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Saturday, June 27, 2015

Are antidepressants ineffective?

This question became quite controversial a few years ago when several authors made the assertion that these medications didn't work any better than placebo. This of course became a lightning rod for critics of pharmacological treatments. A few years later, I came across a very nice summary of the issue in a blog called Science-based Medicine. In retrospect, the answer seems to be the one that has now become widely accepted: that the medications do work, but not as well as might have been believed in the past. A nice thing about this contribution is that is is brief and easy to read, in distinction to some of the polemics that have appeared on this topic.

Friday, June 19, 2015

Suicidal thoughts in a chronic medical condition

A recent study looked at the predictors of suicidal thoughts in people with multiple sclerosis, which is a neurological condition characterized by inflammatory lesions occurring at different times and in different locations in the central nervous system. This work was summarized in a blog called "Everyday Health" and also in the Psychiatric Times. The frequency of suicidal ideation increased with age, which may reflect the increasing burden of such conditions as people get older. Also, the suicidal ideation was more severe in those with very difficult symptoms  to manage, such as bladder and bowel symptoms or difficulty swallowing. But, it is not just a situation of having to deal with difficult problems. The ways in which people coped with problems was also important. For example, those with emotionally focussed coping strategies (looking for ways to avoid painful emotions) had more suicidal ideation that those that used solution-oriented or problem solving strategies. A link the study can be found here.

Monday, June 8, 2015

Is Cognitive Behavioural Therapy Becoming Less Effective?

A recent meta-analysis examined the efficacy of CBT for unipolar major depression, finding a trend towards lower effectiveness over the past few decades. A copy of the paper may be obtained here. The authors hypothesized that diminishing effectiveness may be related to one of two factors: (1) as the therapy has become wildly popular, therapists may be diverging from the manualized protocols for CBT, in other words not administering the therapy to the same high standards as earlier clinical trials did, or (2) as more experience has been gained with the therapy, some of its mystique may have worn off - leading to lower placebo response in the active treatment arms. On the latter point, it is important to remember that in a trial the subset of participants receiving CBT has outcomes that are determined both the specific impact of the treatment and non-specific factors related to the therapy. I wonder if there might not be another explanation. In past decades, few people outside of the mental health world were even aware of CBT and often even the first few, psychoeducationally oriented, CBT sessions were real eye openers for them. The basic concepts of CBT sometimes led to a big change in peoples' ways of looking at the world. In this day and age, however, everyone has heard of CBT, many of read books about it or encountered similar ideas about the relationship between thoughts and emotions in popular media. Skillfully delivered CBT has a lot to offer people who only have a cursory knowledge of it, of those who have tried to do it themselves with books or websites devoted to CBT. However, nowadays, some proportion of the gains may already have been made before people enter therapy.