Thursday, May 21, 2015

Psychoanalytic Therapy

A comparison between psychoanalysis, medication, and cognitive-behavioral therapy.


The effectiveness of psychopharmacology, cognitive-behavioral therapy, and psychoanalysis will be compared to each other in order to describe the most helpful form of treatment. Effectiveness is going to be measured by the effect size and the limitations of each treatment; success is going to be measured by relapse and remission rates as well as the increase or decrease of benefits over time and side effects.
The first form of treatment is with psychopharmacology. The article “Selective Publication of Antidepressant Trials and Its Influence on Apparent Efficacy” will provide the effect size and the number of positive and negative published and unpublished studies done by the FDA and it will compare the outcomes of studies done by journal articles that experiment with the same antidepressants.
 Turner, along with other contributors of the article, looked at all registered FDA antidepressants studies between 1987 and 2004. They found 78 studies with 12,564 patients and 12 antidepressants agents. Out of 78 studies, 38 were positive and all of them except one were published (Turner, 2008). Thirty-six were negative, and out of the negative studies three were published as unsuccessful, 22 were not published, and 11 had a different outcome compared to the FDA’s result (Turner, 2008). Now, the 51% of positive studies had an average effect size of .37 for published studies and a .15 for unpublished studies (Turner, 2008). In other words, 49%, almost half of the studies, are negative. These results are usually left unpublished, and the positive ones, which have a tendency to be published, do not show a significant effect size. This means that antidepressants are not efficient in achieving their purpose and that there is a bias when it comes to publishing evidence on psychopharmacology’s effects.
The STAR*D study will provide the relapse rates of psychopharmacology and CBT. This study is the largest real-world scientific study of depression treatment to date. The STAR*D used more than 4,000 patients in 41 different centers across the U.S. and it consisted of four treatment steps ("Questions and Answers about the NIMH Sequenced Treatment Alternatives to Relieve Depression (STAR*D) Study - All Medication Levels"). At first, patients received Citalopram, which belongs to the SSRI category. If the patient responded well to the medication, there would be a period of 12 to 14 weeks where the patient would continue taking the medication ("Questions and Answers about the NIMH Sequenced Treatment Alternatives to Relieve Depression (STAR*D) Study - All Medication Levels"). If the Citalopram did not have an effect on the patient or if the patient had severe side effects, he or she would continue to step two, which consisted of other medication such as Bupropion, Sertraline, or Venlafaxine. Or they would add medication to the current medication, such as Citalopram plus Buspirone, Citalopram plus cognitive behavior therapy, or they would only receive CBT ("Questions and Answers about the NIMH Sequenced Treatment Alternatives to Relieve Depression (STAR*D) Study - All Medication Levels"). If the patients responded well to the treatment, there would be a follow-up period or the researchers would change their medication to the one corresponding to the third step. This would happen until the patients entered full remission, or if they reached step five, which is the last step.
The remission rates were an average of 67%. They were 36.8% for the first step, 30.6% for the second step, 13.7% for the third, and 13% for the fourth step. In addition, those who went through more steps had higher relapse rates (Rush, 2006). The relapse rates over 12 months were 40.1% in the first step, 55.3% in the second, 64.6% in the third, and 71% in the step fourth. The average months it took to relapse were 4.1 in the first step, 3.9 in the second, 3.1 in the third, and 3.3 in the fourth. This means that by the second step, more than half of the participants were going to relapse on their depression in three months.
       Side effects are another negative characteristic of medication. The Food and Drug Administration (FDA) did a review in 2004 of clinical trials and found that four percent of children and adolescents that took antidepressants thought about or attempted suicide ("Post-Traumatic Stress Disorder (PTSD)"). Two percent of the people who took a placebo attempted suicide. This means that taking an antidepressant doubles your risk of committing suicide. As a result, the FDA put a black box warning the following year in order to alert the consumer and the parents of consumers the increased risk of suicides ("Post-Traumatic Stress Disorder (PTSD)"). Another common side effect of the medication is the worsening of depression. This combined with the danger of suicidal thinking shows that antidepressants increase the risks of what is trying to cure.
       In addition, the same medication used as an antidepressant is given to people who have either a mood or an anxiety disorder. According to the anxiety and depression association of America (ADAA), anxiety and mood disorders are the most common mental illnesses in the U.S. because they affect more than forty millions of Americans ("Facts & Statistics Anxiety and Depression Association of America, ADAA"). The side effects of the most common medication for PTSD are convulsions, sudden loss of consciousness, loss of bladder control, muscle spasms, blurred vision, dry skin, chest pain, weight gain or loss, hair loss, heartburn, indigestion, and insomnia between others ("Sertraline Side Effects in Detail - Drugs.com"). This means that the majority of people who need mental health treatment receive the same type of dangerous medication.
            The next form of treatment is Cognitive Behavioral Therapy. The remission and relapse rates were already provided in the STAR*D study. CBT does not have side effects, but it does have limitations. For example, CBT is not effective at reducing relapse in bipolar disorder and schizophrenia ("Result Filters"). Moreover, CBT is the least effective treatment when compared to antidepressants for adolescents. To become effective, Cognitive Behavioral Therapy has to be combined with medication ("The Treatment for Adolescents with Depression Study (TADS)"). This means that CBT depends on medication to be successful.
            The effect size of CBT depends on what it is treating. In the treatment of substance abuse the effect size ranged from small to medium (Hofmann). Treatment for opioid and alcohol dependence was especially small. It is less efficient than other treatments in reducing the symptoms of schizophrenia, especially the chronic ones (Hofmann). The meta-analysis of CBT regarding mood disorders such as depression and dysthymia is not concrete (Hofmann) because some studies argue that it is really efficient and others assert that it has weak support. However, a study concluded that the effect size of CBT in mood disorders is overestimated greatly because of a publication bias (Cuijpers). This means that the actual effect size is considerably smaller. With Bipolar disorder, CBT’s effect size was also small (Hofmann). In addition, in the treatment of anxiety, this therapy was consistently strong. CBT has a large effect size for OCD and medium ones for the rest of the anxiety disorders (Hofmann). However, this was only measured in short-term therapy. This is a reference to the biggest limitation on CBT, which is the lasting effects on its patients.
Another study found that CBT’s short-term outcomes do not predict the long-term effect on the patient and that if a therapist gives treatment for a six-month period, which is more intense compared to the average 10 sessions, the outcome in long term was not different and the intensity of the therapy did not affect the improvement of the patient (Durham). In addition, a cost-effectiveness analysis showed that there are no advantages of CBT over non-CBT (Durham). Moreover, the positive effects found in the first trials disappeared over longer time periods.
The last therapy is psychoanalysis. A study done by the Cochrane Library found that psychoanalysis had an average effect size of .97 (Shedler), which is a large effect size, on general symptom improvement when compared to wait lists, minimal treatment, and treatment as usual. Moreover, the effect size was .81 for somatic symptoms, 1.08 for anxiety, .59 for depressive symptoms (Shedler). This means that psychoanalysis is at least four times bigger than psychopharmacology and it does not have side effects. Now, in average, more than half of the people who were treated with CBT and psychopharmacology in the second step of the biggest depression study to-date relapsed in three months. But the Cochrane Library checked on the same patients who undertook psychoanalytic therapy after a period of nine months and the results were that general symptom’s effect size increased to 1.51, it also increased to 2.21 for somatic symptoms, 1.35 for anxiety, and .98 for depressive symptoms (Shedler). According to the APA, this means that “effect sizes at follow-up suggests that psychodynamic therapy sets in motion psychological processes that lead to ongoing change, even after therapy has ended (Shedler).”
In conclusion, CBT and psychopharmacology have small effect sizes, however, this is usually not known because of a publication bias. Medication also has side effects such as worsening of depression and an increase in attempts of suicide in children who take an antidepressant. CBT depends on medication to become more effective. Moreover, after three months of stopping treatment with either the medication and/or CBT patients relapsed to their disorder. In addition, psychoanalysis has an effect size four times bigger than medication and CBT when it is measured in short term. It does not have side effects, it does not depend on other forms of treatment, it does not have a publication bias, and when treatment stops, the patient keeps improving to the point that the effect size becomes eight times better than the other two therapies. This means that psychoanalysis is superior in every characteristic compared to other therapies.




Feel free to leave a comment, questions, concerns, or suggestions.





Sources
Turner, E., Mathews, A., Linardatos, E., Tell, R., & Rosenthal, R. (2008). Selective Publication of Antidepressant Trials and Its Influence on Apparent Efficacy. The New England Journal of Medicine. Retrieved from http://www.nejm.org/doi/full/10.1056/NEJMsa065779#t=article
Questions and Answers about the NIMH Sequenced Treatment Alternatives to Relieve Depression (STAR*D) Study - All Medication Levels. (2006, November 1). Retrieved April 21, 2015, from http://www.nimh.nih.gov/funding/clinical-trials-for-researchers/practical/stard/allmedicationlevels.shtml
Rush, A. (2006.). Acute and longer-term outcomes in depressed outpatients requiring one or several treatment steps: A STAR*D report. Retrieved April 21, 2015, from http://www.ncbi.nlm.nih.gov/pubmed/17074942 (Rush, 2006)
Post-Traumatic Stress Disorder (PTSD). (n.d.). Retrieved May 5, 2015, from http://www.nimh.nih.gov/health/publications/post-traumatic-stress-disorder-ptsd/index.shtml
Facts & Statistics | Anxiety and Depression Association of America, ADAA. (n.d.). Retrieved May 5, 2015, from http://www.adaa.org/about-adaa/press-room/facts-statistics
Sertraline Side Effects in Detail - Drugs.com. (n.d.). Retrieved May 5, 2015, from http://www.drugs.com/sfx/sertraline-side-effects.html
Result Filters. (n.d.). Retrieved May 5, 2015, from http://www.ncbi.nlm.nih.gov/pubmed/19476688

The Treatment for Adolescents With Depression Study (TADS). (n.d.). Retrieved May 5, 2015, from http://archpsyc.jamanetwork.com/article.aspx?articleid=210055
Hofmann, S., Asnaani, A., Vonk, I., Sawyer, A., & Fang, A. (n.d.). The Efficacy of Cognitive Behavioral Therapy: A Review of Meta-analyses. Retrieved May 5, 2015, from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3584580/
Cuijpers. (n.d.). Efficacy of cognitive-behavioural therapy and other psychological treatments for adult depression: Meta-analytic study of publication bias. Retrieved May 5, 2015, from http://www.ncbi.nlm.nih.gov/pubmed/20194536
Durham. (n.d.). Long-term outcome of cognitive behaviour therapy clinical trials in central Scotland. Retrieved May 7, 2015, from http://www.ncbi.nlm.nih.gov/pubmed/16266559
Shedler. (n.d.). Retrieved May 7, 2015, from https://www.apa.org/pubs/journals/releases/amp-65-2-98.pdf