opinions on medication management

allantois

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I read from posters of this community that they have never received a referral from a psychiatrist. This made me think about whether psychologists (or other mental health clinicians) are ever reluctant in making psychiatry referrals for one reason or another? Anecdotally, I have personally experienced as a patient 2 therapists (albeit, not psychologists) who tried to discourage me from taking an SSRI for anxiety. Further, I wonder if there are differences between clinical vs counseling psychologists as it relates to this issue. It is my understanding that the two schools have somewhat different foundations. I had wonderful clinical psychologists as faculty members in undergrad with views that mental disease is primarily caused by biological factors. I wonder if some psychology programs place more emphasis on socio-cultural factors and thus their graduates are more reluctant to suggest medication therapy to their clients?
 
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Fan_of_Meehl

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I have recently read from posters of this community that they have never received a referral from a psychiatrist. This made me think about whether psychologists (or other mental health clinicians) are ever reluctant in making psychiatry referrals for one reason or another? Anecdotally, I have personally experienced as a patient 2 therapists (albeit, not psychologists) who tried to discourage me from taking medication for anxiety. Further, I wonder if there are differences between clinical vs counseling psychologists as it relates to this issue. It is my understanding that the two schools have somewhat different foundations. I had wonderful clinical psychologists as faculty members in undergrad with views that mental disease is primarily caused by biological factors. I wonder if some psychology programs place more emphasis on socio-cultural factors and thus their graduates are more reluctant to suggest medication therapy to their clients?
Some meds can make problems worse. Benzodiazepines for anxiety come to mind.

And cognitive behavioral treatment (especially with exposure components) for anxiety disorders represents one of the most robustly effective 'success stories' in all of psychotherapy across decades of research and clinical practice. A lot of the therapeutic approaches within this tradition were strongly informed by the basic clinical science (that actually has foundations in how the central nervous system operates with respect to anxiety or panic responses) and refined over time via dismantling studies and appropriate meta-analytic studies.

My approach is to offer all patients psychoeducation on evidence-based / effective treatment options (psychotherapeutic and psychopharmacologic). Most (but not all) psychotherapeutic treatments I can offer them directly--for others I can refer out. I don't do the meds so I always enter the appropriate consult for these and let the prescribing provider take it from there.
 
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allantois

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Some meds can make problems worse. Benzodiazepines for anxiety come to mind.

And cognitive behavioral treatment (especially with exposure components) for anxiety disorders represents one of the most robustly effective 'success stories' in all of psychotherapy across decades of research and clinical practice. A lot of the therapeutic approaches within this tradition were strongly informed by the basic clinical science (that actually has foundations in how the central nervous system operates with respect to anxiety or panic responses) and refined over time via dismantling studies and appropriate meta-analytic studies.

My approach is to offer all patients psychoeducation on evidence-based / effective treatment options (psychotherapeutic and psychopharmacologic). Most (but not all) psychotherapeutic treatments I can offer them directly--for others I can refer out. I don't do the meds so I always enter the appropriate consult for these and let the prescribing provider take it from there.

VA seems like a pretty good system for mental health. Some systems I found (at least at the two colleges I attended) required a referral by a therapist in order to see a psychiatrist. This brings up an interesting issue. When I am a practicing medical provider, if my patient desires to seek therapy, I don't feel like I have the training to determine whether such therapy is warranted, so I would have no issue with making such referral especially given the patient's motivation for therapy. How is a therapist supposed to determine whether the patient requires a psychiatric evaluation for consideration of medical therapy, while the said therapist was not trained in providing medical therapy? I think there is so much red tape for patients to jump through in order to get the care that they need. Anecdotally, many primary care physicians prefer making referrals to psychology vs psychiatry as they themselves have certain biases about medication management for psychiatric disorders. It seems like everywhere you look in mental health, providers from one discipline have biases against the other discipline that in the end seem to only adversely affect patient care.
 
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How is a therapist supposed to determine whether the patient requires a psychiatric evaluation for consideration of medical therapy, while the said therapist was not trained in providing medical therapy?

You are way overthinking this. Best practice guidelines and models exist for a reason.

Referring or encouraging a psychiatric evaluation to see if medicine would be needed and appropriate is pretty warranted for anything other than adjustment disorders.
 
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I wonder if there are differences between clinical vs counseling psychologists as it relates to this issue. It is my understanding that the two schools have somewhat different foundations.

No. We operate under the same license and are held to the same professional standards.
 
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Fan_of_Meehl

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You are way overthinking. Best practice guidelines exist for a reason.

Referring or encouraging a psychiatric evaluation to see if medicine would be needed and appropriate is pretty warranted for anything other than adjustment disorders.
Yup. This.

I mean, it's also quite reasonable to try a trial of psychotherapy alone first (for many conditions) and then, if the response to therapy isn't satisfactory, consider other options including referral for medication treatment.
 
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Fan_of_Meehl

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VA seems like a pretty good system for mental health. Some systems I found (at least at the two colleges I attended) required a referral by a therapist in order to see a psychiatrist. This brings up an interesting issue. When I am a practicing medical provider, if my patient desires to seek therapy, I don't feel like I have the training to determine whether such therapy is warranted, so I would have no issue with making such referral especially given the patient's motivation for therapy. How is a therapist supposed to determine whether the patient requires a psychiatric evaluation for consideration of medical therapy, while the said therapist was not trained in providing medical therapy? I think there is so much red tape for patients to jump through in order to get the care that they need. Anecdotally, many primary care physicians prefer making referrals to psychology vs psychiatry as they themselves have certain biases about medication management for psychiatric disorders. It seems like everywhere you look in mental health, providers from one discipline have biases against the other discipline that in the end seem to only adversely affect patient care.
Also, just as an aside, you don't need to be motivated for therapy to get psychotherapy in the VA system.

I keed. I keed, lol.
 
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beginner2011

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VA seems like a pretty good system for mental health. Some systems I found (at least at the two colleges I attended) required a referral by a therapist in order to see a psychiatrist. This brings up an interesting issue. When I am a practicing medical provider, if my patient desires to seek therapy, I don't feel like I have the training to determine whether such therapy is warranted, so I would have no issue with making such referral especially given the patient's motivation for therapy. How is a therapist supposed to determine whether the patient requires a psychiatric evaluation for consideration of medical therapy, while the said therapist was not trained in providing medical therapy? I think there is so much red tape for patients to jump through in order to get the care that they need. Anecdotally, many primary care physicians prefer making referrals to psychology vs psychiatry as they themselves have certain biases about medication management for psychiatric disorders. It seems like everywhere you look in mental health, providers from one discipline have biases against the other discipline that in the end seem to only adversely affect patient care.

In reality, most people we see are referred for psychotherapy by a PCP after starting on a low dose of a first line medication to manage their symptoms (assuming this is a patient with no existing history of MH concerns). If the patient does not improve and the PCP has hit their comfort limit on managing psychotropics, a referral to a specialist makes sense as the next step.
 
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calimich

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Counseling psychologist here, main gig as faculty, side gig in pp. I've maintained a close relationship with my intern/postdoc site which operated under an integrated health model at a UCC. There, we worked in interdisciplinary teams with MDs (PCPs and psychiatrists), nutritionists, LCSWs, psychiatric nurse practitioners...to meet patient needs. I get many referrals from that site and have a few "favorite" GPs and psychiatrists with whom I often coordinate care. All this to say yes, I've received many referrals from MDs and have referred many other clients back to them for services I can not provide.
 
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I'm curious how Irving Kirsch's work fits in with peoples' referral decisions. Personally, I am wary of psychopharmacological interventions for many mood and anxiety disorders, especially as a choice for initial treatment.

2019: Placebo Effect in the Treatment of Depression and Anxiety
2014: Antidepressants and the Placebo Effect
2008: Initial Severity and Antidepressant Benefits: A Meta-Analysis of Data Submitted to the Food and Drug Administration - PubMed

This has been discussed ad nauseam on this forum. See



The most succinct and accurate summary is a comment in the second thread:
"Antidepressants have an effect size of 0.3. Proponents and opponents argue whether that counts as "working.""
 
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beginner2011

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This has been discussed ad nauseam on this forum. See



The most succinct and accurate summary is a comment in the second thread:
"Antidepressants have an effect size of 0.3. Proponents and opponents argue whether that counts as "working.""

It seems important to note that the effect of placebo is estimated to be a reduction of an estimated 8.3 points on the HAM-D vs. a reduction of about 10.1 on the HAM-D for antidepressant medications. I think the recommendation by the authors of the most recent review is telling:


What Is to Be Done?
How then shall we treat depression? One suggestion that has been made to me informally is to prescribe antidepressants as active placebos. An active placebo is a pharmacologically active substance that does not have specific activity for the condition being treated. Antidepressant medications have little or no pharmacological effects on depression or anxiety, but they do elicit a substantial placebo effect. Could we not use them as a means of capitalizing on the power of placebo?

The problem with this suggestion is that treatment decisions need to be based on an assessment of risks, as well as benefits. The risks of antidepressant treatment include suicidal and violent aggressive behavior in adolescents and young adults; stroke, death from all causes, falls and fractures, and epileptic seizures in the elderly; and sexual dysfunction, withdrawal symptoms, diabetes, deep vein thrombosis, and gastrointestinal and intracranial bleeding in everyone else (5562). One might argue that these risks might be worth taking for an effective treatment of severe depression, but are they worth risking for a treatment that has no benefit at all over placebo for first-time users?

A second possibility would be to prescribe placebos. They are safe and effective, with relatively few nocebo side effects and no health risks. The problem with prescribing placebos rests with the commonly held assumption that to be effective in clinical practice, placebos have to be presented deceptively as active medications. This assumption has been reported to be false in recent clinical trials [reviewed in Ref. (63)]. In these studies, placebos were presented non-deceptively as placebos with no active ingredients. How could this ever work? The answer is that it was accompanied by a rationale in which it was explained that placebos have been found effective to the condition being treated, that it has been found to involve Pavlovian conditioning, and that it might therefore be effective in treating the person’s condition. This rationale has been found to be critical for the success of the open-label placebo (OLP) intervention (64). Additional OLP trials with larger samples, longer duration, and blinded assessors are warranted.

Unfortunately, only one of the studies assessing OLPs involved the treatment of depression, and that one, although showing promising results, was only a small pilot (65). However, there are many other treatments that equal antidepressants in terms of degree of symptom reduction (6669). These include psychotherapy, physical exercise, acupuncture, omega-3, homeopathy, tai chi, qigong, and yoga. We do not know the mechanisms of these alternative treatments, and their efficacy may be at least partly due to expectancy, but they are certainly safer than antidepressant medication.

The long-term advantage of psychotherapy over medication has been shown in a number of studies [reviewed in Ref. (70)]. Whereas short-term outcomes were equivalent between the two treatments, long-term outcomes were significantly better for patients who had received psychotherapy than for those who had received medication. Additionally, the National Institute of Mental Health (NIMH) Treatment of Depression Collaborative Research Program reported relapse rates of 36% and 33% for cognitive behaviour therapy and interpersonal therapy, respectively, compared with a 50% relapse rate for antidepressant medication (71). However, the rate of relapse for patients who had recovered on placebo was 33%, the same as that for psychotherapy. There are two take-home messages from these data. First, it dispels the myth that placebo responses are short-lived. Second, it raises the questions of whether psychotherapy reduces relapse or medication increases it (72).

Support for the hypothesis that antidepressant medication increases the risk of relapse comes from other studies comparing antidepressant and placebo treatment for depression and anxiety disorders. Consistent with the NIMH data, a 2011 meta-analysis reported a relapse rate of 25% for depressed patients successfully treated with placebo compared to relapse rates ranging from 42% to 57% among those treated with various antidepressants (73). A direct test of the effect of antidepressants and psychotherapy on the risk of relapse comes from a study on the treatment of panic disorder (74). The study compared the 6-month relapse rates for patients who had been treated with a tricyclic antidepressant (imipramine), cognitive behavior therapy (CBT), or the two combined. The results, displayed in Figure 4, indicate that the risk of relapse following imipramine was more than double that following CBT. However, the addition of the antidepressant to imipramine completely erased that benefit. Similarly, physical exercise as a treatment for depression has been shown to have a much lower relapse rate than SSRIs, but that benefit disappears when the two treatments are combined (75).

These studies reveal another benefit of including placebos in clinical trials of medication. They can reveal situations in which the treatment does more harm than good for the condition being treated. For example, placebos have outperformed antipsychotic medication (haloperidol and risperidone) in the treatment of delirium in palliative care patients and aggression in intellectually disabled adults (76, 77). Similarly, placebo was significantly better than a combination of chondroitin and glucosamine in the treatment of knee osteoarthritis (78) and showed similar superiority in a trial of nutraceuticals in the treatment of depression (79).

Given these data, I suggest that the following principles be used in treatment selection. When treatments are equally effective, recommend the safest. When they are equally safe, let the patient choose which he or she prefers. Before making this choice, however, patients should be accurately informed of the potential harms of antidepressant medication (e.g., increased risk of relapse, suicidality, gastrointestinal and intracranial bleeding, deep vein thrombosis, pulmonary embolism, diabetes, stroke, epilepsy, and death from all causes), as well as the finding that all of these treatments appear to be equally effective in the short term but that psychotherapy and physical exercise might be more effective than antidepressants in the long run."

I have yet to meet a psychiatrist who talks about or thinks about their prescription of antidepressants as "an active placebo", and yet that's what the evidence seems to suggest. I've also never heard anyone suggest prescribing a nocebo, but again the evidence supports that. And finally I've only very rarely heard an MD say their first-line response was the safest and most effective recommendation for patients reporting depression symptoms: psychotherapy.

It's hard to look at this research and not wonder if med management for depression is in many cases a more sophisticated and modernized mesmerism.
 
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I mean, that's the metric that the FDA's drug trials use to determine efficacy. If we're going to throw that out then we can't say much about efficacy at all.

Scary, isn't it? My point is that there are psychometric problems with the HAM-D that are rarely addressed. Cronbach's alpha (a very flawed metric anyway) is unacceptably low for clinical utility and methods used to justify validity assume a normal distribution where research has demonstrated that depression is not normally distributed. Depression measurement is more tricky than we might be led to believe.
 

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Scary, isn't it? My point is that there are psychometric problems with the HAM-D that are rarely addressed. Cronbach's alpha (a very flawed metric anyway) is unacceptably low for clinical utility and methods used to justify validity assume a normal distribution where research has demonstrated that depression is not normally distributed. Depression measurement is more tricky than we might be led to believe.
Why is it that they're using the HAM-D in these studies, as opposed to other measures?
 
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Sorry this is ridiculous

"increased risk of relapse, suicidality, gastrointestinal and intracranial bleeding, deep vein thrombosis, pulmonary embolism, diabetes, stroke, epilepsy, and death from all causes"

Just no. SSRIs are among the safest available pharmaceuticals. The bleeding thing is rare and only applies to people with other bleed risks, in which case you discuss risk,/benefit etc and consider other measures. Suicidality is incredibly rare, specific to adolescents, and numerically far outweighed by the more commonly experienced benefit for depression and reduction in SI.

DVT/PE/diabetes/stroke/epilepsy?? Where did those even come from? Not a thing. Bupropion (not SSRI) can lower the seizure threshold, so don't give it to people at risk for seizure. Done. The rest are totally made up. No drug is simultaneously a risk for bleeding and clotting. It's one or the other. Come on.

And I love the way the authors suggest omega 3 as a 'safer' placebo. Omega 3 is no safer than SSRI. Anything can be toxic if taken in excess.


Of course placebo is a big component of SSRI efficacy, but so what? I don't think there is a 'safer' active pill placebo alternative.

Behavioral interventions and psychotherapy are fantastic and I always recommend those in concert with medication. It's not or, it's and. But I think this article underestimates how difficult it is to get someone in a deep vegetative depression to do qi gong or whatever. Pill is a low bar and can help get people to the point where they are able to engage with behavioral treatments.
 
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Why is it that they're using the HAM-D in these studies, as opposed to other measures?

I think there's this idea that clinician rated scales are more reliable than self report. Personally I think this is silly - the clinician rated scale is still the patient's report but now just filtered through the clinician, introducing an additional source of error. Hence the crappy alpha. But I think that's why it gets used.
 
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R. Matey

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Why is it that they're using the HAM-D in these studies, as opposed to other measures?

IMO, it's because it's been around forever. BDI-II isn't normally distributed either. The symptom report measures that are using frequency of depressive symptoms as response categories (PHQ-9) seem to fair better in terms of normally distributed data. There are large scale national studies with those instruments. I'll admit the HAM-D-6 seems to be fairing better than the 17 item version. But it's new.

I think there's this idea that clinician rated scales are more reliable than self report. Personally I think this is silly - the clinician rated scale is still the patient's report but now just filtered through the clinician, introducing an additional source of error. Hence the crappy alpha. But I think that's why it gets used.

Well, the HAM-D has an unknown, poorly defined multidimensional structure with few items measuring multiple distinct factors, which in turn diminishes alpha. With validity, FA used to uncover the structure has been done is very squishy. PCAs with verimax rotations will get nearly any statistician to laugh at you. However, it's a little self-defeating to criticize how a clinician fills out an instrument, but not how they write things down in notes. I'm not sure I can see how having rating criteria in front of you can be a source of error. If the rating criteria includes items like: "Is the patient wearing clown shoes today?" as some of the items on the HAM-D might as well be saying if the goal is depression measurement, then we very likely have found our source of error.

This feels like a thread hijack. So sorry, everyone. I just wanted SDN to know that I was a Ravenclaw :)
 
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Ollie123

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I guess it probably depends on setting and presenting problem, but virtually everyone I know on both sides is perfectly happy to refer. I refer patients for med management all the time. I get referrals from prescribers all the time. Admittedly, I am part of a large system so said individuals are down the hall and/or upstairs. I will loosely discuss the risks/benefits with patients while making it clear meds are outside my wheelhouse. While I admit it is a blurry line, I do make some judgment calls with how hard I push them to take the referral based on how much <I> think they need meds. i.e. long history of severe depressive episodes w/psychosis? Let's call psychiatry during the appt so we get you in asap. "I've been a little 'off' since my divorce last month?" If you want medication I'm happy to refer, but if not I think we can try therapy (in my head..."/wait for regression to the mean") first and see how it goes.

Some meds are riskier than others. Some of the concerns above about SSRIs seem insane in their own right. That said, I'm largely unimpressed by our treatment options in both fields. Therapy has some home runs when it comes to phobia/OCD. Meds have some home runs when it comes to psychosis. Both have some middle ground areas (e.g. CPT/PE - while very effective - still are far from cures and engagement can be tough in many settings). Most everything else (i.e. probably 95% of the patient population) I feel like we are "meh" at treating at best. I certainly feel like I am just spinning the wheels a lot of the time in therapy and I don't know any prescriber who hasn't said the same. That's not an indictment of the field, its hard as hell to get people to change.
 
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There are certainly psychologists who have fairly extreme anti-medication views. Most are much more moderate, and likely view medication as one tool to treat various forms of mental illness, even if they think some things are perhaps over-prescribed or some patients seem over-medicated.

I personally refer to my psychiatry colleagues fairly frequently. I don't make a determination if medication is necessary, nor do I suggest to the patient what type(s) of medication(s) may be most helpful. I talk with them about the services we have available, ask them if they'd be interested in psychotherapy, medication, or possibly both, and go from there. If they ask about specific medications, I tell them medical advice is outside my scope of practice. If they're interested in discussing possible cognitive side-effects or potential benefits (e.g., from, say, donepezil), I can sometimes review the research with them while suggesting they then follow-up with their physicians.
 
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1) What the hell is a referral to psychiatry?! Is this some institutional thing? Why can’t patients just pick up their phone, and make an appointment with whoever they want?

2) Almost all data suggests that medication + psychotherapy produce synergistic effects. Why wouldn’t you want that for a patient?

3) In terms of psychological treatment, what is a socio-cultural emphasis? Obviously understanding the context in which a mental illness occurs is important, but that isn’t a specific treatment. I don’t know if any psychologist that is capable of changing society and/or culture.
 
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AcronymAllergy

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1) What the hell is a referral to psychiatry?! Is this some institutional thing? Why can’t patients just pick up their phone, and make an appointment with whoever they want?

2) Almost all data suggests that medication + psychotherapy produce synergistic effects. Why wouldn’t you want that for a patient?

3) In terms of psychological treatment, what is a socio-cultural emphasis? Obviously understanding the context in which a mental illness occurs is important, but that isn’t a specific treatment. I don’t know if any psychologist that is capable of changing society and/or culture.

Probably primarily institutional in the formal sense, yes; our facility prefers (and some areas require) referral for specialty services, including specialty mental health (i.e., non-PCMHI). I imagine the OP may have also meant a more informal referral in private practice; maybe even something as open-ended as just suggesting the patient could benefit from meeting with a psychiatrist.

Edit: also, I might be a bit skeptical of any psychologist who hasn't ever at some point said to a patient, "you know, you might benefit from meeting with a psychiatrist."
 
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I guess it probably depends on setting and presenting problem, but virtually everyone I know on both sides is perfectly happy to refer. I refer patients for med management all the time. I get referrals from prescribers all the time. Admittedly, I am part of a large system so said individuals are down the hall and/or upstairs. I will loosely discuss the risks/benefits with patients while making it clear meds are outside my wheelhouse. While I admit it is a blurry line, I do make some judgment calls with how hard I push them to take the referral based on how much <I> think they need meds. i.e. long history of severe depressive episodes w/psychosis? Let's call psychiatry during the appt so we get you in asap. "I've been a little 'off' since my divorce last month?" If you want medication I'm happy to refer, but if not I think we can try therapy (in my head..."/wait for regression to the mean") first and see how it goes.

Some meds are riskier than others. Some of the concerns above about SSRIs seem insane in their own right. That said, I'm largely unimpressed by our treatment options in both fields. Therapy has some home runs when it comes to phobia/OCD. Meds have some home runs when it comes to psychosis. Both have some middle ground areas (e.g. CPT/PE - while very effective - still are far from cures and engagement can be tough in many settings). Most everything else (i.e. probably 95% of the patient population) I feel like we are "meh" at treating at best. I certainly feel like I am just spinning the wheels a lot of the time in therapy and I don't know any prescriber who hasn't said the same. That's not an indictment of the field, its hard as hell to get people to change.
I have to constantly keep reminding myself that all I can do is provide folks the OPPORTUNITY to change and be ready to 'hit the ground running' with specific interventions should they get to the point where they're willing to work on themselves. There's very much a 'developmental model/framework' to be applied to the task of psychotherapy along the lines of the whole transtheoretical model for behavior change. Some people, for many reasons, will have both feet eternally planted in precontemplation til the day they die and I can't (directly) change that. I can engage in Socratic dialogue around their beliefs that maintain their precontemplative stance but I can't literally do the cognitive (re)processing for them. And, no, for such folks I do not actually think that showing them longitudinal graphs of their flat PHQ9/PCL5 scores will necessarily 'wake them from their slumber' and cause a personality transformation such that they will then eagerly start engaging in effortful self-examination and self-change. Already tried that enough times to know better.
 
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Ollie123

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They absolutely can. Most of time, that is how it works - it is just jargon. At least to me - referral is just when I initiate the conversation (i.e. "I think it would be worth talking to someone about your medication options") or the patient initiates the conversation and I steer them towards a specific clinic/provider. There's no magic to it beyond that.

Sometimes we'll make the call together if I'm with someone severely dysfunctional/disorganized and I am not confident they will follow through.

There are some occasions and systems where it may mean more than that.
 
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beginner2011

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Sorry this is ridiculous

"Antidepressants have an effect size of 0.3. Proponents and opponents argue whether that counts as "working.""

Again, I'll say what I think are the most compelling points from the literature:

1. Antidepressants have an effect size of .3 on average. (edit: Cohen's d = ~.6)
2. Nocebos have an effect size of .25 on average. (edit: Cohen's d = ~.3)
3. There is evidence of significant side-effects for and withdrawal effects from antidepressants. (1, 2)

I'm confused why this isn't more of a discussion. Ironically, I worked on an inpatient unit at an R1 medical school with an attending psychiatrist who was a few years from retirement and she was the one who turned me on to a lot of this stuff. Why are more psychiatrists and psychologists not aware of these significant concerns?


(1) Suicidality and aggression during antidepressant treatment: systematic review and meta-analyses based on clinical study reports
(2) A systematic review into the incidence, severity and duration of antidepressant withdrawal effects: Are guidelines evidence-based?
 
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Well, the HAM-D has an unknown, poorly defined multidimensional structure with few items measuring multiple distinct factors, which in turn diminishes alpha.

This feels like a thread hijack. So sorry, everyone. I just wanted SDN to know that I was a Ravenclaw :)


To be fair, the entire rationale behind the items initially selected for the HAM-D was "what does Max Hamilton think tends to get better when you give someone clomipramine?" This was probably in retrospect not the best way to construct the instrument that psychotropic drug approvals were going to depend on.
 
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To be fair, the entire rationale behind the items initially selected for the HAM-D was "what does Max Hamilton think tends to get better when you give someone clomipramine?" This was probably in retrospect not the best way to construct the instrument that psychotropic drug approvals were going to depend on.

No argument there and there probably are sad clowns, so that's on me.
 
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It's funny how certain measures or operational definitions of constructs come to be so influential and so revered.

I think a lot of it is attributable to the 'yay science!' crowd who often fail to distinguish the philosophy/process of science from its products.
 
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Sanman

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1) What the hell is a referral to psychiatry?! Is this some institutional thing? Why can’t patients just pick up their phone, and make an appointment with whoever they want?

2) Almost all data suggests that medication + psychotherapy produce synergistic effects. Why wouldn’t you want that for a patient?

3) In terms of psychological treatment, what is a socio-cultural emphasis? Obviously understanding the context in which a mental illness occurs is important, but that isn’t a specific treatment. I don’t know if any psychologist that is capable of changing society and/or culture.

Let patients see whoever they want? How is a starving HMO to make a living?
 
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PsyDr

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IMO

1) There are purely biological affective disorders. These seem to respond to medication. These seem to be a minority of cases.

2) There also seems to be affective disorders that are caused by an mismatch of personality traits, abilities, expectations, behaviors, etc. People can be upset because they think they deserve a life they can't or won't achieve. Medication may help, but if you don't turn off the Kardashans after hour 4.... well, you gonna suck as a person.

When all of those cases are mixed into the outcome research, it's not surprising that the results are not great.

Can't blame medicine for doing what medicine does.
 
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Therapist4Chnge

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Why is it that they're using the HAM-D in these studies, as opposed to other measures?
It's easier to show a statistically significant finding. I read an article years ago about this (or maybe it was a book chapter?) and it became the choice in part bc it was used a lot and in part bc the findings looked better than other measures considered.
 
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Again, I'll say what I think are the most compelling points from the literature:

1. Antidepressants have an effect size of .3 on average.
2. Nocebos have an effect size of .25 on average.
3. There is evidence of significant side-effects for and withdrawal effects from antidepressants. (1, 2)


No. The effect size of 0.3 is what's left over after comparison against placebo. The clinically observable effect size (including placebo) has been calculated to be around 0.6.


Irving Kirsch hypothesized that the fact of the side effects was actually responsible for the benefit over placebo (active placebo effect).
This was later demonstrated not to be true.


I'm confused why this isn't more of a discussion. Ironically, I worked on an inpatient unit at an R1 medical school with an attending psychiatrist who was a few years from retirement and she was the one who turned me on to a lot of this stuff. Why are more psychiatrists and psychologists not aware of these significant concerns?

I think we're all very aware of them as demonstrated by the multiple threads on this subject over the years.
I've been following this issue for over a decade.
Whenever I start an antidepressant I do risk/benefit counseling which includes discussion of withdrawal effects and also includes the SI risk with anyone age 25 or under.
My read of the literature as a whole suggests that benefits generally outweigh risks.
 
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beginner2011

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Thanks very much for your reply. I was mistaken about how the effect size was calculated (looks like it's Cohen's d?), and I was not aware of the Hieronymus meta-analysis. I appreciate your willingness to lay that out.

However, I still think Kirsch's point stands. An average difference in effect of 1.8 points on the HAM-D favoring antidepressants is I think far, far smaller impact than most psychiatrists indicate to their patients. For example, I often saw that when I worked with other psychiatry attending in the same unit there was all of the sudden a much stronger (almost insistent) case being made to patients that antidepressants ought to be on-board.

I'd be interested in seeing what would happen with med management if psychiatrists were allowed to prescribe nocebos (I dont believe this is considered ethical currently?).
 

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Most of us are very aware of the placebo effect and SSRIs. That said, there is research support for the synergistic effects of psychotherapy + medication as @PsyDr mentioned, especially with disorders such as MDD etc.

Counseling psychologist, here. I usually find that clients want to discuss medication and ask for my opinion on it pretty early on in therapy. I am generally neutral, but refer to psychiatrists as needed, and, depending on the issue, will share some of the research findings but then suggest that they speak to a psychiatrist. I do not strongly encourage or discourage medication either way strongly, but do suggest it as a complement to therapy at times.

I've seen some folks benefit more than I ever thought possible from medications, and I've seen people unnecessarily sedated by them. I don't take an extreme view on this at all as a result of seeing the benefits and drawbacks because good psychiatrists will help clients find the right balance, as good psychotherapists help clients find balance as well.

One could argue the same for psychotherapy--that we don't need it, we just need exercise, or journaling, or social support, etc. and the common factors argument taken out of context to suggest that we don't need training, just a good listening ear.

My opinion is that each (psychiatry & psychology) can contribute to well-being in different ways--as long as it isn't bad practice. EDIT: And as long as we aren't deluding ourselves that medication will lead to increased coping skills in the longterm.
 
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I'd be interested in seeing what would happen with med management if psychiatrists were allowed to prescribe nocebos (I dont believe this is considered ethical currently?).

You mean active placebo? (Nocebo = "I shall harm," like if we were to yell at our patients, tell them our treatments are ineffective, and fill our offices with cacophonous noise and noxious odors. I assume that's not what you mean.)

I don't see how an active placebo is preferable to an SSRI. Anything that has identifiable side effects is by definition having some kind of physiological effect. I can't think of what you could give people that would be both biologically active and safer than an SSRI. What is the purpose of choosing a different biologically active agent that expressly lacks antidepressant efficacy?

The reason SSRIs became so widely prescribed is because of their safety and generally benign side effect profile. TCAs and MAOIs are somewhat more effective but much more dangerous, hence rarely used now.
 
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One more thing. The 0.6 effect is an average over all severities, including studies of extremely mild depression. Effect is greater in more severely depressed. These are Kirsch's data.

journal.pmed.0050045.g002.png


Obviously if you give your med to people who aren't depressed in the first place, you are going to dilute your signal.
 
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My clinical work was heavily diagnostic assessment, with a heavy, but not exclusive, focus on ADHD and Autism referrals.

ADHD: With children, referred for PCIT and strongly recommended considering meds (parents were sometimes hardline "no's" on this); with older adolescents and adults, 100% strongly suggested seeing a psychiatrist for meds. Honestly, I've never seen an adult with significant ADHD get much benefit from behavioral strategies without meds because they just wind up with a bunch of theoretically effective strategies that really mean nothing because they lack the executive function to actually use them.

PTSD: 100% psychotherapy as first-line (TF-CBT for children; CPT or PE for adults). I'm trauma researcher and sought out these cases in clinic.

Autism: The physician on our team really tried to discourage or taper anti-psychotics (and very rightly so, based on what I've seen in the literature)

Depression/anxiety: Talked about and suggested both psychotherapy and meds as possible options, including in tandem.

Personality disorders, usually BPD or BPD-ish: The closest thing to fidelity-implemented DBT we could find in the community
 
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beginner2011

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Obviously if you give your med to people who aren't depressed in the first place, you are going to dilute your signal.

It looks like the baseline severity for the majority of those trials was >24?

"The cutoff score on the HAMD that maximized the sum of sensitivity and specificity was 17 for the comparison of mild vs. moderate depression and 24 for the comparison of moderate vs. severe depression."


As an aside, I really appreciate this conversation. As much as I am pushing back, my hope here is that I'm misunderstanding some elements of these findings. I'd much rather have my mind put at ease and not believe that antidepressant meds are over-prescribed and almost as likely to get in the way of good psychotherapeutic intervention as they are to support it. (Yes, I'm aware of the "synergistic effect," but I can't help but be highly skeptical that the combination isn't mostly attributable to placebo.)
 

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My clinical work was heavily diagnostic assessment, with a heavy, but not exclusive, focus on ADHD and Autism referrals.

ADHD: With children, referred for PCIT and strongly recommended considering meds (parents were sometimes hardline "no's" on this); with older adolescents and adults, 100% strongly suggested seeing a psychiatrist for meds. Honestly, I've never seen an adult with significant ADHD get much benefit from behavioral strategies without meds because they just wind up with a bunch of theoretically effective strategies that really mean nothing because they lack the executive function to actually use them.

PTSD: 100% psychotherapy as first-line (TF-CBT for children; CPT or PE for adults). I'm trauma researcher and sought out these cases in clinic.

Autism: The physician on our team really tried to discourage or taper anti-psychotics (and very rightly so, based on what I've seen in the literature)

Depression/anxiety: Talked about and suggested both psychotherapy and meds as possible options, including in tandem.

Personality disorders, usually BPD or BPD-ish: The closest thing to fidelity-implemented DBT we could find in the community

One of my adult ADHD patients: "I'd really like to learn more about how I could try to handle this without medications, I just don't like taking drugs."


Me: "Okay, well based on what you've identified as problems, some people are helped by [brief explanation of a couple of organizational and time management strategies here]. Here's a site that has a lot more details about how to do those and others."

ADHD patient: "okay, cool, that's just the kind of thing I wanted to learn about!"

Two months pass

Patient: "...so I turned in the project with [thoughtless error] and my boss says if I do it again he'll fire me."

Me: "well let's see what we can do to try and prevent that. Where are you at with those behavioral strategies we talked about?"

Patient: "oh that's been fascinating! I found so many YouTube videos about them and I learned about [insert eight more skills here]."

Me: "and which ones have been most helpful so far?"

Patient: "oh. Um. I haven't actually used any yet. But they're really interesting!"
 
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futureapppsy2

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One of my adult ADHD patients: "I'd really like to learn more about how I could try to handle this without medications, I just don't like taking drugs."


Me: "Okay, well based on what you've identified as problems, some people are helped by [brief explanation of a couple of organizational and time management strategies here]. Here's a site that has a lot more details about how to do those and others."

ADHD patient: "okay, cool, that's just the kind of thing I wanted to learn about!"

Two months pass

Patient: "...so I turned in the project with [thoughtless error] and my boss says if I do it again he'll fire me."

Me: "well let's see what we can do to try and prevent that. Where are you at with those behavioral strategies we talked about?"

Patient: "oh that's been fascinating! I found so many YouTube videos about them and I learned about [insert eight more skills here]."

Me: "and which ones have been most helpful so far?"

Patient: "oh. Um. I haven't actually used any yet. But they're really interesting!"
Yep. I've also seen a lot of patients with unmedicated ADHD develop a sense of self-loathing because "I know what to do, but just can't make myself do it, WTF is wrong with me? Why can't I get it together?," which is just sad to see.
 
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futureapppsy2

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2) There also seems to be affective disorders that are caused by an mismatch of personality traits, abilities, expectations, behaviors, etc. People can be upset because they think they deserve a life they can't or won't achieve. Medication may help, but if you don't turn off the Kardashans after hour 4.... well, you gonna suck as a person.
Hey now, Eleanor Shellstrop saved all of humanity! ("Your favorite... ugh... 'book' is Kylie Jenner's instagram feed.")
 
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erg923

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IMO

1) There are purely biological affective disorders. These seem to respond to medication. These seem to be a minority of cases.

2) There also seems to be affective disorders that are caused by an mismatch of personality traits, abilities, expectations, behaviors, etc. People can be upset because they think they deserve a life they can't or won't achieve. Medication may help, but if you don't turn off the Kardashans after hour 4.... well, you gonna suck as a person.

When all of those cases are mixed into the outcome research, it's not surprising that the results are not great.

Can't blame medicine for doing what medicine does.

I think this a great summary that accounts for why:

1. Some patients have VERY significant positive effects on their symptoms, presentation, thinking with medication. I'm sure we have all encountered patients that have responded markedly well to (insert SSRI/SNRI, etc. here) and recover from an "episode" pretty well. Sometimes with a brief course of psychotherapy, sometimes not.
2. Why, despite the above, the prevalence of psychopathology and overall psychic suffering has not decreased in the past 50 years.
3. Why many, many patients come to therapists or psychologists (and continue to present to their NP or psychiatrist) as a hot garbage fire of symptoms and dysfunction despite already being on one or more psychotropic medications. Obviously, no one can readily dispute that this is kinda the norm in our field.

I think @PsyDr post is really the crux of the matter, actually.
 
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I actually think that the idea of a separation between 'biologically based' depression that 'responds to medications' and 'psychosocial depression' that does not is nonsense. The whole concept makes no sense.

Agreed that depression is hugely heterogeneous and arises from a confluence of many, many factors, including (a large number of extremely weak) genetic factors, early environmental influences on development, current stressors, etc.

But there's no evidence for a 'biological subtype' of depression. What would be the pathophysiological difference between a 'biological' depression and a 'nonbiological' depression? Your whole brain is biological AND psychosocial. The bottom line is that all of your psychosocial experiences alter the weights of your synaptic connections in certain ways, just like medication, TMS, and ECT do in other ways, thus shifting the patterns of activity in your neural circuits.

There is evidence for connectivity-based subtypes of depression which have a clear association with treatment response. See

But there's no reason to call one of these 'biological' and another 'psychosocial.'

And interestingly, genetic factors are incredibly poor predictors of both depressive phenotype and treatment response, while early environmental exposures are quite good predictors of both. What's early life stress? Is that a 'biological' factor? Is it a 'psychosocial' factor? Trick question, that's a false distinction. Whatever it is, it makes people much less likely to respond to both therapy and medication than people who had supportive childhoods.

 
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futureapppsy2

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I actually think that the idea of a separation between 'biologically based' depression that 'responds to medications' and 'psychosocial depression' that does not is nonsense. The whole concept makes no sense.

Agreed that depression is hugely heterogeneous and arises from a confluence of many, many factors, including (a large number of extremely weak) genetic factors, early environmental influences on development, current stressors, etc.

But there's no evidence for a 'biological subtype' of depression. What would be the pathophysiological difference between a 'biological' depression and a 'nonbiological' depression? Your whole brain is biological AND psychosocial. The bottom line is that all of your psychosocial experiences alter the weights of your synaptic connections in certain ways, just like medication, TMS, and ECT do in other ways, thus shifting the patterns of activity in your neural circuits.

There is evidence for connectivity-based subtypes of depression which have a clear association with treatment response. See

But there's no reason to call one of these 'biological' and another 'psychosocial.'

And interestingly, genetic factors are incredibly poor predictors of both depressive phenotype and treatment response, while early environmental exposures are quite good predictors of both. What's early life stress? Is that a 'biological' factor? Is it a 'psychosocial' factor? Trick question, that's a false distinction. Whatever it is, it makes people much less likely to respond to both therapy and medication than people who had supportive childhoods.

There's also some evidence that psychotherapeutic interventions can produce observable biological changes (e.g., changes in amygdala size after undergoing exposure-response prevention treatment for OCD).
 
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There's also some evidence that psychotherapeutic interventions can produce observable biological changes (e.g., changes in amygdala size after undergoing exposure-response prevention treatment for OCD).

Of course they do. All experiences create observable changes in synaptic structure. We can watch it happen.
 
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beginner2011

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There's also some evidence that psychotherapeutic interventions can produce observable biological changes (e.g., changes in amygdala size after undergoing exposure-response prevention treatment for OCD).
Of course they do. All experiences create observable changes in synaptic structure. We can watch it happen.

Neuroplasticity and the pattern of changes that occur in the brain following CBT are some of my favorite expectancy inducers!

 
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