Tuesday, November 13, 2012

Psychotherapy and Drugs: A Dangerous Combination?

Recent comments by baz on previous post have drawn me away from the endless reading that is slowly destroying my life and harkened me back to the original idea in relation to that post. My original thought was this:

The use of drugs simultaneously with psychotherapy has value but must be carefully managed. Inducing behavioral change in a patient whose mental state is under the influence of powerful drugs may instantiate the desired behavior change that can easily be lost once the drugs are discontinued simply because the behavior change was created in that context. 
Today I read this: 

Beware small positive studies. By Neuroskeptic.

When selective serotonin reuptake inhibitors (SSRIs) were introduced for depression, effect sizes greater than 1.0 were reported, which created their legacy as a wonder drug. Over the course of 20 years, the mean effect size of SSRIs decreased to around 0.3. A similar trend was demonstrated for cognitive-behavioral therapy.

An effect size of .3 suggest to me that bugger all is going on here. There are some who argue it is worse than that. Oliver James has asserted that while CBT has immediate benefits those benefits disappear within months. I suggest that is because the therapist-patient relationship has ended and the patient is again stuck in the same old world driving the same old problems. Over recent years there has been a rash of studies indicating that antidepressants are not nearly as wonderful as some would have us believe. I have long lost count of the number of abstracts that begin with something like ....

The search for new antidepressants continues apace because there is a poor response rate to existing drugs.
A recent study claimed that ketamine could be the big new thing in Depression City. That betrays a certain desperation because as a psychiatrist informed me that risk of psychosis arising from that drug is too high. At present no-one is sure why ketamine had such a rapid effect on alleviating depression, a rapid response also found in electro shock therapy(much maligned but "magically" powerful in its effects) and a study I read in relation to BDNF infusion in an animal model of depression. That these 3 approaches worked within hours discounts ideas like re-instantiation of neurogenesis, or that depression is an "amine problem". I am presently exploring the idea that the rapid efficacy of these three therapies relates more to growth factors. I have an idea that could be consistent with all three results but am too lazy to work that through. I'm very lucky because I don't have to deal with peoples' mental health issues. I deliberately focused on molecules because I felt I was on safer territory there, fool that I am for committing myself to a reductionist fallacy. Too harsh perhaps because my interest was primarily in neuroimmunology, a field that can be investigated largely independent of any behavior considerations. Which, as I have learned, is kinda like very wrong in some respects.

I was motivated to think about the use of drugs in psychotherapy because a friend of mine is currently undergoing treatment for some mood disorder issues. This has been something of a therapeutic farce. Initially the GP placed  him on an antidepressant. When I quizzed my friend about what the GP told him I was surprised to hear that the GP told him nothing. Moreover I suspect the GP had no knowledge that antidepressants can initially increase anxiety so given the diagnosis of an anxiety disorder I was somewhat perturbed. Even moreso when my friend saw a psychiatrist who stated that the prescribed antidepressant is useless for anxiety. 

Then it got worse. They added an antipsychotic, olanzapine, to the regime. The studies do not support the use of olanzapine for anxiety. Of this I was very worried because I knew that this drug would sedate my friend into oblivion. It took him two months to realise that was the case and he is now attempting to reduce the olanzapine dose. I made a big mistake there: initially I said nothing about his treatment, simply seeking to be kept informed but maintaining silence because I did not wish to interfere with the therapeutic process. I wanted him to believe that it would help. Sometimes belief is not enough. 

Then it became dreadful and this bring us to the crux of my thoughts while walking on a beautiful day. I was pleased to hear that the next psychiatrist he saw began a psychotherapy intervention. Good, I thought, the studies are clear, anxiety treatment is best addressed through psycho-therapeutic interventions. Then that bloody walk during which it occurred to me that psychotherapy for a patient who is heavily sedated must be problematic. That is exactly what happened to me when I first saw my friend after the commencement of olanzapine. He was nearly zombiefied. That was an immediate perception, it was written all over his face and body language. 

What a strange contradiction, to commence psychotherapy in a patient whose sedated state precludes the possibility of any behavior changes becoming sufficiently internalised and reinforced. This goes to the heart of my previous post where I addressed the therapeutic context. In my experience at least if I want to learn something new I do it best with eyes wide open, when my mind is clicking along at a good pace. My friend was in the exact opposite state. 

Recently I found out that the psychotherapy has been discontinued but the drugs remain. BIG mistake. What should happen is that the drugs are used initially to reduce patient distress and drugs can be very valuable in that regard. But ideally during the course of psychotherapy the patient should have the drug load slowly reduced so that desired behavior changes can be reinforced in "normal operating conditions". 

There is a cruel paradox here. The heavily sedated patient, confronted with an authority figure, is probably going to say anything to please that authority figure. The patient is so tired the last thing they are likely to do is challenge the authority figure. Sleep deprivation is a powerful means of promoting acquiescence. 

The goal should be to get the patients off the drugs. That is the real cure. Here though we see a therapeutic strategy which facilitates ongoing use of the drugs. Why? Because even if the psychotherapy has provided value that value is constrained by a drug induced state in which the value was derived. So when the patient decides to discontinue drug use the behavior may revert back to the behaviors that caused the problem in the first place. Is it then that surprising when we read studies indicating that antidepressants may be inducing relapse? Antidepressants are important drugs, alleviated a great deal of suffering but they are not wonder drugs  and the excessive reliance on these drugs has led too many people being unable to live without these drugs. When ceasing these drugs the literature refers to the problems of "serotonin withdrawal syndrome" which is a polite way of saying: we got the patient addicted. At least illicit drug dealers are honest. 

That is no laughing matter. In the USA there is a now a problem with "serotonin babies" and "opioid babies". A recent meta-analysis strongly advised against the use of antidepressants during pregnancy. Ya think!!! Modern Western societies are quite possibly the most psychoactive drug using cultures of all times and I'm not talking about illicit drugs. We have lost our way, a fact not lost on many in the mental health professions but like the rest of us they too are constrained in their treatment options. 

In comments on my previous post Baz makes reference to a study on "extratherapeutic factors". Reminds me of the economic concept "externality". The economists also treat the environment as not being that relevant to our concerns. Yeah that's worked really well for the environment. What is striking is that the study highlighted how lifestyle changes and social support were the most critical elements in behavior change. That statement immediately reminded me of what an old school friend told me some months ago. We were discussing what drives people to join bikie gangs and he remarked, "Johnny, they all come from broken homes!" 

One of our most pervasive cognitive biases is to attribute control to how we think independently of our environment. Over recent months I have read some brilliant books which demonstrate how even religious beliefs are strongly influenced by our environment and especially our culture. We think our behavior is something we have come to by way of rational analysis, that our values are predicated on some absolute frame of reference independent of time and space. No Spocks! Culturally we have inherited the idea that without an absolute frame of reference morals are just "relative", as if that is a bad thing. The need for an absolute frame of refernece is a christian\theist legacy that is based on a near complete misapprehension about human behavior. 

It appears though that we are in process of jumping from the pan into the fire. The extensive reliance on drugs to induce behavioral change is not only being increasingly challenged by the literature but is also a reflection of psychiatry still being heavily influenced by a 19th century exuberant reductionism. Science is all the rage these days and every professional, even economists, wish to appear "scientific". 

Our heavy reliance on drugs to induce behavior change is anything but scientific and reflects cultural entrenched assumptions about human behavior and how it emerges. We are very much creatures of our culture and that is why whistle blowers and iconoclasts so often receive a pounding when they stick their head above the parapet. If you go against the flow it is a hard swim requiring great endurance and the capacity to withstand a tide that can and does sweep many out into the wide open sea where there are no landmarks to guide them back to solid ground. The drugs are important but our current emphasis on the drugs reflects cultural and philosophical presumptions that making us far too reliant on drugs to manage behavior disorders. 


Legal Eagle said...

John, I'm astounded by the number of people who are prescribed anti-depressants by a GP who doesn't tell the person anything about the side-effects or about the treatment. Also - sometimes it just masks the real problem. I can think of a friend who had huge marital problems - her husband just kept blaming her and pushing for her to up the anti-depressants - guess what? The problem was not that my friend was depressed, but that her (now-ex) husband and her had a deeply destructive relationship.

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