Category: psychiatry

Progress in Psychiatry and Psychotherapy: The Half-Full Glass

Seth Roberts3 Comments

Here is an excellent introduction to cognitive-behavioral therapy (CBT) for depression, centering on a Stanford psychiatrist named David Burns. I was especially interested in this:

[Burns] currently draws from at least 15 schools of therapy, calling his methodology TEAM—for testing, empathy, agenda setting and methods. . . . Testing means requiring that patients complete a short mood survey before and after each therapy session. In Chicago, Burns asks how many of the therapists [in the audience] do this. Only three [out of 100] raise their hands. Then how can they know if their patients are making progress? Burns asks. How would they feel if their own doctors didn’t take their blood pressure during each check-up?

Burns says that in the 1970s at Penn [where he learned about CBT], “They didn’t measure because there was no expectation that there would be a significant change in a single session or even over a course of months.” Forty years later, it’s shocking that so little attention is paid to measuring whether therapy makes a difference. . . ”Therapists falsely believe that their impression or gut instinct about what the patient is feeling is accurate,” says May [a Stanford-educated Bay Area psychiatrist], when in fact their accuracy is very low.

When I was a graduate student, I started measuring my acne. One day I told my dermatologist what I’d found. “Why did you do that?” he asked. He really didn’t know. Many years later, an influential psychiatrist — Burns, whose Feeling Good book, a popularization of CBT, has sold millions of copies — tells therapists to give patients a mood survey. That’s progress.

But it is also a testament to the backward thinking of doctors and therapists that Burns didn’t tell his audience:

–have patients fill out a mood survey every day
–graph the results

Even more advanced:

–use the mood scores to measure the effects of different treatments

Three cheap safe things. It is obvious they would help patients. Apparently Burns doesn’t do these things with his own patients, even though his own therapy (TEAM) stresses “testing” and “methods”. It’s 2013. Not only do psychiatrists and therapists not do these things, they don’t even think of doing them. I seem to be the first to suggest them.

Thanks to Alex Chernavsky.

Suicidal Gestures at Princeton: A Staggering Increase

Seth Roberts16 Comments

A friend of mine knows a former (retired) head of psychological services at Princeton University. She told him that in the 1970s, there were one or two suicidal gestures per year. Recently, however, there have been one or two per day.

Something is terribly, horribly wrong. Maybe the increase is due to something at Princeton. For example, maybe new dorms are more isolating than the old dorms they replaced. Or maybe the increase has nothing to do with Princeton. For example, maybe the increase is due to antidepressants, much more common now than in the 1970s.

Whatever the cause, tt would help all Princeton students, present and future, and probably millions of others, if the problem were made public so that anyone, not just a vanishingly small number of people, could try to solve it. It isn’t even clear that anyone is trying to explain/understand/learn from the increase.

Princeton almost surely has records that show the increase. If, as is likely, Princeton administrators never allow the increase to be documented, it will be a tragedy. It is an extraordinary and unprecedented clue about what causes suicidal gestures. Nothing in all mental health epidemiology has found a change by factor of a hundred or more — much less a mysterious huge change.

The increase is an unintended consequence of something else, but what? Because it is so large, there must be something extremely important that most people, or at least Princeton administrators, don’t understand about mental health. The answer might involve seeing faces at night. I found that seeing faces in the morning produced an enormous boost in mood and that faces at night had the opposite effect. I cannot say, however, why seeing faces at night would have increased so much from the 1970s to now.

Assorted Links

Seth Roberts2 Comments

Thanks to Peter McLeod, John Batzel and Joseph Sinatra.

Why Antidepressants Barely Work

Seth Roberts26 Comments

When antidepressants are compared to placebos, they do only slightly better. This is not a problem for psychiatrists. People get better, they can charge money for access — that’s what matters. The rest of us, who would benefit from a better understanding of depression, do not feel bad because we have no idea what we are missing. But the puzzle of weak effectiveness remains. If the theory used to justify the antidepressants is correct, shouldn’t they work better? If the theory is totally wrong, why do they work at all?

John Horgan, a science writer, commented about this recently:

I first took a close look at treatments for mental illness 15 years ago while researching an article for Scientific American. At the time, sales of a new class of antidepressants, selective serotonin reuptake inhibitors, or SSRI’s, were booming. The first SSRI, Prozac, had quickly become the most widely prescribed drug in the world. Many psychiatrists, notably Peter D. Kramer, author of the best seller Listening to Prozac, touted SSRI’s as a revolutionary advance in the treatment of mental illness. Prozac, Kramer said in a phrase that I hope now haunts him, could make patients “better than well.”

Clinical trials told a different story. SSRI’s are no more effective than two older classes of antidepressants, tricyclics and monoamine oxidase inhibitors. What was even more surprising to me—given the rave reviews Prozac had received from Kramer and others—was that antidepressants as a whole were not more effective than so-called talking cures, whether cognitive behavioral therapy or even old-fashioned Freudian psychoanalysis. . . . Psychiatry has made disturbingly little progress since the heyday of Freudian theory.

To psychiatrists, psychiatry has made great progress since Freud. First, it is much easier to prescribe a pill than listen to a patient talk for 50 minutes. Second, the new pseudoscience of serotonin deficiency is far more respectable (more “scientific”) than the old pseudoscience of psychoanalysis (ego, id, super-ego, repression, etc.). It is harder for other doctors to make fun of psychiatrists.

But Horgan was not thinking like a psychiatrist. He was thinking like the rest of us. From that point of view, he should not have been “disturbed” by “little progress”. Antidepressants will never work well. Poor effectiveness is inherent in the situation. Antidepressants must do two things: (a) people must get better and (b) psychiatrists must make a living. Those are different goals (“misaligned incentives”) and they conflict.

Suppose a repairman comes to fix your dryer. One part is broken. The repairman orders a replacement and installs it. Your dryer now works fine. Because you could not diagnose the problem nor fix it, the repairman continues to be necessary. Suppose, on the other hand, the repairman can not replace the broken part. He must do something else. Maybe use duct tape. In this situation, the repair cannot possibly work well. Whatever he does can be better than nothing, but it cannot be a good repair

That is the situation of psychiatrists. I’m sure depression is due to the wrong environment. My work suggests we need to see faces in the morning for our mood-controlling system to work properly. Jon Cousins’ work suggests we need to believe others care about us. Those are two possibilities. Psychiatrists cannot fix the environment. The pieces of the environment we need to be healthy must have been abundant during the Stone Age. This means they must be cheap. Psychiatrists cannot supply things that are cheap and abundant. If that’s what they did, they couldn’t make a living. This means they can only supply something that is not what is missing. Like a repairman who cannot replace a broken part, they are stuck with second-rate solutions. This is the fundamental reason that all mainstream treatments for depression, whether talk or drug, have roughly the same effectiveness — and none of them work very well.

Thanks to James Lucoff.

Assorted Links

Seth Roberts1 Comment
  • Jason Epstein on Jane Jacobs. He edited most of her books.
  • How former Emory psychiatrist Charles “Disgraced” Nemeroff found a home at the University of Miami. A comment on the article put it well: “I am even more concerned as to the scientific truth and validity of the studies, drugs, treatments etc they [= Nemeroff and his supporters] have been involved in.” At the same time her university was hiring Nemeroff, the president of the University, Donna Shalala, sent out a letter boasting how the University of Miami was increasing the “integrity” of their medical school by improving policies related to conflicts of interest! “There is no room for compromise in this area,” wrote Shalala.
  • More about Jane Jacobs

Thanks to Dave Lull, Paul Sas and Alex Chernavsky.