7 Challenges of Psychotherapy

Great post by John Grohol at PsychCentral. Each challenge is accompanied by some thoughtful and pertinent commentary. Here are the first two challenges:

1. It can take awhile to find the “right” therapist and you shouldn’t stop at Therapist #1. Finding the right therapist can be a frustrating hit-or-miss proposition. But it’s also imperative…

2. Therapy is a strange, unnatural combination — an extremely personal, intimate relationship in a professional setting. The very nature of one’s relationship with a therapist is a little weird. Professionals rarely acknowledge it…

Mindfulness and Psychotherapy

Fluffy piece at the New York Times about the use of mindfulness techniques in therapy. This is a very popular area, combining meditation, and meditative practices with psychotherapy. The article rightfully points out both that interest in mindfulness techniques has a faddish quality, but also that it has substantial therapeutic benefits. This has been done by several psychotherapists, as well as in medical settings.

The article also mentions that the research findings to the practice have been lukewarm (second quote below). The reason the research is so inconclusive is that mindfulness meditation is very difficult to quantify. It is very difficult to get researchers to decide 1) which practice is going to be researched and then 2) how it is going to be defined. It sounds simple enough, but it’s a complicated problem.

The article trails off into a muddy ending listing several mindfulness practices: Tai Chi, Transcendental Meditation, Mindfulness Meditation, and Yoga. These are wildly different practices, and if researchers were comparing results from each of these in one study it would be ludicrous (they don’t). Each of these ‘mindful’ practices potentially has therapeutic benefit. Placing them together in some kind of grab-bag mindfulness category is rather sloppy.

Here’s a description of one practice:

Mindfulness meditation is easy to describe. Sit in a comfortable position, eyes closed, preferably with the back upright and unsupported. Relax and take note of body sensations, sounds and moods. Notice them without judgment. Let the mind settle into the rhythm of breathing. If it wanders (and it will), gently redirect attention to the breath. Stay with it for at least 10 minutes.

After mastering control of attention, some therapists say, a person can turn, mentally, to face a threatening or troubling thought — about, say, a strained relationship with a parent — and learn simply to endure the anger or sadness and let it pass, without lapsing into rumination or trying to change the feeling, a move that often backfires.

One woman, a doctor who had been in therapy for years to manage bouts of disabling anxiety, recently began seeing Gaea Logan, a therapist in Austin, Tex., who incorporates mindfulness meditation into her practice. This patient had plenty to worry about, including a mentally ill child, a divorce and what she described as a “harsh internal voice,” Ms. Logan said.

After practicing mindfulness meditation, she continued to feel anxious at times but told Ms. Logan, “I can stop and observe my feelings and thoughts and have compassion for myself.”

And here’s some research responses:

For all these hopeful signs, the science behind mindfulness is in its infancy. The Agency for Healthcare Research and Quality, which researches health practices, last year published a comprehensive review of meditation studies, including T.M., Zen and mindfulness practice, for a wide variety of physical and mental problems. The study found that over all, the research was too sketchy to draw conclusions.

A recent review by Canadian researchers, focusing specifically on mindfulness meditation, concluded that it did “not have a reliable effect on depression and anxiety.”

Kalea Chapman, Psy.D.

Criticism of Newseek Story on Child Bipolar

Furious Seasons (two separate posts) comments:

while it is an article filled with lots of detail and heart, it is also one of the worst pieces of journalism on the alleged disorder that I have ever seen.

Even more discouraging is the magazine’s handling of the most controversial diagnosis in all of psychiatry and psychology. The author, Mary Carmichael, admits a few times in the piece that the diagnosis of bipolar disorder in kids is controversial and that some doctors feel it’s overdiagnosed (since it doesn’t even exist in the DSM, it’s overdiagnosed by definition). However, Carmichael doesn’t include a single quote from a single critic of the child bipolar disorder paradigm.

Newsweek cover story on bipolar depression in kids has come under some heavy criticism. Peter Kramer, author of Listening to Prozac, comments:

A note regarding diagnosis: Yes, the Newsweek text and headlines are pitched to an interest in bipolar disorder, but who knows what this kid has?

Pharmacies to Sell Patient Records in California?

This is verbatim from a Furious Seasons post. It is extremely important news for consumers in California especially:

Pharmacies in California would be allowed to sell confidential patient prescription information to third-party marketing firms working for drug companies under a bill expected to be voted on Thursday by the state Senate.

“The legislation would allow pharmaceutical firms to send mailings directly to patients. Supporters of the proposal say the intent is to remind patients to take their medicine and order refills. But consumer privacy advocates are outraged.”

Is there simply no quit in the sales tactics of the pharma companies? I doubt that too many adults need to be sent reminders to take their meds each day. It’s time for “America’s pharmaceutical research companies,” as Montel Williams puts it, to get the hell out of peoples’ private lives. They already know what our docs prescribe anyway. Enough is enough.

We ban drug dealers and users to keep them away from schools. Why would we let these drug pushers into our homes and medical records?

Fifty Percent Jump of PTSD in Military

This month there’s been a lot of reporting on PTSD. The simple reason is that more and more veterans are returning from their tours of duty with the diagnosis. Below an excerpt from a Washington Post article documenting the 50 percent increase in the diagnosis last year.

Early in May the Rand Corporation suggested that 20 percent of troops returning from Afghanistan and Iraq suffer from the disorder. The recent Washington Post article suggests an even higher 30 percent. This is news because combat PTSD can be extremely debilitating. This is news because treatment of PTSD is going to cost the military and taxpayers a lot of money.

• Increase in diagnosis.
• VA discouraging the diagnosis.
• VA says PTSD “not a mental illness“
• Some tragic outcomes of returning veterans diagnosed with PTSD.
• Whether to award the Purple Heart for PTSD.
• Virtual Reality used to treat PTSD.
• Rate of PTSD connected to multiple tours of duty

Here’s the excerpt from the Washington Post article that cites a 50 percent increase in the diagnosis last year:

The number of U.S. troops diagnosed by the military with post-traumatic stress disorder (PTSD) jumped nearly 50 percent in 2007 over the previous year, as more of them served lengthy and repeated combat tours in Iraq and Afghanistan, Pentagon data released yesterday show.

The increase brings the total number of U.S. troops diagnosed by the military with PTSD after serving in one of the two conflicts from 2003 to 2007 to nearly 40,000.

The vast majority of those diagnosed served in the Army, which had a total of 28,365 cases, including more than 10,000 last year alone. The Marine Corps had the second highest number, with 5,581 total and 2,114 last year. The Air Force and Navy had fewer than 1,000 cases each last year, according to the data from the Office of the Surgeon General on a chart released by the Army.

Military officials cautioned that the numbers represent only a small fraction of all service members who have PTSD because not included are those diagnosed by Department of Veterans Affairs workers or civilian caregivers, and those who avoid seeking care out of concern over stigma or damage to their careers.

Treatment Resistant Depression and Lithium

Found a link to this story at Brain Blogger.

Dr. Shock MD PhD reports an interesting finding about the genetics possibly linked to treatment resistant depression: “Patients with the s/s genotype who according to the literature seem to be at risk for a less favorable response to antidepressant monotherapy might particularly benefit from augmentation strategies. …. early lithium augmentation in these patients (with the s/s genotype) could be a promising strategy and might help to reduce the occurrence of treatment resistance in depressive disorders.”

Although the definition of treatment resistant depression is not always clear, there are several options for treatment resistant depression resulting in 9 possible steps for treatment resistant depression. I am convinced that especially lithium addition is a very effective treatment strategy if an antidepressant fails and should be preferred above more experimental addition strategies such as atypical antipsychotics. Lithium addition can result in a response rate up to 50% in treatment resistant depression and has been studied in many RCT’s, reviews and meta analysis.

Individuals with the short allelic form of this variant showed an increased risk of depression compared to those carrying the long allele but only when exposed to adverse life events or maltreatment.

Women and Marketing Antipsychotics

Very interesting post with great visuals over at Writhe Safely. “I Will Be A Good Girl.” The post includes a typically ominous list of health-threatening side effects. Here’s one of the images:

Here’s the pitch:

Abilify is the medicine that brings you to your senses. Purchase Abilify from understanding international online pharmacies and licensed US pharmacies at savings of up to 85% off of retail and cheap prices with no prior prescription needed. Using our complete online form you can Purchase Abilify through our online foreign pharmacy. Let us fill your prescription with our lower cost online prescription drugs and receive high quality medications.

Here’s the lowdown:

These are not anti-depressants. They’re heavy-hitter atypical neuroleptics designed to treat psychosis; the manufacturers are merely expanding their market in an unrelenting campaign against insecure, anxious nailbiting women with garden variety moodswings.

Veteran Writes About PTSD, Kills Himself

This straight from Mindhacks, word for word:

An US Iraq veteran who wrote about his PTSD, sadly, kills himself.

This is a story that’s not going to go away any time soon. Here’s a link to a Washington Post article about a shift within the VA to diagnose adjustment disorder (no benefits) over PTSD ($2700 monthly benefits). Here are some of the veteran’s conclusions about his own experience:

• Medicine alone will not calm PTSD symptoms. Therapy is a must, and it has to be done with others who have experienced the same war or conflict. In other words, veterans of
Operation IRAQI FREEDOM should not be undergoing therapy with Vietnam or Operation DESERT STORM veterans. The symptoms are the same, but the time periods are different.
• Alcohol and pills don’t mix. The Marine/sailor should never be told that moderate alcohol consumption is acceptable.
• It is okay to mourn those you’ve lost, but remember, they don’t want you to be sad. They want you to celebrate their lives.
• PTSD is not a weakness. It is a normal reaction to a very violent situation.
• I firmly believe that a lot of my problems were caused by overmedication. The medication affected my judgment and my ability to cope with the true issues that haunted me. I also have since suffered from a seizure, which is believed to have occurred from the same cause. So, ensure that the Marines/sailors know that it is okay to question the amount of medications they are taking and why.
• Place more emphasis on the post-deployment health questionnaire all Marines/sailors have to fill out before leaving theater. I remember Marines being told that if they marked “yes” to anything, it would cause problems with their taking leave. They don’t know that PTSD is not even noticeable until they come home. Marines/ sailors should fill out these questionnaires honestly when they get back in garrison, and they need to know that it is okay if they are experiencing difficulties readjusting.
• Leaders should sit down with their Marines/sailors prior to releasing them for leave and cite different examples of PTSD so that they know what to expect and how to recognize
the symptoms.

And from a story on his suicide:

In his Marine Corps Gazette article, written after his fourth tour, he wrote: “All of my symptoms were back, and now I was in the process of destroying my family,” he wrote. “My only regrets are how I let my command down after they had put so much trust in me and how I let my family down by pushing them away.”

Tom Ricks at The Washington Post writes online today that in January he had “carried an excerpt from an article in the Marine Corps Gazette by Marine Staff Sgt. Travis N. Twiggs, detailing his struggle with the post-traumatic stress disorder that resulted from one tour of duty in Afghanistan and three in Iraq. Twiggs pulled no punches about his ‘psychosis,’ writing that he acted out combat episodes in the halls of the Bethesda National Naval Medical Center.

Difficult Emotional Decision? Just Take the Default

Here’s a fascinating behavioral account (decisions are not logical they are psychological) of how people decide whether to donate their organs or not. It’s written by Dan Ariely who calls himself a “behavioral economist” and touts his ideas in his book Predictably Irrational.

His hypothesis is that when faced with a difficult emotional we tend to take the default position (rather than select an option). The huge differences in rates of participation seem to be due to whether the form asked whether the individual wanted to opt-in to the program or opt-out.

Note:

• When the form asks to opt-in, then the default choice is to opt-out, and that’s what most people do in that circumstance.
• When the form asks to opt-out, then the default choice is to opt-in, and that’s what most people do in that circumstance.

The graph below speaks volumes:

So, what could explain these differences? It turns out that it is the design of the form at the DMV. In countries where the form is set as “opt-in” (check this box if you want to participate in the organ donation program) people do not check the box and as a consequence they do not become a part of the program. In countries where the form is set as “opt-out” (check this box if you don’t want to participate in the organ donation program) people also do not check the box and are automatically enrolled in the program. In both cases large proportions of people simply adopt the default option.

You might think that people do this because they don’t care. That the decision about donating their organs is so trivial that they can’t be bothered to lift up the pencil and check the box. But in fact the opposite is true. This is a hard emotional decision about what will happen to our bodies after we die and what effect it will have on our those close to us. It is because of the difficulty and the emotionality of these decisions that they just don’t know what to do so they adopt the default option (by the way this also happens to physicians making medical decisions, and also to people making investment and retirement decisions).

Public Television Show on Depression

Here’s a small part of depression introspection‘s reaction to the recently aired public television show “Depression: Out of the Shadows”. Overall, I’d say her reaction to the show was that it was a “depression 101″ exercise, and not that focussed. It did plug talk therapy, though.

My jaw nearly dropped to the carpet as Andrew Solomon, carefully plucked brightly colored pills from his pillbox that he takes every morning for his unipolar depression: Remeron, Zoloft, Zyprexa, Wellbutrin, Namenda, Ranitidine, and two kinds of fish oil. He might have even mentioned Prozac. He takes Namenda, an Alzheimer’s drug to combat the effects of an adverse interaction between Wellbutrin and one of the other drugs that I can’t remember. Solomon says he’s happy. I’m happy for him and I’m happy that his drug cocktail works for him but I couldn’t help but sit there and wonder, “Isn’t there a better way?”

It’s a thoughtful post, especially worth checking out if you saw the show.