Dan Ariely has written an interesting book, based on his research, called Predictably Irrational (HarperCollins, 2008).
Ariely is an economist but his research is about human behaviour.
There are a lot of studies done over the past few decades in the field of social psychology, which illustrate very similar behavioural phenomena. Ariely's work reminds me specifically of the work of Robert Cialdini, a social psychologist who studied persuasion.
I think this work is important to look at, because it shows that there are powerful factors which influence our decision-making or judgment, which we may not be aware of. The factors are not mysterious phenomena residing in unconscious childhood memories, etc., but are fairly simple--here are some of Ariely's examples:
1) If a person has to choose between two things which are approximately equal (let's call them "item A" and "item B"), there is about a 50% chance of either one being chosen. Suppose a third thing is added, which is similar but modestly inferior to item A; let's call that thing "item A-". This third item could be called a "decoy". If a person has to choose one item out of this group of three, then item A is chosen much more often than item B (in Ariely's experiments, the "item A" gets chosen about 75% of the time).
These experiments show that our decisions are often strongly influenced by irrelevant comparisons.
2) If a cost of something is suggested, it causes us to form an "anchor" in our minds, such that we are more willing to pay that cost or thereabouts, regardless of the true value. This phenomenon is exploited in advertising. But I suspect that as a general principle, we may be influenced to choose something, or to invest a certain amount of energy or commitment into something, based on suggestions, precedents, or personal "anchors", instead of based on the "true value" of the thing.
3) People are much more likely to choose something that is "free" even if it is a worse deal than something else. Free offers substantially bias judgment. Ariel's studies show this nicely, in a quantitative way.
4) Monetary norms and social norms are conflicting motivators. Social norms are healthier and more powerful motivators. Motivations based on money are tenuous, shallow, and easily changeable. Motivations based on social goals are deeper and more stable. The corporate trend to optimize productivity by continuously monitoring worker output is a type of "monetary" strategy. On a social level, it is often offensive and demoralizing. If workers have a sense of social belonging in their workplace, and also a sense that their employer will care for them in a time of need, then the health of the entire system will be much stronger.
Social language can be a persuasive tactic in advertising though, typically through ads (such as with a bank, cable, or insurance company) which make it sound like your relationship with the seller will be something like with a friend or family member. Such advertising could seem persuasive to some, but I think most sellers would not behave like a friend or family member if you got sick and couldn't make your payment on time!
Ariely wisely encourages the development of healthier social goals in education -- to encourage
education as a means to participate in the improvement of society, rather than as a means to get higher scores on a standardized test, or to attain a higher-paying job.
5) Emotional arousal substantially increases the likelihood of making a risky decision. For example, his experiments showed that a random group of college students were about twice as likely to consider engaging in dangerous or illegal sexual activities if they were sexually aroused when asked about it. This phenomenon highlights the need for two types of protection: first, people need to be protected from the potential consequences of making rash decisions in the heat of passion (e.g. being equipped with condoms would protect against the risks of impulsively-chosen sexual activity).
Second--and this is a point that Ariely does not make--people cannot just learn about how to make decisions while in a cool, "rational" state. Perhaps it is important to teach people--through practice-- how to make decisions while in the heat of passion.
I think this is an important idea in a psychotherapeutic process: calm, gentle analysis of thoughts and emotions is valuable (whether this happens in a therapy session or in a CBT journal, etc.) but it may also be necessary to practice rational and healthy decision-making while in an emotionally heated state. This, too, can sometimes happen in therapy sessions, or in CBT journals, etc.
6) Procrastination. Ariely's studies with groups of students showed that a rigid, external imposition of regular deadlines led to the best grades. Requiring students to commit to their own set of deadlines, in advance, led to grades in a middle range. Having no deadlines at all, except for the requirement that all work had to be in by the end of the term, led to the worst grades. Those in the middle group who committed to regularly-spaced deadlines did as well as the first group. This experiment shows that people have a tendency to procrastinate (no surprise here!), and that a commitment to regularly-spaced deadlines is the best way to improve the quality of the work (whether this commitment is chosen by you, or imposed upon you).
I do suspect that there are individual exceptions to this -- I'd be curious to see a study to show this -- in which some people have a better experience with a bit less structure.
He gives a few good applications of this phenomenon: committing in advance to some kind of care plan (whether it be for your health, your car, your teeth, your finances, etc.) will make it less likely that you will procrastinate or forget to do these tasks (e.g. medical check-ups, oil changes, dental cleanings, etc.). With such a system, everyone benefits (e.g. you stay healthier, your car stays in good shape, the auto mechanics get regular work, etc.). The main problem with this is if you are being sold something that you don't really need. The solution is to be be well-informed in advance about the type of care that works best for your needs.
A psychotherapy frame is usually a regularly-spaced commitment of one's time--I certainly do find that people I see are more likely to engage in a beneficial therapeutic process if this kind of structure is in place.
7) Ownership. People have a tendency to value things more when they "own" them already (Ariely gives entertaining examples of studies showing this phenomenon in a monetary sense). This can lead to biased decision-making if the "owned" item is not valuable, necessary, or healthy. This is a similar phenomenon to loss-aversion. We don't like losing something, even if that something is not really good for us. Other social psychology research has shown that this principle applies to ideas as well: if we have espoused an idea, or a viewpoint, or an attitude, about something, we are much more likely to "own" this idea, and to stick to it. We are less likely to change our view, even if the view is unhealthy for us. I find such thinking patterns often involved in chronic depression.
This is definitely a phenomenon that occurs in a psychotherapy environment: therapy is an invitation to change. Even if the change leads to a better quality of life, people are resistant to change, and are more likely to hold on to systems of thought, perception, or behaviour, which perpetuate unhappiness.
8) People are more likely to choose things that seem to be disappearing. Ariely again demonstrates this phemonenon, using economic measures, in a clever experiment. We see this in sales tactics all the time, such as when we are warned that some item is selling out quickly, so we had better act soon! In life, we may tend to spend a harmful amount of time, energy, money, and commitment, keeping multiple options open: as a result, we may never get very far into any pathway we choose.
9) Stereotypes and expectations substantially affect behaviour and choice. In an amusing experiment involving a blinded beer-tasting test, Ariely showed that college subjects presented with two unlabeled containers actually preferred a beer that had been tainted by 10 drops of balsamic vinegar, over the untainted version. But if the students knew in advance that vinegar had been added, then nobody preferred the "vinegar beer". If we believe--or are persuaded to believe--that something is good or desirable, or that something is bad or undesirable (that "something" could be anything from toothpaste, to a new acquaintance, to a job, to our own self or our own skills), then we are significantly more likely to find our beliefs substantiated.
We need to have ways to "stand outside ourselves" at times, to reduce the biases caused by our own beliefs. I think that this, too, is one of the roles of psychotherapy.
10) Things that cost more tend to have a stronger effect. A more expensive placebo tends to be more effective than a less expensive placebo. This is an important, powerful bias to be aware of. This, too, can be a tool exploited by advertisers, in which the high price of their product is displayed prominently as a signifier of higher quality.
I have one major complaint about this book:
Ariely makes a few statements about medical treatments, including "when researchers tested the effect of the six leading antidepressants, they noted that 75% of the effect was duplicated in placebo controls." (p. 178) This claim is based on one single study, from a minor journal, published over 10 years ago, without considering other data from hundreds or thousands of other publications in the research literature. Furthermore, even if this 75% figure was accurate, the remaining 25% of the effect may be very significant for many suffering people. The psychological impact of Ariely's statement may be to cause skepticism and a dismissive attitude towards certain medical treatments, including antidepressant therapy. Ironically, Ariely would then be persuading people against something, based on a tiny, inadequate, and negatively-framed presentation of the evidence.
11) Randomly-chosen college students in Ariely's experiements had a strong tendency to cheat; but if these subjects were reminded of some kind of honour code immediately prior, they had a much smaller tendency to cheat. Based on his findings, he encourages a more prominent role for "honour codes" to reduce dishonesty. He observes that cheating is no trifling matter: fraud accounts for much more stolen money and property than all other forms of crime put together. Also, cheating is much more likely and pronounced if it is perceived to be indirect: people will cheat more if some kind of token is involved, even if the token is worth the same amount as actual money. Our society is evolving to use indirect currencies much more (various forms of credit, for example), which probably will increase systemic dishonesty.
The idea of an "honour code" may seem a bit odd or trite, maybe hard to take seriously. But I think its application could be imaginative and important, and could, at least in a small way, address something that is missing in many workplaces, homes, or individual lives. I suggest this not necessarily as a way to reduce dishonesty, but as a motivational tactic, that can remind us of ways to live healthily. Many workplaces or lives can be so caught up with being busy, competing, getting through the day, that a grounding sense of purpose is rarely contemplated.
An "honour code" in a psychotherapy frame could involve a formal set of statements for oneself, a "mission statement", which could guide choices, motivations, priorities, and attitudes over time.
So it could be an interesting exercise to write down, and answer for yourself:
"What are your morals/values/guiding principles?"
"What is it to be a good person?"
"How can I live honourably in a world which can be harsh and difficult at times, and in a life which can be harsh and difficult at times?"
etc.
Wednesday, April 1, 2009
Wednesday, March 25, 2009
Long-term antidepressant therapy to prevent relapse
Maintenance antidepressant therapy is likely to reduce the probability of depressive relapse. This would involve continuing to take an antidepressant, long-term, even when feeling better. I would restrict such a recommendation to those who have had recurrent or severe depressions. Such maintenance therapy is best indicated for those who have actually had an acute benefit from a specific antidepressant.
I emphasize the importance of psychotherapy and healthy lifestyle change, which also reduce relapse rates (in the case of CBT, for example, the reduction in relapse rate persists long after the course of CBT is over).
This is a 2008 link to findings from the so-called PREVENT study, which showed that 67% of patients on venlafaxine remained well over 2.5 years of follow-up, compared to 41% of patients on placebo:
http://www.ncbi.nlm.nih.gov/pubmed/18854724
A weakness of this study is that they did not allow for an extremely gradual taper of venlafaxine in the group randomized to receive placebo maintenance; therefore the worse outcome in the placebo maintenance group could have partly been due to withdrawal symptoms. However, there is a brief discussion of this possibility in some letters from the Journal of Clinical Psychiatry (2008 May; 69(5): 865-866) , and the authors of the PREVENT study make some good points about why withdrawal symptoms are not likely to account for the worse outcome in the placebo group.
There are a variety of older studies showing reduced relapse rates in patients taking long-term antidepressant maintenance. Here is an example, using imipramine:
http://www.ncbi.nlm.nih.gov/pubmed/8478502
Withdrawal effects are unlikely to account for the worse outcome in the control group, because the control group actually still received the active antidepressant, but just at a lower dose. The point of this study is that a full dose of the antidepressant is probably required in a long-term maintenance phase.
Here is another study from 1992 in Archives of General Psychiatry, showing significant preventative effects from taking full-dose imipramine over 5 years of follow-up, with or without adjunctive psychotherapy:
http://www.ncbi.nlm.nih.gov/pubmed/1417428
Here is a link to a 1990 study in Archives of General Psychiatry showing that full-dose imipramine had substantial preventative effects, moreso than interpersonal therapy, over 3 years of follow-up:
http://www.ncbi.nlm.nih.gov/pubmed/2244793
For this study, I need to go back and look carefully over the full text, which I can't find at this moment.
This study is another compelling piece of evidence, from JAMA in 1999, supporting antidepressant maintenance, and it had an excellent design:
http://www.ncbi.nlm.nih.gov/pubmed/9892449
It showed that elderly patients who had recovered from a bout of recurrent depression, who then received placebo, had a relapse rate of 90% over 3 years. Treatment with interpersonal psychotherapy alone reduced the relapse rate to 64% over 3 years. Treatment with the antidepressant nortriptyline alone reduced this relapse rate to 43% over 3 years. Nortriptyline plus interpersonal therapy combined, led to a relapse rate of only 20% over 3 years. Withdrawal effects from notriptyline are unlikely to have substantially favoured the nortriptyline group, since the follow-up was over a 3 year period, which is way beyond any period of withdrawal effects.
Here is another 2007 review paper, from The Canadian Journal of Psychiatry, summarizing strong research support that long-term antidepressant therapy reduces relapse rate in major depression by about 50%:
http://www.ncbi.nlm.nih.gov/pubmed/17953158
I emphasize the importance of psychotherapy and healthy lifestyle change, which also reduce relapse rates (in the case of CBT, for example, the reduction in relapse rate persists long after the course of CBT is over).
This is a 2008 link to findings from the so-called PREVENT study, which showed that 67% of patients on venlafaxine remained well over 2.5 years of follow-up, compared to 41% of patients on placebo:
http://www.ncbi.nlm.nih.gov/pubmed/18854724
A weakness of this study is that they did not allow for an extremely gradual taper of venlafaxine in the group randomized to receive placebo maintenance; therefore the worse outcome in the placebo maintenance group could have partly been due to withdrawal symptoms. However, there is a brief discussion of this possibility in some letters from the Journal of Clinical Psychiatry (2008 May; 69(5): 865-866) , and the authors of the PREVENT study make some good points about why withdrawal symptoms are not likely to account for the worse outcome in the placebo group.
There are a variety of older studies showing reduced relapse rates in patients taking long-term antidepressant maintenance. Here is an example, using imipramine:
http://www.ncbi.nlm.nih.gov/pubmed/8478502
Withdrawal effects are unlikely to account for the worse outcome in the control group, because the control group actually still received the active antidepressant, but just at a lower dose. The point of this study is that a full dose of the antidepressant is probably required in a long-term maintenance phase.
Here is another study from 1992 in Archives of General Psychiatry, showing significant preventative effects from taking full-dose imipramine over 5 years of follow-up, with or without adjunctive psychotherapy:
http://www.ncbi.nlm.nih.gov/pubmed/1417428
Here is a link to a 1990 study in Archives of General Psychiatry showing that full-dose imipramine had substantial preventative effects, moreso than interpersonal therapy, over 3 years of follow-up:
http://www.ncbi.nlm.nih.gov/pubmed/2244793
For this study, I need to go back and look carefully over the full text, which I can't find at this moment.
This study is another compelling piece of evidence, from JAMA in 1999, supporting antidepressant maintenance, and it had an excellent design:
http://www.ncbi.nlm.nih.gov/pubmed/9892449
It showed that elderly patients who had recovered from a bout of recurrent depression, who then received placebo, had a relapse rate of 90% over 3 years. Treatment with interpersonal psychotherapy alone reduced the relapse rate to 64% over 3 years. Treatment with the antidepressant nortriptyline alone reduced this relapse rate to 43% over 3 years. Nortriptyline plus interpersonal therapy combined, led to a relapse rate of only 20% over 3 years. Withdrawal effects from notriptyline are unlikely to have substantially favoured the nortriptyline group, since the follow-up was over a 3 year period, which is way beyond any period of withdrawal effects.
Here is another 2007 review paper, from The Canadian Journal of Psychiatry, summarizing strong research support that long-term antidepressant therapy reduces relapse rate in major depression by about 50%:
http://www.ncbi.nlm.nih.gov/pubmed/17953158
St. John's Wort
St. John's Wort is a herbal antidepressant. Its mechanism is not well-understood, and at this point is in the realm of speculation, but may involve multiple compounds rather than just a single ingredient (one of the many ingredients in St. John's Wort extracts, for example, is hyperforin).
There is an evidence base in the research literature, supporting its use. However, I find many of the articles to be published in minor journals, and to be of questionable quality.
I will restrict my present survey to a few studies that I consider to be of higher quality:
Here is an article abstract discussing possible mechanisms of action:
http://www.ncbi.nlm.nih.gov/pubmed/12775192
This is a reference to a Cochrane review from 2008.
http://www.ncbi.nlm.nih.gov/pubmed/18843608
It supports the use of St. John's Wort for treating major depression, and concludes that response rates were similar, compared to SSRIs and tricyclic antidepressants. It also concludes that St. John's Wort was much better-tolerated than other antidepressants, with a greatly reduced risk of side-effects or of discontinuing the medication due to side-effects. The authors note that studies from German-speaking countries tend to report a greater benefit from St. John's Wort.
I note that this review was written by authors from a "Centre for Complementary Medicine Research" in Germany. It may be that researchers at such a site could have a biased view in favour of complementary therapies.
This review from the major journal BMJ in 2005 gives much less enthusiastic conclusions about St. John's Wort:
http://www.ncbi.nlm.nih.gov/pubmed/15684231
It gives a rigorous analysis of the data, and concludes that there is evidence, mainly from older, smaller, lower-quality studies, that St. John's Wort is beneficial compared to placebo, particularly for mild to moderate depression. More recent, larger, more rigorous studies, and studies including patients with more severe depression, show smaller treatment effects.
It does strongly emphasize that different preparations of St. John's Wort may differ in quality, especially since it is an over-the-counter product in most places, and therefore may lack the guaranteed quality control of regulated pharmaceutical products.
Here are links to 2 carefully done studies from 2001 and 2002, published in JAMA, showing no therapeutic benefit of St. John's Wort. The first study compared only with placebo, the second study also compared with sertraline, an SSRI--in the latter study the sertraline actually didn't do well against placebo either! I have to wonder if particular samplings of depressed patients are relatively less treatment-responsive compared to placebo, for a variety of reasons. Also, it may be that some preparations of St. John's Wort are more effective than others:
http://www.ncbi.nlm.nih.gov/pubmed/11308434
http://www.ncbi.nlm.nih.gov/pubmed/11939866
Here is a link to a recent German study showing that people who respond to St. John's Wort have lower rates of relapse, compared to placebo, if they continue to take it for a year:
http://www.ncbi.nlm.nih.gov/pubmed/18694635
There are some interactions St. John's Wort may have with other drugs; mainly the concern is that St. John's Wort induces the liver to metabolize other drugs more actively, therefore reducing the levels of other drugs. This could be a danger for some people. Here is a reference about this:
http://www.ncbi.nlm.nih.gov/pubmed/15260917
There are case reports of St. John's Wort causing mania, so it would need to be used carefully in persons with bipolar disorder. But there are no studies that I can find, which give clear estimates of risk for St. John's Wort to cause mania or rapid cycling, particular when compared to other treatments for depression in bipolar disorder.
There is a poor evidence base looking at the safety of combining St. John's Wort with other antidepressants, but there are a few case reports of possibly dangerous states such as serotonin syndrome.
I will add to this posting later, but for now I would say that St. John's Wort is probably quite safe for most people, and is probably easier to tolerate (in terms of side-effects) than prescription antidepressants. It may be effective, for some people, to treat or reduce symptoms of depression and anxiety. It may reduce levels of other medications, including contraceptives, and may interact with other drugs, so these possibilities have to be considered very carefully, and discussed with your prescribing physician.
Also, I should add that different brands of St. John's Wort may differ in quality, differ in the extraction method used, etc. So if you are going to give St. John's Wort a try, it may be worthwhile to try several different brands. Given the abundance of positive research studies from Germany, it might be worthwhile to try a German brand.
Wednesday, March 18, 2009
How to Quit Smoking
It is difficult to quit smoking.
Here is my summary of the evidence about things that help:
The single most effective treatment to help smokers quit is a new drug called varenicline. This drug works by mildly stimulating a nicotine receptor, while blocking nicotine itself from interacting with the receptor: in this way it is a "nicotine receptor partial agonist." Varenicline is quite well-tolerated, the most common side-effects being nausea and insomnia. Usually these settle with time, and are less a problem if the dose is started low, and built up gradually. There have been reports of adverse psychiatric side effects (e.g. agitation, worsened insomnia, worsened depression) so it would have to be used cautiously in those with mental illnesses. I have reviewed a few studies below which affirm its usefulness among patients with psychiatric problems.
Evidence shows that there is only about a 10% chance of being able to quit smoking on your own (by quitting, we mean staying abstinent for at least a year).
A 3-month course of bupropion (an antidepressant) approximately doubles your chance of being able to quit. However, this raises your chance only to about 20%.
Tricyclic antidepressants such as nortriptyline can increase abstinence rates, probably comparable to bupropion.
Nicotine replacement (e.g. gum or patch) is less effective than bupropion. But it does increase your chances of quitting to about 15%.
Varenicline is most effective of all; a 3-month course increases your chance of quitting to about 25%.
Probably, combinations of the above pharmacological treatments increase your chances further.
Also I should note that many of the studies looking at pharmacological treatments for smoking addiction only used the active treatment for three months. It seems to me that longer courses of treatment would be more likely to help people maintain sustained abstinence; addictions and other long-standing phenomena in the brain persist, or change, over a course of years, not just months.
Psychotherapeutic strategies (e.g. CBT and other behavioural therapies) may help, but the evidence is weaker. The evidence that is available suggests that if psychotherapeutic or motivational strategies are to be effective, they need to be maintained over the long-term (perhaps permanently). In this regard, it reminds me of a "12-step" philosophy, which emphasizes the permanence of an addictive problem, and emphasizes that lifelong vigilance is needed to prevent relapse.
The following study published in CMAJ showed 54% 1-year abstinence in a group of smokers who had suffered an heart attack (MI), and who were given an "intensive anti-smoking intervention" (advice, an hour of counseling, and 7 telephone follow-up sessions over 60 days). The counseling employed "Marlatt and Gordon's relapse prevention model." A similar group of smokers not receiving this intervention had a 35% 1-year abstinence rate. Interestingly, medications were permitted in this study, and were associated with markedly worse abstinence rates. But the medications were administered more or less ad lib, so the effect of medications would be very confounded and unclear (for example, perhaps only the patients struggling most would have opted for medications--the reason they didn't do as well is because they were more severely addicted in the first place, not because of the medications. Also, with a haphazard administration of medications, patients might not realize the need to continue medications longer-term to maintain a therapeutic effect).
http://www.ncbi.nlm.nih.gov/pubmed/19546455
In my opinion, the level of "intervention" here actually seems quite minimal, yet it seems impressive that an organized effort of any kind to help prevent smoking through counseling methods would produce good results.
This is the best review article about medication treatments to date, in my opinion; it is from The Canadian Medical Association Journal (July 2008):
http://www.ncbi.nlm.nih.gov/pubmed/18625984?ordinalpos=87&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DefaultReportPanel.Pubmed_RVDocSum
A current study by Michael Steinberg et al. in Annals of Internal Medicine (2009;150:447-454) shows that combination therapy with bupropion + nicotine patch + nicotine inhaler, increased abstinence rates at 26 weeks to 35% in a group of medically ill smokers, compared to 19% in a group receiving only a nicotine patch. Those in the combination group were encouraged to use the treatments as long as they felt necessary, then to taper and discontinue as they felt able. This instruction, in my opinion, would have discouraged the participants from considering that bupropion could work to prevent relapse in the long-term, therefore they would probably have chosen to discontinue the bupropion as soon as they felt free of their smoking habit for a short time. As I look at the study in detail, I see that most of the combination group indeed did not maintain the bupropion beyond the 3 month mark. I suspect that if people were strongly encouraged to continue the treatments longer, on a preventative basis, then the abstinence rates could have been much higher than 35%.
Here is a 2005 meta-analysis showing that the tricyclic antidepressant nortriptyline can be effective. Once again, the effects were significant but modest. Most of the studies used only a standard 3-month course of treatment, followed by a taper and discontinuing the nortriptyline. In the one study allowing a full year of nortriptyline treatment, the abstinence rate was much higher (40%):
http://www.ncbi.nlm.nih.gov/pubmed/15733245?ordinalpos=1&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DiscoveryPanel.Pubmed_Discovery_RA&linkpos=4&log$=relatedreviews&logdbfrom=pubmed
Similarly, in a study maintaining varenicline for 52 weeks, the abstinence rate was 36.7%, compared to 7.9% with placebo. However, while the existing evidence about the safety of using varenicline on a long-term basis is generally reassuring, more long-term experience is necessary with this drug to know for sure. I think the potential risks would have to be weighed against the risks of continuing to smoke. Here is a link to the study:
http://www.ncbi.nlm.nih.gov/pubmed/17407636?ordinalpos=1&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DiscoveryPanel.Pubmed_Discovery_RA&linkpos=1&log$=relatedarticles&logdbfrom=pubmed
Similarly again, in the one long-term study of bupropion (a full year of medication), there were considerably higher abstinence rates:
http://www.ncbi.nlm.nih.gov/pubmed/11560455?ordinalpos=18&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DefaultReportPanel.Pubmed_RVDocSum
The following small study showed that varenicline helped reduce smoking in patients with schizophrenia, and appeared to have some beneficial cognitive effects in this group.
http://www.ncbi.nlm.nih.gov/pubmed/19251401?ordinalpos=6&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DefaultReportPanel.Pubmed_RVDocSum
The following small study showed possible increased abstinence rates when varenicline and bupropion therapy was combined:
http://www.ncbi.nlm.nih.gov/pubmed/19246427?ordinalpos=8&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DefaultReportPanel.Pubmed_RVDocSum
Another study supporting the idea that combination therapy (e.g. varenicline + nicotine replacement) is more effective than one treatment alone, for helping smokers quit:
http://www.ncbi.nlm.nih.gov/pubmed/18826906?ordinalpos=56&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DefaultReportPanel.Pubmed_RVDocSum
The following study shows that varenicline is similarly tolerated and effective in patients with depression, compared with patients without a history of depression. Stress and mood scores improved slightly with time:
http://www.ncbi.nlm.nih.gov/pubmed/19238488?ordinalpos=12&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DefaultReportPanel.Pubmed_RVDocSum
This 2009 study from Biological Psychiatry suggests that varenicline could also reduce alcohol consumption in heavy-drinking smokers:
http://www.ncbi.nlm.nih.gov/pubmed/19249750?ordinalpos=2&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DefaultReportPanel.Pubmed_RVDocSum
This is a 2009 Cochrane review of smoking relapse prevention interventions; it supports extended treatment with varenicline to prevent relapse, and concludes that there is insufficient evidence at this point to comment one way or another on specific behaviour therapies:
http://www.ncbi.nlm.nih.gov/pubmed/19160228?ordinalpos=1&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DiscoveryPanel.Pubmed_Discovery_RA&linkpos=1&log$=relatedreviews&logdbfrom=pubmed
This study looked at 20 weeks of adjunctive CBT, and found no significant difference in abstinence rates after a year. But it did find an advantage in the CBT group in the shorter term, during the course of CBT (45% abstinence in the CBT group vs. 29% in the control group, at the 20 week mark). This suggests that long-term, ongoing, continuous CBT may be helpful to boost abstinence rates, but the therapy loses its effectiveness if it is not maintained:
http://www.ncbi.nlm.nih.gov/pubmed/18855829?ordinalpos=3&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DefaultReportPanel.Pubmed_RVDocSum
All of these studies support the idea that smoking addiction is a long-term problem. Short-term strategies (typically over a few months) definitely help, but long-term, continuing effort or treatment is needed to maintain abstinence for most people. These strategies could include medications such as varenicline, bupropion, or nortriptyline; and they could include psychotherapeutic approaches such as CBT.
Individuals with psychiatric illnesses such as depression, bipolar disorder, ADHD, and especially schizophrenia, have much higher rates of smoking. Here is a reference:
http://www.ncbi.nlm.nih.gov/pubmed/15949648?ordinalpos=1&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DiscoveryPanel.Pubmed_Discovery_RA&linkpos=2&log$=relatedarticles&logdbfrom=pubmed
There is evidence that nicotine can acutely improve elements of cognitive performance and to reduce impulsivity, particularly in those with illnesses such as schizophrenia and ADHD. This may be one of the reasons why individuals with these problems are more drawn to cigarette smoking. Here is some evidence:
http://www.ncbi.nlm.nih.gov/pubmed/17443126?ordinalpos=6&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DefaultReportPanel.Pubmed_RVDocSum
http://www.ncbi.nlm.nih.gov/pubmed/18022679
Also there is evidence that nicotine can improve performance in attention tests in elderly people with dementia:
http://www.ncbi.nlm.nih.gov/pubmed/10326778?ordinalpos=1&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DiscoveryPanel.Pubmed_Discovery_RA&linkpos=3&log$=relatedarticles&logdbfrom=pubmed
Yet, of course, nicotine has numerous harmful effects. And it is likely that nicotine could cause long-term harm to cognitive function, through several mechanisms, even if it causes short-term enhancement. A medication such as varenicline, due to its agonist effect on nicotine receptors, may be especially helpful to address some of the cognitive or attentional problems in persons with mental illnesses.
In terms of health care policy, I am puzzled about why effective therapies to improve smoking cessation are not publicly funded. Smoking is one of the largest public health problems in the world, and causes an enormous burden of premature disease and death, as well as an enormous financial drain on the health care system. I believe that all proven therapies for smoking cessation should be freely available.
Unfortunately, varenicline -- and other anti-smoking therapies -- are expensive, and they are often not covered by health plans.
Here is my summary of the evidence about things that help:
The single most effective treatment to help smokers quit is a new drug called varenicline. This drug works by mildly stimulating a nicotine receptor, while blocking nicotine itself from interacting with the receptor: in this way it is a "nicotine receptor partial agonist." Varenicline is quite well-tolerated, the most common side-effects being nausea and insomnia. Usually these settle with time, and are less a problem if the dose is started low, and built up gradually. There have been reports of adverse psychiatric side effects (e.g. agitation, worsened insomnia, worsened depression) so it would have to be used cautiously in those with mental illnesses. I have reviewed a few studies below which affirm its usefulness among patients with psychiatric problems.
Evidence shows that there is only about a 10% chance of being able to quit smoking on your own (by quitting, we mean staying abstinent for at least a year).
A 3-month course of bupropion (an antidepressant) approximately doubles your chance of being able to quit. However, this raises your chance only to about 20%.
Tricyclic antidepressants such as nortriptyline can increase abstinence rates, probably comparable to bupropion.
Nicotine replacement (e.g. gum or patch) is less effective than bupropion. But it does increase your chances of quitting to about 15%.
Varenicline is most effective of all; a 3-month course increases your chance of quitting to about 25%.
Probably, combinations of the above pharmacological treatments increase your chances further.
Also I should note that many of the studies looking at pharmacological treatments for smoking addiction only used the active treatment for three months. It seems to me that longer courses of treatment would be more likely to help people maintain sustained abstinence; addictions and other long-standing phenomena in the brain persist, or change, over a course of years, not just months.
Psychotherapeutic strategies (e.g. CBT and other behavioural therapies) may help, but the evidence is weaker. The evidence that is available suggests that if psychotherapeutic or motivational strategies are to be effective, they need to be maintained over the long-term (perhaps permanently). In this regard, it reminds me of a "12-step" philosophy, which emphasizes the permanence of an addictive problem, and emphasizes that lifelong vigilance is needed to prevent relapse.
The following study published in CMAJ showed 54% 1-year abstinence in a group of smokers who had suffered an heart attack (MI), and who were given an "intensive anti-smoking intervention" (advice, an hour of counseling, and 7 telephone follow-up sessions over 60 days). The counseling employed "Marlatt and Gordon's relapse prevention model." A similar group of smokers not receiving this intervention had a 35% 1-year abstinence rate. Interestingly, medications were permitted in this study, and were associated with markedly worse abstinence rates. But the medications were administered more or less ad lib, so the effect of medications would be very confounded and unclear (for example, perhaps only the patients struggling most would have opted for medications--the reason they didn't do as well is because they were more severely addicted in the first place, not because of the medications. Also, with a haphazard administration of medications, patients might not realize the need to continue medications longer-term to maintain a therapeutic effect).
http://www.ncbi.nlm.nih.gov/pubmed/19546455
In my opinion, the level of "intervention" here actually seems quite minimal, yet it seems impressive that an organized effort of any kind to help prevent smoking through counseling methods would produce good results.
This is the best review article about medication treatments to date, in my opinion; it is from The Canadian Medical Association Journal (July 2008):
http://www.ncbi.nlm.nih.gov/pubmed/18625984?ordinalpos=87&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DefaultReportPanel.Pubmed_RVDocSum
A current study by Michael Steinberg et al. in Annals of Internal Medicine (2009;150:447-454) shows that combination therapy with bupropion + nicotine patch + nicotine inhaler, increased abstinence rates at 26 weeks to 35% in a group of medically ill smokers, compared to 19% in a group receiving only a nicotine patch. Those in the combination group were encouraged to use the treatments as long as they felt necessary, then to taper and discontinue as they felt able. This instruction, in my opinion, would have discouraged the participants from considering that bupropion could work to prevent relapse in the long-term, therefore they would probably have chosen to discontinue the bupropion as soon as they felt free of their smoking habit for a short time. As I look at the study in detail, I see that most of the combination group indeed did not maintain the bupropion beyond the 3 month mark. I suspect that if people were strongly encouraged to continue the treatments longer, on a preventative basis, then the abstinence rates could have been much higher than 35%.
Here is a 2005 meta-analysis showing that the tricyclic antidepressant nortriptyline can be effective. Once again, the effects were significant but modest. Most of the studies used only a standard 3-month course of treatment, followed by a taper and discontinuing the nortriptyline. In the one study allowing a full year of nortriptyline treatment, the abstinence rate was much higher (40%):
http://www.ncbi.nlm.nih.gov/pubmed/15733245?ordinalpos=1&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DiscoveryPanel.Pubmed_Discovery_RA&linkpos=4&log$=relatedreviews&logdbfrom=pubmed
Similarly, in a study maintaining varenicline for 52 weeks, the abstinence rate was 36.7%, compared to 7.9% with placebo. However, while the existing evidence about the safety of using varenicline on a long-term basis is generally reassuring, more long-term experience is necessary with this drug to know for sure. I think the potential risks would have to be weighed against the risks of continuing to smoke. Here is a link to the study:
http://www.ncbi.nlm.nih.gov/pubmed/17407636?ordinalpos=1&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DiscoveryPanel.Pubmed_Discovery_RA&linkpos=1&log$=relatedarticles&logdbfrom=pubmed
Similarly again, in the one long-term study of bupropion (a full year of medication), there were considerably higher abstinence rates:
http://www.ncbi.nlm.nih.gov/pubmed/11560455?ordinalpos=18&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DefaultReportPanel.Pubmed_RVDocSum
The following small study showed that varenicline helped reduce smoking in patients with schizophrenia, and appeared to have some beneficial cognitive effects in this group.
http://www.ncbi.nlm.nih.gov/pubmed/19251401?ordinalpos=6&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DefaultReportPanel.Pubmed_RVDocSum
The following small study showed possible increased abstinence rates when varenicline and bupropion therapy was combined:
http://www.ncbi.nlm.nih.gov/pubmed/19246427?ordinalpos=8&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DefaultReportPanel.Pubmed_RVDocSum
Another study supporting the idea that combination therapy (e.g. varenicline + nicotine replacement) is more effective than one treatment alone, for helping smokers quit:
http://www.ncbi.nlm.nih.gov/pubmed/18826906?ordinalpos=56&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DefaultReportPanel.Pubmed_RVDocSum
The following study shows that varenicline is similarly tolerated and effective in patients with depression, compared with patients without a history of depression. Stress and mood scores improved slightly with time:
http://www.ncbi.nlm.nih.gov/pubmed/19238488?ordinalpos=12&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DefaultReportPanel.Pubmed_RVDocSum
This 2009 study from Biological Psychiatry suggests that varenicline could also reduce alcohol consumption in heavy-drinking smokers:
http://www.ncbi.nlm.nih.gov/pubmed/19249750?ordinalpos=2&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DefaultReportPanel.Pubmed_RVDocSum
This is a 2009 Cochrane review of smoking relapse prevention interventions; it supports extended treatment with varenicline to prevent relapse, and concludes that there is insufficient evidence at this point to comment one way or another on specific behaviour therapies:
http://www.ncbi.nlm.nih.gov/pubmed/19160228?ordinalpos=1&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DiscoveryPanel.Pubmed_Discovery_RA&linkpos=1&log$=relatedreviews&logdbfrom=pubmed
This study looked at 20 weeks of adjunctive CBT, and found no significant difference in abstinence rates after a year. But it did find an advantage in the CBT group in the shorter term, during the course of CBT (45% abstinence in the CBT group vs. 29% in the control group, at the 20 week mark). This suggests that long-term, ongoing, continuous CBT may be helpful to boost abstinence rates, but the therapy loses its effectiveness if it is not maintained:
http://www.ncbi.nlm.nih.gov/pubmed/18855829?ordinalpos=3&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DefaultReportPanel.Pubmed_RVDocSum
All of these studies support the idea that smoking addiction is a long-term problem. Short-term strategies (typically over a few months) definitely help, but long-term, continuing effort or treatment is needed to maintain abstinence for most people. These strategies could include medications such as varenicline, bupropion, or nortriptyline; and they could include psychotherapeutic approaches such as CBT.
Individuals with psychiatric illnesses such as depression, bipolar disorder, ADHD, and especially schizophrenia, have much higher rates of smoking. Here is a reference:
http://www.ncbi.nlm.nih.gov/pubmed/15949648?ordinalpos=1&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DiscoveryPanel.Pubmed_Discovery_RA&linkpos=2&log$=relatedarticles&logdbfrom=pubmed
There is evidence that nicotine can acutely improve elements of cognitive performance and to reduce impulsivity, particularly in those with illnesses such as schizophrenia and ADHD. This may be one of the reasons why individuals with these problems are more drawn to cigarette smoking. Here is some evidence:
http://www.ncbi.nlm.nih.gov/pubmed/17443126?ordinalpos=6&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DefaultReportPanel.Pubmed_RVDocSum
http://www.ncbi.nlm.nih.gov/pubmed/18022679
Also there is evidence that nicotine can improve performance in attention tests in elderly people with dementia:
http://www.ncbi.nlm.nih.gov/pubmed/10326778?ordinalpos=1&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DiscoveryPanel.Pubmed_Discovery_RA&linkpos=3&log$=relatedarticles&logdbfrom=pubmed
Yet, of course, nicotine has numerous harmful effects. And it is likely that nicotine could cause long-term harm to cognitive function, through several mechanisms, even if it causes short-term enhancement. A medication such as varenicline, due to its agonist effect on nicotine receptors, may be especially helpful to address some of the cognitive or attentional problems in persons with mental illnesses.
In terms of health care policy, I am puzzled about why effective therapies to improve smoking cessation are not publicly funded. Smoking is one of the largest public health problems in the world, and causes an enormous burden of premature disease and death, as well as an enormous financial drain on the health care system. I believe that all proven therapies for smoking cessation should be freely available.
Unfortunately, varenicline -- and other anti-smoking therapies -- are expensive, and they are often not covered by health plans.
Tuesday, March 17, 2009
Psychoanalysis & Neuroplasticity
This post is based in part on my thoughts regarding Doidge's book on neuroplasticity.
Psychoanalysis is a type of psychotherapy in which patients usually attend sessions almost every day (3-5 days per week, 50 minutes each time). The details of theory and practice vary, but in general psychoanalysts tend to believe that early childhood events and memories are very important to examine and understand, and that these events (e.g. relationships with mother) have direct causal links to adult personality traits and psychological symptoms. Also psychoanalysts tend to believe that the relationship with the therapist is a setting in which prior relationship dynamics recur, in the form of "transference." Most psychoanalysts assume a relatively quiet or passive stance, tending not to have active conversation or "problem solving" dialogs with patients. Also most psychoanalysts would tend to interpret various types of phenomena, such as dreams, behavioural habits, etc. as laden with meaning. A course of psychoanalysis might take years, and in general the model would be that the patient would "work through" various childhood conflicts, including as they might be transferentially manifest in the therapy, and that the patient might come to understand the various themes at play in their lives, as manifest in dreams, habits, and interpersonal behaviour. This process of understanding and "working through" is thought to lead to symptom relief and life change.
Doidge himself is a psychoanalyst. One of the chapters in his book describes psychoanalysis as a "neuroplastic therapy." (chapter 9, Turning our Ghosts into Ancestors). Part of the support for his claim comes from a case study (a type of evidence characteristic of psychoanalytic thinking). And part of his support comes from briefly describing the life and work of Eric Kandel, the great nobel laureate neuroscientist.
Kandel's work brilliantly demonstrated some of the specific anatomic and molecular changes that happen in neurons as memories are formed.
Kandel himself has been an advocate of incorporating recent biological scientific knowledge into the practice of psychiatry and psychoanalysis (see: http://www.hhmi.org/bulletin/kandel/), and had apparently planned to become a psychoanalyst himself.
I consider it not to be particularly relevant to mention Kandel at all, other than to quote someone important who probably considers psychoanalysis a good thing. It is a common sales tactic to mention an important person's name while trying to convince someone of something. Also it is common in medicine and psychiatry--but especially in alternative medicine--for there to be some mention of something that sounds "scientific" to bolster the public opinion of a product, while the science itself, if looked at closely, is only obliquely related. For example, many questionably effective naturopathic remedies, sold at quite a profit, include advertising laden with some kind of biochemical jargon, much of which, at close examination, lacks substance, but which sounds impressive.
I believe that psychoanalysis can be a powerful and transformative experience. However,I also strongly suspect that there are elements of dogma contained within the theory which are irrelevant to its beneficial effects, and which at times could make it an inefficient therapy.
Consider this thought experiment:
Suppose the beneficial effects of psychoanalysis are due to the following factors:
1) meeting with someone for an hour per day, who will listen and try to understand life problems
2) finding an "explanation" for symptoms. In the case of psychoanalysis this explanation tends to come from an examination of early life events.
Suppose that it is the belief in the explanation that causes symptom improvement, therefore that if some alternative "explanation" for symptoms could be developed, then it would lead to the same symptom improvement. Therefore, suppose that the psychoanalytic theory of character and symptom development is actually a fiction, akin to a dogmatic religious belief system, but that adherence to this belief system, and the resultant faith and conviction, would be the causes of symptom relief and character change.
A way to test this would be to conduct a randomized study of two types of intensive, long-term psychotherapy. Both would be 5 sessions per week, 50 minutes per session, lasting 5 years.
Group 1 patients would have psychoanalysis.
Group 2 patients would receive the same intensive, empathic, sessions, with intelligent and thoughtful, well-boundaried therapists. But let us imagine that some other belief system would underlie the therapy for group 2. For example, astrology. Or some form of religious fundamentalism (of any variety). Here, interpretations would be based on the positions of stars & planets, or on passages from religious texts.
A condition for this type of experiment would be that the patients in both groups would have to lack any differences in bias for or against the style of therapy. So, for example, patients in group 1 would have to have a similar level of belief that psychoanalysis is a valid and culturally-accepted system of thought, and have similar respect for the therapist, compared to the beliefs about therapist and therapy style of patients in group 2 (regarding astrology or fundamentalism, etc.).
In both groups, I suspect that subject matter would come up in the sessions, which would require the therapists to respond either empathically or interpretively. There would probably be dreams that would come up, probably interpreted quite differently--or not at all-- in both groups. The process of therapy, dream interpretation, feelings of closeness with therapist, etc. might well be experienced similarly between groups.
My hypothesis is that both the groups would show similar improvement in a 5 year course of therapy, with only a slight advantage for group 1. I believe this is because the core effect of such therapy is not from the theoretical belief system, but from the process, which is caring, consistent, empathic, understanding, and interpretive. Failed therapy experiences may happen in both groups, some of which because the patients do not like the style or belief system which is being introduced, some of which because life problems can be treatment-resistant at times, some of which because the patient did not feel well-matched with the therapist. I think group 1 would do very slightly better than group 2, because despite the dogma involved in psychoanalytic theory, the underlying process is more intellectually open (at its best).
Unfortunately, I think there is a substantial risk for people in both groups to come out of the experience with stronger dogmatic beliefs, irrespective of any therapeutic improvement. In a more mature psychoanalytic frame, I think this risk would be diminished, as the process would hopefully be more intellectually open.
I do believe that we as intelligent creatures should always seek the "truth" as best we can know it, and therefore we need to challenge our dogmas. The best therapies, in my opinion, need to seek such truths without being restricted by dogma. This is consistent with the underlying theme of psychoanalysis, which I think is about liberation (liberation from symptoms, liberation from past harms or traumas, etc.).
I am reminded now of Joseph Campbell, the comparative mythologist, who might argue that the different styles of therapy are something like different mythologies, none of which are literally "true", but perhaps all of which might contain core aspects of wisdom about the human condition. He might also argue that dogmatic, literalistic adherence to any system of belief could obstruct its underlying message. But he would also agree, I think, that one has to have "faith"--a sense of trust, engagement, and belief--in order to have a transformative experience from anything.
In psychoanalysis, I think it is immensely valuable to seek meaning by examining early childhood events, and by searching for meaning and themes in dreams and nuances of behaviour. But I think it can be can be obstructive to believe, literally, for example, that specific non-traumatic events or patterns of engagement with one's mother at the age of 2, are the causes of specific adult symptoms. I consider the greatness of psychoanalytic interpretation to lie in its focus upon a human life as though it is a great novel or work of art, and that the therapy is partly an experience of understanding, analyzing themes, interpreting, looking at context, in order to enrichen the experience of the art.
A weakness in psychoanalytic practice can, in my opinion, be due to its passive approach at times, which can render it less efficient. Another weakness can be due to a dogmatic or literalistic over-absorption with the theory, causing the therapy to digress--sometimes for years--into an examination of early childhood events, when the core elements of therapeutic need lie solidly in the present, or in the more recent past. I think modern psychoanalysis needs to much more actively incorporate ideas from cognitive and behavioural therapies, from social psychology, as well as from behavioural genetics, etc., and to actively question its dogma.
From a "neuroplastic" point of view, I think the immense advantage of psychoanalysis is in the frame, which is intense (5 days per week), long-term (over years), intellectually open (anything that passes through one's mind is encouraged to be spoken), and consistent. If one was taking language or music lessons, we would see MUCH more "neuroplastic change" in the brain (and, much more importantly, we would see much more language or music learning), if the lessons took place 5 times a week for 5 years, rather than just once a week for 6 months. The consistency and discipline of the psychoanalytic frame is powerfully motivational, just as is any other consistent and disciplined educational framework.
Psychoanalysis is a type of psychotherapy in which patients usually attend sessions almost every day (3-5 days per week, 50 minutes each time). The details of theory and practice vary, but in general psychoanalysts tend to believe that early childhood events and memories are very important to examine and understand, and that these events (e.g. relationships with mother) have direct causal links to adult personality traits and psychological symptoms. Also psychoanalysts tend to believe that the relationship with the therapist is a setting in which prior relationship dynamics recur, in the form of "transference." Most psychoanalysts assume a relatively quiet or passive stance, tending not to have active conversation or "problem solving" dialogs with patients. Also most psychoanalysts would tend to interpret various types of phenomena, such as dreams, behavioural habits, etc. as laden with meaning. A course of psychoanalysis might take years, and in general the model would be that the patient would "work through" various childhood conflicts, including as they might be transferentially manifest in the therapy, and that the patient might come to understand the various themes at play in their lives, as manifest in dreams, habits, and interpersonal behaviour. This process of understanding and "working through" is thought to lead to symptom relief and life change.
Doidge himself is a psychoanalyst. One of the chapters in his book describes psychoanalysis as a "neuroplastic therapy." (chapter 9, Turning our Ghosts into Ancestors). Part of the support for his claim comes from a case study (a type of evidence characteristic of psychoanalytic thinking). And part of his support comes from briefly describing the life and work of Eric Kandel, the great nobel laureate neuroscientist.
Kandel's work brilliantly demonstrated some of the specific anatomic and molecular changes that happen in neurons as memories are formed.
Kandel himself has been an advocate of incorporating recent biological scientific knowledge into the practice of psychiatry and psychoanalysis (see: http://www.hhmi.org/bulletin/kandel/), and had apparently planned to become a psychoanalyst himself.
I consider it not to be particularly relevant to mention Kandel at all, other than to quote someone important who probably considers psychoanalysis a good thing. It is a common sales tactic to mention an important person's name while trying to convince someone of something. Also it is common in medicine and psychiatry--but especially in alternative medicine--for there to be some mention of something that sounds "scientific" to bolster the public opinion of a product, while the science itself, if looked at closely, is only obliquely related. For example, many questionably effective naturopathic remedies, sold at quite a profit, include advertising laden with some kind of biochemical jargon, much of which, at close examination, lacks substance, but which sounds impressive.
I believe that psychoanalysis can be a powerful and transformative experience. However,I also strongly suspect that there are elements of dogma contained within the theory which are irrelevant to its beneficial effects, and which at times could make it an inefficient therapy.
Consider this thought experiment:
Suppose the beneficial effects of psychoanalysis are due to the following factors:
1) meeting with someone for an hour per day, who will listen and try to understand life problems
2) finding an "explanation" for symptoms. In the case of psychoanalysis this explanation tends to come from an examination of early life events.
Suppose that it is the belief in the explanation that causes symptom improvement, therefore that if some alternative "explanation" for symptoms could be developed, then it would lead to the same symptom improvement. Therefore, suppose that the psychoanalytic theory of character and symptom development is actually a fiction, akin to a dogmatic religious belief system, but that adherence to this belief system, and the resultant faith and conviction, would be the causes of symptom relief and character change.
A way to test this would be to conduct a randomized study of two types of intensive, long-term psychotherapy. Both would be 5 sessions per week, 50 minutes per session, lasting 5 years.
Group 1 patients would have psychoanalysis.
Group 2 patients would receive the same intensive, empathic, sessions, with intelligent and thoughtful, well-boundaried therapists. But let us imagine that some other belief system would underlie the therapy for group 2. For example, astrology. Or some form of religious fundamentalism (of any variety). Here, interpretations would be based on the positions of stars & planets, or on passages from religious texts.
A condition for this type of experiment would be that the patients in both groups would have to lack any differences in bias for or against the style of therapy. So, for example, patients in group 1 would have to have a similar level of belief that psychoanalysis is a valid and culturally-accepted system of thought, and have similar respect for the therapist, compared to the beliefs about therapist and therapy style of patients in group 2 (regarding astrology or fundamentalism, etc.).
In both groups, I suspect that subject matter would come up in the sessions, which would require the therapists to respond either empathically or interpretively. There would probably be dreams that would come up, probably interpreted quite differently--or not at all-- in both groups. The process of therapy, dream interpretation, feelings of closeness with therapist, etc. might well be experienced similarly between groups.
My hypothesis is that both the groups would show similar improvement in a 5 year course of therapy, with only a slight advantage for group 1. I believe this is because the core effect of such therapy is not from the theoretical belief system, but from the process, which is caring, consistent, empathic, understanding, and interpretive. Failed therapy experiences may happen in both groups, some of which because the patients do not like the style or belief system which is being introduced, some of which because life problems can be treatment-resistant at times, some of which because the patient did not feel well-matched with the therapist. I think group 1 would do very slightly better than group 2, because despite the dogma involved in psychoanalytic theory, the underlying process is more intellectually open (at its best).
Unfortunately, I think there is a substantial risk for people in both groups to come out of the experience with stronger dogmatic beliefs, irrespective of any therapeutic improvement. In a more mature psychoanalytic frame, I think this risk would be diminished, as the process would hopefully be more intellectually open.
I do believe that we as intelligent creatures should always seek the "truth" as best we can know it, and therefore we need to challenge our dogmas. The best therapies, in my opinion, need to seek such truths without being restricted by dogma. This is consistent with the underlying theme of psychoanalysis, which I think is about liberation (liberation from symptoms, liberation from past harms or traumas, etc.).
I am reminded now of Joseph Campbell, the comparative mythologist, who might argue that the different styles of therapy are something like different mythologies, none of which are literally "true", but perhaps all of which might contain core aspects of wisdom about the human condition. He might also argue that dogmatic, literalistic adherence to any system of belief could obstruct its underlying message. But he would also agree, I think, that one has to have "faith"--a sense of trust, engagement, and belief--in order to have a transformative experience from anything.
In psychoanalysis, I think it is immensely valuable to seek meaning by examining early childhood events, and by searching for meaning and themes in dreams and nuances of behaviour. But I think it can be can be obstructive to believe, literally, for example, that specific non-traumatic events or patterns of engagement with one's mother at the age of 2, are the causes of specific adult symptoms. I consider the greatness of psychoanalytic interpretation to lie in its focus upon a human life as though it is a great novel or work of art, and that the therapy is partly an experience of understanding, analyzing themes, interpreting, looking at context, in order to enrichen the experience of the art.
A weakness in psychoanalytic practice can, in my opinion, be due to its passive approach at times, which can render it less efficient. Another weakness can be due to a dogmatic or literalistic over-absorption with the theory, causing the therapy to digress--sometimes for years--into an examination of early childhood events, when the core elements of therapeutic need lie solidly in the present, or in the more recent past. I think modern psychoanalysis needs to much more actively incorporate ideas from cognitive and behavioural therapies, from social psychology, as well as from behavioural genetics, etc., and to actively question its dogma.
From a "neuroplastic" point of view, I think the immense advantage of psychoanalysis is in the frame, which is intense (5 days per week), long-term (over years), intellectually open (anything that passes through one's mind is encouraged to be spoken), and consistent. If one was taking language or music lessons, we would see MUCH more "neuroplastic change" in the brain (and, much more importantly, we would see much more language or music learning), if the lessons took place 5 times a week for 5 years, rather than just once a week for 6 months. The consistency and discipline of the psychoanalytic frame is powerfully motivational, just as is any other consistent and disciplined educational framework.
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