A Meta-Analysis Comparing Psychotherapy and Medication for OCD

A Meta-Analysis Comparing Psychotherapy and Medication for OCD

This post was featured on our client-centered blog The Art and Science of Living Well, but I thought it would be of interest to therapists as well.

The post is about a finding from a meta-analysis by Cuipjers and colleagues that looked at studies comparing medication against psychotherapy in the treatment of anxiety disorders and depression. For obsessive-compulsive disorder, the researchers found a clear advantage of evidence-based psychotherapy for OCD above medication.

You can read the post by clicking here, and it includes links to the original article, which you can download for free.

Ketamine May Alleviate Bipolar Depression, Too

Ketamine May Alleviate Bipolar Depression, Too

Some months back, I wrote a blog post about researchers using the ketamine as a fast acting treatment for depression. Recently I was alerted to another study by the same core researchers from the National Institute of Mental Health (NIMH) using ketamine to treatment depression in people with bipolar disorder (Zarate et al., 2012). The study was a replication of a similar study published a few years ago (Diazgranados  et al., 2010).

It’s still just ketamine for depression

In this study, ketamine wasn’t used to treat bipolar disorder as a whole. Rather, ketamine was used to treat depressive symptoms in people with bipolar disorder who were currently depressed. The people in the study were also maintained on mood stabilizers to help manage bipolar mania and hypomania.

Otherwise, the procedure and findings were similar to the other studies. People were randomly assigned to receive two infusions of either ketamine or a placebo (saline). The infusions took about 40 minutes, and the second infusion took place 2 weeks after the first.

Most people who received ketamine (79%) felt less depressed, but no one who received the placebo showed improvements. I should note, though, that it was probably pretty obvious to people who received the placebo that it was not ketamine, as ketamine is a powerful psychoactive with obvious psychological effects. In contrast, saline isn’t likely to cause a detectable physiological response.

The treatment is still very experimental

After my earlier post was published, I received calls from a few people looking for ketamine treatment in Oregon. I’m afraid ketamine is still very much an experimental treatment, and no one, to my knowledge, is using it outside of well-controlled research studies. The only studies I’ve come across were conducted by NIMH researchers in Bethesda, Maryland.

The caveats I discussed in my previous post about the feasibility of ketamine for treating depression remain the same. At this point, we’re still not sure what the long-term effects are of using ketamine for depression. Given that it’s so fast-acting and is already a club drug, there is some potential for abuse and addiction.

Ketamine might be a useful intervention for people who are acutely depressed and acutely suicidal. In this respect, I remain cautiously optimistic, as it could reduce costly inpatient stays.

I’m skeptical, though, that ketamine will prove to be a cure-all wonder drug. For example, a newer study found that people treated with ketamine relapse into depression in an average of 2 weeks (Ibrahim et al., 2012). Although ketamine is safely used as an anesthetic in surgical procedures, we don’t know the impact of frequent doses across an extended period of time.

The newer research I cite in this post doesn’t take any steps towards answering questions about ketamine’s effectiveness beyond a few weeks, but it does suggest that people with bipolar disorder who are in a state of deep depression might find quick, if not enduring, relief from depression.

The medical and mental health community speak out about the dangers of “antipsychotic” drugs and proven, non-drug alternatives

The medical and mental health community speak out about the dangers of “antipsychotic” drugs and proven, non-drug alternatives

A couple of decades ago, big pharma promised to revolutionize the treatment of serious mental health concerns with a new class of atypical antipsychotic drugs such as Abilify and Seroquel. In terms of financial success, those two drugs were “revolutionary.” They are now the 5th and 6th most commonly prescribed drugs in America — despite mounting evidence that questions the efficacy and safety of these drugs (e.g. the huge CATIE and CUtLASS trials). Prominent members of the psychological and psychiatric communities are sounding the alarm about the overuse of these drugs and the erosion of other forms of treatment, particularly evidence-based psychosocial approaches.

In a recent article in the New York Times, Richard Friedman, M.D., expresses concern over increasing use of these drugs for unproven conditions, calling the use of “antipsychotic” drugs to treat everything from anxiety to insomnia as “unbelievable.” Studies on the use of antipsychotics to treat anxiety have failed to show that they are effective and there is no FDA approval for any atypical antipsychotic for the treatment of any anxiety disorder. Despite this lack of evidence, a recent study showed that prescribing of antipsychotics by psychiatrists for anxiety almost doubled between 1996 and 2007.  In this study, 21% of individuals who sought treatment from a psychiatrist for an anxiety disorder in 2007 were prescribed an antipsychotic drug versus  11% in 1996. Moreover, as Dr. Friedman points out, antipsychotics, including  newer “atypical” drugs, frequently have serious side effects such as increased blood lipids and cholesterol, irreversible movement disorders, and weight gain. If these statistics are correct, there are hundreds of thousands of people in the US alone who are taking antipsychotic medications for conditions they have been shown to not work with and suffering under the serious side effects of these medications.

Dr. Friedman is not alone in sounding the alarm. Just this year, the editor of the British Journal of Psychiatry (BJP), probably the most influential psychiatry journal in Britain, called for an “end to the psychopharmacological revolution.” In this piece in BJP, he stated that the prescription of antipsychotic medications needs to be drastically reduced. He stated that the side effects of antipsychotic drugs are too extreme to justify their limited benefit, even in the treatment of schizophrenia and bipolar disorder, for which there exists the largest evidence base supporting the use of these drugs. He stressed that non-drug therapies, such as cognitive behavioral therapy, are proven, effective, and affordable alternatives that need to be used much more frequently. This statement comes from someone who is a prominent member of the medical and psychiatric communities, where drug treatments are usually preferred over psychosocial interventions.

Psychological treatments for schizophrenia, anxiety, and other mental health conditions continue to advance and are becoming more readily available. Based on the current state of the evidence on the use of antipsychotics and the rapidly growing evidence for the use of psychological versus pharmacological treatments, consumers of mental health services need to understand that there are effective alternatives to medications. While it is our opinion that there can be a role for medication in the treatment of mental health difficulties, we want consumers to be informed about the limited effectiveness of antipsychotics, the large potential downsides of using this kind of medication, and the availability of effective psychological treatments. Big pharma is not going to send this message, and people need to be able to make informed choices about their mental health care.

Many in the scientific community are sounding the alarm about the rapidly growing use of antipsychotic medications. But is that alarm loud enough to be heard above the incredibly well-funded big pharma marketing campaigns? We hope so.

Do Antipsychotics Help With PTSD? A New VA Study Says, “No”

Do Antipsychotics Help With PTSD? A New VA Study Says, “No”

This may be just my limited, subjective impression, but I’ve noticed lately more and more clients who’ve been prescribed antipsychotic medications for reasons other than psychosis—sleep   problems, rumination, or suicidal ideation, for example. I’m not anti-med, but given the documented side effects of antipsychotics—weight gain, diabetes, and motor control problems—I think we should be cautious in how these meds are used.

When a recent New York Times article came across my desk that suggested a commonly prescribed antipsychotic, risperidone, may not be very useful in the treatment of PTSD, I was intrigued. Being a dutiful scientist, I tracked down the original article in the Journal of the American Medical Association.

What Did the Study Look At?

In this study, patients were recruited from multiple Veterans Affairs Hospitals across the country. Veterans with PTSD who had not responded to at least two trials of antidepressants were recruited. The 296 participants were randomly assigned to receive either risperidone or a placebo for 6 months. The vast majority of the veterans were Vietnam era and male (96.6%). Nearly three-fourths had also received outpatient mental health services in the preceding month.

The results: There were no difference between antipsychotic medication and placebo

At the end of 6 months, there was no difference between veterans who received risperidone and those who received placebo on PTSD symptoms or anything else that was measured, including depression, anxiety, and quality of life. I will note that contrary to my concern about the potential dangers of antipsychotics, the researchers didn’t find any notable adverse effects of risperidone—at least within the 6-month trial. Given that most of these veterans are Vietnam era and older, it’s very sad that no treatment has been very successful in addressing their PTSD.

Antipsychotics May Not Be an Effective Treatment for PTSD

According to this study, antipsychotics don’t appear to contribute to improvements in PTSD—at least for veterans with whom antidepressants didn’t work. Knowing what doesn’t work can be as important as knowing what does work. It was also heartening to see that, despite listing multiple ties to various pharmaceutical companies, the two main authors of this study let the data speak for itself. Too often, I read about researchers receiving pharmaceutical money massaging data to look more favorably for the meds they’re studying. The authors here seemed very conscientious in how they interpreted the data.

In the same issue of JAMA, Dr. Charles Hoge offers a commentary on treating veterans with PTSD. He supports the use of psychotherapy, antidepressants, and the hypertensive medication prazosin, and warns against the use of antipsychotics and benzodiazepines.

Off label use of antipsychotics seems to be a growing trend. A study that came out last month found that antipsychotic prescriptions for anxiety disorders more than doubled in 10 years—even though there’s no published data suggesting antipsychotics are an effective treatment for anxiety! This trend is worth keeping an eye on.

UPCOMING TRAINING EVENTS


An Introduction to Psychedelic-Assisted Psychotherapy for Clinicians

Brian Pilecki, PhD and Jason Luoma, PhD
October 22nd, 2021 from 9am-12:15pm

Psychedelic assisted therapy is emerging as a highly effective form of mental health treatment. This workshop will provide health care professionals an overview of this new clinical area. The workshop will highlight the importance of preparation and integration, as well as how to use a harm reduction approach to provide therapeutic support to clients using psychedelics on their own. The current legal status of psychedelics will be reviewed, including Oregon’s developing a legal psilocybin-assisted therapy program. Finally, diversity issues around lack of access for underserved and non-majority populations will be explored, as well as the prevalence of cultural appropriation and colonialism in modern psychedelic medicine. Read More.


Acceptance & Commitment Therapy – An Experiential & Practical Introduction

Jason Luoma, PhD and Jenna LeJeune, PhD
November 13th and 14th, 2021 from 8:30am-4:30pm
at Hilton Garden Inn Portland Airport
This two-day in-person workshop provides a thorough overview of the theory, principles, and techniques of Acceptance and Commitment Therapy. It is intended for those who are relatively new to ACT and for those who have done some reading on their own about ACT but who may not have had the opportunity to participate in more experiential learning, observe models, or receive feedback while using the ACT model. Read More.


Ethical & Legal Considerations in Psychedelic Integration Therapy

Brian Pilecki, PhD and Jason Luoma, PhD
November 19th, 2021 from 9am-11am

There is an increasing demand from clients seeking therapeutic support in their personal use of psychedelics. However, many clinicians interested in psychedelic preparation and integration are unsure as to how to provide these services as psychedelics mostly remain illegal. In this workshop, we will outline legal and ethical frameworks relevant to providing therapy to clients around their personal use of psychedelics, as well as describe how harm reduction approaches are suitable for this developing clinical area. Read More.


De-Mystifying Self-As-Context in ACT: Practical Strategies for Clients

Brian Pilecki, PhD and Kati Lear, PhD
December 3rd, 2021 from 12pm-1:30pm

This workshop will outline how self-as-context can be used to conceptualize commonly discussed topics in therapy such as self-esteem, confidence, identity, and inner conflict. Participants will learn how to flexibly practice practical self-as-context interventions that can be used with clients, as well as have a chance to practice newly learned skills through structured role-play exercises in breakout groups. Read More.


Values in Therapy: An Intro to Working with Values from an ACT Perspective

Jenna LeJeune, PhD
January 21, 2022 from 12pm-2:00pm

This workshop will provide a theoretical and conceptual overview of values from a contextual behavioral science perspective. We will cover the “what”, “why”, “when”, and “how” of values within ACT. While we will also provide an overview of various values exercises and measures that can be used with clients, the emphasis in this workshop will be on providing a foundational framework that will help clinicians approach values work from a functional perspective rather than a primarily technique-focused approach. Read More.



Culturally Responsive Therapy: How to Apply Anti-Racist Values in Session

Christy Tadros, LPCC and RaQuel Neal, LCSW
February 4th, 2022 from 1:30pm-4:45pm
and February 5th from 9:00am-12:00pm

This 2 day 6-hour training will help therapists develop their ability to support clients from a different racial background than them, with a particular focus on Black, Indigenous and People of Color. Through a multicultural social justice framework, it will integrate research and clinical experience to teach a therapeutic model for rapport building, assessment, and treatment. This model is not a rigid therapeutic modality, but provides a contextual lens to build a strong, culturally grounded therapeutic relationship. It is a flexible model and can align with many therapeutic modalities, including a contextual behavioral approach to therapy. Read More.


Truffle Hunting: Bringing Values to Life in the Therapy Room

Jenna LeJeune, PhD
February 25, 2022 from 12pm-2:00pm

This brief workshop is designed to help clinicians deepen their values work with clients by shifting the focus from the content of values conversations to the quality of those conversation. By listening for and deepening the qualities of effective values conversations participants will get a taste for how more experiential and relationally-based values work can supercharge therapy. Participants will have opportunities to both observe demonstrations and practice in small groups with the benefit of feedback. Read More.


Values Prototyping: Using Action to Help Clients Explore Their Values

Jenna LeJeune, PhD
March 18, 2022 from 12pm-2:00pm

This workshop will focus on one specific experiential tool called “values prototyping” that helps clients learn more about their values through engaging in intentional valuing. As participants will hopefully already have a solid foundation of some of the core concepts of the values process in ACT, this workshop will dive right in on how to use values prototyping to help clients learn more about what they would choose to value in their life. You will have the chance to practice developing a values prototype in small groups with the benefit of feedback, so that by the end of the workshop you will be able to use this tool in your work with clients. Read More.


The Invitation to Change Approach: Helping Families Affected by Addiction

Jeff Foote, PhD and Cordelia Kraus, LPC, CADC 1, certified CRAFT clinician
May 13th and 14th, 2022 from 9:00am-5:00pm
at University of Portland, Terrace Room
This two-day in-person workshop will provide skills training for professionals focused on the process of working with clients who have a loved one struggling with substance use issues. The Invitation to Change Approach draws on CRAFT (Community Reinforcement and Family Training), MI (Motivational Interviewing), and ACT (Acceptance and Commitment Therapy) to provide a compassionate and collaborative way of working with the families and concerned significant others of people who struggle with substance use. Read More.


Therapy and Research in Psychedelic Science (TRIPS) Seminar Series

Second Friday of each month from 12:00 PM – 1:00 PM (PT)

TRIPS is an online seminar series that hosts speakers discussing science-informed presentations and discussions about psychedelics to educate healthcare professionals. This series was created to guide healthcare providers and students preparing to be professionals towards the most relevant, pragmatic, and essential information about psychedelic-assisted therapy, changing legal statuses, and harm reduction approaches in order to better serve clients and communities. This seminar series is a fundraiser for our clinical trial of MDMA-assisted psychotherapy for social anxiety disorder that Portland Psychotherapy investigators are preparing for and starting in the Fall of 2021. All proceeds after presenter remuneration will go to fund this clinical trial. Read more.

November 12th, 2021Psychedelic Research: Implications for Palliative Care and End-of-Life Existential Distress with Anthony Bossis, Ph.D.

December 10th, 2021Implementing Culturally-Attuned & Anti-Racist Psychedelic Therapy: Impact over Intention with Jamilah R. George, M.Div., M.S.

January 14th, 2022Psilocybin-Assisted Therapy of Major Depressive Disorder using Acceptance and Commitment Therapy as a Therapeutic Frame with Jordan Sloshower, MD, MSc

February 11th, 2022 – Drug-Drug Interactions Between Psychiatric Medications and MDMA or Psilocybin with Aryan Sarparast, MD