Study shows psychotherapy not helpful vs. meds

[Anasazi23]

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Here's an article from Medscape that's interesting. Seems like the long held beliefs that psychotherapy + meds or psychotherapy alone beign equally effective is waning ?

http://www.medscape.com/viewarticle/712439

 

[trophyhusband]

Just wanted to let you know that the website is password protected and if you click the link it shows your user ID which seems to be your full name. You might want to delete the link you're using if you're trying to maintain some semblance of anonymity. Just an FYI.

 

[loveoforganic]

got sent to the login as well, but no identifying information present

 

[trophyhusband]

got sent to the login as well, but no identifying information present

Well it looks like pingouin's edit may have worked. I must be seeing the login still because it's in my browser's history. Thanks for letting us know loveoforganic.

 

[cleareyedguy]

Here's an article from Medscape that's interesting. Seems like the long held beliefs that psychotherapy + meds or psychotherapy alone beign equally effective is waning ?

http://www.medscape.com/viewarticle/712439

I wasn't able to open that particular site either, but the prevailing winds are actually in the opposite direction. Here are three pertinent, recent articles.


1. A manualized form of psychodynamic therapy works:

Psychodynamic psychotherapy outcome for generalized anxiety disorder.
Milrod B.
Am J Psychiatry. 2009 Aug;166(8):841-4.


2. A manualized form of psychoanalytic therapy (ie, transference focused) works:

Transference focused psychotherapy: overview and update.
Kernberg OF, Yeomans FE, Clarkin JF, Levy KN.
Int J Psychoanal. 2008 Jun;89(3):601-20.

3. Pharm trials have been seriously (criminally??) misreported so that negative studies are systematically excluded:

Lost in Transmission--FDA Drug Information that Never Reaches Clinicians
Schwartz L, Woloshin S
New England J Med Oct 29, 2009. 1717-1720

 

[Anasazi23]

Here's a more direct link.

http://archpsyc.ama-assn.org/cgi/content/short/66/11/1178?home

 

[strangeglove]

Seems consistent with prior work. However, this is not evidence of psychotherapy not working. There is a lot of good evidence (some cited by ClearEyedGuy) that psychotherapy alone works, that medications alone work, and that there is no difference between either alone for patients with a primary diagnosis of MDD without other Axis I or Axis II comorbidities. I think the emerging idea here is that if a patient with pure MDD is willing and able to take a medication, there is no need to do psychotherapy along with that. That doesn't mean that you should not offer psychotherapy alone as a first line treatment, since many patients would prefer to stay off of a med, or may have contraindications (like being pregnant). That should be part of your evaluation, if you ask me. Also, this study does not take into account the fact that many if not most patients with MDD also have a comorbid personality disorder (studies like this tend to exclude these patients). This population tends to benefit more, I imagine, from a combined treatment than from medication alone. Has anyone looked at that?

 

[Doc Samson]

The study is unusual in that it adds psychotherapy to a med regimen that is already producing partial response. So from this we can take away that when meds are working a little bit, adding psychotherapy won't really changes the chances of them working better if the dose is increased. Not sure it really provides any evidence on the efficacy of psychotherapy one way or the other.

 

[whopper]

For those that can't access it...

No Added Benefit of Adjunctive Psychotherapy to Antidepressants Alone in Chronic Depression
Janis C. Kelly

Authors and Disclosures

Physician Rating: ( 6 Votes ) Rate This Article:




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Read patient profiles November 16, 2009 — Adjunctive psychotherapy in combination with antidepressant medication appears to offer no additional therapeutic benefit in patients with chronic depression, a large, randomized, 12-week trial suggests.

Investigators at Weill Cornell Medical College in New York found that after 12 weeks of continued pharmacotherapy plus either brief supportive psychotherapy (BSP) or cognitive behavioral analysis system of psychotherapy (CBASP), outcomes were no better than if patients received medication alone.

"It would be fair to say that the approaches were equally effective," lead investigator James H. Kocsis, MD, told Medscape Psychiatry.

The study is published in the November issue of Archives of General Psychiatry.

Findings Contrary to Study Hypothesis

The trial included 491 patients with chronic depression. Participants had depressive symptoms for a minimum of 2 years without remission and met diagnostic criteria for double depression, chronic major depression, or recurrent major depression with incomplete recovery between episodes.

The study's main outcome measures were proportion of remitters, partial remitters, and nonresponders and change from baseline in the Hamilton Scale for Depression scores.

Participants were randomized to receive 12 weeks of continued pharmacotherapy plus CBASP, continued pharmacotherapy with BSP, or continued optimized pharmacotherapy alone.

At the end of the study period, the investigators found no statistically significant differences among the 3 treatment groups in the proportions of patients in remission, partial response, or nonresponse, suggesting, said Dr. Kocsis, that although chronic depression is often helped by medication, there is little evidence of added benefit with adjunctive psychotherapy.

"We were surprised. The results went against our hypotheses. We are interested in studying differential predictors of response to drugs versus psychotherapy. We think early life adversity and childhood maltreatment may be important in predicting need for psychotherapy," Dr. Kocsis said.

Dr. Kocsis also noted that current American Psychiatric Association treatment guidelines only address major depression and not chronic depression. "Perhaps they should develop separate guidelines for chronic depression," he said.

Convincing but Not Conclusive

Pim Cuijpers, PhD, who has published 2 meta-analyses of psychotherapies for chronic depression, described the Kocsis study as "sobering." Dr. Cuijpers is professor of clinical psychology, chair of the Department of Clinical Psychology, and vice-director of the EMGO Institute for Health and Care Research at VU University, Amsterdam, The Netherlands.

Dr. Cuijpers told Medscape Psychiatry that, although he finds these data convincing, they are not conclusive. "The conclusion that pharmacotherapy alone is just as good as combined treatments is not supported by the total body of research in this area," he said.

The Cuijpers' meta-analysis of psychotherapies for chronic depression, which is currently in press, concluded that combined treatments have a small benefit over pharmacotherapy alone.

"I do not think the Kocsis study [which was published after the meta-analysis was completed] would change the results of our meta-analysis if it had been included. Our meta-analysis, however, also shows that the results of psychotherapy are not very high in chronic depression," Dr. Cuijpers said.

The study was sponsored by the National Institute of Mental Health. All medications were donated by Forest Laboratories, GlaxoSmithKline, Organon Pharmaceuticals Inc, Pfizer Inc, and Wyeth Pharmaceuticals. Dr. Kocsis reports receiving research support from AstraZeneca, Burroughs Wellcome Trust, CNS Response Inc, Forest Pharmaceuticals, the National Institute on Drug Abuse, the National Institute of Mental Health, Pritzker Consortium, and Sanofi Aventis; participating on the speaker's bureau for AstraZeneca, Pfizer Inc, and Wyeth; and acting as a consultant to Wyeth.

Arch Gen Psychiatry. 2009;66:1178–1188.

[CLOSE WINDOW]
Authors and Disclosures
Journalist
Janis Kelly
Janis Kelly is a freelance writer for Medscape. She has been a medical journalist since 1976, with extensive work in rheumatology, immunology, neurology, sports medicine, AIDS and infectious diseases, oncology, and respiratory medicine.

 

[whopper]

Makes me wonder if there's something about chronic depression on a psychopharmacological level that makes it different than MDD. There already are theories that the longer depression lingers, the more its ingrained into the memory, the circuits that cause depression are excercised, etc.

If you look for example at children with depression, the data suggests antidepressants don't work as well as they do in adults. Children in general wouldn't be as depressed as long as adults with chronic depression and this study suggests that psychotherapy does not work, but antidepressants do work.

I'm just writing some thoughts on this that are speculation.

 

[cleareyedguy]

A few issues. First, it's one study.
Second, the study refers to only 1 type of depression (chronic, for 2 years) and therapy that is begun after a partial response--this study doesn't attempt to provide a sweeping generalization.
Third, the study tests CBASP, a CBT based manualized therapy that does not speak for all psychotherapies. It also does not speak for all psychotherapists.
Fourth, the treatments were apparently short term and don't seem to be controlled for the extent of childhood abuse (which has lower success rates).
Fifth, I don't see the overall success rates, which would be informative.
Finally, Kocsis is a strong researcher, but he would make it clear that while sobering, his study was not intended to be the final word on the subject.

 

[erg923]

Makes me wonder if there's something about chronic depression on a psychopharmacological level that makes it different than MDD. There already are theories that the longer depression lingers, the more its ingrained into the memory, the circuits that cause depression are excercised, etc.

There is lots of good work on MDD chroncity and imaging and MDD chroncity influencing the dysregulation of the HPA system that supports this hypothesis.

 

[Regnvejr]

The study is unusual in that it adds psychotherapy to a med regimen that is already producing partial response. So from this we can take away that when meds are working a little bit, adding psychotherapy won't really changes the chances of them working better if the dose is increased. Not sure it really provides any evidence on the efficacy of psychotherapy one way or the other.

It is also a question of what we're measuring. I encourage all my patients to go to therapy. Frankly, meds will hold you today but gives you no coping skills for tomorrow, nor will they give skills for handling when stress escalates.

Meds really are helping better function in therapy, and a more robust long-term protection against relapse.

And there have been enough studies under all sorts of conditions of therapy & meds that one study won't convince me of a whole lot. Like everything else in mental health, there are no clear answers.

 

[Regnvejr]

Makes me wonder if there's something about chronic depression on a psychopharmacological level that makes it different than MDD. There already are theories that the longer depression lingers, the more its ingrained into the memory, the circuits that cause depression are excercised, etc.

Well, I think the studies on the Serotonin Transporter gene have been quite conclusive. AFAIR, it also showed some difference in short-term vs chronic depression (It' s been awhile since I reviewed that). And the autopsy studies did show brains of people with chronic depression statistically lighter, indicating cell-loss or at least dendrite loss?

If you look for example at children with depression, the data suggests antidepressants don't work as well as they do in adults. Children in general wouldn't be as depressed as long as adults with chronic depression and this study suggests that psychotherapy does not work, but antidepressants do work.

I'm just writing some thoughts on this that are speculation.

Children also have much more external locus of control, they are more likely to expect being 'fixed" rather than getting help with control. And they tend to be more emotionally reactive and more likely to be irritable than depressed.

 

[SOLDIER]

Well, I think the studies on the Serotonin Transporter gene have been quite conclusive. AFAIR, it also showed some difference in short-term vs chronic depression (It' s been awhile since I reviewed that). And the autopsy studies did show brains of people with chronic depression statistically lighter, indicating cell-loss or at least dendrite loss?

Children also have much more external locus of control, they are more likely to expect being 'fixed" rather than getting help with control. And they tend to be more emotionally reactive and more likely to be irritable than depressed.

Heloooooooooo

 

[whopper]

And the autopsy studies did show brains of people with chronic depression statistically lighter, indicating cell-loss or at least dendrite loss?

Those that are depressed do not produce brain derived neurotrophic factor (BDNF) as much as non-depressed people. This does cause long term damage to the brain.

There is also data showing that the longer someone is depressed, the more likely the person will be depressed again even if they get out of their depression. The more times someone is clinically depressed, the more likely they will be depressed again.

Taking this into account with the data that antidepressants don't work as well in children (and your mention that with their depression, their often is an external locus), I speculate that with chronic depression there may be more of a biological component than a psychosocial component--> which may explain the results of the study.

That is of course with full disclosure that I agree with Cleareyedguy's statements. Its only one study, it was only one form of psychotherapy.....

Just speculation on my part.

 

[BabyPsychDoc]

It is also a question of what we're measuring. I encourage all my patients to go to therapy. Frankly, meds will hold you today but gives you no coping skills for tomorrow, nor will they give skills for handling when stress escalates.

Meds really are helping better function in therapy, and a more robust long-term protection against relapse.

Amen.

 

[Psych2014]

Genetics are clearly a significant factor in the etiology of many mild to severe mental illnesses, therefore there are many mentally ill people who can benefint only from lifetime medication which is correcting an inherited defect. Their genetics are missing something, and they struggle through life, often very high functioning professionals, self medicating with non-presribed substances, or work addictions (adrenaline, dopamine).

So I seriously question that medication is a temporary portal into relief, with therapy being the only real fix for their problem.

Isn't the brain an organ prone to anatomical and physiological defects, much like the heart or kidneys for example, that a person can either live with and struggle against, or get a corrective medication, and/or therapy for?

 

[Regnvejr]

..So I seriously question that medication is a temporary portal into relief, with therapy being the only real fix for their problem. ...

Even in chronic conditions, therapy gives coping skills to handle them.

 

[Genkishi]

Participants had depressive symptoms for a minimum of 2 years without remission and met diagnostic criteria for double depression, chronic major depression, or recurrent major depression with incomplete recovery between episodes.

This pretty much explains why psychotherapy doesn't really work. This study dealt with a spectrum of the population of ppl suffering from MDD who suffer from quite a severe form, judging from the fact that there is recurrence and incomplete remission of symptoms

With increasing severity, this makes the condition refractory for many forms of therapy. Hence it's pretty obvious that psychotherapy wouldn't really work in severe illnesses.

However, one can do a search at pubmed. Interpersonal therapy has been proven to be effective for mild to moderate forms of MDD.