Daily Archives: September 1, 2010

Shaking the Tree of Psychotherapy – On Intuition and Spontaneity

I am both pleased and surprised that “throw-ins” are confirmed as the metaphorical bread and butter of the counseling profession.  (Corsini & Wedding, 2011)  I am a huge proponent of both intuition and spontaneity.  It feels more genuine than the robotic process that strictly “following the plan” requires.  It reminds me of my experience in the Intensive Residential Treatment Center (IRTC) at a local hospital.  Their process, while proven, is totally scripted.  Ideally, there is no deviation from the process… there is consistent treatment of every youth regardless of their current situation, condition, or circumstance.  The process left very little room for interpretation, and even less room for “throw-ins.”  To the point, I can’t work like that.

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There are some helping professionals who prefer to work in a structured environment like that… I would compare them to members of a symphony orchestra.  They read the music off the sheet, and when it comes together… it is a work of art.  I, on the other hand, am more like a jazz musician… give me a beat and let me improvise… you can keep your sheet music.  Although having a theoretical base is as important as knowing your scales and arpeggios (to continue the music analogy), I would much prefer to make use of that technical knowledge on the fly.  I left that position feeling like a jazz musician in the middle of a symphony… I just didn’t fit.  It would suffice to say that I am impressed that Corsini and Wedding (2011) can appreciate that perspective.

From my perspective, psychotherapy is an art with scientific roots.  Of course research is needed and appreciated… but someone has to apply it, or customize it, to individual circumstances.  Of course, when my approach fails (and inevitably it will) I will need to go back and shake the tree of science to see what fruit it yields.  In the end, I am perfectly content with deciding how I eat the fruit, and when.

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Corsini, R. J., & Wedding, D. (2011). Current psychotherapies (9th ed.). Belmont, CA: Brooks/Cole.

Major Depressive Disorder (MDD) treatment options – Examining the STAR*D Trial

When weighing the effectiveness of Major Depressive Disorder (MDD) treatment options, the most logical place to start is the largest open-label pragmatic trial ever rendered; The Sequenced Treatment Alternatives to Relieve Depression (STAR*D) trial.  The STAR*D trial concluded that there were no statistically significant differences in short term remission or response rates between tested treatment options, including both CBT and pharmacological remedies, but that some treatment options had advantages over others in terms of side effects and/or mean time to remission.  (Sinyor, Schaffer, & Levitt, 2010)

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There are many different flavors of CBTs intended to treat mood disorders.  Those flavors include those predominantly focused on learning theory or behavioral activation (BA), predominantly cognitive models such as Cognitive Therapy (CT/CBT), and models incorporating additional elements such as Cognitive Behavioral Analysis System Psychotherapy (CBASP) and Mindfulness-Based Cognitive Behavioral Therapy (MCBT).  (Meyer & Scott, 2008, p. 685)  CBT, when practiced by inexperienced STAR*D clinicians, was at least equally effective in short term follow-ups when compared with pharmacological remedies.  CBT was also associated with significantly fewer side effects.  Those facts alone should serve as reasonable justification in recommending CBT over all other treatment methods.

CBT was associated with longer times to remission when compared with pharmacological remedies, when they were effective, so if speed of improvement is of critical importance the client could potentially benefit the pharmacological treatment option.  Despite the apparent speed with which the pharmacological agents worked, choosing which drug is no easy task.  STAR*D found no clear medication “winner” for patients whose depression does not remit after one or more aggressive medication trials.  (Gaynes, Warden, Trivedi, & Wisniewski, 2009, p. 1443)  Matter of fact, every drug and combination of drugs showed the same effect as every other drug and drug combination.  (Leventhal & Antonuccio, 2009)  Some studies suggest that use of multiple antidepressant medications may double the likelihood of remission compared with use of a single medication.  (Blier, Ward, Tremblay, & Laberge, 2010)  Guess who funded that study?

There is increasing evidence that the biological explanation and pharmacological treatment of depressions is a failure.  STAR*D provides compelling evidence to that the placebo effect is the prime explanation for favorable outcomes that occur with antidepressants.  Of the patients that were found to respond positively to pharmacotherapy on the short term, the STAR*D study found that at the end of a year’s time almost all of the patients (97%) had either relapsed or dropped out.  (Leventhal & Antonuccio, 2009)  Even if we continue to leverage the pharmacological remedies, the long-range outcomes of clients with MDD are better when CBT is included, regardless of whether CBT is concurrent with or follows pharmacotherapy.  (Friedman, Wright, Jarrett, & Thase, 2006, p. 327)  The beneficial effects of CBT persist several years into post treatment and are strongly associated with preventing relapse (Kuyken, Dalgleish, & Holden, 2007), especially among individuals discontinuing medication use.  (Friedman, 2004)

As controversial as they are, “brain stimulation therapies” like electroconvulsive treatment (ECT) are effective in days, not weeks, and most have a higher response rate than any treatment tested in the STAR*D trial.  (Insel & Wang, 2009)  While ECT is still the gold standard in brain stimulation therapies, clinicians now have a growing list of FDA approved brain stimulation interventions. “These interventions include new modifications of ECT, vagus nerve stimulation, transcranial magnetic stimulation (TMS), magnetic seizure therapy, deep brain stimulation, transcranial direct current stimulation, implanted cortical stimulation, and others on the horizon.”  (Lisanby & Novakovic, 2009, p. 734)  Studies that utilized brain stimulation therapies to treat depression revealed significant increases in the release of norepinephrine as well as increased serotonergic activity, both of which are purported to have antidepressant effects.  (Weaver, 2009)  However, ECT is use is “limited by its invasive nature, which includes the requirement of general anesthesia and the risk of retrograde amnesia, which may be irreversible in some patients.”  (Rot, Mathew, & Charney, 2009, p. 311)  As a result, brain stimulation therapies are usually reserved for cases where depression is resistant to conventional treatments.  In addition, use of brain stimulation therapy is entirely dependent on the prescribing clinician believing in a tenuous underlying premise that norepinephrine plays a key role in depression onset and recurrence.

It would suffice to say that I favor the CBT methodology of treatment for unipolar depression, in most, if not all cases.  Personally, I would endeavor to enhance the CBT experience by utilizing cutting edge technological alternatives to traditional CBT… like virtual reality, or VR, simulations.  VR simulations are computer generated environments constructed to elicit an appropriate emotional response from clients… responses we as therapists can use in therapy.  (David, 2010)  Coupling responses that rival in vivo responses with well trained and knowledgeable CBT methods, we could usher in a new alternative to the placebo effect that passes for pharmacological intervention today.  The failure of antidepressants to provide lasting benefit, and the underlying truth that 100 years of research has failed to identify an underlying physical cause for mental disorders (including depression) leads me to believe that a “biopsychosocial model may be more useful than a disease model for conceptualizing and treating depression.”  (Leventhal & Antonuccio, 2009, p. 199)

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Blier, P., Ward, H. E., Tremblay, P., & Laberge, L. (2010, Mar). Combination of antidepressant medications from treatment initiation for major depressive disorder: A double-blind randomized study. The American Journal of Psychiatry, 167(3), 281-288. Retrieved from http://ezproxy.bellevue.edu:80/login?url=http://proquest.umi.com.ezproxy.bellevue.edu/pqdweb?did=1976013231&sid=18&Fmt=4&clientId=4683&RQT=309&VName=PQD

David, D. (2010, Mar). Cutting edge deveopments in psychology: Virtual reality applications. Interview with two leading experts. Journal of Cognitive and Behavioral Psychotherapies, 10(1), 115-126. Retrieved from http://ezproxy.bellevue.edu:80/login?url=http://proquest.umi.com.ezproxy.bellevue.edu/pqdweb?did=2010171911&sid=2&Fmt=3&clientId=4683&RQT=309&VName=PQD

Friedman, E. S., Wright, J. H., Jarrett, R. B., & Thase, M. E. (2006, May). Combining cognitive therapy and medication for mood disorders. Psychiatric Annals, 36(5), 320-329. Retrieved from http://ezproxy.bellevue.edu:80/login?url=http://proquest.umi.com.ezproxy.bellevue.edu/pqdweb?did=1069483751&sid=4&Fmt=3&clientId=4683&RQT=309&VName=PQD

Friedman, M. A. (2004, Spring). Combined psychotherapy and pharmacotherapy for the treatment of major depressive disorder. Clinical Psychology: Science and Practice, 11(1), 47-68. Retrieved from http://proquest.umi.com.ezproxy.bellevue.edu/pqdweb?index=40&did=526558591&SrchMode=1&sid=5&Fmt=10&VInst=PROD&VType=PQD&RQT=309&VName=PQD&TS=1272666830&clientId=4683

Gaynes, B. N., Warden, D., Trivedi, M. H., & Wisniewski, S. R. (2009, Nov). What did STAR*D teach us? Results from a large-scale, practical, clinical trial for patients with depression. Psychiatric Services, 60(11), 1439-1445. Retrieved from http://ezproxy.bellevue.edu:80/login?url=http://proquest.umi.com.ezproxy.bellevue.edu/pqdweb?did=1921563151&sid=2&Fmt=3&clientId=4683&RQT=309&VName=PQD

Insel, T. R., & Wang, P. S. (2009, Nov). The STAR*D trial: Revealing the need for better treatments. Psychiatric Services, 60(11), 1466-1467. Retrieved from http://proquest.umi.com.ezproxy.bellevue.edu/pqdweb?index=28&did=1921563061&SrchMode=1&sid=6&Fmt=6&VInst=PROD&VType=PQD&RQT=309&VName=PQD&TS=1272667182&clientId=4683

Kuyken, W., Dalgleish, T., & Holden, E. R. (2007, Jan). Advances in cognitive-behavioural therapy for unipolar depression. Canadian Journal of Psychiatry, 52(1), 5-14. Retrieved from http://ezproxy.bellevue.edu:80/login?url=http://proquest.umi.com.ezproxy.bellevue.edu/pqdweb?did=1203220561&sid=5&Fmt=3&clientId=4683&RQT=309&VName=PQD

Leventhal, A. M., & Antonuccio, D. O. (2009). On chemical imbalances, antidepressants, and the diagnosis of depression. Ethical Human Psychology and Psychiatry, 11(3), 199-214. Retrieved from http://ezproxy.bellevue.edu:80/login?url=http://proquest.umi.com.ezproxy.bellevue.edu/pqdweb?did=1923231211&sid=19&Fmt=3&clientId=4683&RQT=309&VName=PQD

Lisanby, S. H., & Novakovic, V. (2009, Jun). Brain stimulation therapies for clinicians. The American Journal of Psychiatry, 166(6), 734-736. Retrieved from http://ezproxy.bellevue.edu:80/login?url=http://proquest.umi.com.ezproxy.bellevue.edu/pqdweb?did=1738370431&sid=14&Fmt=3&clientId=4683&RQT=309&VName=PQD

Meyer, T. D., & Scott, J. (2008, Nov). Cognitive behavioural therapy for mood disorders. Behavioural and Cognitive Psychotherapy, 36(6), 685-693. doi: 10.1017/S1352465808004761

Rot, M. A., Mathew, S. J., & Charney, D. S. (2009, Feb 3). Neurobiological mechanisms in major depressive disorder. Canadian Medical Association. Journal, 180(3), 305-313. Retrieved from http://ezproxy.bellevue.edu:80/login?url=http://proquest.umi.com.ezproxy.bellevue.edu/pqdweb?did=1634710771&sid=14&Fmt=3&clientId=4683&RQT=309&VName=PQD

Sinyor, M., Schaffer, A., & Levitt, A. (2010, Mar). The sequenced treatment alternatives to relieve depression (STAR*D) trial: A review. Canadian Journal of Psychiatry, 55(3), 126-136. Retrieved from http://ezproxy.bellevue.edu:80/login?url=http://proquest.umi.com.ezproxy.bellevue.edu/pqdweb?did=2016794701&sid=2&Fmt=3&clientId=4683&RQT=309&VName=PQD

Weaver, D. F. (2009, Summer). Self-induced “therapeutic seizures” for the treatment of depression. The Journal of Neuropsychiatry and Clinical Neurosciences, 21(3), 355-357. Retrieved from http://proquest.umi.com.ezproxy.bellevue.edu/pqdweb?index=71&did=1868802651&SrchMode=1&sid=14&Fmt=3&VInst=PROD&VType=PQD&RQT=309&VName=PQD&TS=1272668233&clientId=4683

Differential Diagnosis – Dysthymic Disorder vs. Major Depressive Disorder

The differential diagnosis of Dysthymic Disorder (DD, also known as depressive neurosis, minor depression disorder, or neurotic depression) and Major Depressive Disorder (MDD) is made difficult because they share the same symptom constellations.  The word ‘Dysthymic’ is of Greek origin, literally translating into “resembling a bad (or abnormal) spirit.”  (Colman, 2009, p. 234)  “In Major Depressive Disorder (MDD), the depressed mood must be present for most of the day, nearly every day, for a period of at least 2 weeks, whereas Dysthymic Disorder (DD) must be present for more days than not over a period of at least 2 years.”  (American Psychiatric Association, Diagnostic and statistical manual of mental disorders, 2000, p. 374)  Thus, we can visualize DD as a chronic, yet less severe type of depression that typically persists for many years.  Clients with DD may report that they do not recall being depressed and they may lead fully functional lives… as a result, it may be exceedingly difficult to distinguish DD from the client’s usual functioning or personality type.  The bottom line is that the onset, persistence, and severity of depression episodes are not easily evaluated retrospectively.

The DSM-IV-TR, the diagnostic tool of choice for clinicians, sums up differential diagnosis best.  “If the initial onset of chronic depressive symptoms is of sufficient severity and number to meet the full criteria for a Major Depressive Episode, the diagnosis would be Major Depressive Disorder, Chronic (if the full criteria are still met, or Major Depressive Disorder, In Partial Remission (if the full criteria are no longer met).  The diagnosis of DD can be made following MDD only if the DD was established prior to the first Major Depressive Episode (i.e., no Major Depressive Episodes during the first 2 years of dysthymic symptoms), or if there has been a full remission of the MDD lasting (i.e., lasting at least 2 months) before the onset of the DD.”  (4th ed., text rev.; DSM-IV-TR; American Psychiatric Association, 2000, p. 379)

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This distinction is further complicated by the diagnoses of mood disorder due to a general medical condition and substance-induced mood disorders, both of which are rather self explanatory.  It is also worth noting that depressive symptoms are frequently associated with chronic Psychotic Disorders like Schizophrenia and Schizoaffective Disorder.  A separate diagnosis of DD is not made of the symptoms occur exclusively during the course of the Psychotic Disorder.  (4th ed., text rev.; DSM-IV-TR; American Psychiatric Association, 2000, p. 380)

Beyond the typical differential diagnosis techniques, some have suggested that Axis II personality dimensions (PDs) can be utilized in the differential diagnosis of Axis I Depression disorders.  “Personality dimensions are on the forefront of discussions regarding how to improve diagnostic clarification, and may provide a useful way in which to understand and model the comorbidities among and between Axis I and II conditions.”  (Bagby, Quilty, & Ryder, 2008, expression Conclusions)  Not only can PDs have significant impact on the diagnosis process, but they can dramatically alter the course of treatment.  For example, Bagby and associates (2008) found that neurotic personalities respond better to pharmacotherapy when compared to psychotherapy.  Inevitably, to be effective at diagnosis and treatment, we need to consider more than just the DSM-IV-TR… we need to individualize treatment plans based on a true representation of the individual client.  That representation, in my opinion, must include the underlying PDs that compose the fabric of the human experience.

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American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders (4th ed., text rev.). Washington, DC: Author.

Bagby, R. M., Quilty, L. C., & Ryder, A. C. (2008, Jan). Personality and depression. Canadian Journal of Psychiatry, 53(1), 14-26. Retrieved from http://ezproxy.bellevue.edu:80/login?url=http://proquest.umi.com.ezproxy.bellevue.edu/pqdweb?did=1426048691&sid=4&Fmt=3&clientId=4683&RQT=309&VName=PQD

Colman, A. M. (2009). Oxford dictionary of psychology (3rd ed.). Oxford, NY: Oxford University Press.