Thursday, January 12, 2006

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."


Dr. Deborah Serani said...

I'm a psychoanalyst and I see patients 2 and three times a week. There are many patients who cannot be treated via this method and I so agree that issues of anxiety, especially OCD are best treated with Behavioral and CB tecyhniques. I recently went to a Virtual Reality workshop and loved what I saw. Too bad it is so expensive right now, but the exposure aspects and the success rates were amazing. The truth in our field is that we need to work together as a community, recognizing that each orientation offers something to the field. It *would* be great if we could get commercials to grab the public's attention. I'd love to see high profile celebs doing a PSAs for psychotherapy.

Have a great weekend,

Psych Pundit said...


Thanks for the great comments. I couldn't agree more about the importance of clinicians from all theoretical backgrounds working together. A few years ago, I had hoped that the easiest form of common ground among psychologists would be simply to rally around treatments that actually work (for any given disorder): evidence-based practice. Unfortunately, the American Psychological Association has not enthusiastically lined up behind such a standard, as many members feel threatened by it ("what if my pet therapy - the one I was trained in - doesn't actually work as well as some others?"). It's too bad . . .

On another note, I wanted to make sure you know that I have great respect for the healing potential of psychoanalysis, especially when it comes to addressing personality disorders. My best supervisor in grad school was a Freudian psychoanalyst, so I would certainly never dismiss it out of hand . . . I just wish there were more analysts like you who listen to the research!

Patricia Tryon said...

"If only someone had the money for a series of slick prime time commercials..."

Seems like this ought to interest a foundation some day. It seems worth a thought, and I'll give it one. Or a few :-)

Anonymous said...

The signs and symptoms of Obsessive Compulsive Disorder over 6.6 million people (one out of every 40 people) suffer from Obsessive Compulsive Disorder (OCS). This disorder often begins at times of emotional stress, major life transitions, health problems, and events representing new levels of responsibility.

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My best friend is a psychiatrist and she is always analyzing commercials. I have learned much from her. In fact, I am considering the idea of becoming a psychoanalyst too

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Well this is the type of discoveries and investigations that should be there at hand in order to change the medical perspective we have on Western... I'm glad to know this, thank you for sharing such an interesting information. if69

Anonymous said...

im scared i have ocd and it wont be curable back to the normal persons level. please offer me hope