Thursday, June 23, 2011

Mental Illness: Alternatives to Drugs

Unhinged: The Trouble with Psychiatry - A Doctor's Revelations about a Profession in Crisis

After writing so many negative articles about psychiatry it seemed appropriate to seek something positive to say.

One of the motives psychiatrists claim for moving away from classical psychoanalysis to drug therapy is simple economics. Since we are in a positive mood we will ignore the economic factors of gifts and bribes that are available from the drug companies and focus on a more fundamental issue.

Standard “talk therapy” in which the method involves searching for underlying causes of emotional responses can be long and expensive, and with no guarantee of success. Even if a cause is found, that does not necessarily equate to a cure. Medical insurance companies are hesitant to invest in such an open-ended process. A drug regimen, on the other hand is well-defined and more predictable. A psychiatrist has the choice of billing his hour as 50 minutes of therapy or four 15 minute medication sessions. With a little luck a medicated patient will fall into a monthly 15 minute checkup pattern. Daniel Carlat, in his book: Unhinged: The Trouble with Psychiatry—A Doctor’s Revelations about a Profession in Crisis, points out that the medication route can double a psychiatrist’s income. That is a significant and tempting amount of money.

Carlat acknowledges that there continues to be a role for medications in treating mental illness, but he believes that a greater role has to be reacquired by therapy if justice is to be done to the patients. Clearly a solution to the economics issue would be possible if more efficient forms of therapy were available. Carlat believes there is such a technique. It is called cognitive behavioral therapy (CBT).

“....devised by a disenchanted psychoanalyst named Aaron Beck. Beck became impatient with the global pace of progress in psychoanalysis, and decided that a more efficient way to get patients to feel better is to teach them to think better. Instead of asking ‘How does that make you feel,’ he began asking patients ‘How does that make you think?’ He found that depression and anxiety are often triggered by irrational thoughts and ideas. If patients could identify their distorted thoughts and question them, they could presumably change the negative emotions the thoughts had triggered.”

The efficiency of this approach derives from the fact that it deals with the present rather than the past. Treatment then can have a definable duration rather than being open ended. There is even the suggestion that the approach is amenable to self-guided, computer-driven therapy.

“CBT has been studied by comparison with medications and has been found to be equally effective for depression and anxiety disorders. In some cases, it is more effective, especially for preventing relapses over the long term.”

The fact that the placebo effect is so strong in the cases of those suffering from depression and anxiety would indicate that the cause of the problem can be controlled by the unconscious mind. If the unconscious can eliminate the condition, then the conscious mind ought to be able to learn how to do it also.

The Economist has an article titled Therapist-Free Therapy. They describe CBT as an effective treatment for depression and anxiety that can be accomplished in 12-16 one hour sessions. They then proceed to describe cognitive-bias-modification (CBM) which has been shown to produce results in a few 15 minute sessions at a computer.

“CBM is based on the idea that many psychological problems are caused by automatic, unconscious biases in thinking. People suffering from anxiety, for instance, may have what is known as an attentional bias towards threats: they are drawn irresistibly to things they perceive to be dangerous. Similar biases may affect memory and the interpretation of events. For example, if an acquaintance walks past without saying hello, it might mean either that he has ignored you or that he has not seen you. The anxious, according to the theory behind CBM, have a bias towards assuming the former and reacting accordingly.”

“The goal of CBM is to alter such biases, and doing so has proved surprisingly easy. A common way of debiasing attention is to show someone two words or pictures—one neutral and the other threatening—on a computer screen. In the case of social anxiety these might be a neutral face and a disgusted face. Presented with this choice, an anxious person instinctively focuses on the disgusted visage. The program, however, prods him to complete tasks involving the neutral picture, such as identifying letters that appear in its place on the screen. Repeating the procedure around a thousand times, over a total of two hours, changes the user’s tendency to focus on the anxious face. That change is then carried into the wider world.”

This approach sounds like it is too new to be properly evaluated, but preliminary results involving “social anxiety” were sufficiently promising that larger studies are underway, and attempts are being made to expand the technique into other areas.

There is no biological justification for treating mental illness with drugs. Drugs can only provide short-term remission of symptoms. Carlat quotes a pediatrician named Ingeborg Van Pelt who provides an appropriate metaphor.

“Tranquilizers and psychotropic drugs serve as a life jacket—they keep you afloat, but they do not show you the way back to shore.”

To which Carlat adds:

“Therapy gets patients back to shore.”

If we can arrive at more efficient and effective modes of therapy then we would finally have a true “revolution in psychiatry.”

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