CBT becoming more available in the U.K.

Starting in 2006, the British government undertook an initiative to make high quality psychotherapy more widely available for people suffering from depression, anxiety, and related problems. While many different types of psychotherapy were already available, the government chose to make therapies proven to be effective available to as many patients as possible. Cognitive behavioral therapy is one example of a psychotherapy that the British government is attempting to make more widely available.

UK Health Secretary Alan Johnson was quoted in a recent BBC article saying that "For many people prescribing medication is a successful treatment but we know that psychological therapies work equally well."

In making decisions about whether to undertake a treatment of medication, psychotherapy, or both, it is important to educate yourself about which treatments have been proven effective through research studies. Fortunately, the FDA restricts use of psychopharmacological medications to problems for which a particular drug has been demonstrated to be effective. Fortunately or unfortunately, psychotherapies are not regulated by any government agency, and thus it is especially helpful to get as much information as you can about which type of psychotherapy is helpful for your particular issue. One recommendation I have is to ask a prospective psychotherapist what kind of therapy they would use with you, given your symptoms. They may insist on an in-person consultation before answering this question, which is appropriate. Another recommendation is to ask a prospective psychotherapist whether there is research to suggest that this particular kind of therapy is effective for your particular problem.

Given all the research that has been done to determine which types of psychotherapy are helpful for particular problems, psychotherapists are now able to more easily determine which type of psychotherapy is likely to be beneficial in given situations. Help yourself by asking your therapist what research there is to support their particular approach for a given problem.

Mindfulness in therapy

An article in the New York Times health section today, entitled "Lotus Therapy," describes the increasingly prevalent use of mindfulness techniques in psychotherapy over the past ten years. The article describes the state of research on the use of mindfulness meditation as "thin," and indeed the evidence for the effectiveness of mindfulness' use for anxiety and depression is not as substantial as the evidence for cognitive-behavioral therapy or antidepressant medication. However, the research that has been conducted to this point paints a picture of mindfulness meditation as a useful tool -- for those inclined to use it -- in fighting depression and anxiety.

A fair consideration of the strength of evidence for mindfulness meditation vs. psychotherapy and pharmacological treatments should keep in mind a few key points:

1) Few people make the claim that mindfulness meditation is an appropriate substitute for either cognitive-behavioral therapy or for medication. Typically it is described as an important complement to psychotherapy. Comparing its effectiveness to that of either of the other two treatment modalities sets up a false dichotomy.

2) The use of mindfulness in psychotherapy has become widespread only relatively recently, and thus has not had the benefit of decades of research studies to support its effectiveness. As mentioned in the Times article, there is an increasing effort being made to include mindfulness in NIH-funded research studies.

Challenges to seeking help

A recent New York Times article highlighted the difficulty many people face in deciding whether or not to seek help for emotional problems – readable at http://www.nytimes.com/2008/04/18/us/18vets.html. The article describes a recent privately conducted research study that concluded that 19% of the 1.6 million members of the American military who have recently served in Iraq or Afghanistan have symptoms of posttraumatic stress disorder or major depression. Of the 19%, however, only slightly more than half have sought help.

There are many reasons that people are reluctant to seeking help for emotional difficulties. One reason is the commonly held belief that one should be able to handle whatever life throws one’s way, and that seeking help is akin to cheating, or to admitting defeat. Many people truly, deeply believe that the problems they are experiencing are their own fault, and thus, it would wrong to seek help. While it may be true that they have contributed to these problems, it is often untrue that seeking help would be a copout. For example, let’s say that you had a close friend who started to drink too much. Let’s say this drinking became a problem in their lives, and affected your friend’s relationships and work. Fortunately, your friend recognized that the drinking had become problematic, but blamed themselves for “letting things get to this point” and insisted that cutting back on drinking was the only answer to their problems – “simple as that.” Wouldn’t you want your friend to at least try to seek help, even if they ultimately decided that it wasn’t for them?

Ultimately, whatever change does happen in psychotherapy occurs because of changes made by the person themselves, regardless of any guidance from a therapist.

Another factor that plays into reluctance to seek help is described very well in the New York Times article – fear of one’s employer finding out, resulting in negative consequences. In the case of the military, servicemen and women are typically aware that their commanding officer has access to their full medical records, which would include any mental health services received, especially those received from the U.S. Military health system. For people outside of the military, working in the private sector, there are often similar fears. A typical source of these concerns is the question of whether a company’s human resources departments can obtain personal health information from the health insurer. Unfortunately there is often little information available about how justified this concern may be.

CBT for OCD

For many sufferers of Obsessive-Compulsive Disorder (OCD) and other types of anxiety, deciding to seek help can be a difficult decision to make. Once that decision is made, another choice is required: what kind of help is best for me? Two of the most researched treatment options available are pharmacological treatment (medication) and cognitive-behavioral therapy. Many people will prefer one or the other, saying, “Oh, I would never want to take medication unless I had to,” or alternatively, “Just give me the pill, what’s the big deal?” This is a very personal choice that each person must make individually. For those that wonder how effective each option may be for them, good news – there is a good deal of research on exactly how effective each of these two treatment options can be.

Much of the research on the effectiveness of various medications for OCD focuses on the class of medications known as the SSRIs (selective serotonin reuptake inhibitors). This class of medications is relatively new, having been first used in the late 1980’s. Medications like Celexa, Lexapro, Prozac, Zoloft, Luvox, and Paxil belong to this class. They are widely used, partially because their side effect profiles are favorable. Some possible side effects are difficulties with sexual arousal, lowered interest in sex, headache, and changes in appetite. However each medication will have a different set of potential side effects, and of course you should consult your prescriber before deciding which medication might be best for you.

Much of the research on the effectiveness of psychotherapy for OCD and anxiety disorders focuses on different types of cognitive-behavioral therapy (CBT). For OCD, a form of cognitive-behavioral therapy known as Exposure and Ritual Prevention (ExRP) has been shown to be effective in treatment. ExRP is the updated form of Exposure and Response Prevention (ERP), and it focuses on changing the strategies used by the OCD sufferer to cope with anxiety. For more on ExRP, click here.

Both SSRI and CBT are considered first-line treatments for simple OCD, meaning that one of the two will typically be the first thing recommended for someone with OCD. Research has generally not shown either one to be more effective than the other; both are considered effective in reducing symptoms of COD. Occasionally there is research that compares these two types of OCD treatment, and a study was published in July 2006 that did just that. Some researchers in Brazil compared Zoloft to a CBT group therapy. CBT group therapy for OCD has been shown to be comparably effective to individual CBT for OCD. In the Brazilian study, a summary of which is included below, the CBT that was studied included “techniques of ERP” as well as some classic elements of CBT. While details were not explicit in the article, the therapy used may be best understood as a hybrid of ERP and conventional CBT.

Here is the summary, as reported in 2006 by Reuters:

OCD Responds Better to Cognitive-Behavioral Therapy Than to Sertraline

NEW YORK (Reuters Health) Aug 28 - Combination treatment withcognitive-behavioral group therapy plus sertraline (Zoloft) is effective for the treatment of obsessive-compulsive disorder (OCD), but when each treatment is given alone, cognitive-behavioral therapy is superior to sertraline. Although OCD is responsive to the combination of these two therapeutic approaches, Dr. Aristides V. Cordioli and colleagues from Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil, wrote, "there is no consensus about which of these forms of treatment is more effective" when used alone.

In the current study, published in the July issue of the Journal of Clinical Psychiatry, the researchers compared the efficacy of cognitive behavioral therapy versus sertraline in reducing symptoms of OCD. They evaluated 50 OCD outpatients randomized to 100 mg/day sertraline or cognitive behavioral group therapy for 12 weeks. The patients were assessed at baseline and weeks 4, 8, and 12.

While the patients responded to both treatments, "the reduction of symptoms for cognitive behavioral group therapy patients was 44.07% while in the sertraline group it was 27.78% (p = 0.033)," Dr. Cordioli's team reports.

Patients who received cognitive behavioral group therapy also experienced asignificantly greater reduction in the intensity of compulsions (p = 0.030).

Complete remission of OCD symptoms was observed in eight patients in the cognitive behavioral therapy group compared with only one patient in the sertraline group.

No significant reductions in the intensity of anxiety and depression symptoms were seen with either treatment.

This study showed that the group receiving CBT experienced greater reduction in symptoms than the group receiving Zoloft. The authors point out that the study was conducted on patients suffering from OCD but not from any other psychological problems (e.g., depression, social anxiety), and that the results obtained in the study may not apply to people with other difficulties in addition to OCD. This study can be interpreted as confirmation of the effectiveness of both CBT and Zoloft in treatment of OCD, and also as showing some newer results about the superiority of CBT in the “intensity of compulsions, the rate of symptom reduction, and in complete remission.”

Some people with OCD wonder about the advisability of taking medication while in therapy. There are advantages and disadvantages to this. One advantage to not taking any psychoactive medication while in CBT is that you will learn new skills to cope with your OCD, anxiety, depression, etc., while you are experiencing those symptoms. If you began CBT while on medication, and then later came off the medication, your symptoms may overwhelm your ability to use the tools you had learned in CBT. Some people report that while medication is helpful for them, it is not helpful anymore after they stop taking it, and they are vulnerable to feeling that they are “back at square one.”

There has been other recent research on the neurophysiology of OCD that shows differences in brain activity patterns in people with OCD compared to people without OCD. Research has also found that these patterns change after successful CBT or SSRI treatment. While some sufferers of OCD may be alarmed at the notion that their brains are different than anyone else’s, it is important to remember that the brain is a remarkable, dynamic, constantly changing organ. Every time we learn something new, nerve cells in our brains form new and different connections that were not there before. Patterns of activity in the brain change when we perform seemingly simple tasks: every time we open our eyes in the morning, a complex wave of electrical activity makes its way from our optic nerve to various parts of our cerebral cortex. Given the sensitivity of the brain to new information and new habits (both mental and physical), it should not be a surprise, nor undue cause for alarm, that patterns of activity in the brain should be different in people with OCD. Some interpret research studies on the effects of CBT and medication on the brain as simply complementary to other studies showing the effectiveness of these treatment options.

In conclusion, the choice of whether to pursue CBT, medication, or both can be a difficult one. Fortunately, sufferers of OCD today can take some comfort in the fact that both of these treatments have been shown to be effective, as neither was available just a few decades ago.

Meditation brain research

A recent meditation study out of California has recently garnered significant publicity.

I will take this example as an opportunity to comment on media coverage of current brain research. It should be no surprise to anyone that the brain is the most complex organs in the body, and the most difficult to understand. Despite the frequent headlines about scientific advances, researchers have only a relatively primitive understanding of how the brain works. Some areas are well understood as very important to, say, breathing or balance. However, much “higher-order” cognitive functioning is very difficult to pin down in the brain. For example, long term memory does not appear to be localized to one part of the brain; rather, your brain uses many different locations in the supremely complex task of storing long-term memory. It is also important to note that many aspects of brain functioning are not localized to one patch of gray matter. Research has revealed that many aspects of our cognitive functioning make use of “circuits” in the brain comprised of nerve cells reaching from one end of the brain to the other.

In the study described above, researchers at UCLA did two studies on emotional processing in the brain. They used functional magnetic resonance imaging (fMRI) to study which parts of the brain were more active during separate tasks. This method of studying the brain is one of the most complex and accurate methods currently available. One of their reported results was that people who were more “mindful” displayed different brain functioning than those who were not. Here the word “mindful” presumably refers to those traits that are associated with long-term experience with meditation. One result the researchers found was that people who were more mindful displayed more of the brain patterns found in people who are good at “putting feelings into words.” This result may be partly explained by the fact that a tendency to label one’s emotions is often included in descriptions of mindfulness. However, it is possible that this study illuminates an important difference in brain functioning between people who are mindful and those who are not.

We should beware the headlines that often accompany articles like this one. The above URL links to an article whose headline reads, “Brain Scans Reveal Why Meditation Works.” On one hand, this seems like a gross exaggeration. The uninformed reader may glance at this and conclude, “Hey, how about that, those scientists cracked another mystery. Case closed.” However there is much about meditation and much about the brain that is poorly understood by scientists. The recent trend to explain the subjective and objective effects of meditation in terms of neurobiological functioning is a welcome one, to this writer, but we have a long way to go before the mysteries of “why meditation works” can be considered “cracked.”