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Drugs Or Therapy (The Best Medicine)

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  • 1. (facts & fictions in mental health) The Best Medicine? How drugs stack up against talk therapy for the treatment of depression BY HAL ARKOWITZ AND SCOTT O. LILIENFELD IMAGINE a treatment for depression that possesses the following proper- ties: It is as effective as antidepressant medications but lacks their side ef- fects. Its therapeutic results last longer than those of antidepressant medi- cations after treatment has ended. Its benefits generalize to many do- mains of life. It causes changes in the brain in processes associated with depression. It usually needs to be ad- ministered only once a week. It gener- ally costs the same or less than medi- cations. Sound too good to be true? In fact, such a treatment has been around for decades, although many people do not know about it. It is C O U R T E S Y O F H A L A R KO W I T Z ( t o p ) ; C O U R T E S Y O F S C O T T O . L I L I E N F E L D ( b o t t o m ) ; G E T T Y I M AG E S ( i l l u s t r a t i o n ) called psychotherapy. Why are so many people unaware of these facts? One reason is that phar- maceutical companies have huge ad- vertising budgets to aggressively mar- ket antidepressant medications to the public and to the physicians who write prescriptions. In contrast, psychother- apists have little or no budget for mar- keting. In this column, we will try to level the playing field by providing a scorecard of how antidepressants compare with psychotherapies. vidual, some antidepressants work some clients, depression is better but better than others; no one antidepres- still present, whereas others become Antidepressants: Pros and Cons sant has been shown to be more effec- symptom-free. Residual symptoms af- Although a number of different tive than any other at a group level. ter treatment are problematic because classes of antidepressants exist, we Many people undergoing treatment for they signal a significant risk factor for will focus on the most commonly pre- depression try two or three SSRIs (or a repeat depression. scribed class today: SSRIs, or selective other antidepressants) before they find After therapeutic effects appear, serotonin reuptake inhibitors [see box one that works and that has tolerable clients are usually told to continue on on opposite page]. side effects. Studies find that about 50 the drug for at least an additional six People who take antidepressants to 70 percent of those who take SSRIs to 12 months to prevent relapse. If pa- usually do not show improvement for are responders, showing a 50 percent tients have had several previous epi- two to four weeks. For any given indi- or greater reduction in symptoms. For sodes or if their depression is severe, ( Imagine a treatment for depression that is as effective as antidepressant medications but lacks their side effects. ) 80 SCIENTIFIC AMERICAN MIND COPYRIGHT 2007 SCIENTIFIC AMERICAN, INC. O c to b e r/ N ove m b e r 2 0 07
  • 2. ( Some studies have shown that combining psychotherapy and medications is more effective than either alone for adults. ) they may be told to remain on the drug sions, although the evidence on this thinking. Interpersonal psychothera- longer to avoid recurrence of depres- point is mixed. py (IPT) has the second greatest sion. Using antidepressants for main- amount of supporting data. Research tenance in this way reduces the relapse The Scoop on Psychotherapy on other therapies, such as short-term rate as compared with a placebo. Save Despite the voluminous research psychodynamic therapy, client-cen- for Prozac, antidepressant therapy has on psychotherapy as a treatment for tered therapy and emotion-focused not been shown to be effective for chil- depression, scientists have evaluated therapy, has just begun, but outcomes dren and adolescents and may not be only a few types of psychotherapy. in these few studies have been positive safe for a small percentage of people CBT has been the most extensively [see box below]. In the remainder of younger than 24 years old, as we studied by far. Such therapies teach this column, our discussion of psycho- discussed in our last column, “Can and encourage new behaviors and help therapy refers to those practices that Antidepressants Cause Suicide?” [Sci- people change excessively negative have been supported by research. entific American Mind, August/ September 2007]. In addition, antide- pressants can cause fetal damage, so Antidepressants and Common Side Effects pregnant women are strongly advised Selective serotonin reuptake inhibitors, or SSRIs, can relieve depression not to take them. but can have drawbacks. In most drug trials, all patients receive the same antidepressant. In Trade name Chemical name Common Side Effects of SSRIs the real world, however, psychiatrists Paxil paroxetine >> Short-term (lasting a few weeks): often try a different medication if one nausea, diarrhea, nervousness Prozac fluoxetine and insomnia prescription does not work. A recent study by A. John Rush of the Univer- Lexapro escitalopram >> Long-term (lasting months or sity of Texas Southwestern Medical longer): low sexual desire or Center and his colleagues more close- Celexa citalopram sexual dysfunction (in 50 to 75 ly approximated how SSRIs are used percent of patients) and sedation Zoloft sertraline in practice. The researchers presented depressed patients with a four-step set of options to be used if necessary. All subjects started on the same anti- Research-Supported Psychotherapies depressant (Celexa). At each of three Scientists have evaluated only a few types of psychotherapy. The most subsequent steps, those who either did supporting data exist for cognitive-behavior therapy and interpersonal psycho- therapy, which have been shown to be effective in treating depression. Only not respond or could not tolerate the a few studies have examined the performance of the other three therapies side effects got a menu of options, listed below, but their outcomes are encouraging. which included changing medication, adding medication, or adding or Name Approach switching to cognitive-behavior ther- Cognitive-behavior therapy Teaches and encourages new behaviors apy (CBT). This study yielded an over- to help people change overly negative all remission rate of 67 percent, far thinking superior to that of most studies that Interpersonal psychotherapy Focuses on the social difficulties and show remission rates (excluding conflicts associated with depression improvement rates) of closer to 33 Short-term psychodynamic Emphasizes understanding and correction percent. therapy of problematic interpersonal patterns Some studies of adults have shown Client-centered therapy Emphasizes the therapeutic potential of that combining psychotherapy and the therapist-client relationship medications is more effective than ei- ther treatment alone. Further, several Emotion-focused therapy Builds on client-centered therapy by adding a focus on increasing awareness studies with adults have found that of thoughts and feelings and resolving drug therapy may be more effective persistent and problematic emotional than psychotherapy for severe depres- reactions COPYRIGHT 2007 SCIENTIFIC AMERICAN, INC.
  • 3. (facts & fictions in mental health) The findings regarding the efficacy mate the efficacy of psychotherapy for tients with coping skills that let them of CBT are remarkably similar to depression, although that conjecture deal better with life events. In con- those of most SSRI studies. Approxi- awaits formal research. trast, antidepressant treatments may mately two thirds of patients who un- Numerous studies have demon- be more palliative, suppressing symp- dergo 12 to 16 sessions of CBT show strated that after treatment has ended, toms for as long as the medications are improvement or remission. (The rea- patients treated with medication alone taken. Even so, approximately half of son therapy costs the same or less than relapse at twice the rate of those treat- those who respond to CBT relapse medications is largely because people ed with CBT alone. Further, dropout within two years, suggesting that we are usually on antidepressants far lon- rates for antidepressant treatments are psychologists still have our work cut ger than they are in psychotherapy.) So two to three times as high as those for out for us. CBT researchers are work- far most comparisons among different CBT, with one large-scale study find- ing on ways to further reduce post- therapies have shown them to be about ing a 72 percent dropout rate for anti- treatment relapse. For example, recent equally effective. As of this writing, depressants by 90 days of use. Recov- studies have found that an eight-ses- however, no studies of psychotherapy ered patients who had received antide- sion group booster treatment known have adopted the multistage approach pressants and continued on them for as mindfulness-based cognitive thera- used by Rush and his colleagues with maintenance showed relapse rates py given to recovered depressed pa- antidepressants; in practice, psycho- roughly equivalent to those who had tients during the year after the end of therapists often switch strategies if the completed CBT with no further treat- initial treatment reduces relapse for one they are using is not working. Be- ment. These findings suggest that CBT those who have had three or more epi- cause psychotherapy studies use only may address some of the underlying sodes of depression. one approach for purposes of experi- causal processes better than medica- In depressed children and adoles- mental control, they may underesti- tion does or that it may provide pa- cents, only one of the antidepressants Psychotherapy and the Brain D rug company marketing suggests that depression must be caused by that imbalance. Inferring causality from is caused by a “chemical imbalance” in the brain. the success of a treatment is frequently a flawed endeavor: For example, an advertisement by the maker of the aspirin is effective for headaches, but no one would selective serotonin reuptake inhibitor (SSRI) Zoloft states: seriously claim that headaches are caused by a deficiency “While the cause is unknown, of aspirin. depression may be related In addition, biological to an imbalance of natural PRE-THERAPY POST-THERAPY treatments are not unique chemicals between nerve in their ability to cause cells in the brain. Prescrip- changes in the brain. Using tion Zoloft works to correct neuroimaging techniques, this imbalance.” The imbal- many studies have shown ance to which the SSRI ads significant brain changes in refer is a deficit of the neu- Area of patients treated with psycho- interest rotransmitter serotonin at therapy alone. One study receptor sites in the brain. PET images of a patient with obsessive-compulsive dis- with depressed patients Such advertising is mislead- order before (left) and after (right) successful psycho- demonstrated that cogni- ing, however, and does not therapy show decreases in glucose metabolic rates. tive-behavior therapy led to reflect scientific findings. Such brain changes have also been found in depressed decreased activity in the SOURCE : LEWIS R. BA XTER, JR., ET AL . There is no clear scientific patients who have received therapy. frontal regions of the brain, evidence that neurotransmit- some of which may be re- ter deficits cause depression or that there is an optimal lated to rumination, a common feature of depression. “balance” of neurotransmitter levels in the brain. More- Some studies have found brain changes identical to those over, medications that primarily affect chemical messen- caused by antidepressant medications, whereas others gers other than serotonin are as effective as SSRIs. have found different brain changes. These findings sup- Undoubtedly, antidepressants are helpful in alleviating port the idea that psychotherapy produces measurable depression. But there is a form of circular reasoning that changes in the brain, although these modifications may goes: if SSRIs are helpful in alleviating depression, and if sometimes differ from those produced by medication. they do change the “chemical imbalance,” then depression — H.A. and S.O.L. 82 SCIENTIFIC AMERICAN MIND COPYRIGHT 2007 SCIENTIFIC AMERICAN, INC. O c to b e r/ N ove m b e r 2 0 07
  • 4. (Prozac) has been shown to help, to half the relapse rate of drug therapy dren and adolescents. It also can whereas several different types of psy- over a two-year follow-up period, re- change the biology associated with de- chotherapies have proved beneficial. In lapse rates for both remain disturb- pression [see box on opposite page]. both cases, however, treatment effects ingly high. CBT and IPT (the two best empiri- have been only moderate. The results Psychotherapy, drug therapy and cally supported therapies for depres- of studies on the combination of drug a combination of the two are all help- sion) and possibly other psychothera- therapy and psychotherapy for these ful for adult depression, but effects pies with some empirical support populations show either no advantage are weaker in children and adoles- should be seriously considered for a ( Many studies have shown significant brain changes in patients treated with psychotherapy alone. ) or a slight advantage for the combina- cents who are depressed. Drug thera- depressed person seeking treatment. If tion over either single treatment. py may be better for some people, psy- the response to psychotherapy is not Although results are somewhat chotherapy for others, and the combi- adequate, other types of psychothera- mixed, most of the evidence suggests nation for others still. We do not py may be tried or a drug regimen may that combined psychotherapy and know which people will respond best be added. Although the combination drug treatments are more effective for to any given treatment. Moreover, of psychotherapy and drug therapy adults but not necessarily for children many other important questions re- may be somewhat more effective than and adolescents. One well-designed main unanswered. Would longer psy- either alone, drug side effects can be large-scale study in chronically de- chotherapeutic treatments such as problematic. pressed adults compared a non-SSRI those typically used in clinical prac- We hope that the information we antidepressant medication, a modi- tice lead to better initial outcomes have provided will counter some of fied form of CBT that emphasized than those that result from the short- the mistaken impressions fueled by changing interpersonal relationship term psychotherapies that have been the marketing strategies of some drug patterns and negative thinking, as researched so far? Would a sequential companies and that it will encourage well as their combination. Whereas strategy such as that used by Rush and readers to think of psychotherapy as response rates for each of the single his associates for drug therapy im- a viable treatment for depression that treatments were comparable to those prove psychotherapy outcomes? What has several advantages over drug usually obtained in depression treat- can we do to further reduce or elimi- therapy. M ment studies, the response rate for the nate relapse? Are some treatments combination treatment was a dramat- better for some types of people and HAL ARKOWITZ and SCOTT O. LILIENFELD ic 85 percent! depression than for others? serve on the board of advisers for Scientific So, to the bottom line. We have American Mind. Arkowitz is a psychology Putting It Together learned that psychotherapy and drug professor at the University of Arizona, and Antidepressant medication and therapy are both fairly effective. We Lilienfeld is a psychology professor at Emory certain forms of psychotherapy are know that psychotherapy prevents re- University. Send suggestions for column reasonably effective for the treatment lapse better than drug therapy does topics to editors@sciammind.com. The of adult depression, but there is con- when treatment is discontinued, that authors thank Steve Hollon of Vanderbilt siderable room for improvement in ini- there are few, if any, negative side ef- University for his invaluable help with this tial response rates and relapse rates. fects of psychotherapy, and that psy- column. Any statements made in the column, Response rates (improvement or re- chotherapy is a safe and moderately however, are solely the responsibility of the mission) for both treatments average effective treatment for depressed chil- co-authors. at around two thirds. This means that many people are helped but are left (Further Reading) with some depressive symptoms, ◆ Psychotherapy and Medication in the Treatment of Adult and Geriatric Depression: whereas others are not helped at all. Which Monotherapy or Combined Treatment? S. D. Hollon, R. B. Jarrett, A. A. Nieren- The combination of psychotherapy berg, M. E. Thase, M. Trivedi and A. J. Rush in Journal of Clinical Psychiatry, Vol. 66, and drug therapy may yield better No. 4, pages 455–468; 2005. outcomes for adults but little or no ◆ The Empirical Status of Cognitive-Behavioral Therapy: A Review of Meta-analyses. added benefits for children and adoles- A. C. Butler, J. E. Chapman, E. M. Forman and A. T. Beck in Clinical Psychology Review, cents. Although psychotherapy leads Vol. 26, No. 1, pages 17–31; 2006. w w w. s c i a m m i n d .c o m COPYRIGHT 2007 SCIENTIFIC AMERICAN, INC. SCIENTIFIC AMERICAN MIND 83

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