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

Case Conceptualization in Acceptance and Commitment Therapy

Jason Luoma, Ph.D. and Brian Pilecki, Ph.D.
May 21, 2021 from 12-2pm

This workshop provides a chance to learn concrete methods for conceptualizing cases from the perspective of Acceptance and Commitment Therapy. Formulating a useful case conceptualization is a foundational clinical skill that is essential in delivering effective treatment, and one that can be often overlooked in the process of working with clients. Participants will learn several formats for doing formal case conceptualization outside of session as a means to further develop knowledge and skill with ACT theory, as well as to learn a means to enhance treatment planning. The importance of ongoing case conceptualization throughout a course of treatment will be emphasized, as well as common pitfalls in conceptualizing client problems. Participants will also have a chance to practice newly learned skills with a case in breakout groups. Read More.


Lunchtime Panel Discussion: Psilocybin Therapy and Mental Health Care in Oregon: What is Happening and Where do We Need to Go from Here?

Moderated by Brian Pilecki, Ph.D. with Ingmar Gorman, Ph.D, Kelly Sykes, Ph.D, Alan Davis, Ph.D, Aja Molinar, and Sam Chapman
May 28, 2021 from 12-1pm

Oregon Voters have recently approved a measure that will pave the way for the legal administration of psilocybin by state credentialed providers to begin in 2023. In this panel discussion, leading advocates, psychedelic therapy researchers, and psychedelic therapist training providers will elaborate on the implications during a moderated panel discussion and answer audience questions. Presenters will give an update on the status of the Oregon Psilocybin initiative, particularly as it relates to the training of facilitators, and will describe ways local therapists can get training in the practice of psilocybin-assisted therapy. Read More.


ACT Precision Training: In-Session Case Conceptualization in Acceptance and Commitment Therapy to Help You be Focused and Strategic in Your Interventions

Jason Luoma, Ph.D. and Jenna LeJeune, Ph.D
June 18, 2021 from 12-2pm

This workshop provides a chance to learn and practice in-session, in-the-moment case conceptualization of cases from the perspective of Acceptance and Commitment Therapy. This workshop focuses on helping you use ACT theory & in-session clinical markers to make more precise and strategic interventions. The main goal of this workshop is to help you become more adept at identifying in-session client behaviors that are indicators for particular ACT processes that are likely to be most relevant. The workshop uses a process we call ACT Circuit Training, which involves intensive analysis of a video of an ACT session and intentional practice in conceptualizing client behavior and generating possible ACT responses, followed by discussion and feedback. Read More.



Developing the ACT Concept of Defusion in Kids and Teens

Julianna Sapienza, Ph.D, LP
June 25, 2021 from 12-1:30pm

Cognitive restructuring is a concept that is useful for many patients, but many others really struggle with fighting or changing their negative thinking patterns. This 1.5 hour hands-on workshop is designed to introduce child and adolescent practitioners to defusion, an ACT concept that helps patients drop the struggle with their thoughts while also not buying into them. You will learn all about defusion, how to introduce the concept to child and teen clients, and how to use your creativity to make these skills effective for your clients. Read More.


ACT Agility Training: In-Session Case Conceptualization in Acceptance and Commitment Therapy to Increase Flexible Responding

Jason Luoma, Ph.D. and Jenna LeJeune, Ph.D
July 16, 2021 from 12-2pm

This workshop provides a chance to learn and practice in-session, in-the-moment case conceptualization of cases from the perspective of Acceptance and Commitment Therapy. This workshop is intended to help therapists be more flexible and nimble in their use of ACT processes, strengthening their ability to fluidly shift as needed between processes within sessions. Therapist learning ACT often develop tunnel vision, focusing too much on particular processes or responding rigidly when more flexibility is needed. 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.

May 14th, 2021  Research on MDMA and Psychedelic-Assisted Therapy: An Overview of the Evidence for Clinicians with Jason Luoma, Ph.D.
June 11th, 2021 Becoming a Psychedelic-Informed Therapist: Toward Developing Your Own Practice with Nathan Gates, M.A., LCPC