Based on scores on the Hamilton Depression Rating Scale (HDRS), the researchers divided the patients into mild to moderately depressed, severely depressed, and very severely depressed. This is a 17 item scale that is filled out by a psychologist or psychiatrist, and measures various aspects of depression. It is used in most studies of depression. They then analyzed the response to antidepressant medication based on how severe the initial depression was.

The two antidepressants studied were imipramine and paroxetine (Paxil). Imipramine is an older, tricyclic antidepressant, and Paxil is a more modern SSRI antidepressant.

What did they find? They were looking at the size of the difference between the medication groups and the placebo groups. Rather than do the typical thing of just looking at statistical significance, which is simply a measure of whether the difference could be explained by chance, they looked at clinical significance. They used the definition used by NICE (National Institute of Clinical Excellence in England), which was an effect size of 0.50 or a difference of 3 points on the HDRS. This is defined as a medium effect size.

What they found was very disheartening to those who use antidepressant medications in their practices. They divided the patients into three groups based on their initial HDRS scores: mild to moderate depression (HDRS 18 or less), severe depression (HDRS 19 to 22), and very severe depression (HDRS 23 or greater).

For the mild to moderately depressed patients, the effect size was d=0.11, and for severely depressed patients the effect size was d = 0.17. Both of these effect sizes are below the standard description of a small effect which is 0.20. For the patients in the very severe group, the effect size was 0.47 which is just below the accepted value of 0.50 for a medium effect size.

When they did further statistical analysis, they found that in order to meet the NICE criteria of effect size of a 3 points difference, patients had to have an initial HDRS score of 25 or above.  To meet the criteria of an effect size of .50, or medium effect size, they had to have a score of 25 or above, and to have a large effect size, 27 or above.

What does this all mean for patient care? It means that for the vast majority of clinically depressed patients who fall below the very severely depressed range, antidepressant medications most likely won’t help. The sadder news is that even for the very severely depressed, medications have a very modest effect. Looking at the scoring of the HDRS, the normal, undepressed range is 0 to 7. The very severely depressed patients had scores of 25 or above, and a medium effect size was a drop in scores of 3 or more points compared to placebo patients. Looking at the one graph in the paper that show the actual drops in HDRS scores, the medication group had a mean drop of 12 points when their initial score was 25. That means they went from 25 to 13, which is still in the depressed range, although only mildly depressed. Patients who initially were at 38 dropped by roughly 20 points, ending at 18, which is still pretty depressed. And the placebo group had only slightly worse results.

One interesting thing is how strong the placebo effects are in these studies. It seems that for depressions less serious than very severe, placebo pills work as well as antidepressant medication.  Is this because antidepressants don’t work very well, or because placebos work too well? It’s hard to know. Maybe doctors should give their patients sugar pills, and call the new drug Eliftimood!

So in summary, here are the main observations I make from this study.

• If you are very severely depressed, antidepressants may help, and are worth trying.
• If you are mildly, moderately, or even severely depressed, there is little evidence that antidepressants will help better than a placebo. You would be better off with CBT (Cognitive Behavioral Therapy), which has a proven track record with less severe depressions, and which has no side effects.
• Interestingly, CBT is less effective for the most severe depressions, so for these kinds of depressions medication treatment makes a lot of sense.
• If you are taking antidepressants and having good results, don’t change what you are doing. You may be wired in such a way that you are a good responder to antidepressants.
• If you have been taking antidepressants for mild to severe (but not very severe) depression, and not getting very good results, this is consistent with the research, and you might want to discuss alternative treatments such as CBT with your doctor. Don’t just stop the medications, as this can produce withdrawal symptoms, work with your doctor to taper off them.
• Even in very severely depressed patients, for whom antidepressants have some effects, they may only get the patient to a state of moderate depression, but not to “cure”. To get to an undepressed, normal state, behavioral therapy may be necessary in addition to medications.
• How do you find out how depressed you are? Unfortunately there is no online version of the HDRS for direct comparison. You may want to see a professional psychologist or psychiatrist if you think you might be depressed, and ask them to administer the HDRS to you.  There are also online depression tests, such as here and here. If you score in the highest ranges you might want to consider trying antidepressant medications, if you score lower you might want to first try CBT.
• The most important thing is not to ignore depression, as it tends to get worse over time. Get some help, talk to a professional.

I’m off to take my Obecalp pills now, as it’s been raining here in Northern California for more than a week, and I need a boost in my mood. (Hint: what does Obecalp spell backwards?)

Copyright © 2010 Andrew Gottlieb, Ph.D. /The Psychology Lounge/TPL Productions

• “bupropion SR (sustained release; Zyban, GlaxoSmithKline), 150 mg twice daily for 1 week before a target quit date and 8 weeks after the quit date;
• nicotine lozenge (2 or 4 mg) for 12 weeks after the quit date;
• nicotine patch (24-hour, 21, 14, and 7 mg titrated down during 8 weeks after quitting;
• nicotine patch plus nicotine lozenge;
• bupropion SR plus nicotine lozenge; or
• placebo (1 matched to each of the 5 treatments).”

Everyone received six 10- to 20-minute individual counseling sessions, with the first 2 sessions scheduled before quitting.

What were the results?

Three treatments worked better than placebo during the immediate quit period: the patch, bupropion plus lozenge, and patch plus lozenge.

At six months, only one treatment was effective; the nicotine patch plus nicotine lozenge. The exact numbers , as confirmed by carbon monoxide tests, were: “40.1% for the patch plus lozenge, 34.4% for the patch alone, 33.5% for the lozenge alone, 33.2% for bupropion plus lozenge, 31.8% for bupropion alone, and 22.2% for placebo.”

So we see that the combined nicotine substitution therapy worked best, followed closely by either nicotine substitute alone. Zyban or Welbutrin (bupropion) was a bust, no more effective than the simple nicotine lozenge. The only advantage to Zyban would be if one prefers not to use nicotine substitutes.

Now I mentioned that they omitted one drug treatment, which is the drug Chantix (varenicline). This is probably because the drug is a nicotine receptor blocker, so wouldn’t have made sense to combine with nicotine substitutes. Also, there have been some disturbing case reports of people having severe depressive reactions to Chantrix.

Of course, there was one glaring omission that any card-carrying psychologist would spot in a moment–the lack of a behavior therapy component. Giving 6 ten minute sessions is hardly therapy. I would have liked to see true smoking cessation behavior therapy combined with the drug treatments.

So, if you’re trying to quit smoking, combine nicotine patches with nicotine lozenges, sold in any pharmacy. If you do, you have a 40 percent chance of succeeding at 6 months.

Now I am off to have a cigarette….just kidding.

Study: http://cme.medscape.com/viewarticle/712074_print

Copyright © 2009/2010 Andrew Gottlieb, Ph.D. /The Psychology Lounge/TPL Productions

The article documents how most psychologists fail to provide empirically proven treatment approaches and instead use methods which are often ineffective. The truth is there is very little evidence for most of the types of therapy commonly performed in private practices by psychologists and by Masters level therapists. If you are shopping for the most effective types of therapy you need to find a practitioner who is skilled at cognitive behavioral therapy (CBT) which is one of the few psychotherapy approaches that has been proven to work on a variety of problems.

Another interesting article in Newsweek about evidence-based treatment discussed bulimia. Here’s the summary:

So the bottom line is this:

1. Most psychologists who don’t practice Cognitive Behavioral Therapy (CBT) are just winging it, using treatments that haven’t been shown to work by scientific studies. It’s as if you went to a regular physician and got treatment with leaches!

2. Many psychologists claim to use CBT but haven’t really trained in the use of CBT, or have taken a weekend workshop. Unless they prescribe weekly homework that involves writing down thoughts, and learning skills to analyze and change your thoughts, then they aren’t really doing CBT, and I recommend you find someone else.

3. If you have an anxiety disorder, depression, bulimia, or obsessive compulsive disorder, and haven’t been offered CBT, then you are not receiving state of the art treatment.

Copyright © 2009 Andrew Gottlieb, Ph.D. /The Psychology Lounge/TPL Productions

Copyright © 2009 Andrew Gottlieb, Ph.D. /The Psychology Lounge/TPL Productions

This study of 439 teenage children with major depression, done at the University of Texas Southwestern Medical Center at Dallas tested anti-depressant medication (fluoxetine or Prozac), cognitive behavioral therapy (CBT), and a combination of both (COMB). They found that only 23% of the patients had their depression cured by 12 weeks of therapy. But 9 months of therapy was much more effective, with 60 percent going into remission.

The bad news though is that this means that almost half of the teenagers (40%) were still depressed after 9 months of therapy.

The good news is in terms of relapse. Of those who responded quickly to treatment, two-thirds retained the benefits of treatment over 9 months. The same was true of those who took longer to respond.

Which treatment was better? That is an interesting picture.

It depends at which time point you are looking at. At 12 weeks, the results for percentage fully remitted (cured) of depression were: combined drug and CBT therapy (37%), drug therapy only (23%), and CBT therapy only (16%). The combined therapy was significantly better than the other therapies. But note that overall, only 23% of the teenagers had recovered at 12 weeks, which means that 77% were still suffering!

But at nine months the outcomes look quite different. The combination therapy is still the best, but by less of a margin. The results for remission at at 9 months were: combination, 60%; drug, 55%; cognitive-behavioral therapy, 64%; and overall, 60%. By 24 weeks all the treatments were working well. But a full 40% of the teenagers were still depressed.

So the right answer to the question of which treatment works better is neither. Both drugs and cognitive behavioral therapy were equally effective, over the long term. But the combination of both was worked more quickly. As the researchers said, “choosing just one therapy might delay many teenagers’ recovery by 2 or 3 months.” As the saying goes, candy is dandy, but liquor is quicker, and we might conclude that drugs or CBT are dandy, but combined therapy is quicker.

So what does this mean to parents of depressed teenagers? Here are my takeaway messages:

1. Don’t expect treatment for depression to work quickly. It may take more than 9 months of weekly treatment before your teenager responds to therapy. This means at least 40 sessions of therapy.
2. Be patient, and set reasonable expectations for both yourself and for your child. Tell them that therapy will help, but it may take a while. Let support networks such as school counselors or trusted teachers know to be patient.
   
3. Although medications and cognitive behavioral therapy were equally effective in the long run, the combination of both tended to work much more quickly. So if you can afford it, and have access to good practitioners who do cognitive behavioral therapy, use both.
   
4. Be aware that in other studies, the relapse rate for medication treatment of depression was significantly higher than for cognitive behavioral therapy, once the medications are discontinued. So choosing medications only may increase the risk that your teenager will relapse into depression.
   
5. Be aware that much teenage depression can be a reaction to social environments. This includes the family, the school, and peers. Be sure that your teen’s therapist is attuned to family, school, and peer issues. They should meet with the whole family at least several times.
   
6. Take teenage depression seriously. It’s not just a phase. Teenage depression, when serious, can greatly increase the risk of suicide. All suspected depression should be evaluated by a professional and treated if present.
   

Copyright © 2009 Andrew Gottlieb, Ph.D. /The Psychology Lounge/TPL Productions

SOURCE: Journal of the American Academy of Child and Adolescent Psychiatry, February 2009 . And December 2006 issue too .

Playing with Spiders

I recently had a very satisfying experience in the clinical practice. A client of mine asked me if she could bring her grandchildren to a session, in order to work on their spider phobia.  I told her that if they were willing, I’d be happy to work with them. We would be able to make some progress by having the children look at pictures of spiders on my computer. The kids were 10 and 13, let’s call them David and Janet.

She surprised them (and me) by announcing at the beginning of the session that she had actually brought two live spiders in jars.  This changed my plans for the session. I told the kids that we would only work with the live spiders if they were comfortable doing so. (It’s not a good idea to spring surprises during desensitization sessions.)

So we started doing what is called desensitization.  This is a process where step-by-step, in a gradated way, the client is exposed to the fearful object.  We started off by looking at pictures of spiders on the web (pun not intended).  I picked less scary pictures at first, and I asked the children to rate their anxiety.  Then I asked them to see if they could lower their anxiety numbers.  We used a hundred point scale, and when they were able to lower their anxiety from 70 or 80 to 30 or below, we moved on to the next picture.

Eventually they were looking at pictures which were quite scary looking, even for me, and I like spiders!

Next we went on to work with the actual spiders.  There were two spiders.  One of them was a small daddy long-legs spider, and the other was a relatively small but scary looking spider.  I decided to work with the daddy long-legs spider, as it was slower moving, and less scary looking.

First I had them look at the spider in the jar.  Next I had them hold the jar.  They were able to do this fairly rapidly.  The next step was to open the jar, and look into the jar with the spider walking around inside the jar. David and Janet were able to do this without very much anxiety at all.

The next step was harder. It was to allow the spider to walk around on my office floor, and to have them touch the spider.  I made this a little bit easier by having them put on surgical gloves.  First I modeled the behavior for them.  I touched the spider, and then I allowed the spider to walk over my hand.

Now it was their turn.  First one, then the other, tentatively touched the spider.  At first their anxiety rating was quite high, 70 or 80.  Then I had them do this repeatedly, until they were able to do it with relatively low anxiety ratings of about 40.

One of the advantages of working with both of them simultaneously was that they were a bit competitive.  Janet was initially a little braver, but David quickly responded to this challenge, and matched her touch for touch.

Once they were comfortable touching the spider with gloves on, it was time to take the gloves off.  Once again I modeled for them touching the spider comfortably.  In a few minutes, they were able to allow the spider to walk over the back of their hand.  After a few minutes more, they were able to have the spider walk up their arm.

By the end of the session they were very comfortable playing with this small spider.  They were actually having fun playing with Mr. Daddy Long-Legs. And this was only a 60 minute session!

Once again, I was amazed at the power of simple behavioral tools.  Modeling — where the therapist demonstrates a behavior.  Gradated exposure — gradually exposing the person to increasingly fearful stimuli.  Reinforcement — where the therapist complements and praises the client for successful exposures.  Shaping — where the client is reinforced for behaviors that gradually approximate the target behavior.

In less than 60 minutes I was able to take these two brave children from being terrified of spiders to relative comfort with spiders.  Given that most people are not comfortable having a spider crawl up their arm, by the end of the session they had actually exceeded the comfort level of the average person.

(I recently got a follow-up report on the kids. According to grandma, David now can pick up dead spiders with his fingers, without using paper, which he could not do before. While his family was recently eating dinner, they noticed a large fly buzzing around. During their meal, the fly got caught in a spider web in the corner of nearby window. After the family had eaten dinner, they inspected the web and found the spider wrapping the fly. They left the web in place, deciding that it was beneficial, and David was comfortable with the arrangement. Janet reported that was able to put her hand on a picture of a big, multi-colored ugly black tarantula in her science textbook, with her mom watching. )

Bridging the Gap

Another opportunity for using the science of behavior therapy arose on a vacation. My partner and I were visiting Vancouver Canada, and one of the attractions there is the Capilano Suspension bridge (www.capbridge.com ). The bridge is a 6 foot wide suspension bridge which is 439 feet long, and 230 feet above a river gorge. It’s like the bridge in Indiana Jones and the Temple of Doom, swaying as you walk across it.

There was only one catch, my partner is very afraid of heights. She hates any situation involving them, and doesn’t even like walking across the Golden Gate Bridge.

But I thought that this might be an opportunity for her to overcome this fear, and offered to do in vivo desensitization with her if she was willing.

So we did. First I had her approach the edge of the bridge, and once again, I had her rate her anxiety using a 100 point scale. Ninety, she said. I then asked her to use breathing and relaxation to lower the anxiety. Before long she was able to stand at the very end of the bridge.

Next I had her advance out a few feet onto the bridge, stay there as long as she needed, and then retreat to solid land. She repeated this several times, until it was more comfortable.

Then I modeled walking partly across the bridge. I went slowly and hesitantly, modeling caution and slowness rather than speed and bravado. A coping model that shows the person overcoming fear is more effective than a perfectly confident model, I have found.

She then walked 10 or so feet across the bridge, and stood on the swaying bridge. Fear spiked and then subsided.

All along, I was giving her a lot of praise and encouragement. Next she managed 15 feet, and then retreated. Then she advanced 20 feet, then 30, then 40, and so on, until she was able to walk all the way across the bridge. Once she had accomplished that success, I had her repeat the process until her comfort level increased. I even invited her to jump up and down on the bridge, to demonstrate her lowered fear levels.

By the end of our visit there, not only was she able to traverse the bridge (which I admit was scary, even for me), but she was also able to traverse another attraction, a catwalk that was built between a number of Douglas Fir trees, which at points is 100 feet off the forest floor. This required more desensitization, but was successful in the end.

By the end of the day my brave partner had successfully overcome a lifelong fear of heights, and experienced some tourist attractions that she never would have enjoyed previously. When I showed her the video of her walking across the bridge, she was amazed at what she had been able to do.

Which is what I truly love about behavioral therapy; the ability to quickly and without lengthy therapy to overcome lifelong fears and expand one’s personal horizons!

Shaping Sandy to Swim

Another technique of behavior therapy is called shaping. What is shaping? Shaping is a technique where you reinforce gradual approximations of that behavior until you achieve the full behavior.

I had an opportunity to utilize shaping last summer when we spent some time at Lake Tahoe. We were renting a house on the beach, and our next-door neighbors had an adorable golden retriever named Sandy. Sandy loved to play on the beach, and her favorite game was fetch. But she wouldn’t go in the water past her ankles, and was afraid to swim. The owner said that she had never been willing to swim, even though they came up to Lake Tahoe regularly. The dog was about three years old.

I was challenged. Could I use behavior therapy to help Sandy overcome her fear of water and start swimming? I knew one thing; that dogs instinctively know how to swim, so it wasn’t a question of skill.

I decided to utilize the technique of shaping. First I made friends with Sandy by playing fetch on the beach. Pretty soon whenever I came out to the beach Sandy would run over with a stick to play.

Next I trained Sandy to follow me with the stick. She would follow me anywhere on the beach. Then I went into the water and encouraged her to follow me a few feet in order to grab the stick. She was willing to come into the water a little bit. I would praise her, and I would play some more with her on the beach.

Next I made it a little bit more difficult. In order to grab the stick she had to follow me into the water a few feet more.

I kept repeating this, each time requiring her to follow me further out into the water. Pretty soon she was following me five or 10 feet out into the water, but she still wasn’t swimming. Her feet were still on the bottom.

Next I used a slightly different technique. This time I had her come out into the water and grab the stick with her mouth. Instead of releasing it, I held on and moved out deeper into the water. Pretty soon her feet were off the bottom and she was swimming. I would then let go and she would swim back to shore, shake off, and play with me some more. The first time I did this she seemed a little perturbed, but quickly got into the game.

Over a couple of training sessions during the same day I continued this process. She got more and more confident, and was willing to swim out to grab the stick.

Finally I had her owner call to her while swimming in the deeper part of the beach. I threw a tennis ball out to the owner, and Sandy much to everyone’s surprise, swam out to the owner, grabbed the tennis ball, and swam back to the beach!

After that, Sandy seemed comfortable swimming in order to fetch a stick or a ball, even when it required her to swim in deeper water. Shaping had allowed her to learn gradually to overcome her fear and be able to swim with comfort.

The owners were amazed, as many times they had tried to coax her into the water. All I did was apply systematic methods of behavior therapy in order to allow Sandy to succeed. I shaped Sandy to swim, and she followed her destiny as a waterdog retriever.

Finding the Right Reinforcer

I want to tell one more story about behavior therapy, this time with dogs.

Although I’m a human therapist, I am very fond of dogs, and if I had an alternate career it would be as a dog trainer.

My friends Marli and Stu have two adorable dogs.  They are Papillons, which are small cute toy dogs, who look a little bit like the gremlin "Gizmo" in the movie Gremlins .  They have the same floppy ears and big eyes. (But they don’t turn into monsters if you feed them after midnight!)
In an effort to make their lives a bit more convenient, my friends had installed a dog door into their bedroom so that the dogs could go outside without needing help.

The problem was that neither Vinnie, the older dog, nor Bowie, the younger dog, was willing to use the dog door.  They were both afraid of it.  After weeks and weeks of hoping the dogs would figure out how to use the door, they still had not. Stu and Marli kept putting the dogs through the door, but the dogs never figured out how to use the door on their own.

Enter the confident behavior therapist, who offered to solve this problem.  I was very confident that I could use food treats to entice the dogs through the door.  Once having learned how to go through the dog door, I felt that they would continue to use it without treats.

I asked my friends not to feed the dogs the day I came over so that the dogs would be hungry and more motivated by food.

To make a long story short, I failed miserably.  I was able to coax the dogs through the dog door by physically picking them up and pushing them through the door, but no amount of food treats would entice them to go through the door.  They seemed uninterested in food treats. After several hours of trying everything I could think of, I gave up.

This bothered me greatly.  Had I lost my behavior therapist powers?  Had the technology failed?  That night, as I tried to fall asleep, I found myself obsessing a lot about the problem.  Just as I was about to fall asleep I realized the solution.

Can you guess what the solution was?  I will give you a hint that it had to do with what type of reinforcements I had selected.  Let me give you one more hint.  Both of these dogs are very attached to my friend Marli.  They like Stu, but they are crazy about Marli! They follow her everywhere. When she comes home from work they go nuts wanting to play with her.

The solution was to change the reinforcement.  Instead of putting food on the other side of the dog door, I needed to put Love!  What I did was to have a Marli call her husband Stu right before she came home.  Then he would put the dogs outside.  She would come inside the house, and call to the dogs through the dog door.  The first time she did this both dogs dove through the dog door as if it wasn’t even there!

The next time she came home she came through the yard, and called to the dogs from the outside.  Once again, motivated by love, they were very willing to use the dog door to get outside.

After a few days, they no longer had to use this procedure, as the dogs were happily using the dog door on their own.  Behavior therapy had triumphed once again, but it required a more careful behavioral analysis of what these particular dogs found reinforcing.  They were more motivated by love than by food.

And that’s a key secret…sometimes the best motivators are subtle, and never forget the power of love to motivate! If reinforcement isn’t working, it’s probably because you are not using the right reinforcement.

Copyright 2008 Andrew Gottlieb, Ph.D./The Psychology Lounge/TPL Productions

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