Psychoanalytic Therapy
A comparison between psychoanalysis, medication, and cognitive-behavioral therapy.
The effectiveness of medication, 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 sizes 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 that will be explored revolves around psychopharmacology. The article “Selective Publication of Antidepressant Trials and Its Influence on Apparent Efficacy” will provide the effect sizes of antidepressants, the number of positive and negative published and unpublished studies done by the FDA, and it will compare the long--term outcomes of using medication as a form of treatment.
Turner, along with the other authors, looked at all registered FDA antidepressant studies between 1987 and 2004. They found 78 studies with 12,564 patients and 12 antidepressant 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). It is important to note that a .2 effect size is considered small, a .5 is medium, and a .8 large one. Now, the 51% of positive studies had an average effect size of .37 for published studies and a .15 for unpublished studies (Turner, 2008). It is worth noting that the negative results are usually left unpublished, and the positive ones, which have a tendency to be published, do not show a large effect size. This suggests that antidepressants might not be as efficient in achieving their purpose as expected and that there is a bias when it comes to publishing evidence on those effects.
The STAR*D study will be used to examine the relapse rates of CBT and medication used to treat depression and anxiety. This study is the largest real-world scientific study of depression treatment to date. The STAR*D looked at 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 is an SSRI (this is a drug that selectively targets the serotonin reuptake protein). 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. 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 medications 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. If the patients responded well to the treatment, there would be a follow-up period, but if they didn't the patients would receive medication 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.
It is important to consider the posible existence of side effects as 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 experienced suicidal ideation and behaviors compared to two percent of the control group who took a placebo ("Post-Traumatic Stress Disorder (PTSD)"). As a result, the FDA put a black box warning the following year in order to alert the consumers and the parents of consumers of the increased risk ("Post-Traumatic Stress Disorder (PTSD)"). Another common side effect of medication is the worsening of depression. This combined with the increased risk of suicidal thinking shows that antidepressants might worsen the the symptoms 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, an anxiety disorder, 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 it is very likely that the majority of people who receive medication experiencing side effects. 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 more effective, Cognitive Behavioral Therapy has to be combined with medication ("The Treatment for Adolescents with Depression Study (TADS)").
The first form of treatment that will be explored revolves around psychopharmacology. The article “Selective Publication of Antidepressant Trials and Its Influence on Apparent Efficacy” will provide the effect sizes of antidepressants, the number of positive and negative published and unpublished studies done by the FDA, and it will compare the long--term outcomes of using medication as a form of treatment.
Turner, along with the other authors, looked at all registered FDA antidepressant studies between 1987 and 2004. They found 78 studies with 12,564 patients and 12 antidepressant 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). It is important to note that a .2 effect size is considered small, a .5 is medium, and a .8 large one. Now, the 51% of positive studies had an average effect size of .37 for published studies and a .15 for unpublished studies (Turner, 2008). It is worth noting that the negative results are usually left unpublished, and the positive ones, which have a tendency to be published, do not show a large effect size. This suggests that antidepressants might not be as efficient in achieving their purpose as expected and that there is a bias when it comes to publishing evidence on those effects.
The STAR*D study will be used to examine the relapse rates of CBT and medication used to treat depression and anxiety. This study is the largest real-world scientific study of depression treatment to date. The STAR*D looked at 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 is an SSRI (this is a drug that selectively targets the serotonin reuptake protein). 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. 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 medications 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. If the patients responded well to the treatment, there would be a follow-up period, but if they didn't the patients would receive medication 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.
It is important to consider the posible existence of side effects as 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 experienced suicidal ideation and behaviors compared to two percent of the control group who took a placebo ("Post-Traumatic Stress Disorder (PTSD)"). As a result, the FDA put a black box warning the following year in order to alert the consumers and the parents of consumers of the increased risk ("Post-Traumatic Stress Disorder (PTSD)"). Another common side effect of medication is the worsening of depression. This combined with the increased risk of suicidal thinking shows that antidepressants might worsen the the symptoms 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, an anxiety disorder, 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 it is very likely that the majority of people who receive medication experiencing side effects. 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 more effective, Cognitive Behavioral Therapy has to be combined with medication ("The Treatment for Adolescents with Depression Study (TADS)").
The effect size of CBT depends on what it is treating. In the treatment of substance abuse, the effect sizes 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, the effect sizes were consistently strong. CBT had a large effect sizes 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 effects on patients and that intensity did not alter long-term outcomes. Specifically, when therapists provided more sessions than average during a six-month period, which is longer than average, the long-term outcome remained unaffected (Durham). In addition, a cost-effectiveness analysis showed that there are no advantages of CBT over other forms of therapy (Durham). Finally, the positive effects found in the first trials disappeared over longer time periods.
The last form of treatment 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, and .59 for depressive symptoms (Shedler). This means that its effect sizes are at least four times bigger than medication and it does not have side effects. Now, in average, more than half of the people who were treated with CBT and antidepressants 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 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 antidepressants 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 suicidal thinking 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 tend to relapse back to their disorder. In addition, psychoanalysis has an effect size on average four times bigger than medication and CBT when it is measured as a form of short-term treatment. 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 forms of treatment. This suggest that psychoanalysis might be a better option when compared to other forms of treatment.
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
Nice blog! since nobody wants to experience this problem in their life and seek cognitive behavioural therapy for depression treatment, thus you are pointing them in the right route.
ReplyDeleteYour review of "Psychoanalytic Therapy: What is it?" was a thought-provoking and insightful read. Your analysis of the author's approach and explanation of the various concepts involved in psychoanalytic therapy was clear and concise. Your commentary on the limitations and benefits of this type of therapy was particularly informative. Your review is a valuable resource for anyone looking to gain a deeper understanding of psychoanalytic therapy. Right Brain Training or Flash cards
ReplyDeleteThank you for sharing your expertise and perspective on this important topic.
Psychoanalytic therapy delves deep into the subconscious, unraveling underlying conflicts and patterns. Its exploration of the mind's complexities offers profound insights and healing potential.Dynamic Family Therapy LLC
ReplyDeletePsychoanalytic therapy delves into subconscious roots of behavior, offering profound insights and healing. Its focus on deep self-awareness fosters lasting personal growth.Dynamic Family Therapy LLC.
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