Living With the Devil We Know

For the last 40 years or so, our profession has assumed that by copying the medical model, using science-based, pathology-focused, diagnosis-specific treatments, we’d have medical-style success (forget, for the moment, that medicine itself isn’t nearly as predictable and successful as advertised, nor even as scientific). By now, you’d think we’d have just about licked most ordinary mental disorders. Anxiety and depression—which get the lion’s share of therapists’ attention—should have gone the way of smallpox and polio, shouldn’t they? Well, not so much. If anything, given the sheer numbers of depressed, anxious, angry, violent, drug- and alcohol-addled people we see in our offices and around us, it would seem that rates of emotional and mental disorders in our society are just as high as ever, or possibly even on the rise.

Of course, psychotherapy “works”; we have plenty of evidence for that. It’s just that, even with all the fancy high-tech, evidence-supported, protocol-driven therapies, we aren’t doing nearly as well as we sometimes imagine, even with our own patients.

The findings from the British CoBalT trial that were recently published in the The Lancet underscore this fact. The investigators randomly assigned 469 chronically depressed, treatment-resistant patients either to the usual care (primarily antidepressant medications) or to the usual care plus cognitive-behavioral therapy (CBT). At the six-month evaluation, only 22 percent of the treatment-as-usual group had improved significantly, as compared with 46 percent of the patients in the meds-plus-CBT group.

These results indicate that neither treatment was terribly effective, since improvement was defined as a 50-percent reduction in patients’ scores on the Beck Depression Inventory (BDI). That’s not too impressive, since most patients with such a reduction in BDI scores will still be quite symptomatic: they definitely won’t be feeling much joy or self-esteem. The results also indicate that the antidepressants the patients in the treatment-as-usual group received appeared to have few, if any, beneficial effects above and beyond the positive effects caused by the passage of time. A 22-percent “improvement” rate is pathetic, to be blunt. Finally, although the psychotherapy helped, the effects left a lot to be desired, too, since more than half the patients didn’t even achieve a 50-percent reduction in depression severity.

Unfortunately, the findings from this study aren’t unusual. I’m not aware of any controlled-outcome studies in which any form of psychotherapy (or antidepressant drug therapy) has shown really dramatic or impressive results. In fact, in most cases, the outcomes for the treatment groups are barely greater than the outcomes for patients receiving placebos. I think all of us can agree that, despite the significant progress that’s been made in therapeutic treatment, there’s still enormous room for improvement in even those forms of psychotherapy that are heralded as state-of-the-art.

The Learning Curve

I began my career as a biological psychiatrist at the University of Pennsylvania during the early ’70s, the opening years of psychopharmacology’s appropriation of psychiatry. At the drug company presentations at the conferences I attended, I heard that 85 percent of depressed patients could be treated effectively with meds, but soon discovered otherwise. While some of my patients improved a bit, many others continued to suffer, no matter how many drugs I prescribed or how long I listened and supported them with traditional talk therapy. I could clearly see that my success rates were fairly similar to those in the treatment-as-usual arm of the CoBalT trial.

I began looking for a new and different treatment method to supplement the drugs, and my department chairman suggested I try the relatively new CBT approach, but I was highly skeptical. The idea of trying to change the negative thinking patterns of depressed and anxious people sounded too superficial, too “power of positive thinking,” and not nearly “deep” or “biological” enough to have any meaningful effects. To my amazement, however, CBT seemed to work a lot better than medications and talk therapy, and clients liked it. Sometimes, the results were fast and spectacular, even with discouraged clients who’d tried years of talk therapy and meds without much success.

However, despite many successes, my results were still far from perfect, especially in the treatment of anxiety. Many patients would begin to improve, achieving a 50- to 60-precent reduction in symptoms. Then they’d get stuck and continue to struggle with crippling shyness, post-traumatic stress disorder (PTSD), obsessive-compulsive disorder (OCD), or some other type of anxiety, no matter how many techniques I tried.