Changing Thoughts May Be Better Than Changing Behavior in the Early Stage of Psychotherapy for Severe Depression

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A recent study took a close look at what predicts improvement in depression in the first five sessions of cognitive behavioral therapy. They looked at the degree to which the therapists used either cognitive therapy methods, practiced structuring the sessions clearly, and how much they used behavioral methods/homework. They also examined whether the patients cooperated with these parts of cognitive behavioral therapy. They also measured the strength of the therapeutic alliance.

Sixty patients with major depression participated in the study. Their sessions were videotaped and trained raters rated how much the therapists used cognitive versus behavioral methods.

What they found was only two aspects of therapist behavior predicted improvement between sessions. Depression was measured after every session, and these measurements showed that patients felt better when therapists used cognitive techniques, but didn’t improve when the therapists focused on behavioral techniques.

Patients also showed greater improvement when they adhered to suggestions made by the therapist, which is not surprising.

The behavioral methods used were techniques such as having patients schedule their activities to become more active, and tracking how they actually spent their time. This is called behavioral activation, and previous studies have suggested it is an effective approach to treating depression. The behavioral activation model is that depressed patients tend to do very little, and this leads to further depression. Patients are encouraged to schedule activities that are fun, or activities that provide a sense of mastery or success. This leads to a lessening of depressive feelings.

The cognitive methods were techniques such as writing down what your thoughts are, and using cognitive therapy to challenge or modify distorted thinking.

So how to interpret the results of this study?

It’s only one small study and I would be cautious about taking too much from it. It does suggest that at least in the early sessions of therapy, cognitive methods may be superior to behavioral methods. This makes sense to me because early in therapy depressed patients feel a lot of pain and lethargy, and getting them to suddenly increase their activity can be very challenging and perhaps too difficult. This may lead to a sense of failure which increases depression rather than reducing it. On the other hand, using cognitive methods may lead to more immediate sense of control and relief, which would tend to reduce depression levels.

My sense is that later in therapy behavioral activation techniques are very useful. But typically in order to get patients to cooperate with these techniques there needs to be a strong alliance with the therapist. This takes some time to build.

It would have been interesting if they had continued the study beyond the first five sessions, and looked at whether over time the relative importance of the cognitive versus behavioral techniques would have shifted.

The study shows that therapist behavior in sessions does matter. This is one of my pet peeves. Many psychotherapists claim to use cognitive behavioral therapy, yet fail to actually use any cognitive behavioral techniques on a regular basis in sessions. This study shows that therapist adherence to structuring sessions and using cognitive techniques matters.

So from a consumer point of view there are a few take-home lessons.

1. If you are seeking cognitive behavioral therapy, make sure your therapist actually does cognitive behavioral therapy during sessions. This means they should structure the sessions clearly, as opposed to simply letting you talk about whatever is on your mind. It also means they should be asking you to track your self talk in written form, during sessions go over those thoughts, helping you learn to identify and correct distortions in the thoughts. If they don’t do these behaviors, and therapy feels free-form, then you’re probably not getting cognitive behavioral therapy, and you might want to look elsewhere. If you don’t regularly get homework to do between tasks, you aren’t receiving cognitive behavioral therapy.

2. At least in the early part of therapy pure cognitive therapy techniques may be more effective than behavioral techniques. You may want to focus your own homework more on identifying and changing your inner thoughts, rather than trying to increase positive behaviors. This probably will yield more relief of depression.

3. The study also confirmed that when clients cooperate and are more involved using cognitive therapy techniques, they improve faster. So even if you’re feeling skeptical, try to fully participate during sessions and in between sessions, as that provides you the best chance of more rapid relief.

Your off to analyze his thoughts psychologist,

Andrew Gottlieb, Ph.D.

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

Dr. Andrew Gottlieb is a clinical psychologist in Palo Alto, California. His practice serves the greater Silicon Valley area, including the towns of San Jose, Cupertino, Santa Clara, Sunnyvale, Mountain View, Los Altos, Menlo Park, San Carlos, Redwood City, Belmont, and San Mateo. Dr. Gottlieb specializes in treating anxiety, depression, relationship problems, OCD, and other difficulties using evidence-based Cognitive Behavioral Therapy (CBT). CBT is a modern no-drug therapy approach that is targeted, skill-based, and proven effective by many research studies. Visit his website at CambridgeTherapy.com or watch Dr. Gottlieb on YouTube. He can be reached by phone at (650) 324-2666 and email at: Dr. Gottlieb Email.

Which Anti-depressant Should You Take? Now We Know

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Accepted wisdom for a number of years has been that all modern anti-depressants work equally well, and that drug selection depends more on the side effect profile desired. Thus a lethargic patient might benefit from an activating antidepressant like Prozac, and an anxious patient would be better off with Paxil. Often prescribing practices are based on individual doctors’ preferences and biases. But a newly published study suggests that this may be wrong. There may be antidepressants that not only work better, but are easier for patients to tolerate.

A terrific new study was recently published in the Lancet medical journal. A team of international researchers, led by Andrea Cipriani at the University of Verona in Italy, reviewed 117 studies of antidepressants which included 25928 patients, two-thirds of whom were women. These studies, done all around the world, compared various antidepressants to either placebo or other antidepressants.

The researcher compared the results of 12 new generation antidepressants in terms of efficacy and acceptabiltiy. They defined efficacy as the proportion of patients who improved at least 50% on a depression rating scale by 8 weeks of treatment. They defined acceptability as the proportion of patients who did not drop out of the study. They made an attempt to adjust for dosages, and did very sophisticated statistical analyses to compare all of the drugs. They used fluoxetine (Prozac) as the common comparison drug, since it has been on the market for the longest time.

What were the results? The winners in terms of short term effectiveness were: (drum roll) mirtazapine (Remeron), escitalopram (Lexapro), venlafaxine (Effexor), and sertraline (Zoloft). The winners in terms of acceptability were: escitalopram (Lexapro), sertraline (Zoloft), citalopram (Celexa), and bupropion (Wellbutrin) were better tolerated than other new-generation antidepressants. Note that the overall winners for effectiveness combined with tolerability were escitalopram (Lexapro) and sertraline (Zoloft). Two of the best drugs in terms of effectiveness (mirtazapine (Remeron) and venlafaxine (Effexor)) were not among the best tolerated medicines.

The losers in terms of both effectiveness and tolerability were reboxetine (Edronax), fluvoxamine (Luvox), paroxetine (Paxil), and duloxetine (Cymbalta). The worst drug of all was reboxetine (Edronax).

So what about cost? I’ve developed a spreadsheet of all of the drugs’ costs based on a 30 day supply, paying full retail price at Costco pharmacy, and using generic equivalents when available. Of the winners in terms of effectiveness and tolerability, the clear cost winner was sertraline (Zoloft), at $12 a month. The other winner, escitalopram (Lexapro), was a loser in terms of cost at $88 a month! The other winners in terms of effectiveness were quite cost effective too, with mirtazapine (Remeron) at $14 a month, and venlafaxine (Effexor) at $28 a month.

So what should doctors and patients do? For patients, the two best drugs appear to be escitalopram (Lexapro) and sertraline (Zoloft), with sertraline the clear winner if you pay much for prescription drugs. Doctors might want to consider costs as well, as this can help with overall health care inflation. If you can tolerate the side effects, consider trying mirtazapine (Remeron), or venlafaxine (Effexor).

Now there are of course a few caveats about this study. It is possible that another meta-analysis could find different results. One criticism was that the study only looked at effectiveness over 8 weeks of treatment. It is possible that some drugs work more slowly, and at 12 or 16 weeks might have different results. But most patients want results in two months or less, so this is not a major criticism.

Another issue is funding bias. Although none of the authors of this study were paid by drug companies, many of the studies they analyzed were funded by drug companies, and may have reflected some bias. But for now, this is the best information we have in terms of effectiveness and toleration of antidepressant medications.

So who’s the winner? Sertraline (Zoloft) was the clear winner by effectiveness, tolerability, and cost!

Should you change medications if you are not on one of the winners? No, of course not. If your medication is working, don’t change it. But if it’s not working, then talk with your doctor about switching.

And no, I don’t receive any funding or sponsorship from any drug companies…

 

Here’s the table of drug price comparisons.
Comparison of Antidepressant Costs for 30 Day Supply (Costco Pharmacy, Generic Equivalents if possible)
Bolded Drugs were most effective

Drug            Generic Name         Cost          Dose(mg)

Celexa             citalopram                   $3                 40
Prozac             fluoxetine                    $6                  20
Zoloft             sertraline                       $12             100
Remeron     mirtazapine                    $14               30
Luvox              fluvoxamine               $24             100
Effexor         venlafaxine                    $28                75
Welbutrin      bupropion                   $74             200
Lexapro       escitalopram                 $88                10
Paxil                paroxetine                   $91             37.5
Cymbalta       duloxetine                   $128              60

 

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

Dr. Andrew Gottlieb is a clinical psychologist in Palo Alto, California. His practice serves the greater Silicon Valley area, including the towns of San Jose, Cupertino, Santa Clara, Sunnyvale, Mountain View, Los Altos, Menlo Park, San Carlos, Redwood City, Belmont, and San Mateo. Dr. Gottlieb specializes in treating anxiety, depression, relationship problems, OCD, and other difficulties using evidence-based Cognitive Behavioral Therapy (CBT). CBT is a modern no-drug therapy approach that is targeted, skill-based, and proven effective by many research studies. Visit his website at CambridgeTherapy.com or watch Dr. Gottlieb on YouTube. He can be reached by phone at (650) 324-2666 and email at: Dr. Gottlieb Email.

Does TV Watching Increase the Risk of Depression in Teenagers?

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A study published in the February 2009 issue of the Archives of General Psychiatry found that those teenagers who watched more than 9 hours a day of television where more likely to become depressed as young adults.

The researchers used data from a larger study of 4,142 adolescents who were initially not depressed. After seven years of followup, more than 7 percent had symptoms of depression.

But only 6 percent of the children who watched less than three hours a day of TV became depressed, while more than 17 percent of those who watched 9 or more hours a day became depressed.

Interestingly, there was no association with playing video games, or listening to music, or watching videos. The association of TV and depression was stronger for boys than girls, and was constant after the researchers adjusted for age, race, wealth, and educational level.

So what does this mean? First of all, it’s important to put this into context. Nine hours of TV watching is a lot!!!! It means that these kids came home from school at 3pm, and turned on the TV, and kept it on until midnight! Or it means that they spent the entire weekend watching television. So these findings are not so surprising. Basically television was their entire life, and that means that they had no hobbies, no friends, and no sports or extra-curricular activities. All these are a prescription for depression. The kids who watched less than 3 hours of television a day had lives, which is probably why fewer of them got depressed.

So the moral of the story is make sure your children have balanced lives, and limit screen time (which includes video gaming) to 2 or 3 hours a day, or less. One good way to control television time is not to have television sets in children’s bedrooms. Have a main television in the living room, and that allows you to know when and what your children are watching.

Okay, now I am off to watch no more than two hours of my favorite television shows…

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

Dr. Andrew Gottlieb is a clinical psychologist in Palo Alto, California. His practice serves the greater Silicon Valley area, including the towns of San Jose, Cupertino, Santa Clara, Sunnyvale, Mountain View, Los Altos, Menlo Park, San Carlos, Redwood City, Belmont, and San Mateo. Dr. Gottlieb specializes in treating anxiety, depression, relationship problems, OCD, and other difficulties using evidence-based Cognitive Behavioral Therapy (CBT). CBT is a modern no-drug therapy approach that is targeted, skill-based, and proven effective by many research studies. Visit his website at CambridgeTherapy.com or watch Dr. Gottlieb on YouTube. He can be reached by phone at (650) 324-2666 and email at: Dr. Gottlieb Email.