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Dr. Bob is Robert Hsiung, MD,
bob@dr-bob.orgShown: posts 1 to 25 of 44. This is the beginning of the thread.
Posted by SLS on November 20, 2009, at 15:27:50
It looks like the inclusion criteria used were optimized to select subjects with putatively biological depressive disorders. Chronic and recurrent presentations were studied.
- Scott
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No Added Benefit of Adjunctive Psychotherapy to Antidepressants Alone in Chronic DepressionNovember 16, 2009 Adjunctive psychotherapy in combination with antidepressant medication appears to offer no additional therapeutic benefit in patients with chronic depression, a large, randomized, 12-week trial suggests.
Investigators at Weill Cornell Medical College in New York found that after 12 weeks of continued pharmacotherapy plus either brief supportive psychotherapy (BSP) or cognitive behavioral analysis system of psychotherapy (CBASP), outcomes were no better than if patients received medication alone.
"It would be fair to say that the approaches were equally effective," lead investigator James H. Kocsis, MD, told Medscape Psychiatry.
The study is published in the November issue of Archives of General Psychiatry.
Findings Contrary to Study Hypothesis
The trial included 491 patients with chronic depression. Participants had depressive symptoms for a minimum of 2 years without remission and met diagnostic criteria for double depression, chronic major depression, or recurrent major depression with incomplete recovery between episodes.
The study's main outcome measures were proportion of remitters, partial remitters, and nonresponders and change from baseline in the Hamilton Scale for Depression scores.
Participants were randomized to receive 12 weeks of continued pharmacotherapy plus CBASP, continued pharmacotherapy with BSP, or continued optimized pharmacotherapy alone.
At the end of the study period, the investigators found no statistically significant differences among the 3 treatment groups in the proportions of patients in remission, partial response, or nonresponse, suggesting, said Dr. Kocsis, that although chronic depression is often helped by medication, there is little evidence of added benefit with adjunctive psychotherapy.
"We were surprised. The results went against our hypotheses. We are interested in studying differential predictors of response to drugs versus psychotherapy. We think early life adversity and childhood maltreatment may be important in predicting need for psychotherapy," Dr. Kocsis said.
Dr. Kocsis also noted that current American Psychiatric Association treatment guidelines only address major depression and not chronic depression. "Perhaps they should develop separate guidelines for chronic depression," he said.
Convincing but Not Conclusive
Pim Cuijpers, PhD, who has published 2 meta-analyses of psychotherapies for chronic depression, described the Kocsis study as "sobering." Dr. Cuijpers is professor of clinical psychology, chair of the Department of Clinical Psychology, and vice-director of the EMGO Institute for Health and Care Research at VU University, Amsterdam, The Netherlands.
Dr. Cuijpers told Medscape Psychiatry that, although he finds these data convincing, they are not conclusive. "The conclusion that pharmacotherapy alone is just as good as combined treatments is not supported by the total body of research in this area," he said.
The Cuijpers' meta-analysis of psychotherapies for chronic depression, which is currently in press, concluded that combined treatments have a small benefit over pharmacotherapy alone.
"I do not think the Kocsis study [which was published after the meta-analysis was completed] would change the results of our meta-analysis if it had been included. Our meta-analysis, however, also shows that the results of psychotherapy are not very high in chronic depression," Dr. Cuijpers said.
The study was sponsored by the National Institute of Mental Health. All medications were donated by Forest Laboratories, GlaxoSmithKline, Organon Pharmaceuticals Inc, Pfizer Inc, and Wyeth Pharmaceuticals. Dr. Kocsis reports receiving research support from AstraZeneca, Burroughs Wellcome Trust, CNS Response Inc, Forest Pharmaceuticals, the National Institute on Drug Abuse, the National Institute of Mental Health, Pritzker Consortium, and Sanofi Aventis; participating on the speaker's bureau for AstraZeneca, Pfizer Inc, and Wyeth; and acting as a consultant to Wyeth.
Arch Gen Psychiatry. 2009;66:11781188.
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Posted by Phillipa on November 20, 2009, at 16:12:09
In reply to No benefit to adding psychotherapy to medication, posted by SLS on November 20, 2009, at 15:27:50
Furnished by the drug companies as said to me before. So that could be a reason. Phillipa
Posted by SLS on November 20, 2009, at 16:39:53
In reply to Re: No benefit to adding psychotherapy to medication » SLS, posted by Phillipa on November 20, 2009, at 16:12:09
> Furnished by the drug companies as said to me before. So that could be a reason. Phillipa
Who knows?
It would be disappointing to discover that the investigators at Cornell are abject liars. Afterall, they proved their own hypothesis to be wrong.
Do you think the results reported are in error?
- Scott
Posted by Zyprexa on November 20, 2009, at 17:43:57
In reply to No benefit to adding psychotherapy to medication, posted by SLS on November 20, 2009, at 15:27:50
Thats what I'm saying!
Never did anything for me either.
Posted by Cecilia on November 20, 2009, at 20:36:37
In reply to Re: No benefit to adding psychotherapy to medication, posted by Zyprexa on November 20, 2009, at 17:43:57
Neither therapy ( over 7 years) or medications (dozens) have ever done anything to help my chronic depression, but that said, this study is totally absurd. Expecting 12 weeks of therapy to do anything is absolutely ridiculous-it takes far far longer than 12 weeks before most people with chronic depression are likely to even begins to trust their T, let alone begin to deal with their issues. Cecilia
Posted by Phillipa on November 20, 2009, at 20:49:45
In reply to Re: No benefit to adding psychotherapy to medication, posted by SLS on November 20, 2009, at 16:39:53
Seriously once upon a time I had a good therapist and we were truly making progress. What struck me was one thing he said in particular. We were going to move to the beach at the time he said changing location is not the answer it's staying put and working through things. Unfortunately my husband didn't believe me that I did want to stay so I went along with him moved and it's been a disaster ever since. I feel that if you find someone who makes sense and you have been on any type of medication depression or anxiety that much longer than 12 weeks is needed. Trust means everything in relationships whether it be marriage or docs etc. If only. Phillipa ps everything is relevant post this on psychology but unfortunately from what I read on admin it's not getting posters.
Posted by SLS on November 20, 2009, at 23:11:21
In reply to Re: No benefit to adding psychotherapy to medicati, posted by Cecilia on November 20, 2009, at 20:36:37
> Neither therapy ( over 7 years) or medications (dozens) have ever done anything to help my chronic depression, but that said, this study is totally absurd. Expecting 12 weeks of therapy to do anything is absolutely ridiculous-it takes far far longer than 12 weeks before most people with chronic depression are likely to even begins to trust their T, let alone begin to deal with their issues. Cecilia
In fairness, the psychotherapeutic modalities chosen were meant to be brief and quick-acting. So I guess the real question is whether or not these two methods of psychotherapy are effective.
What type of psychotherapy were you referring to?
- Scott
Posted by morganator on November 20, 2009, at 23:43:26
In reply to No benefit to adding psychotherapy to medication, posted by SLS on November 20, 2009, at 15:27:50
I have seen psychotherapy help several people that were taking medication. I have seen the most improvement with people that are in individual therapy and then moved on the group therapy. Flat out therapy works for many many people. The problem is that it is NOT easy at all. I think this may be one reason why so many people don't have success with it. Also, it is hard to find a really good therapist. Hopefully this will change.
Posted by morganator on November 20, 2009, at 23:47:12
In reply to Re: No benefit to adding psychotherapy to medicati » Cecilia, posted by SLS on November 20, 2009, at 23:11:21
She was probably referring to psychodynamic therapy.
I think that CBT and EMDR may be two of the only types of therapy I know of that may have a significant benefit in a 12 week period. Actually, group therapy can have a fairly profound impact as well in a short period of time.
Posted by SLS on November 21, 2009, at 0:13:34
In reply to Re: No benefit to adding psychotherapy to medication » SLS, posted by morganator on November 20, 2009, at 23:43:26
> I have seen psychotherapy help several people that were taking medication. I have seen the most improvement with people that are in individual therapy and then moved on the group therapy. Flat out therapy works for many many people. The problem is that it is NOT easy at all. I think this may be one reason why so many people don't have success with it. Also, it is hard to find a really good therapist. Hopefully this will change.
I believe that psychotherapy can be helpful for a whole lot of people with depression. Otherwise, I wouldn't bother with it myself. However, with affective disorders, it often happens that little progress is made with psychotherapy until one begins to respond to somatic therapy.
- Scott
Posted by morganator on November 21, 2009, at 1:24:09
In reply to Re: No benefit to adding psychotherapy to medication » morganator, posted by SLS on November 21, 2009, at 0:13:34
I hear ya
Posted by SLS on November 21, 2009, at 5:46:12
In reply to Re: No benefit to adding psychotherapy to medication » SLS, posted by morganator on November 21, 2009, at 1:24:09
> I hear ya
I enjoy reading your posts and learn much from them.
I am still partial to the idea that, along a spectrum of relative contributions of the biological and the psychological, psychosocial stress can trigger or reinforce a depressive episode. At one end of the spectrum are people whose depression is biologically driven without input from psychological pathology. At the other end of the spectrum are people whose depression is psychologically driven, and will remit as psychological issues are resolved.
It is my opinion that if a diagnosis of major depressive disorder or bipolar disorder is made properly, the illness will be predominantly biological and more resistant to psychological treatment. Even here, though, psychotherapy can be supportive and help provide coping tools to use while the depression persists. Of course, having a biological affective disorder does not preclude the presence of psychological issues as well.
One thing I don't like seeing is a psychotherapist disregarding the biological nature of affective disorders and place the responsibility of mental health on the psyche of the patient. This is a cruel sort of sabotage.
- Scott
Posted by Iansf on November 21, 2009, at 16:21:30
In reply to Re: No benefit to adding psychotherapy to medication » morganator, posted by SLS on November 21, 2009, at 5:46:12
Personally, I never found any kind of psychotherapy helpful in dealing with depression. And I tried many different kinds of therapy. Some, in fact, made the situation worse - though I think that was due more to the arrogance of particular practitioners than the mode of therapy. Still, antidepressants were the only thing that helped.
Well, antidepressants and more recently one other factor. In contrast to Philippa's experience, I found that moving greatly benefitted me. But that's because I moved somewhere I knew I loved, not just anywhere. The reason I moved where I did - Puerto Vallarta, Mexico - is that it seemed so friendly on numerous visits. Having moved here, that observation has borne itself out. I've gone from being alone much of the time, with only intermittent contact with friends, to building a very wide circle of friends, at least some of whom I see every day. I've discovered that a significant part of the reason for my loneliness indeed had to do with where I lived (San Francisco), not with something being wrong with me.
Which is not to say I could have come to this point without the help of antidepressants. They provided the necessary foundation to begin overcoming my shyness and exploring my options. But while living in San Francisco, I found I could never get beyond a certain point, even with meds. Here I have been able to move forward very fast - to such an extent that for the past three months, I haven't needed meds. I realize I may need them again sometime and will gladly take them if necessary. Nonetheless, the change of location to somewhere people actually seem to put friendship ahead of work, culture, fitness or whatever has been just as important as the meds in lifting my spirits.
Posted by Zyprexa on November 21, 2009, at 16:48:32
In reply to Re: No benefit to adding psychotherapy to medicati, posted by Cecilia on November 20, 2009, at 20:36:37
My meds work great!
Posted by Phillipa on November 21, 2009, at 19:32:21
In reply to Re: No benefit to adding psychotherapy to medication, posted by Iansf on November 21, 2009, at 16:21:30
I better preface my statement as this was when I was no longer working and getting scared and alone all the time the damage was done. In a nutshell should have never ever moved to NC. I can't stand this state. Being from CT I first moved to Virginia Beach and loved in there and felt great. Basicially took maybe .25 xanax at night. It was when I left this state bad mistake that I got sick. One week after getting married thyroid went and lymes discovered. So how could I be well in one state and sick one week later. Oh no theraphy ever till NC. Phillipa
Posted by floatingbridge on November 21, 2009, at 21:16:31
In reply to Re: No benefit to adding psychotherapy to medication » morganator, posted by SLS on November 21, 2009, at 5:46:12
>
> One thing I don't like seeing is a psychotherapist disregarding the biological nature of affective disorders and place the responsibility of mental health on the psyche of the patient. This is a cruel sort of sabotage.
>
>
> - ScottYes, I absolutely agree with you. And here in the sunny west, that attitude has trickled down to the general population of pop-psychology readers. The same attitude that blames a Parkinson's patient for precipitating illness by too much negative thinking, or even, karma!
Yesterday, my pdoc showed me the latest publication on managing major depression (a slim book by some neuroscience organization). Interpersonal therapy--or any therapy--was suggested as an adjunct in the 4th (or last) step in dealing with major depression. Therapy was placed in the same tier as ECT, VNS, and rTMS. I was shocked. I mean, therapy does not help some people, for many reasons--that I understand. To wait to try it until one presents as ready for last and most invasive measures does not seem wise. What a disconnect, imho.
fb
Posted by SLS on November 21, 2009, at 23:23:24
In reply to Re: No benefit to adding psychotherapy to medicati » SLS, posted by floatingbridge on November 21, 2009, at 21:16:31
Hi FB.
> > One thing I don't like seeing is a psychotherapist disregarding the biological nature of affective disorders and place the responsibility of mental health on the psyche of the patient. This is a cruel sort of sabotage.
> Yes, I absolutely agree with you. And here in the sunny west, that attitude has trickled down to the general population of pop-psychology readers. The same attitude that blames a Parkinson's patient for precipitating illness by too much negative thinking, or even, karma!
>
> Yesterday, my pdoc showed me the latest publication on managing major depression (a slim book by some neuroscience organization). Interpersonal therapy--or any therapy--was suggested as an adjunct in the 4th (or last) step in dealing with major depression. Therapy was placed in the same tier as ECT, VNS, and rTMS. I was shocked. I mean, therapy does not help some people, for many reasons--that I understand. To wait to try it until one presents as ready for last and most invasive measures does not seem wise. What a disconnect, imho.Gosh.
What comes with the next tier - positive affirmations and psychosurgery?
You know, it would make a hell of a discussion to consider whether or not psychotherapies should be included in a treatment algorithm for depression, and if so, where they should be positioned.
I favor the use of a psychological evaluation at some point, perhaps as part of an intake process, rather than a rigid placement of psychotherapy in a treatment algorithm. For MDD and BD, I'm not sure there is enough scientific evidence that psychotherapy is effective such that it should deserve a prominent role in treatment. I would prefer to establish an indication for psychotherapy first through psychometric testing or some other form of psychological evaluation. This could help set up a treatment protocol that includes both somatic and psychological therapies.
- Scott
Posted by floatingbridge on November 21, 2009, at 23:55:50
In reply to Re: No benefit to adding psychotherapy to medicati » floatingbridge, posted by SLS on November 21, 2009, at 23:23:24
>
> What comes with the next tier - positive affirmations and psychosurgery?
>Well, sadly, and as you know, right now that is the last tier--though my pdoc seems very excited about what will be happening in the next ten years--he thinks it will be revolutionary. As for the time being....
> You know, it would make a hell of a discussion to consider whether or not psychotherapies should be included in a treatment algorithm for depression, and if so, where they should be positioned.
>A great discussion here. Seems some others have had that discussion already--and sent it out to our pdocs. (Though mine said he was 'agnostic' in regards to the psychiatric community. I suspect many are--I hope.)
> I favor the use of a psychological evaluation at some point, perhaps as part of an intake process, rather than a rigid placement of psychotherapy in a treatment algorithm. For MDD and BD, I'm not sure there is enough scientific evidence that psychotherapy is effective such that it should deserve a prominent role in treatment. I would prefer to establish an indication for psychotherapy first through psychometric testing or some other form of psychological evaluation. This could help set up a treatment protocol that includes both somatic and psychological therapies.
This idea sounds good to me!
:-)
fb
Posted by morganator on November 22, 2009, at 3:23:32
In reply to Re: No benefit to adding psychotherapy to medication » morganator, posted by SLS on November 21, 2009, at 5:46:12
Well I'm glad you have enjoyed some of my posts, thank you. Yours are very insightful and interesting I must say.
I'm too tired to make a long argument but I feel the need to briefly express my opinion on the subject. I believe that with people who have struggled with bipolar and major depressive disorder also did not get what they needed in childhood. Yes there is a biological predisposition, but if people suffering from these disorders had gotten what they needed from day one, I do not believe the suffering would be so severe. Now, the people who do not have the genetic predisposition to develop such severe disorders but are exposed to the same environment in early and later stages of development will still have issues. The difference with these people is that they will be able to continue on through life without their depression and anxiety growing into the monster that feeds on many of us. Look, bad parenting, child abuse, lack of love and nurture have been part of the human condition for a long time. There have been very few parents truly capable of giving their children what they need. We cannot deny that this has not had a major impact on our lives. I think finally now we are learning to truly love ourselves and our children. This generation of parents is much different than those in the past. We are far from perfect but I think we are better off than before. Fathers are more involved and able to show more emotion. People are getting married later so hopefully they will be less likely to get divorced, which by the way is incredibly destructive to the emotional psyche of the children involved. Even if both parents handle the divorce perfectly the children will suffer, maybe not as bad but they will still suffer. It is known that children from divorced parents have problems with anxiety, amongst other potential problems.
I guess I just don't think that it is possible for disorders to develop to such a severe state without environment and nurture playing a significant role. I have had two psychiatrists, not psychotherapists, admit to me that conditions in my childhood very well have made me more likely to experience such extreme mixed states later on. You have to also consider that we may have been more equipped to avoid the stressors that sent us deep into our states of suffering if we had what we needed throughout our development.
We may not have felt the need to use as much alcohol or drugs(which I believe can contribute to episodes). We may have been able to form relationships and maintain them better which would have given us more stability. We may have not carried all the anxiety and anger(by the way, believe it or not, almost all of us carry some anger about something, it's a different kind of anger) that interfered with so many things in our lives. This interference added to the instability that contributed to the suffering. We may have loved ourselves more and been more confident.Scott, while we agree on some things, we may have to disagree on others. Even with schizophrenia it is not inevitable that one will develop it just because they have the gene or the predisposition. The person may be a little different but they may never have a psychotic break given the right conditions.
I would love to hear in detail about the childhoods of all of those suffering from depression, major depression, bipolar, schizophrenia. I can almost guarantee that everyone will have some not so good things to talk about. Some may have some serious trauma. Others may have had a verbally abusive mother or father. Many will have had gone through a divorce. Maybe some never knew their mother or father and the single parent struggled to hold things together. Many may be in complete denial and say that there was nothing wrong with their parents or childhood. Denial is the most powerful of all coping mechanisms.
Oops I lied, I wasn't that tired after all.
Posted by SLS on November 22, 2009, at 6:31:27
In reply to Re: No benefit to adding psychotherapy to medication » SLS, posted by morganator on November 22, 2009, at 3:23:32
You know, I have never seen a study investigating the psychosocial history of people suffering from Axis I mental illnesses as they come in for treatment. Such a study would reveal much about the evolution of these disorders.
I agree with you. Even identical twins can express schizophrenia differently. Again, it would be interesting to try to identify differences in early psychosocial experiences between each individual. Living under the same roof is no guarantee of identical developmental environments. All of these disorders must have some epigenetic counterpart as there is not a one-to-one genotype to phenotype relationship. I don't think we are looking at a simple dynamic, though.
- Scott
Posted by bleauberry on November 22, 2009, at 7:44:50
In reply to No benefit to adding psychotherapy to medication, posted by SLS on November 20, 2009, at 15:27:50
I did psychotherapy twice...weekly for 6 months each time.
It was helpful but only for the half hour or so following the appointment. Ya know, a good counselor can lift your spirits, give confidence, get you relaxed and feeling better. The problem is, as soon as you leave, get in the car and start driving in the real world again, all of that evaporates real fast.
I think the best uses of psychotherapy are:
1. When there is a definite life issue involved...divorce, death, loss of career, etc.
2. For pure biochemical depression without a life crisis component, I think psychotherapy serves a good purpose to help keep the patient on track while waiting for the medicine to hopefully kick in. It's almost kind of like having a cheerleading squad in your corner to send you back into the boxing ring each round with a renewed sense of confidence, hope, and patience. Without the counselor, we might abandon our meds too soon. They can help keep us on the path our doctor has chosen for us, or spot a situation where a doctor has made an obviously gross error.
Posted by floatingbridge on November 22, 2009, at 15:07:00
In reply to Re: No benefit to adding psychotherapy to medication » SLS, posted by morganator on November 22, 2009, at 3:23:32
Morganator,> Oops I lied, I wasn't that tired after all.
:-)
I recently said to a group of 'healthy' friends, when one mom quipped about what her son would take to therapy with him as a grown man, "So, what's wrong w/ therapy? Probably everybody could use some." The group laughed in recognition and agreement--and the mom who spoke said 'Right on!"
fb
Posted by floatingbridge on November 22, 2009, at 15:13:06
In reply to Re: No benefit to adding psychotherapy to medication, posted by bleauberry on November 22, 2009, at 7:44:50
> I did psychotherapy twice...weekly for 6 months each time.
>
> It was helpful but only for the half hour or so following the appointment. Ya know, a good counselor can lift your spirits, give confidence, get you relaxed and feeling better. The problem is, as soon as you leave, get in the car and start driving in the real world again, all of that evaporates real fast.
>
> I think the best uses of psychotherapy are:
>
> 1. When there is a definite life issue involved...divorce, death, loss of career, etc.
>
> 2. For pure biochemical depression without a life crisis component, I think psychotherapy serves a good purpose to help keep the patient on track while waiting for the medicine to hopefully kick in. It's almost kind of like having a cheerleading squad in your corner to send you back into the boxing ring each round with a renewed sense of confidence, hope, and patience. Without the counselor, we might abandon our meds too soon. They can help keep us on the path our doctor has chosen for us, or spot a situation where a doctor has made an obviously gross error.Bleauberry, I'm curious in the context of this discussion--I don't mean to pry--so take a pass on this if you want to. My understanding of your situation is that it derives from, primarily, lymes disease (I could very well be mistaken). Maybe you do not have very much trauma (or life/situational) distress to process? And therefore, maybe not too much maladaptive behavior/cognition?
Best regards,
fb
Posted by SLS on November 22, 2009, at 16:05:50
In reply to Re: No benefit to adding psychotherapy to medicati » bleauberry, posted by floatingbridge on November 22, 2009, at 15:13:06
I don't know if I made this clear earlier, but psychotherapy has never improved my depression in the slightest. However, I try not to extrapolate my experience upon those suffering from all types of depression. Perhaps bipolar disorder, which is what I have, is less responsive to psychotherapy than unipolar disorder (major depressive disorder). I really don't know. Still, there are some pretty compelling reasons to taking advantage of psychotherapeutic counseling. If nothing else, it can help change the content of thought and thus reduce what I like to call "depressive pressure". To reduce depressive pressure can only help and not hurt. It can improve one's chances of responding to drug treatment and reduce the risk of relapse or medication breakthrough after a response is obtained.
- Scott
Posted by floatingbridge on November 22, 2009, at 16:26:37
In reply to Re: No benefit to adding psychotherapy to medicati, posted by SLS on November 22, 2009, at 16:05:50
> I don't know if I made this clear earlier, but psychotherapy has never improved my depression in the slightest.
However, I try not to extrapolate my experience upon those suffering from all types of depression. Perhaps bipolar disorder, which is what I have, is less responsive to psychotherapy than unipolar disorder (major depressive disorder). I really don't know. Still, there are some pretty compelling reasons to taking advantage of psychotherapeutic counseling. If nothing else, it can help change the content of thought and thus reduce what I like to call "depressive pressure". To reduce depressive pressure can only help and not hurt. It can improve one's chances of responding to drug treatment and reduce the risk of relapse or medication breakthrough after a response is obtained.
>
>
> - ScottScott, this is interesting. And it did go over my head that therapy has not helped your depression. "Depressive pressure"--is that your own coinage? (I like it.) Hmmm. I have in mind my recent MBCT class which seeks to help one become aware of thoughts and sensations (and also examine & endure those that are categorized as 'painful'), and Southernsky's recent posts about the benefits of therapy for dealing with maladaptive behavior and TRD (now that's paraphrasing an eloquent set of posts!).
fb
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