Controversy over DSM-V

This week, I finally got a reprieve from numerous reports and paperwork, so I can dust off the old blog and have some fun again. There is no better place to begin than the controversy over DSM-V.

Background

First, some background. DSM-V stands for Diagnostic and Statistical Manual--Fifth Edition. Of course, in psychiatry, numbers can be misleading. DSM-V will actually be the seventh revision, as DSM-III was revised once (DSM-III-R) and DSM-IV was also revised (DSM-IV-TR. TR stands for "Text Revision.") It's published (and jealously guarded) by the American Psychiatric Association.

When I started out in the 1970's, DSM-II was the manual we used, and it was awful. Definitions were vague, and you could diagnose the same person with anything from depressive neurosis to schizophrenia without much difficulty. DSM-II was generally denounced as irrelevant and unnecessary by behaviorists and humanists. At the time, diagnosis had little to do with treatment, so it really was unnecessary. In hospitals, physicians would argue endlessly about a patient's diagnosis, with no change in treatment after they had differentiated what kind of schizophrenic they were dealing with.

DSM-III changed all that, as diagnoses were made on the basis of behavior. Specific symptoms were identified and you had identify a certain number of symptoms in order to diagnose depression. This was a great advance in two areas. First, research could be focused. If you wanted to research a treatment for depression, there was now a clear operational definition for depression. That means that we could compare different studies without comparing apples and oranges.

Second, DSM-III gave us the ability to communicate what we were treating to third parties. It was published when insurance companies were beginning to pay for psychotherapy. Unfortunately, many therapists didn't know an adjustment disorder from major depression. Consequently, managed care used DSM-III to refuse to pay for many treatments. We had to learn to say, "Here are the symptoms that show the client is depressed and here is the progress I am making on them. Once we learned to do that, managed care stopped refusing psychotherapy and we now generally get as much time to treat clients as we need.

The Controversy

DSM-IV has been a small improvement over DSM-III, but it's still controversial. Now DSM-V is on the horizon and it's generating more heat. A recent article in the New York Times picked up on the controversy. There are a number of points of controversy.

First, there is no real understanding of the causes of mental illness. We're still not even sure if there is such a thing as a mental illness. Psychiatry has been moving toward a neurobiological model of mental illness, but is still far away. If you ask a psychiatrist what causes depression, you'll hear one of two answers. You might hear, "We don't know," which is the honest answer. However, more likely, you will hear some mumbling about serotonin and biochemical imbalances. Those guys are just blowing smoke. Just ask them to define a healthy biochemical balance; their response will be entertaining. Unfortuantely, more than half of the members of the task force writing DSM-V have drug company connections, so you know they will remain committed to a neurobiological model.

Second, diagnoses are often points on a continuum. Consider what is now called Attention Deficit/Hyperactivity Disorder (ADHD). Our ability to pay attention falls along a continuum from fleeting to intense. When we diagnose someone with ADHD we are saying that their attention on the average, falls below some imaginary point on that continuum. That imaginary point is also arbitrary. Do we abandon children who fall just to the normal side of that point? How about children who fall mostly to the average side of that point, but occasionally their attention and concentration crash and burn?

Third, the inclusion of a diagnosis in the manual has always been unsystematic and has many social implications. Why is repetitive handwashing considered obsessive compulsive disorder, while repetitive shopping is not? Is binge eating a disorder, or does the person just need to grow up and get some self control? In DSM-II, homosexuality was considered a diagnosable mental illness. In DSM-III, homosexuality was removed as a diagnosis. There is a straight line from deciding homosexuality is not a mental illness to deciding gays should have the right to marry.

Fourth, how open should the process be? The APA has had the members of the DSM-V task force sign conficentiality agreements. Dr. Robert Spitzer, a member of the APA task force on DSM-V has raised concerns about it. (More about the controversy can be found here.) Given the social implications for some diagnoses, there's a lot at stake here. But, it's difficult to balance the need for open, scholarly discorse, with the risk of being personally attacked by one pressure group or another.

Who gets treatment is affected by diagnosis. When I diagnose a child with autism, that child becomes eligible for a wide range of services that a child with plain old "mental retardation," would not get. Interest groups in a lot of areas would like to see their own diagnoses included, so more services become available. A battle is raging over whether or not transsexuality should be included in DSM-V as a mental illness. Some would like it to be normalized; a person should be able to cross dress if they want to. However, others would like to have insurance cover sexual reassignment surgery. You can't cover a procedure if it isn't treating a diagnosis.

Conclusions

DSM-V will almost certainly move closer to a neurobiological model and away from a psychosocial model. That will lead to less emphasis on psychosocial treatment. I don't hold that against psychiatry; they treat mental illness biologically. However, psychotherapy still has much to offer. Psychotherapy is still the best (or at least a competitive) treatment for personality disorder, post-traumatic stress disorder, and some depressive and anxiety disorders. Generally, psychotherapy reduces the risk of relapse. Yet, if we structure our diagnoses around neurobiolgical models, psychotherapy will be marginalized. Already, family and marital therapies are extremely difficult to justify using DSM-IV. Somehow, diagnoses should also be there to allow for psychosocial treatment and to encourage more research in that area.

Despite these problems, we still need a diagnostic manual. Psychiatric diagnoses, for all their arbitrariness, give us a way of organizing research and communicating therapeutic information. At some point research will give us a handle on the nature of mental illness, and a clear diagnostic system will emerge from that. In the meantime, this is the best we've got, and none of the critics have given us a good alternative to the writing of a new manual.

APA Passes Resolution Passes on Psychologists' Working in Detention Settings

The American Psychological Association has just issued a press release stating that the membership passed a resolution forbidding work in settings where "persons are held outside of, or in violation of, either International Law (e.g., the UN Convention Against Torture and the Geneva Conventions) or the US Constitution (where appropriate), unless they are working directly for the persons being detained or for an independent third party working to protect human rights."

The full text of the petition is here.

If I read this right, there are no significant loopholes.  Psychologists should either work for detainee's well being or not at all.

It's about time!

I think some people thought that there was room for psychologists to work within the system to better the detainees' situation.  I don't believe that's possible.  While it's enticing to think of the heroic psychologist fighting the system, human nature (not to mention Solomon Asch and BF Skinner) tells me that the psychologist would just be co-opted into the system.

It was also particularly galling that the AMA had done this long ago while the APA wimped out. So, as I often teach my clients, time only goes forward.  It would have been better for APA to have done this sooner, but doing it today is better than doing it tomorrow.

JND in Top 100 Mental Health and Psychology Blogs

Just Noticeable Differences has been mentioned in the Top 100 Mental Health and Psychology Blogs. It is an interesting site, and I found some good stuff there. I appreciate the mention, especially when I haven't blogged since May. My goal this year was to blog weekly, and I haven't come close.

I have been extremely busy. Work has gotten chaotic and I have been spending all my free time at home either working on the house or, more often, writing reports. After you've spent several hours on a weekend writing such deathless prose as, "On examination, Mr. Johnson was alert and oriented in three spheres," blogging isn't high on the list.

There are several reasons work has gotten chaotic. First, as I've said elsewhere, fees for psychotherapy services are static. I will get a 3% raise soon, but with inflation about 5.6%, I will still still have to work more hours to stay even.

Making matters worse, there has been a lot of conflict in my office. I think it's due mismanagement, but hey, nobody listens to me, anyway. At this point, I'm so disgusted that I'd like to leave and restart my private practice. Unfortunately, I am the source of health insurance in my family and I would have to purchase insurance separately if I resigned. I calculate that if I and my wife were lucky enough to qualify for it, we would pay through the nose. There is also no guarantee that if we got sick and tried to use it we would be able to keep it. So, isn't this great? I get both ends of the health insurance mess at the same time.

I've learned one critical lesson from this. Republican opposition to national health insurance has nothing to do with taxes or small government or any other nonsense. Republicans oppose national health insurance because it makes employees more dependent on their employer. Because I can't just pick up and start a private practice, my employer has more control over me.

Like many Republican policies, this is at best penny-wise and pound foolish. At worst, it is self defeating. Opposing national health insurance helps the large corporations, but it hurts the US economy. The lack of national health care almost certainly hinders small business formation. Small businesses are an important part of our economy. It is small businesses that bring innovation into the marketplace.

So, I'm watching the campaign very closely this year. Having a Republican in the White House will probably mean 4 more years of this nonsense. Unfortunately, Obama has apparently inherited the Dukakis strategists: McCain is beating up on him and he's on vacation.

Net Neutrality

A few years ago, an idea was floated by the large ISP's that they should be allowed to prioritize the access to different web sites. The initial plan was focused on providing faster access to users for a fee. While that idea sounds logical, the devil is in the details.

High volume users, such as Google, have objected strenuously. It will certainly make their operation more expensive, but more importantly, small content providers who rely on Google will be affected by it. After all, the little guys get their start blogging on Blogger and similar sites. It will be those users who will be affected by increased costs to Google and other providers like them. So, little guys like me could be forced off the net.

Now, I know that losing me wouldn't be a great loss. I'm not controversial and I don't blog much. But losing me, means that you could lose someone more important. Why not, for example, make life more difficult for Daily Kos (who just happens to be blogging on this on May 19, as I am)? This is something that we need to be very worried about. The New York Times, in an editorial today, commented that the ISP's

have realized that they could make a lot of money by charging some Web sites a premium to have their content delivered faster than that of other sites. Web sites relegated to Internet “slow lanes” would have trouble competing.

This sort of discrimination would interfere with innovation. Many major Web sites, like eBay or YouTube, might never have gotten past the start-up stage if their creators had been forced to pay to get their content through. Content discrimination would also allow I.S.P.’s to censor speech they do not like — something that has already begun. Last year, Verizon Wireless refused to allow Naral Pro-Choice America to send text messages over its network, reversing itself only after bad publicity.

So, there is a risk that non-neutral access to the web could result in limiting access to sites that express ideas the corporations don't want. Do you think that will be left-wing or right-wing ideas?

I'm going to share an idea that I've held for a long time. It's a little crackpot, but no one I've mentioned it to has been able to punch holes in it. As I look back over the last century, it seems to me that liberal/progressive ideas flowered at two times: the 1930's and the 1960's. I believe it happened because both eras were marked by inexpensive and decentralized media, allowing the left to reach its audience.

In the 1930's, there was excess printing capacity as newspapers and publishers failed during the Great Depression. Radio was a new medium and small radio stations slowly started up. During this period, the Socialist Party flourished. Labor unions started to take off. Roosevelt's New Deal was inked. But then, during World War II, small newspapers and radio stations fell by the wayside. Both the draft and the defense industries needed bodies, and small radio stations and newspapers were a luxury that couldn't be afforded. After World War II, the remaining radio stations and newspapers started folding into ever larger corporate bodies. Since corporations are politically conservative, outlets for left-wing messages were closed down. Not surprisingly then, the 1950's was a politically conservative era.

In the 1960's, new legislation and regulations readjusted the radio spectrum and required that AM radio receivers also receive FM. This allowed FM radio to come into its own. Small family-owned FM radio stations started gaining listeners. The stations found new content in the music and the left-wing politics of the times. As a result, people heard messages that they would otherwise have missed. Left-wing politics bloomed. But in the 1970's, corporations began buying the small stations, and with centralization, left-wing politics again fell by the wayside.

If I'm right, Ronald Reagan was the Teflon President, not because he was the Great Communicator, it was because he was the Only Communicator. George II similarly got a free ride until the internet really matured. He could hide the coffins coming back from Iraq from television. But now he can't stop pictures of the war from being posted on YouTube and things are looking bad for the Republican party.

The Republicans understand this dynamic. Previously, they make no effort to hide their view that Public Broadcasting is a left-wing voice. They've worked hard to harass public television and have tried repeatedly to shut it down. They have also worked hard to relax the rules against corporate ownership of multiple stations in the same market. With the development of the internet, of blogging, of podcasts, of YouTube, and so forth, communications are again being decentralized. If we, who consider ourselves liberal or progressive, want to keep our lines of communication open, we need the internet.

"Net neutrality" refers to protecting the internet from prioritized access. The Times editorial indicates that several net neutrality laws have been proposed to Congress, but they have gone nowhere. Why am I not surprised? The Republicans don't want net neutrality and the Democrats are too stupid to realize how important it is to them.

Learn more about net neutrality at Wikipedia and at Common Cause. There are petitions to sign at SavetheInternet.com or MoveOn.org.

Autism and Vaccines

The New York Times has a story on a lawsuit over vaccines and autism. It opens as follows:

Study after study has failed to show any link between vaccines and autism, but many parents of autistic children remain unconvinced. For the skeptics, the case of 9-year-old Hannah Poling shows that they have been right along.

The government has conceded that vaccines may have hurt Hannah, and it has agreed to pay her family for her care. Advocates say the settlement — reached last fall in a federal compensation court for people injured by vaccines, but disclosed only in recent days — is a long-overdue government recognition that vaccinations can cause autism.

“This decision gives people significant reason to be cautious about vaccinating their children,” John Gilmore, executive director of the group Autism United, said Friday.

The government argued that it did not cave in to anti-vaccine hysteria:

“Let me be very clear that the government has made absolutely no statement indicating that vaccines are a cause of autism,” Dr. Julie L. Gerberding, director of the Centers for Disease Control and Prevention, said Thursday. “That is a complete mischaracterization of the findings of the case and a complete mischaracterization of any of the science that we have at our disposal today.”

So, why did they settle? It's not clear from the news stories, and I don't have access to the settlement. Given the attitude toward science in our government, decision-makers may have decided not to let the facts bother them when their minds were made up. Or, maybe they just decided that they didn't want to put this one in front of a jury that might be controlled by sympathy, rather than science.

To understand the science, you have to understand some background. There are two reasons why people began worrying that vaccines may be causing an "epidemic" of autism. The first is that autism rates have been rising along with vaccination rates. The second is that symptoms of autism emerge at roughly the same time as vaccinations occur. So, it seemed like a logical hypothesis. Thimerosal quickly became the culprit.

Thimerosal is a vaccine preservative, and it contains ethylmercury in very low doses. There had been general consensus that the doses were low enough to be of no concern. However, the safety standards were based on methylmercury exposure, and it was thought remotely possible that there could be greater risk with ethlymercury. Alternative preservatives had been developed and it seemed prudent to eliminate thimerosal. Beginning in 1989 thimerosal levels were reduced in vaccines. The process was completed in 1992.

Because Thimerosal levels have been reduced over the years, a good way to track the effects of Thimerosal exposure is look at rates of autism as they correspond to Thimerosal exposure. A number of these studies (summarized here) have looked at this. Of particular interest is the California study. They looked at autism rates in California from 1989 to 1992, when Thimerosal was being removed from vaccines. Had Thimerosal increased risk of autism, rates of autism would have dropped over the course of the study. Instead, there was no change in the frequency of autism. Since they were relying on practitioner's diagnoses, there was no room for bias (by massaging diagnoses) in the study.

Hannah, the autistic girl in the lawsuit, was a member of the age group in the California study. According to the story, she got 5 immunizations at the same time, but still, she would have been getting lowered doses of Thimerosal, because she was getting them after 1989. Again, overall, Hannah's age group showed no change in it's rates of autism over the course of the study.

As an alternative to Thimerisol, there has also been concern about the measles, mumps, and rubella (MMR vaccine) itself causing autism. Here, the evidence is even weaker. Studies purporting to show a relationship usually involve smaller numbers of cases. They often rely on investigating groups of autistic children and try to relate the emergence of autism with receiving the MMR vaccine. However, as I said before, vaccination occurs at the same age that autism emerges, so you're bound to see a correlation. The only way to identify a relationship here is to examine individuals both with and without autism who have both received vaccinations.

The data just doesn't support a relationship between vaccines and autism. The best explanation for rising autism rates comes from two sources. First, there have been marked changes in diagnosis. We used to see autism as a single entity. You were either autistic or you weren't. Today, we see autism as a spectrum of disorders; you may be more or less autistic. So, people previously diagnosed as mentally retarded are now seen as autistic. High functioning autistic individuals used to be diagnosed with "childhood schizophrenia." Today they're diagnosed with Asperger's disorder, which is considered a form of autism.

Secondly, and perhaps more cynically, diagnostic labels determine access to some services. There are a large range of services for people who are called autistic. If someone's "just" mentally retarded, they may not have access to the same services. Hence, providers may say, "This kid needs Day Training Program A. If I call him 'autistic,' he'll get it. If I call him mentally retarded, he won't." I can't prove this happens, but it wouldn't surprise anyone in this business.

My first professional position after graduate school involved working in an institution for people with mental retardation. I was involved in the group of professionals who made it possible to clear the institutions and get people with cognitive and developmental disabilities living in the community. So, over the years, I've seen a lot. What I've seem mostly, is parents struggling with their disabled children.

As late as the 1960's, the conventional wisdom was to tell parents to put their cognitively disabled children in an institution and try to forget about them. Parents who followed that advice were often consumed by guilt. Today, thankfully, disabled children live and are educated in the community. But it's a terrible strain on the parents and on other family members to have a disabled person in the house. Behavior modification, the best treatment for autism, requires an incredible amount of time and effort. Even so, the guilt hasn't been completely eliminated.

Parents wonder if they caused their child's autism. Was it that drink I had when I was 3 months pregnant? Or that I smoked, or that I chose to have a child at 38? Maybe it was a toxin I was exposed to at work? Maybe I shouldn't have worked? Maybe I should have taken better care of myself?

Wouldn't it be nice if autism was caused by the doctor, and not me?

My heart goes out to parents of disabled children. Their desperation leads to all kinds of ideas; I've seen them come and go. Megavitamin therapy was big for a while. Give lots of vitamins to your autistic child and he won't be autistic any more. Didn't do a thing. Remember assisted communication? The idea was that autistic children had only impaired communication skills and if we helped them communicate they would be just fine. It turned out that the people that helped them communicate were really doing the communication themselves. It's hard to find a good reference to it now on Google.

This doesn't mean we should throw our hands up in despair. As Rabbi Tarphon, a Jewish sage remarked, "It is not required that you complete the job, but neither are you free to abstain from it." We cannot cure or prevent autism yet, but as a community we can support autistic people, their families and other caregivers. We cannot give support by pretending there is an easy cure or an easy explanation for their children's illness.

Ken Pope Resigns from APA

This story was just emailed to me on the PsyUSA mailing list. Ken Pope, long active in the American Psychological Association, just resigned. His reason for his resignation was the unwillingness of APA to take a clear stand against torturing detainees. I won't bother quoting his letter at all. Ken makes his stand very clear.

I support Ken Pope completely in this. I resigned from APA several years ago because I felt that I was paying too much money for an organization that seemed to have no clear agenda. Ken makes it clear that APA has also lost its moral compass.

Some commentary on Ken's resignation also popped up on Daily Kos. Some of the commenters have questioned why more psychologists haven't resigned. In fact, others have. We don't know how many; they just didn't send out announcements. Other commenters questioned the value of withholding dues as a protest. Personally, I think it's a valid response. They are making their protest known, but they are still part of APA and still have the ability to influence it.

I hope that Ken's action will inspire others to withhold dues or to resign. Maybe APA will finally get the message and follow the lead of the AMA which has forbidden it's doctors to participate in interrogations.

Questions about Psychotherapy

A recent editorial in the Journal of Psychopharmacology by David J. Nutt and Michael Sharpe raises questions about the efficacy and safety of psychotherapy. It's currently available free of charge, but will be placed behind a pay wall 90 days after initial publication.

Clearly, an editorial in a psychopharmacology journal is not going to be sympathetic to psychotherapy and this article does not disappoint. I'm going to discuss four of their points.

1. Is Psychotherapy Effective?

Nutt and Sharpe begin by questioning the effectiveness of psychotherapy. They say, "few psychotherapy trials have complied with the standard regulations that are required of all drug treatments." This is both true and not true. Psychotherapy cannot be evaluated in the same way as drug therapy. It's a different treatment and there are different issues in evaluating it. Psychotherapy is a procedure, and as such, it is more akin to surgery, than it is to pharmacotherapy.

Nevertheless, psychotherapy has a rich and diverse research base, going back over 50 years. In particular, cognitive behavior therapy (CBT), always grudgingly acknowledged as an empirically based therapy, is based on a large body of literature involving operant conditioning, classical conditioning, rational emotive behavior therapy, self control and self-management. There are large numbers of outcome studies available. While few are large-scale studies, the accumulation of the data through meta analysis still shows fairly robust and positive results.

This research base has given us a good understanding of how CBT works. See the Handbook of Psychotherapy and Behavior Change for some excellent reviews of the research. In fact, we have a better idea of how CBT works than how drug therapy works. We have a pretty good idea about how changing thoughts change mood, and how exposure changes anxiety. In contrast, we still haven't been able to define that "biochemical imbalance" that allegedly causes depression. If you think we have, ask a psychopharmacologist what the balance is, or ask why one SSRI works and another doesn't.

Nutt and Sharpe also raise the issue of whether or not psychotherapy has been evaluated with double blind studies and placebo controls. I'm going to leave that issue for another day. I think they're wrong, but that's going to require more research than I have time for tonight.

Is Psychotherapy Safe?

Nutt and Sharpe question the safety of psychotherapy. They begin by arguing that psychotherapy can, in some cases, worsen outcomes. In particular, they identify suicidal patients and manic patients as being at risk. However, any treatment can cause problems in these patients. We have all heard of the worsening of suicidal ideation in adolescents on SSRI's (Nutt and Sharpe minimize this, but the black box is still there). Less well known is that SSRI's can also cause a manic episode in people with bipolar disorder. One advantage of psychotherapy is that the individual is seen more frequently and can be managed if they deteriorate. In contrast, people receiving drug therapy may not have any contact with their physician for a month or longer.

Another issue they raise involves an old technique called flooding. In exposure therapy, we deliberately expose people to feared stimuli, but in gradual steps. Flooding therapy involves fully immersing the subject in the feared situation all at once. Here is what Nutt and Sharp say about it:

When taken to its logical extreme [exposure therapy] becomes flooding therapy, which was once popular. The anxiety induced by flooding can be extraordinarily distressing and there are well recognised examples of patients escaping in fear from their treatment andrefusing further sessions. David Nutt runs a specialist anxiety disorders clinic in which we have seen a number of patients who could be considered as suffering from a PTSD-like syndrome as a consequence of failed flooding treatment for phobias and OCD. (p.4)

I can believe that a "PTSD-like syndrome" could occur as a result of premature termination of flooding. In fact, I never thought I would have the intestinal fortitude to keep a client in a feared situation long enough to make the procedure work. So, I never did any flooding, and, in fact, I've never met a therapist who ever did any flooding. They must have been out there, but I never traveled in their circles. So, I can't believe it was "popular."

Besides, isn't this an example of the pot calling the kettle black? Shall I now list the now-rejected medical procedures that have hurt people? Ever read the book, The Lobotomist? We who help those in pain often feel the need to "do something," to help people and we often wind up hurting instead of helping.

Nutt and Sharpe then raise the "false memory syndrome" canard. According to advocates of this syndrome, questioning people about past trauma can cause people to develop false memories of events. In reality, experimental evidence for false memory syndrome is weak. Ken Pope has a good discussion of the problems with false memory syndrome here.

Nutt and Sharpe unwittingly provide an excellent example of how badly false memory syndrome is abused. They say:

One young adult patient of David Nutt’s with severe OCD (obsessive-compulsive disorder--F.O.) was quizzed by a therapist about the possibility that she had suffered sexual abuse by family members. This led to her developing chronic ruminations about the possibility that she might have been abused by her father, even though she knew this had not happened. As a consequence for years she was unable to tolerate being in the same room as him, which markedly exacerbated her problems and caused great distress to the family. (emphasis added; p.4)

The section I italicized is the key. The patient knew full well that her father never abused her, so this could never have been an issue of false memories. Instead, this woman was struggling with an obsession. No big surprise. She had OCD. The woman obsessed over the possibility of her father abusing her.

There have clearly been some therapeutic abuses in the name of uncovering a history of trauma. This ain't one of them. A therapist who doesn't consider the possibility of trauma in a severely ill patient isn't doing his or her job.

Are Effective Treatments Withheld?

Moving on, Nutt and Sharpe argue, "Another proven potential risk of psychotherapeutic treatment is that effective drug treatments are withheld either because the therapist does not believe in their efficacy or because the patients are not introduced to the possibility of their being useful in their condition (Klerman, 1991)." True, but this is not a risk of psychotherapy. It's a risk of being a true believer. How many times have patients not been referred to psychotherapists because the physician doesn't believe in it?

Therapist Misconduct

Finally, Nutt and Sharpe bring up the risk of sexual misconduct. They site a 1986 study showing 7% of male psychiatrists and 3% of female psychiatrists have engaged in sexual contact with their patients. I am assuming these are psychiatrists who are providing psychotherapy. But this data is over 20 years old and since then, laws have been enacted, and licensing boards have been aggressive in enforcing a ban on so-called dual relationships. In Pennsylvania, it's a felony to sleep with a client. Yes, I know it still happens. But overall, this isn't a problem with psychotherapy. It's a problem with power relationships. Professors sleep with their students. Business people sleep with their secretaries. This kind of sexual misconduct occurs everywhere there's a power imbalance between men and women. Thankfully, my profession has been aggressive about stopping this.

Conclusions

After all this, I'm not willing to just write off Nutt and Sharpe as a pair of physicians with an axe to grind. I agree that psychotherapy is not as closely regulated as pharmacotherapy and I'd like to see greater quality control over psychotherapeutic services. But like other hands-on treatments, such as surgery, physical therapy, occupational therapy, and others, much of the effectiveness of treatment relies on the skills of the provider. This comes from training. One of the great disappointments to me has been the unwillingness of the leadership in psychology to improve training and accountability.

Psychology defines itself as the science of behavior, and we often research psychotherapy. But, when it comes time to say, "Yes, I believe the data. We should do A and not B to treat depression," we back down and run away. Too many people view any effort to develop treatment guidelines as an attack on psychotherapy. It's a shame that papers like this are so poorly drawn that they reinforce this belief.

Treating Depression in the Elderly: Medication, Psychotherapy, or Both?

An article in Psychiatric Times discusses the status of treatment for elderly people who are depressed. Written by Mark Miller, it opens with this observation:

There are hundreds of studies that show that pharmacotherapy is used to treat depression in adult and geriatric populations. There are far fewer studies that test the efficacy of psychotherapies and even fewer studies that focus on combined treatment for older patients. This discrepancy is largely a consequence of industry support of research in the former and the dependence on NIMH funding in the latter two. The sober lesson we have learned from STAR*D is that there are no pharmacological treatments that work for everyone.

STAR*D (Sequenced Treatment Alternatives to Relieve Depression) was a massive set of studies, conducted under grants from NIMH, in which they attempted to replicate real world treatment of depression. In the real world, depression often--if not usually--coexists with another disorder, such as anxiety. In most studies, the subjects have uncomplicated depression. That makes it easier to interpret the results, but raises questions about applicability of the results to the real world. In most studies, the subjects were given one medication and evaluated for depression after a set period. In the real world, if the patient isn't responding to treatment, the treatment is changed.

In STAR*D, the subjects were more heterogeneous and they were given sequenced treatment. Hence, the treatment was more applicable to the real world. The results, which Miller summarizes in one sentence above, are, I think, consistent with what all of us practitioners know. Treatment effects are significant, but there is no
predictability in response to treatment. Not everyone gets better easily.

In the real world, psychotherapy is often added to medication management. In STAR*D, there were a number of studies of psychotherapy. Here is one report of adding cognitive therapy to the mix. NIMH summarizes the results as follows:

Switching to or adding cognitive therapy (CT) after a first unsuccessful attempt at treating depression with an antidepressant medication is generally as effective as switching to or adding another medication, but remission may take longer to achieve.

I believe also, that either this study or another study had evidence that showed that the subjects, when given a choice of medication change or psychotherapy, often opt for medication change. There are two reasons for this. First, taking medication is easier and less anxiety-provoking than going once a week for psychotherapy. Second, all of the television ads for drugs give the impression that they are the way to go. Yet several types of psychotherapy, most notably cognitive therapy and interpersonal therapy, have very good track records.

All of this is equally true with the elderly. Miller argues that psychotherapy is particularly important for the elderly:

Every depression is expressed in an interpersonal context and thus its effects in the patient cause ripples that sometimes damage relationships that need to be addressed for potential repair work. The goals of combination treatment in late life are to:

• Be able to restore a state of homeostasis or balance by lessening the severity of the depression (and any comorbid anxiety).
• Maximize the coping ability of the patient.
  
• Foster a more positive outlook of remaining strengths and opportunities.
  
• Solicit external supports to foster not only a sense of being "backed up" but also a sense of having valued and purposeful integration into a social network.

Working with the elderly is different from other types of psychotherapy, because there is more emphasis on coping with problems in the real world. Therapists often worry that elderly clients will be too rigid to benefit from therapy. However, that rigidity is often outweighed by a strength not possessed by younger clients. Elderly persons have been through a lifetime of problems and usually have a well-developed repertoire of coping skills. The trick in therapy is to identify them and encourage the client to use them again.

So, the answer to the question, medication, psychotherapy, or both? is "It depends." It's frustrating that mental health professionals have not been able to identify who will profit from what kind of treatment. It's still very much a trial-and-error process, despite a significant amount of science in both medicine and psychology. By combining psychotherapy and medication, we can often bring out the best of both treatments. Miller illustrates this by paraphrasing Kay Redfield Jamison (An Unquiet Mind): "Lithium diminishes my depression, but psychotherapy heals."

I'm Having Flashbacks

I just discovered Ph.D. Comics. The most recent comic is giving me flashbacks to grad school.

Happy New Year and a Return to Blogging

Once again, I'm back; this time after a 5 month hiatus. I've been away for several reasons. I just finished some remodeling work in my house, which took a lot longer than I thought. My house is almost 100 years old, so there's always something to be done, and it's never as simple as it starts out to be. Then, too, I had to enjoy the summer. But, it's the new year, and it's time get back on the horse. I do enjoy blogging. It just takes so much energy.

The New York Times has an interesting article entitled, "The New Year's Cocktail: Regret with a Dash of Bitters." It's about New Years Day descent into regret about choices not made:

An opportunity, that is, to forestall the traditional morning-after descent into self-examination, that lonely echo chamber of what should and could be.

Ghosts roam around down there, after all, and they are the worst kind — alternate versions of oneself. The one who did not quit graduate school, for instance. The one who made the marriage work. Or stuck with singing, playwriting or painting and made a career of it.

Lost possible selves, some psychologists call them. Others are more blunt: the person you could have been.

This is a lyrical, but a-grammatical passage, which is somewhat surprising for the Times. But I like the metaphor of the ghosts. Looking at those ghosts may make us say, "If only I had done this differently, my life would have been WONDERFUL!!"

Ecch. When I start thinking that way, I always get in contact with my inner H. L. Mencken. Yeah, I could have stuck with singing. And today I could be living in a dump asking myself why I didn't go to grad school.

Life is about choices. Every time we make a choice, we cut off one universe of possibilities and embrace another universe of possibilities. I think of these possibilities as paths, and we walk along the path set by our previous choices. The great joy of life is how those paths take us to unpredictable places. Sometimes the places are enjoyable, sometimes they're not. When we find our path taking us to a place we don't want to be, all we can do is make new choices.

Because of this idea, I've been trying to stop referring to good or bad decisions. A decision puts us on a path which itself is infinite, so it never “turns out.” It simply opens up some choices and closes off others. I can make a decision very carefully, by considering all the options, seeking advice, and carefully selecting a plan of action. It can still put me on a path that takes me to a bad place. Once I see that I'm coming to a bad place all I can do it make new choices. But I will never know what would have happened if I had made a different choice and not taken that path.

Ultimately, our lives are the totality of the choices made and the paths taken. When we take a path, we make it real. The paths not taken exist only in the realm of imagination. So, if you ever find yourself wondering, "Why was I so stupid as to make that choice?" just remember the old line. "It seemed like a good idea at the time."Then go and make more decisions and make some new paths real.