Antidepressant news - recommended reading

On January 29th there appeared a well researched and well written piece in Newsweek on the effectiveness of antidepressants. The article, by Sharon Begley, explains some important aspects of the process by which pharmaceutical agents are brought to market and come to be prescribed.
The article explains about the relevance of the placebo effect in clinical trials, and explains that for antidepressant medications, much of the improvement they produce can be attributed to the placebo effect. The placebo effect is the extent to which our experiences and expectations that a drug will work actually help us improve. For example, let's say that you get frequent headaches, and find that aspirin gets rid of them pretty effectively. Then one day your prankster roommate replaces your aspirin with breath mints... but your headache still goes away after you take one! Some would explain this via the placebo effect - you expected it to work, and so it did. The placebo effect is a mysterious and very important part of medical research; so much so that it is a focus of significant ongoing research at medical institutions around the world (e.g., at UCLA and at Harvard Medical School.)
Scientists have known about the placebo effect for many decades, and account for it in research often by using what are called placebo-controlled studies -- i.e., studies where half the patients receive the drug under investigation, and the other half receive a placebo. Thus they can look at the difference in improvement between the two groups, and conclude that any difference is likely due to the true effect of the drug.
Begley's Newsweek article not only may surprise you in its description of how strong the placebo effect is for antidepressant medications, but in its description of how such medications are approved by the FDA. She describes how the FDA, at present, does not have a mechanism by which trials with negative results (showing that a drug was ineffective) are accounted for in its pharmaceutical approval process. That means that a drug shown to be no better than placebo in six studies, but shown to be somewhat effective in two others, can be approved for widespread use.
Read the article, and be an informed consumer!

Reassurance

One way to recognize OCD is to look for excessive efforts to get reassurance. This can take many forms, and in my experience often comes up as questions asked to a spouse. "Did you check the locks on the door?" "I'm feeling a little ill, do you think I have lupus?" A recent interview with Dr. Wayne Goodman correctly suggests that the best way a spouse can respond to such questions, in cases of OCD, is to try to avoid providing that reassurance that only strengthens the compulsive tendency. Sometimes arguments over such requests for reassurance can become problematic for couples. In that case, consultation with an OCD specialist is appropriate.

Is your therapy actually helping?

A previous posting on this blog discussed the recent controversy over "effective" psychotherapy. A more recent article in the LA Times outlines the two sides of the debate. Regardless of what you think about this controversy, one important message to take away is that it's important to consider whether your therapy is helpful. That may sound obvious, but whatever the reasons you sought therapy to begin with, it can be helpful to periodically ask yourself whether you feel that things are tangibly changing for you. If not, have a frank discussion with your therapist -- a good therapist will share your desire for tangible meaningful change, and would welcome such a discussion.

Science and Psychotherapy

Most people closely associate medicine and science, but how many of us think of psychotherapy and science as being related? Maybe we don’t, but we should. A recent research article that has received significant media attention has drawn attention to this issue.

While it's true that psychotherapy has little to do with scientific tools like Petri dishes and test tubes, the process of determining which types of psychotherapy are most helpful for specific problems is a scientific one. For decades, major universities and other research institutions have investigated whether some approaches to psychotherapy are more effective than others. Fortunately, after thousands of such rigorously conducted studies, we now possess scientific knowledge about whether specific psychotherapies are helpful for specific problems. Sounds like good news, right? It is! But here’s the bad news. There is no guarantee that a visit to your local therapist will result in your receiving the best-established type of therapy for your problem.

If you see your primary care doctor for advice on high cholesterol, you’re likely to be counseled on which changes to your diet might be helpful and which medications might be appropriate. You wouldn’t expect to be told to take up model boat building, however useful the physician might deem that to be. Why? Because early last century, medicine committed to the use of a scientific approach in selecting treatments. That means that if research shows that iron supplements are more helpful for anemia than, say, leeches, your physician will recommend iron (even if he is an amateur leech farmer).

Unfortunately, this approach has not been as widely accepted by psychotherapists as it has by physicians. Two important reasons for this involve therapist training and accountability. Many therapists attend training programs in only one type of therapy, and graduate from training thinking that this type of therapy is superior and appropriate for many (or all) types of problems. This represents a shortcoming of some therapy training programs. The other factor creating ambiguity around the standard of care among therapists has to do with accountability. If your doctor gives you penicillin for your melanoma, you can file a complaint with the state licensing board. You might even be able to bring legal action. However, therapists are typically not held accountable in the ways physicians are.

There are many reasons -- some very good -- for the different standards. For one, the consequences of applying the wrong treatment are typically different in psychotherapy than in medicine. Additionally, it’s often much clearer whether or not a broken arm is healing as opposed to whether someone’s depression has improved. So while it may be inappropriate hold therapists to the same standards we have for physicians, it is certainly reasonable to expect that therapists be cognizant of the research base for any type of therapy they provide.

Psychotherapy for OCD

For people suffering from OCD, it can be hard to find help. Being an informed consumer can make all the difference.

It is common for people who think they might have OCD to say, "I'd better see someone," and go to see a psychotherapist. So far, so good. However, there are different types of therapy for OCD, and evidence suggests that some work better than others. Many people who seek help for obsessions or compulsions with a psychotherapist find that sometimes, after months or years of therapy, their symptoms are still a problem. There can be many possible reasons for this.

One possibility is that OCD is not the only problem that the patient has. Other co-occurring conditions (e.g., depression, eating disorders) can worsen prognosis.

Another possibility involves the fact that even the most effective treatments for OCD don't work for everyone. Exposure and Ritual Prevention (ERP), a kind of psychotherapy for OCD, is often found to produce significant improvement in two thirds to three quarters of patients in clinical research studies (e.g, as described in a previous post). This means that a significant proportion of people trying this type of therapy will not see significant improvement.

The most alarming possibility, perhaps, is that the patient sees no improvement, and is not receiving the appropriate type of therapy. Many people have called me over the years saying that they are contemplating switching therapists. When asked why, they often say something like, "Well, I really like my therapist and all, but we've been talking about my childhood and my parents for 2-3 years now, and I'm still checking my kitchen stove 30 times a day. I'm getting tired of it!" If you think you may have OCD and decide to see a therapist to work on it, ask them whether they recommend ERP for you. They may have a good reason for not recommending it; however if they're not familiar with it, you might consider seeking out a second opinion.