There are various research articles done in the past which describe rates of change in psychotherapy patients, some studies for example describing a plateau after about 25 sessions or so. I find these studies very weak, because of the multitude of confounding factors: severity and chronicity are obvious variables, also the type of follow-up assessments done.
In the CBT literature, a typical trial of therapy is perhaps 16-20 sessions.
In light of our evolving knowledge of neuroplasticity, and our breadth of understanding about education & learning, it seems to me that the most important variable of all is the amount of focused, deliberate practice time spent in a therapeutic activity. Oddly, most psychotherapy studies--even CBT studies--do not look at how many hours of practice patients have done in-between therapy appointments. This would be like looking at the progress of music students based on how many lessons they get, without taking into account how much they practice during the week.
I have often compared psychological symptom change to the changes which occur, for example, with language learning or with learning a musical instrument.
So, I believe that a reasonable estimate of the amount of time required in psychotherapy depends on what one is trying to accomplish:
-Some types of therapeutic problems might be resolved with a few hours of work, or with a single feedback session with a therapist. This would be akin to a musician with some kind of technical problem who needs just some clear instruction about a few techniques or exercises to practice. Or it might be akin to a person who is already fluent in a foreign language, but needs a few tips from a local speaker about idioms, or perhaps some help with editing or grammar in a written text.
-Many more therapeutic problems could improve with perhaps 100 hours of work. This would be like learning to swim or skate competently if you have never done these activities before. Regular lessons ("therapy") would most likely speed up your rate of progress substantially. But most of those 100 hours would be practice on your own, unless you're okay with the progress taking place over a year or more. With the language analogy, think of how fluent you might become in a foreign language with 100 hours of focused, deliberate practice. For most of us, this would lead to an ability to have a very simple conversational exchange, perhaps to get around in the most basic way in another country.
-A much larger change is possible with 1000 hours of work: with music, one could become quite fluent but probably not an expert. With a foreign language, comfortable fluency would probably be possible, though probably still with an accent and a preference for the old language.
-With 5000-10000 hours of work (this is several hours per day over a decade or more) one could become an expert at a skill or a language in most cases.
In psychotherapy, another confound though is whether the times in-between "practice sessions" lead to a regression of learning. An educational analogy would be of practicing math exercises an hour per day with a good teacher, but then practicing another 8 hours a day with another teacher whose methods contradict the first. Often times, learning will still take place with this paradigm, but it might be much less efficient. Persistent mental habits, in the context of mental illnesses, can be akin to the "second teacher" in this metaphor, and unfortunately they do tend to plague people for many hours per day.
This reminds me of the evolving evidence about stroke rehabilitation & neuroplasticity: substantial brain change can happen in as short a time as 16 days--but it requires very strict inhibition or constraint of the pathways which obstruct rehabilitation. (note: 16 days of continuous "immersion" = 16*24 = 384 hours!) In stroke rehabilitation, the neuroplasticity effect is much more pronounced if the unaffected limb is restrained, compelling the brain to optimize improvement in function of the afflicted limb. Here is a recent reference showing rapid brain changes following limb immobilization: http://www.ncbi.nlm.nih.gov/pubmed/22249495
In conclusion, I believe that it is important to have a clear idea about how much time and deliberate, focused effort are needed to change psychological symptoms or problems through therapeutic activities. A little bit of meaningful change could happen with just a few hours of work. In most cases, 100 hours is needed simply to get started with a new skill. 1000 hours is needed to become fluent. And 5000-10000 hours is needed to master something. These times would be much longer still if the periods between practice sessions are regressive. In the case of addictions, eating disorders, self-harm, or OCD, for example, relapses or even fantasies about relapse will substantially prolong the time it takes for any therapeutic effort to help. Of course, it is the nature of these problems to have relapses, or fantasies about relapse--so one should let go of the temptation to feel guilty if there are relapses. But if one is struggling with an addictive problem of this sort, it may help to remind oneself that the brain can change very substantially if one can hold onto to quite a strict behavioural pattern for the hundreds or thousands of hours which are needed.
As a visual reminder of this process, start with an empty transparent bottle, which can hold 250-500 mLof liquid (1-2 cups), and which can be tightly sealed with a small cap. Add one drop of water every time you invest one hour of focused, deliberate therapeutic work. The amount of time you need to spend in therapy depends on your goal. If the goal is total mastery--then you must fill the entire bottle. If simple competence in a new skill is an adequate goal, then you must fill just the cap of the bottle. If there are activities in your day which contradict the therapeutic work, it would be like a little bit of water leaking out of your bottle. So you must also attend to repairing any "leaks." But every hour of your effort counts towards your growth.
Tuesday, February 7, 2012
Monday, February 6, 2012
Scopolamine for Depression
Scopolamine is an acetylcholine-receptor blocker, which is usually used to treat or prevent motion sickness. Some recent studies show that it might be useful to treat depression. Here is some background, followed by a few references to research studies:
The old tricyclic antidepressants (such as amitriptyline) were shown over many years to work very well for many people. Unfortunately, they are laden with side-effect problems and a significant toxicity risk (they can be lethal in overdose). The side effects are due to various different pharmacologic effects, particularly the blockade of acetylcholine and histamine receptors. Newer antidepressants, such as those in the SSRI group, have very few such receptor blockade effects.
In some studies, however, the old tricyclics actually are superior to newer antidepressants, especially for severely ill hospitalized depression patients.
It is interesting to consider whether some of the receptor blockade effects which were previously considered just nuisances or side-effect problems, could actually be part of the antidepressant activity. Or, in some cases, drugs which primarily have receptor blockade side effects may actually be indirectly modulating various other neurotransmitter systems.
A clear precedent exists in this regard: clozapine is undoubtedly the most effective antipsychotic, but it is loaded with multiple side effects and receptor blockades. It may be --at least in part-- because of the receptor blockades, not in spite of them, that it works so well.
Another example of this effect, quite possibly, is related to what I call the "active placebo" literature (I have referred to it elsewhere on this blog: http://garthkroeker.blogspot.com/2009/03/active-placebos.html) The active placebos used in these studies usually had side effects due to acetylcholine blockade, and the active placebo groups usually improved quite a bit more than those with inert placebos. This suggests another interpretation of the "active placebo" effect: perhaps it is not simply the existence of side-effects that psychologically boosts a placebo effect here, it is that the side-effects themselves are due to a pharmacologic action that is actually of direct relevance to the treatment of depression.
Here are some studies looking at scopolamine infusions to treat depression:
http://www.ncbi.nlm.nih.gov/pubmed/17015814
This 2006 study from Archives of General Psychiatry showed that 4 mcg/kg IV infusions of scopolamine (given in 3 doses, every 3-5 days) led to a rapid reduction in depression symptoms (halving of the MADRS score), with a pronounced difference from placebo. Of particular note is that the cohort consisted mainly of chronically depressed patients with comorbidities and unsuccessful trials of other treatments. Surprisingly, there were few side effect problems, aside from a higher rate of the expected anticholinergic-induced dry mouth and dizziness.
http://www.ncbi.nlm.nih.gov/pubmed/20074703
This is a replication of the study mentioned above, published in Biological Psychiatry in 2010.
http://www.ncbi.nlm.nih.gov/pubmed/20736989
Another similar study, this time showing a greater effect in women; again a 4 mcg/kg infusion protocol was used.
http://www.ncbi.nlm.nih.gov/pubmed/20926947
evidence from an animal study that scopolamine --or acetylcholine blockade in general-- affects NMDA-related activity, in general antagonizing the effects of NMDA. This is consistent with a theory that scopolamine may work in a similar manner to the NMDA-blocker ketamine (which has been associated with rapid improvement in depression symptoms) but without nearly as much risk of dangerous medical or neuropsychiatric side-effects.
http://www.ncbi.nlm.nih.gov/pubmed/21306419
This article looks at the pharmacokinetics of infused scopolamine, and also gives a detailed account of side-effects. There are notable cognitive side-effects, such as reduced efficiency of short-term memory.
http://www.ncbi.nlm.nih.gov/pubmed/16719539
This study looks at dosing scopolamine as a patch. The patch is designed to give a rapidly absorbed loading dose, then a gradual release to maintain a fairly constant level over 3 days. My own estimation, based on reviewing this information, is that a scopolamine patch would roughly approximate the IV doses used in the depression treatment studies described above, though of course the serum levels would be more constant.
Transdermal scopolamine (patches) are available in Canada from pharmacists without a physician's prescription.
While this is an interesting--though far from proven-- treatment idea, it is very important to be aware of anticholinergic side effects, which at times could be physically and psychologically unpleasant. At worst, cognitive impairment or delirium could occur as a result of excessive cholinergic blockade. Therefore, any attempt to treat psychiatric symptoms using anticholinergics should be undertaken with close collaboration with a psychiatrist.
The old tricyclic antidepressants (such as amitriptyline) were shown over many years to work very well for many people. Unfortunately, they are laden with side-effect problems and a significant toxicity risk (they can be lethal in overdose). The side effects are due to various different pharmacologic effects, particularly the blockade of acetylcholine and histamine receptors. Newer antidepressants, such as those in the SSRI group, have very few such receptor blockade effects.
In some studies, however, the old tricyclics actually are superior to newer antidepressants, especially for severely ill hospitalized depression patients.
It is interesting to consider whether some of the receptor blockade effects which were previously considered just nuisances or side-effect problems, could actually be part of the antidepressant activity. Or, in some cases, drugs which primarily have receptor blockade side effects may actually be indirectly modulating various other neurotransmitter systems.
A clear precedent exists in this regard: clozapine is undoubtedly the most effective antipsychotic, but it is loaded with multiple side effects and receptor blockades. It may be --at least in part-- because of the receptor blockades, not in spite of them, that it works so well.
Another example of this effect, quite possibly, is related to what I call the "active placebo" literature (I have referred to it elsewhere on this blog: http://garthkroeker.blogspot.com/2009/03/active-placebos.html) The active placebos used in these studies usually had side effects due to acetylcholine blockade, and the active placebo groups usually improved quite a bit more than those with inert placebos. This suggests another interpretation of the "active placebo" effect: perhaps it is not simply the existence of side-effects that psychologically boosts a placebo effect here, it is that the side-effects themselves are due to a pharmacologic action that is actually of direct relevance to the treatment of depression.
Here are some studies looking at scopolamine infusions to treat depression:
http://www.ncbi.nlm.nih.gov/pubmed/17015814
This 2006 study from Archives of General Psychiatry showed that 4 mcg/kg IV infusions of scopolamine (given in 3 doses, every 3-5 days) led to a rapid reduction in depression symptoms (halving of the MADRS score), with a pronounced difference from placebo. Of particular note is that the cohort consisted mainly of chronically depressed patients with comorbidities and unsuccessful trials of other treatments. Surprisingly, there were few side effect problems, aside from a higher rate of the expected anticholinergic-induced dry mouth and dizziness.
http://www.ncbi.nlm.nih.gov/pubmed/20074703
This is a replication of the study mentioned above, published in Biological Psychiatry in 2010.
http://www.ncbi.nlm.nih.gov/pubmed/20736989
Another similar study, this time showing a greater effect in women; again a 4 mcg/kg infusion protocol was used.
http://www.ncbi.nlm.nih.gov/pubmed/20926947
evidence from an animal study that scopolamine --or acetylcholine blockade in general-- affects NMDA-related activity, in general antagonizing the effects of NMDA. This is consistent with a theory that scopolamine may work in a similar manner to the NMDA-blocker ketamine (which has been associated with rapid improvement in depression symptoms) but without nearly as much risk of dangerous medical or neuropsychiatric side-effects.
http://www.ncbi.nlm.nih.gov/pubmed/21306419
This article looks at the pharmacokinetics of infused scopolamine, and also gives a detailed account of side-effects. There are notable cognitive side-effects, such as reduced efficiency of short-term memory.
http://www.ncbi.nlm.nih.gov/pubmed/16719539
This study looks at dosing scopolamine as a patch. The patch is designed to give a rapidly absorbed loading dose, then a gradual release to maintain a fairly constant level over 3 days. My own estimation, based on reviewing this information, is that a scopolamine patch would roughly approximate the IV doses used in the depression treatment studies described above, though of course the serum levels would be more constant.
Transdermal scopolamine (patches) are available in Canada from pharmacists without a physician's prescription.
While this is an interesting--though far from proven-- treatment idea, it is very important to be aware of anticholinergic side effects, which at times could be physically and psychologically unpleasant. At worst, cognitive impairment or delirium could occur as a result of excessive cholinergic blockade. Therefore, any attempt to treat psychiatric symptoms using anticholinergics should be undertaken with close collaboration with a psychiatrist.
Thursday, December 22, 2011
Mental health issues in the workplace
A frequent source of unhappiness I see has to do with a psychologically unhealthy work environment. I am interested to survey the research literature on this subject, but for starters here are a few thoughts:
1) many businesses simply do not seem to value the idea of simply treating employees well. Instead, a short-sighted view is taken, of attempting to maximize the work output or efficiency of the workers, while minimizing costs. On a short term basis (perhaps confirmed by mathematical models composed by the recent business or commerce graduate who is now in a managerial position), this leads to more profit for the business with fewer expenses. On a longer-term basis, however, this pattern leads to poor morale, loss of good or talented employees, higher rates of absenteeism, lower productivity, lower worker loyalty, which in turn must undoubtedly be perceived or intuited by customers, all of which would severely dampen the prosperity of the business.
2) counter-examples exist, of particular businesses which treat employees very well, allowing them more autonomy, healthy scheduling, security, non-authoritarian leadership, even paid time to attend fitness activities, etc. I can think of a few examples like this in which the business and the employees are prospering together, with a very positive public image as well.
3) I have to wonder if the current educational system biases the business world to perpetuate these types of problems. University programs in commerce, economics, or business may have a variety of biases: a money or wealth-acquisition-oriented value system may be very frequent in students drawn to these areas. The programs themselves, I observe, may be dealing with subject matter that involves very interesting, complex, and subtle interactions between human motivations, emotions, and behaviours. Yet the programs tend to have very little instruction or requirement for students to study the obviously related fields of psychology, sociology, ethics, history, political science, etc. Unfortunately this may equip graduates, who may be involved in group leadership and policy-making decisions affecting thousands of people, with strong profit-optimization skills, but very little wisdom or education about human nature or a foundation in altruistic values.
4) In any case, I think many employer-employee interactions are like a dysfunctional family: the "parents" either too authoritarian or enmeshed, or too detached and uninvolved. Usually there are problems with communication. Unfortunately, it is usually very difficult for this type of "family" to come for group therapy: it seems more common for these types of group problems to become more entrenched with time.
The field of "corporate psychology" seems to address some of these issues. I will be interested to survey this literature in the coming months, and hopefully add to this post in a helpful way. Aside from therapeutic ideas to make beneficial changes in business group dynamics, I wonder if it could be a useful trend in the future to allow free economic forces to help things along: if one is considering being a customer or an investor in a business, how about checking out how happy the employees are? It would be a service to the community, in the name of public and individual mental health, to support businesses which provide a healthy community not only to the public, but to their own employees.
1) many businesses simply do not seem to value the idea of simply treating employees well. Instead, a short-sighted view is taken, of attempting to maximize the work output or efficiency of the workers, while minimizing costs. On a short term basis (perhaps confirmed by mathematical models composed by the recent business or commerce graduate who is now in a managerial position), this leads to more profit for the business with fewer expenses. On a longer-term basis, however, this pattern leads to poor morale, loss of good or talented employees, higher rates of absenteeism, lower productivity, lower worker loyalty, which in turn must undoubtedly be perceived or intuited by customers, all of which would severely dampen the prosperity of the business.
2) counter-examples exist, of particular businesses which treat employees very well, allowing them more autonomy, healthy scheduling, security, non-authoritarian leadership, even paid time to attend fitness activities, etc. I can think of a few examples like this in which the business and the employees are prospering together, with a very positive public image as well.
3) I have to wonder if the current educational system biases the business world to perpetuate these types of problems. University programs in commerce, economics, or business may have a variety of biases: a money or wealth-acquisition-oriented value system may be very frequent in students drawn to these areas. The programs themselves, I observe, may be dealing with subject matter that involves very interesting, complex, and subtle interactions between human motivations, emotions, and behaviours. Yet the programs tend to have very little instruction or requirement for students to study the obviously related fields of psychology, sociology, ethics, history, political science, etc. Unfortunately this may equip graduates, who may be involved in group leadership and policy-making decisions affecting thousands of people, with strong profit-optimization skills, but very little wisdom or education about human nature or a foundation in altruistic values.
4) In any case, I think many employer-employee interactions are like a dysfunctional family: the "parents" either too authoritarian or enmeshed, or too detached and uninvolved. Usually there are problems with communication. Unfortunately, it is usually very difficult for this type of "family" to come for group therapy: it seems more common for these types of group problems to become more entrenched with time.
The field of "corporate psychology" seems to address some of these issues. I will be interested to survey this literature in the coming months, and hopefully add to this post in a helpful way. Aside from therapeutic ideas to make beneficial changes in business group dynamics, I wonder if it could be a useful trend in the future to allow free economic forces to help things along: if one is considering being a customer or an investor in a business, how about checking out how happy the employees are? It would be a service to the community, in the name of public and individual mental health, to support businesses which provide a healthy community not only to the public, but to their own employees.
Antidepressants = Psychotherapy = Placebo ?
Jacques Barber et al. have recently published the results of a randomized, controlled study conducted between 2001 and 2007, comparing antidepressant therapy, short-term dynamic psychotherapy, and placebo in a 16-week course of treatment for 156 depressed adults. Here is a link to the abstract: http://www.ncbi.nlm.nih.gov/pubmed/22152401
The bottom line in the study was that there was no significant difference between antidepressants, psychotherapy, or placebo. Response rates were 31% for medication, 28% for psychotherapy, and 24% for placebo -- which has a low probability of being statistically different. Remission rates were 26% for medication, 22% for psychotherapy, and 20% for placebo.
Critics trying to explain these findings might attempt to argue that the psychotherapy or the medication regime was not sufficient, etc. -- but I do not see this to be true. The medications (venlafaxine or sertraline) were given at quite sufficient doses for good lengths of time. The psychotherapy was not CBT (which has a larger research evidence base) but there is little reason, in my opinion, to believe that the therapy style was inferior.
The authors attempt to do some secondary analyses looking for explanations, but their conclusions seem quite weak to me (e.g. regarding race or gender). The fact that they spin these conclusions into a prominently framed set of "clinical points" seems quite inappropriate to me -- this is a negative study, there are no "clinical points" to be found here, unless they recommend placebos and cessation of other therapies!
There are a number of issues from this study that I do find very important to discuss:
1) despite a massive amount of data showing that various therapies (e.g. antidepressants or psychotherapy) are effective for various problems, there are examples of carefully-conducted negative studies, such as this one. These results cannot simply be explained away as statistical aberration: there must be a reason why one group of people responds to a treatment, while another does not. Many of these reasons are poorly understood. It may be that the diagnostic category of "major depressive disorder" is inadequate, in that it correlates poorly on its own with treatment responsiveness.
2) the subjects in this study had a high degree of comorbidity (e.g. substance abuse problems, anxiety disorders, and axis II problems). While the severity and chronicity of depression was not found to actually correlate with treatment responsiveness, I suspect that the comorbidities would substantially affect response to a relatively short-term course of therapy.
3) the subjects in this study were socioeconomically disadvantaged; while the effect of SES was also not found to "influence the initial findings," I believe that low SES is not necessarily a direct negative influence upon mental health; rather it is an indirect factor which for many people increases the likelihood of some profound mental health negatives (e.g. unemployment, lack of meaningful or satisfying employment, lack of healthy or safe community, lack of availability to do healthy or meaningful leisure activities, not enough money to eat healthily, etc.). I believe that the environmental adversities need to be looked at very closely in a study of this type.
This leads to what I believe is an obvious explanation for the findings here: there is no therapy for depression that is likely to help unless ALL contributing factors (including obvious environmental contributing factors) are addressed. By way of analogy, I believe it is pointless to treat insomnia using a powerful sedative if a person is sleeping in a room which is continuously noisy, cold, and prone to break-ins by violent intruders. The environmental issues need to be addressed first! Another analogy I have often used is of trying to repair a water supply system for a city: it is a waste of effort to pipe in more water from rivers, or to dig a deeper reservoir, if the walls of the reservoir and the pipes are leaking or bursting because of structural defects. In order for a therapeutic strategy to work, the "leaks" have to be repaired first. For a person with anemia, it is not an appropriate strategy to simply give a blood transfusion: while a transfusion may be necessary, it will not be sufficient--and could even make matters worse-- if the underlying cause of blood loss is not addressed and treated.
In the case of medications or psychotherapy, I believe these can be very helpful, but only if environmental adversity is also remedied. In some instances, of course, relief of a psychiatric symptom could help a person to improve the environmental circumstances. But in most other cases, I think the issue is broader, and could be considered a political or social policy matter.
Another related issue is that I do not believe "depression" can be treated on its own without addressing all psychiatric and medical comorbidities at the same time. Ongoing substance abuse, in my opinion, is often a powerful enough factor--psychologically as well as neurophysiologically--to completely dominate and dissolve the positive influences of psychotherapy or effective medication. In this study, 30-40% of the cohort reported substance use problems.
As a final thought, I think the "5 axis" model of diagnosis in the DSM system deserves some affirmation; many times, however, we only pay attention to Axis I (diagnoses such as depression or schizophrenia, etc.) or Axis II (personality disorder). I think that studies such as this one highlight the necessity to look closely at Axes III (medical illnesses) and IV (social, community, financial, and relational problems). It is likely that issues on these latter two axes can prevent any resolution of problems on the first two.
The bottom line in the study was that there was no significant difference between antidepressants, psychotherapy, or placebo. Response rates were 31% for medication, 28% for psychotherapy, and 24% for placebo -- which has a low probability of being statistically different. Remission rates were 26% for medication, 22% for psychotherapy, and 20% for placebo.
Critics trying to explain these findings might attempt to argue that the psychotherapy or the medication regime was not sufficient, etc. -- but I do not see this to be true. The medications (venlafaxine or sertraline) were given at quite sufficient doses for good lengths of time. The psychotherapy was not CBT (which has a larger research evidence base) but there is little reason, in my opinion, to believe that the therapy style was inferior.
The authors attempt to do some secondary analyses looking for explanations, but their conclusions seem quite weak to me (e.g. regarding race or gender). The fact that they spin these conclusions into a prominently framed set of "clinical points" seems quite inappropriate to me -- this is a negative study, there are no "clinical points" to be found here, unless they recommend placebos and cessation of other therapies!
There are a number of issues from this study that I do find very important to discuss:
1) despite a massive amount of data showing that various therapies (e.g. antidepressants or psychotherapy) are effective for various problems, there are examples of carefully-conducted negative studies, such as this one. These results cannot simply be explained away as statistical aberration: there must be a reason why one group of people responds to a treatment, while another does not. Many of these reasons are poorly understood. It may be that the diagnostic category of "major depressive disorder" is inadequate, in that it correlates poorly on its own with treatment responsiveness.
2) the subjects in this study had a high degree of comorbidity (e.g. substance abuse problems, anxiety disorders, and axis II problems). While the severity and chronicity of depression was not found to actually correlate with treatment responsiveness, I suspect that the comorbidities would substantially affect response to a relatively short-term course of therapy.
3) the subjects in this study were socioeconomically disadvantaged; while the effect of SES was also not found to "influence the initial findings," I believe that low SES is not necessarily a direct negative influence upon mental health; rather it is an indirect factor which for many people increases the likelihood of some profound mental health negatives (e.g. unemployment, lack of meaningful or satisfying employment, lack of healthy or safe community, lack of availability to do healthy or meaningful leisure activities, not enough money to eat healthily, etc.). I believe that the environmental adversities need to be looked at very closely in a study of this type.
This leads to what I believe is an obvious explanation for the findings here: there is no therapy for depression that is likely to help unless ALL contributing factors (including obvious environmental contributing factors) are addressed. By way of analogy, I believe it is pointless to treat insomnia using a powerful sedative if a person is sleeping in a room which is continuously noisy, cold, and prone to break-ins by violent intruders. The environmental issues need to be addressed first! Another analogy I have often used is of trying to repair a water supply system for a city: it is a waste of effort to pipe in more water from rivers, or to dig a deeper reservoir, if the walls of the reservoir and the pipes are leaking or bursting because of structural defects. In order for a therapeutic strategy to work, the "leaks" have to be repaired first. For a person with anemia, it is not an appropriate strategy to simply give a blood transfusion: while a transfusion may be necessary, it will not be sufficient--and could even make matters worse-- if the underlying cause of blood loss is not addressed and treated.
In the case of medications or psychotherapy, I believe these can be very helpful, but only if environmental adversity is also remedied. In some instances, of course, relief of a psychiatric symptom could help a person to improve the environmental circumstances. But in most other cases, I think the issue is broader, and could be considered a political or social policy matter.
Another related issue is that I do not believe "depression" can be treated on its own without addressing all psychiatric and medical comorbidities at the same time. Ongoing substance abuse, in my opinion, is often a powerful enough factor--psychologically as well as neurophysiologically--to completely dominate and dissolve the positive influences of psychotherapy or effective medication. In this study, 30-40% of the cohort reported substance use problems.
As a final thought, I think the "5 axis" model of diagnosis in the DSM system deserves some affirmation; many times, however, we only pay attention to Axis I (diagnoses such as depression or schizophrenia, etc.) or Axis II (personality disorder). I think that studies such as this one highlight the necessity to look closely at Axes III (medical illnesses) and IV (social, community, financial, and relational problems). It is likely that issues on these latter two axes can prevent any resolution of problems on the first two.
Saturday, December 10, 2011
Worksheets
Here's a good site that has many links to free therapy worksheets: http://therapyworksheets.blogspot.com/
Spending some focused time with a worksheet can be a healthy, useful, structured component of therapy or self-help. Worksheets can be especially useful if you want to build up healthy therapeutic habits, both in terms of inner reflection and external action, but find yourself in need of more clear structure to get started or to continue guiding you. I find this can be analogous to learning a subject at school, or a musical instrument, etc. : practicing is obviously important, but it can certainly help guide and discipline your practice efficiently to have a good textbook to work through.
Many thanks to the person who recommended this site to me!
Spending some focused time with a worksheet can be a healthy, useful, structured component of therapy or self-help. Worksheets can be especially useful if you want to build up healthy therapeutic habits, both in terms of inner reflection and external action, but find yourself in need of more clear structure to get started or to continue guiding you. I find this can be analogous to learning a subject at school, or a musical instrument, etc. : practicing is obviously important, but it can certainly help guide and discipline your practice efficiently to have a good textbook to work through.
Many thanks to the person who recommended this site to me!
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