That’s based on 48 studies with 3,054 participants. CBT (typically, 15 to 20 sessions over five months) helps patients understand their patterns of binge eating and purging, recognize and anticipate the triggers for it, and summon the strength to resist them; it stops bingeing in just over one third of patients. Interpersonal therapy produced comparable results, but took months longer; other therapies helped no more than 22 percent of patients. If you or someone you love seeks treatment for bulimia, and is offered something other than CBT first, it’s not unreasonable to ask why. Cynthia Bulik, director of the University of North Carolina Eating Disorders Program, summarized it this way: “Bulimia nervosa is treatable; some treatment is better than no treatment; CBT is associated with the best outcome.”

So the bottom line is this:

1. Most psychologists who don’t practice Cognitive Behavioral Therapy (CBT) are just winging it, using treatments that haven’t been shown to work by scientific studies. It’s as if you went to a regular physician and got treatment with leaches!

2. Many psychologists claim to use CBT but haven’t really trained in the use of CBT, or have taken a weekend workshop. Unless they prescribe weekly homework that involves writing down thoughts, and learning skills to analyze and change your thoughts, then they aren’t really doing CBT, and I recommend you find someone else.

3. If you have an anxiety disorder, depression, bulimia, or obsessive compulsive disorder, and haven’t been offered CBT, then you are not receiving state of the art treatment.

The Psychology Lounge ™

by Dr. Andrew Gottlieb (650) 324-2666

Category Archives: Behavior Therapy

Changing Thoughts May Be Better Than Changing Behavior in the Early Stage of Psychotherapy for Severe Depression

New Study Shows Antidepressant Medication Fails to Help Most Depressed Patients

New Study Finds the Best Pharmacological Stop Smoking Solution: (Hint, it’s not what you’d think)

Why do Most Psychologists Ignore Science Based Therapy? Evidence Based Psychotherapy and the Failure of Practicioners