The Dark Side

Dan, my old college roommate, offers this interesting post on the Jungian concept of the shadow. It makes for provocative reading! Here's a short excerpt to whet your appetite:

The shadow is a moral problem that challenges the whole personality, for no one can become conscious of the shadow without considerable moral effort. To become conscious of it involves recognizing the dark aspects of the personality as present and real. This act is the essential condition for any kind of self-knowledge. (Aion, 1951, in Collected Works 9, Part II, p. 14)

The Mind-Body Problem

What are the most common - and most damaging - myths about mental illness out there? Every semester I collect 'reflection papers' from the 300 undergrads in my courses, so I've developed a pretty good inventory of these myths over the years. You'd probably guess many of them . . . things like:

"Depressed people could just 'snap out of it' if they really wanted to";

"Schizophrenic patients have multiple personalities";

"If you have an eating disorder, you were probably sexually abused".

There are dozens more that come quickly to mind. Maybe I'll do a whole post on it some day. But if I had to nominate the one myth that's the most widespread and damaging in its influence, I think I might pick the "myth of mind-body dualism".

This is the idea that the mind and the body (brain) are completely different entities, made of completely different 'stuff'. It's an idea with an impressive pedigree (luminaries like Plato and Descartes), but that's not why most people believe it. No, it's believed because dualism just seems so obviously true. After all, it feels for all the world like there's a completely non-physical self inside - thinking and feeling and acting on its own, regardless of what the rest of the body is up to.

Anthropologists tell us that remote people groups all over the world are mind-body dualists. They've yet to encounter a clan, band, or tribe that's not. Likewise, researchers have found that children are natural born dualists - making claims about non-physical minds as early as age 4-5.

But science, of course, is about discovering things that aren't obvious. Sometimes it means discovering that our most obvious intuitions are dead wrong:

It feels for all the world like the sun revolves around the earth, and for thousands of years everyone just assumed it did. It seems perfectly obvious that light can't be both a wave and a stream of particles at the same time, but it is. It seems obvious that living things have to be animated by some essence of life (elan vital) that's fundamentally different from non-living chemicals, but we know now that it's not.

Likewise, we know from neuroscience that the mind is what the brain does. In fact, the mind and the brain are flip sides of the same underlying reality.

This means anything that changes your brain also changes your mind. But perhaps more importantly - it means anything that changes your mind also changes your brain.

If, as a psychologist, I can help change a patient's thoughts, I've also (by definition) helped change his brain. Changing behavior changes the brain. Changing feelings changes the brain.

In a nutshell: experience changes the brain.

Why is this important? Because when it comes to mental illness, so many people automatically assume, "Oh, well the doctor said I probably have a 'chemical imbalance' or something wrong with my brain, so that means I have to take drugs to fix it." But if we understand that experience changes the brain - that the mind and brain are flip sides of the same underlying reality - we won't make this logical error.

In most cases, so-called 'chemical imbalance' may be just as readily cured by a healing experience as by a healing chemical.

The Doctor Is: Out

Alas, I'm swamped with academic duties (and a book deadline) at the start of a new semester, so it will be a few days before I can post another article.

In the meantime, I'm trying to talk Dan, erstwhile psychology major and my old college roommate, into writing a post for the Psych Pundit blog.

In one of life's little ironies, I never took an undergrad psych class (math major, believe it or not) but wound up as a psychology professor, while Dan - the psych major - now works as an attorney doing business valuation (lots of math stuff). Back in college, I used to tease Dan about the 'bogus' nature of psychology, so maybe god's got an interesting sense of humor . . .

As Good As It Gets?

I got a call from a psychiatrist colleague of mine a few years ago. He was an old-school Freudian psychoanalyst who had his patients come in twice a week to lie back on a couch, talk about their dreams, and free-associate about their early childhood experiences. Although this type of treatment may be useful for some patients - especially those who wish to better understand and change troublesome personality patterns - it has not been very strongly supported by research.

As it turned out, the psychiatrist was calling to ask if I would take on one of his patients who suffered from obsessive-compulsive disorder (OCD) - a debilitating mental illness that afflicts about 2% of the population (it was the disorder depicted by Jack Nicholson in the film, As Good As It Gets). The psychiatrist had already been treating this distraught young man for over 4 years, but his OCD symptoms had actually worsened over that span of time. Since there's no scientific evidence Freudian psychoanalysis can successfully treat OCD, I was willing to have the case transferred to my care.

Fortunately, during my grad school training at Duke, I had a set of instructors and supervisors who emphasized the importance of asking, for each form of mental illness: which of the hundreds of possible treatments for this disorder is the one most strongly supported by the research evidence?

For OCD, this is a no-brainer: a form of behavior therapy called exposure and ritual prevention has outperformed every other treatment (including meds) in every large-scale outcome trial ever published.

To get some idea of the potency of behavior therapy for OCD, consider the results of the largest OCD treatment outcome study to date sponsored by the National Institutes of Mental Health. The study pitted behavior therapy against a drug called Anafranil (clomiprimine), the most effective OCD medication currently on the market. Here were the results:

Behavior Therapy: 86% recovered
Anafranil: 48% recovered
Placebo: 10% recovered

As you can see, OCD is such a severe disorder that it has a minimal placebo response . . . it takes much more than placebo-induced positive expectancies to cure this particular illness. And even though the drug certainly beats the placebo (48% to 10%), it's obvious that behavior therapy is the treatment of choice (with a whopping 86% cure rate). In fact, it's not even a close call!

There's a genuine tragedy, though, embedded in these numbers . . . for the vast majority of OCD patients will never even know that behavior therapy exists. While some will waste their time and money on ineffective forms of psychotherapy, most OCD patients will simply be told that they have a 'chemical imbalance', handed a prescription of Anafranil or a similar medication, and told in effect, "this is as good as it gets". Obviously, it's not!

Sadly, it's so hard to get the word out about behavior therapy for OCD. Few mental health reporters understand the field well enough to do the story. Drug companies (as I've mentioned before) have multibillion dollar budgets to promote their products - for better and for worse - whereas psychotherapists skilled in behavior therapy for OCD are small in both numbers and financial resources. (To find such a therapist near you, try contacting the Center for Anxiety and Related Disorders.)

Oh, in case you're wondering . . . within 4 months of my taking on that OCD patient and treating him with standard behavior therapy, his symptoms were in complete remission. I've seen it repeatedly over the course of my career, and I'm not even a particularly gifted therapist (research is my main gig), nor is OCD my area of specialty.

So lately, whenever I see one of those silly Zoloft commercials (the ones with the sad little chemically imbalanced ovoid creatures), I find myself thinking, "If only someone had the money for a series of slick prime time commercials about behavior therapy. We've got to find a way to tell the 6 million OCD sufferers that there's a better treatment out there - one (alas) they've never even heard of."

On 'Chemical Imbalance'

Drug companies spend billions of dollars each year advertising their products. In fact, according to a brilliant expose of the pharmaceutical industry by Dr. Marcia Angell (former editor of The New England Journal of Medicine), drug companies spend about 3 times as much on marketing as they do on research and development!

And they've hit on a particularly effective marketing angle for their profitable line of antidepressant meds: it's all about 'chemical imbalance'. Just tell people they have a brain-related 'chemical imbalance', and most will assume it's a condition that can only be remedied by ingesting more chemicals (i.e., by taking expensive medications).

But this widespread assumption is flawed in its underlying logic. Simply put: medication is not the only way to change the depressed brain. Psychotherapy changes the brain. Pill placebo changes the brain. Exercise changes the brain.

Let's look at this last point in a little more detail. One of the most serious consequences of depression is the fact that it suppresses a key growth hormone in the brain (it's called BDNF, or brain-derived neurotrophin factor). Without adequate levels of this growth hormone, we can't form new connections between neurons, and those new connections are crucial to our ability to form new memories (this is the reason, in fact, that most depressed patients experience poor short-term memory). Over time, low levels of this growth hormone cause key regions of the brain to shrink. That's right: over time, depression causes brain damage.

But when we get aerobic exercise, this triggers a massive increase in the brain's production of neural growth hormone (BDNF). Not only does exercise help protect the depressed brain from damage, but it serves as a powerful antidepressant activity in its own right.

In a landmark study at Duke Medical Center, aerobic exercise (just 3 times per week for 30 minutes) was found to be as effective as Zoloft in the short term, and even more effective than Zoloft in the long-term treatment of depression.

Exercise is a potent treatment for depression. This is why the British Medical Association (a group much less influenced by the drug industry than our own American Medical Association) recently recommended exercise over antidepressant meds as a first-line treatment for depressive illness. The Brits now seem to understand what most Americans do not: chemical imbalance can be remedied by experience, not just medication.

Got Placebo?

It was just over 3 years ago, and reporters breathlessly heralded the news: "St. John's Wort Is Ineffective For Depression". Unfortunately, they got the story wrong, and missed the real story sitting right under their noses.

Here's what happened. The National Institutes of Health had just sponsored a large outcome study in which hundreds of depressed patients were randomly assigned to one of three treatment conditions: Zoloft (the best-selling antidepressant), St. John's Wort, or Placebo (an inert sugar pill). None of the treatments worked particularly well. After 8 weeks, the following proportions of patients were found to be recovered within each treatment group:

Placebo - 32%
Zoloft - 25%
St. John's Wort - 24%

Notice anything interesting? Yes, oddly enough, the sugar pill yielded the best results of all.(Statistically speaking, though, the 3 treatments were judged to be in a virtual tie.) Now, in order for medical researchers to conclude that any given drug is effective, it has to outperform a placebo control condition. Clearly, this didn't happen for St. John's Wort (hence the headlines) . . . but it didn't happen for Zoloft either (a fact that was completely ignored by the press)!

However, at this point, perhaps you're thinking, "Surely this study is some sort of anomaly. A fluke outcome. We already know that Zoloft and similar drugs are much more effective than a sugar pill." But do we?

Clinical researcher Irving Kirsch and his colleagues recently petitioned the Food and Drug Administration under the Freedom of Information Act for data on the 47 drug trials submitted by the pharmaceutical industry in their quest to get FDA approval for 6 of the most popular antidepressant medications (Prozac, Paxil, Zoloft, Celexa, Effexor, and Serzone). Most of these drug studies had never even been published, as drug companies tend only to publish the studies that show their drugs in a favorable light . . . but the FDA keeps permanent records of every such trial.

What did the FDA records show? Remarkably, Kirsch and colleagues found that in the majority of these drug trials, the antidepressant did not beat the placebo. In fact, when the researchers averaged across all 47 studies, they found that the placebo led to symptom reduction that was fully 85% as large as that of the active medications. This amounted to a 2-point average difference on a 52-point symptom rating scale; this magnitude of difference is not considered to be clinically significant.

Does this mean that Zoloft and similar drugs don't work? No. It's clear that they lead to complete remission for about 1/3 of the patients who take them (and to some improvement for many others) . . . It's just that much of this benefit for many patients is based on the placebo effect. The data on this point are crystal clear.

And how does the placebo effect work? This will be the subject of an upcoming post . . .

How Effective Are Antidepressants?

A growing body of scientific evidence suggests that antidepressant drugs are only modestly effective, probably much less so than you realize. Unfortunately, these medications just don't live up to the hype.

An eagerly awaited landmark study published in the American Journal of Psychiatry this week makes the point quite clearly. Researchers followed 2,876 depressed patients at 41 different clinics while they were treated with Celexa (citalopram) - one of the best-selling depression medications, and a close chemical cousin of drugs like Zoloft, Prozac, Paxil, and Lexapro.

According to researchers, after 10 weeks of treatment:

Remission rates were 28% [based on clinicians' ratings] and 33% [based on patients' ratings].

This means that fewer than 1 in 3 patients recovered on Celexa, regardless of whether we look at the patients' own ratings of their symptoms or those of their clinicians.

It gets worse.

Patients in this study got much better care than the vast majority of patients "in the real world." They saw their doctors every couple of weeks - much more frequently than almost any insurance plan will cover. Their doctors also carefully evaluated medication levels at each visit, and increased dosage if the meds didn't seem to be producing an adequate response at the initial dose (again, this doesn't happen as efficiently in real world settings). Thus, by the end of the treatment period, the average dose was about 50mg per day - a higher dose than most patients will ever take (typical starting dose is 20mg).

Finally, the study's 28% response rate is actually an over-estimate, since it excludes the many patients who quit taking the meds right away (i.e., before they completed their first followup evaluation) as well as those who were switched by their doctors to a different drug for any reason (e.g., intolerable side effects).

Bottom line: The great majority of patients who take antidepressant medications do not experience a complete and lasting cure of their depression. This is why, for example, the epidemic of depression in the U.S. keeps getting worse (the lifetime prevalence of depressive illness is now nearly 25%) despite the millions of prescriptions dispensed each week.

I truly wish it were otherwise. And if you happen to be one of those who have benefited enormously from taking an antidepressant medication (as a practicing clinician, I've seen many), then know that I rejoice with you . . . if only it happened more often.

In posts to follow, I'll discuss what the research literature has to say about more effective and enduring treatments for depression.