The whole issue of e-mental health induces quite a bit of resistance in me, which causes me to pause and reflect.
The issue perhaps represents, somehow, a threat to the way I like to practice psychiatry. Therefore, I may be prone to some biases, and simple resistance to change.
On the one hand, I love gadgetry, and I love technological innovation. But I also love to practice psychiatry in a way which does not require any gadgetry of any sort. I like, quite simply, to see my patients regularly, in person. I am averse to a system which would make this type of practice less possible.
There is no personal financial reason why e-mental health would need to be opposed. Seeing patients in person, for an hour at a time, is financially disfavoured in the current system. E-mental health certainly does not need to pose any threat to the financial well-being of therapists. It may actually facilitate higher earnings for many therapists. In fact, if anything, there may be a bias towards using more e-mental health, as a therapist may be able to offer these types of services in a zero overhead environment, to large numbers of clients, therefore maximizing financial profit.
I have thought that various e-mental health resources are "impersonal," but I realize that I may need to be a bit more open-minded about this. I am reminded of my own experience in university, many years ago:
I can think of many examples of courses I took in university, even in medical school, in which attending the lectures was not effective for good learning. It was often a passive activity, involving a struggle to stay awake; many professors may have been great experts in their fields, but were not effective, dynamic, or interesting teachers. It would have been better for my learning to have skipped the lecture and just spent the time reading on my own. Maybe in-person psychotherapy can be like this, in some cases.
Nowadays, students often have opportunities to take courses entirely
online. Also, many teaching resources, such as lectures (including those done at famous universities) are available
online. While taking a course online could be less "personal" in many
ways, it is not necessarily so. Personal interaction with a professor
or classmates may in some cases be easier online than in an in-person
lecture. It is only the medium which is different.
For many types of psychotherapy, there can be a sort of "curriculum" akin to the material presented in a university course. This is especially true in CBT (cognitive-behavioural therapy). In many cases, structured self-learning, possibly with an on-line "curriculum," could be more effective, engaging, and enjoyable than attending in-person appointments.
What are the variables that might determine this? Individual factors relating to personal needs are obviously relevant here--in many cases of depression or anxiety, it is the CBT-like "curriculum" which is the most important element to be mastered, in order to have relief of symptoms. It may not necessarily be the case that these patients have a particular need for interpersonal care from a therapist, at least not in an in-person setting. The optimal way, and even the most enjoyable way, for a person to benefit from this "curriculum" may, just like a student in a university course, be through taking a "CBT course" online. But, of course, in many cases, the "curriculum" does not really matter so much as the "therapeutic alliance" or the personal experience in a therapy setting.
Another variable is the therapist's personal style. This reminds me, once again, of professors I took university courses with long ago. In some cases, the courses were wonderful, meaningful, engaging, energetic, and delightful experiences, with a professor who was full of love for the subject, enthusiasm, and personal care for the students. This made the course a joy to attend, even if the subject matter might have been approachable in an on-line or indirect fashion.
I suspect a similar dynamic can occur in therapy--in order for a one-on-one therapy experience to be worthwhile, or superior to an on-line substitute, there would have to be a meaningful engagement with a therapist, whose style would suit the patient's interest, and kindle the patient's motivations.
Unfortunately, in today's therapy environment, personal sessions are often in short supply. Courses of therapy are often very time-limited. There is often, as a result, an excessive focus on simple, trite therapeutic advice, with very little time allowed to form an ongoing therapeutic connection. If this form of therapeutic encounter is compared with a computer app, I am not surprised that the app has similar effectiveness! I do see that this type of simple, brief, limited therapeutic encounter is indeed helpful for many people (e.g. with stress-related anxiety or mild, transient depression), but I also see that such an encounter would be very frustrating and ineffectual for many who have a more complex or difficult psychological history.
Here are some other dynamics to watch for:
1) "the Christmas gift effect." Sometimes, parents will buy expensive gifts for their children, during the Christmas season. These parents may not have had much time for the children during the year, and indeed the children may well have been asking for various expensive toys or gadgets. The expensive gifts are appreciated excitedly -- but they don't really help the children feel better! They are just more "stuff," and may even condition the children to become more materialistic. What the children may really desire is to have parents who spend more time with them, attending to them, playing with them, and caring for them. They don't really want gadgets -- they want care and love. But in the absence of the care and attention, the children may only identify a wish for more presents or gadgets. This is what Kahneman might call "miswanting," a distortion of identified desire caused by short-term materialistic reflexes, while longer term substantive needs are unmet.
I am concerned that various examples of e-mental health are a bit like expensive Christmas gift gadgetry. Everyone is excited about it (not least the vendors who are selling the electronics required for it, or the researchers clamoring to publish journal articles about it), but in the midst of the fray, it may not be noticed that even less time, care, and attention is spent actually caring for patients directly. More time in front of computer screens, less time in front of other people.
2) The "curriculum" benefits of e-mental health could be obtained in a variety of other trivial ways. If CBT curricula were widely available online already (which is ever more the case) or if they were introduced as health care programs during childhood, etc., then e-mental health curricula may have much less measurable impact. It would be like taking the same university course (which you already passed) a second time. For this cohort, a more direct, personalized form of care may be even more important.
3) Hidden costs. While e-mental health ideas may indeed be effective in many situations, or may be equal in some measure of effectiveness to other established treatments, there could be hidden problems. For example, suppose a cohort of therapists who love providing personalized, direct therapeutic care are compelled to spend their time supervising e-mental health activities (for example, sitting alone in an office, in front of a computer screen) for an expanding proportion of their time. In this case, perhaps an equal (or greater) number of patients or clients could be seen and helped. But--those individual clients who would have benefited most by seeing someone in person would not have been seen and helped, because the therapist was sitting in front of a computer screen instead!
Another hidden problem is the detriment to morale caused by compelling people to spend even more time in front of a computer screen, instead of in front of an actual person. An effective psychotherapist (or teacher, or musician, or worker of any type) is one who feels joy and passion and excitement and personal connection for the work. Imagine seeing a therapist or a teacher who appears disconnected, distant, or absorbed with an electronic gadget instead of with a person! If joy of personal connection is deprived, through the use of supposedly efficient technology, then the effectiveness of the entire system is at risk.
Furthermore, there could be a selection bias evolving in a therapists' population if this trend continues, favouring those who can tolerate more impersonal interactions as a norm. Those who are most comfortable with simple personal connection, and less comfortable with technology, may feel more and more uncomfortable with entering into a therapy profession at all. Yet, those with the highest comfort for personal connection are arguably the most valuable and talented therapists!
The Golden Rule Question:
In trying to sort out this issue, I think we could ask ourselves a type of "Golden Rule" question: if it was you yourself, or if it was your partner, your spouse, your mother, your child, or your closest friend, who needed help for managing serious anxiety, depression, or some other psychological distress--how would you feel about an electronic resource being offered instead of a one-on-one therapist?
As I ask myself this question, I think that it ought not to be either/or. I suspect, for me, that I would appreciate using various electronic resources. And I suspect, for me, that it would also depend on the therapist who was available: would I like that person? Would that person seem compatible? Would that person have the time and the commitment to offer the help needed (possibly over a long period of time)?
If I was told that the use of e-mental health modalities would reduce the total amount of direct in-person time available for clients or patients, this might further demote my enthusiasm for them.
In a system which is already failing to attend to providing adequate personalized care, I would be worried about a strategy in which even more time, money, and attention was given to a gadget, rather than to a human relationship. The consequences of such movement away from personalized care affect not only clients or patients, but also the morale and health of the therapist community, and arguably the health of society as a whole.
But, if e-mental health simply expanded the accessibility of therapy, allowed people trapped at home or in remote locations to access care, allowed playful educational engagement, while still allowing clients and therapists to have direct, personal time in a therapeutic framework, then I think this technology could be embraced in a way which is healthy for all.
In subsequent posts on this subject, I would like to survey some of the literature on this. Much of the recent literature is very positive and enthusiastic about e-mental health. While I am curious, and am sometimes delighted, by some of the ideas, I am also wary about the lack of consideration for the issues described above. There is a long history in psychiatry, and in medicine generally, of big enthusiastic trends of practice, sometimes following political motives, leading in retrospect to regrettable decrements in care.
Tuesday, April 26, 2016
Wednesday, March 9, 2016
Stimulant Medications for treating ADHD: A comparison
ADHD medication is a big business in the world today. Annual sales of ADHD medication are projected to be 15-20 billion dollars by 2020, increasing at a rate of about 8% per year. To put this in perspective, this is similar to the value of the worldwide market for fresh vegetables
( http://siteresources.worldbank.org/INTPROSPECTS/Resources/GATChapter13.pdf ).
It is an amount of money that would pay for the salaries of
400 000 teachers, each of whom paid $50 000 per year.
A relevant article to look at about this is by Alan Schwartz, published in the New York Times in 2013:
http://www.nytimes.com/2013/12/15/health/the-selling-of-attention-deficit-disorder.html?pagewanted=all&_r=0
I am not meaning this post to be a discussion of the controversies of ADHD diagnosis. Instead, this post will focus mainly about ADHD medication. I think the rising rate of ADHD diagnosis, and the rising rate of stimulant prescription, is a very concerning trend, particularly if these diagnoses and treatments are offered without attending adequately to other biopsychosocial factors, and particularly if these treatments are being offered under the influence of un-recognized biases due to the financial power and influence of the manufacturers.
On the other hand, the rising awareness and acceptance of ADHD can allow those children, adults, and families who are dealing with ADHD-related issues to feel less stigmatized, judged, and unfairly treated. In families, knowledge and acceptance of ADHD can help child-rearing practices to be adapted, so as to avoid a harshly punitive stance towards those children with attention problems.
The newer ADHD medications are, not surprisingly, very popular, frequently prescribed, are often touted as being better than the older medications, and are listed first on medication advice guideline sheets (such as the CADDRA recommendations).
Here is a comparison of costs per day between the different ADHD drugs, looking at a typical full therapeutic dose for an adult. These cost estimates come from a site called "Pharmacy Compass" which searches for the best local prices for medications at pharmacies.
1. Newer drugs (CADDRA considers these to be the only "first line" medications):
Adderall XR 30 mg:$3.91 per day
Biphentin 80 mg:$4.36 per day
Concerta 72 mg:$5.92 per day
Vyvanse 60 mg: $5.14 per day
Strattera 100 mg: $5.51 per day
2. Older drugs (CADDRA considers these "second line"):
Dexedrine spansules 40 mg: $3.59 per day
Ritalin (methylphenidate) 60 mg: $0.81 per day
Ritalin SR 60 mg $0.66 per day
So we see that the least expensive option is methylphenidate or methylphenidate SR. Dexedrine is over 5 times as expensive. Concerta and Vyvanse are about 8 times as expensive, per day.
I mention these expense differences not necessarily in an effort to favour the cheaper medication, but rather to heighten your anticipation that there could be bias in any research results regarding these medications--especially if the research is sponsored by the manufacturers-- due to the huge profit motives involved.
It would be fair to look for studies which carefully and prospectively treat ADHD patients with Ritalin vs. one of the newer medications, in randomized comparisons.
1) Vyvanse vs. Ritalin. Almost no studies in the literature! In one study, all they looked at was whether patients stuck to a dosing regimen, in which case the Vyvanse group did "better." (http://www.ncbi.nlm.nih.gov/pubmed/23937642 ) But this measure had nothing to do with the patients actually feeling better or improving more!
A better study compared Vyvanse with Oros-MPH, a long-acting version of Ritalin (though not plain old Ritalin itself!)
[ http://www.ncbi.nlm.nih.gov/pubmed/23801529]
In this study, at first glance it certainly appears that Vyvanse is better! But looking carefully, one finds statements such as this: "At endpoint, the difference between lisdexamfetamine and OROS-MPH in the percentage of patients with an ADHD-RS-IV total score less than or equal to the mean for their age was not statistically significant." (p.747) This statement was tucked into the results section but left out of the conclusion. Looking at side-effects, we find a lower total rate of adverse effects in the Ritalin group. Reduced appetite, insomnia, and nausea were more common in the Vyvanse group. Notably, there is a long list of conflicts of interest at the end of this paper, including some of the authors being employees of the Vyvanse manufacturer, and owning stocks in the company!
In conclusion here, there is no doubt that Vyvanse is an effective medication for ADHD. The dosing regime is very convenient, which may be particularly effective and helpful for many. But it is not necessarily superior to much cheaper alternatives. For some people (including many patients I have seen), regular methylphenidate (Ritalin) allows better fine control of symptoms during the course of the day, without being "stuck" with a continuous sustained-release effect. For others, they certainly do prefer the Vyvanse. I just think that Vyvanse should not be assumed to be better, as the evidence is very weak that it is, while it is 8 times more expensive than Ritalin!
2) Concerta vs. Ritalin
http://www.ncbi.nlm.nih.gov/pubmed/11389303
This is a good early study, directly comparing the two medications, published in Pediatrics in 2001. Here is the authors' concise summary: "On virtually all measures in all settings, both drug conditions were significantly different from placebo, and the 2 drugs were not different from each other." The reason to choose Concerta over Ritalin would be convenience. The authors do point out that "compliance" is more likely on a long-acting formulation. But remember that "compliance" is a very, very indirect, and possibly irrelevant, measure of health and well-being!! Why is it important that there be better "compliance?" Should the only criteria not be well-being? Certainly this is not a reason to classify Concerta as "better" or "first line". Concerta is 9 times more expensive than Ritalin!
3) Adderall vs Ritalin
http://www.ncbi.nlm.nih.gov/pubmed/10103335
In this study, published in Pediatrics in 1999, Adderall comes out as looking better than Ritalin. But, once again, the study was sponsored by the manufacturer. On a close look, a couple of problems: first, the doses of the medications were fixed. The ritalin doses appear too low, so as not to match the equivalent doses of Adderall given. At this point, one would usually give Ritalin doses at least twice that of Adderall (i.e. 100% higher) but in this study the Ritalin dose was only 40% higher than the Adderall dose. In accordance with this under-dosing, the Adderall group not surprisingly had more side effects such as insomnia.
In conclusion, there is no doubt that Adderall XR is a good medication for ADHD. Many of my patients have preferred it over other alternatives. But it is not fair, once again, to assume that it is better. It does not deserve to be considered "first line" while a similarly-effective alternative that is one-sixth the cost is considered "second line."
4) Meta-analytic comparison:
Faraone and Glatt (2010) have published a good meta-analytic review paper, which is worth reading in detail, with particular attention to the data tables and graphs: http://www.ncbi.nlm.nih.gov/pubmed/20051220
In the conclusion of this paper, the authors state that they "found no significant differences between short- and long-acting stimulant medications."
Addendum: a recent Cochrane review, published in February 2016 by Punja et al., concludes that there is a lot of evidence that amphetamines reduce core symptoms of ADHD, but cause a variety of problematic side-effects. They note that there was evidence of a lot of bias in the studies they looked at, with the quality of evidence being low to very low.
Here is a direct quote from their conclusion: "This review found no evidence that supports any one amphetamine derivative over another, and does not reveal any differences between long-acting and short-acting amphetamine preparations."
( http://siteresources.worldbank.org/INTPROSPECTS/Resources/GATChapter13.pdf ).
It is an amount of money that would pay for the salaries of
400 000 teachers, each of whom paid $50 000 per year.
A relevant article to look at about this is by Alan Schwartz, published in the New York Times in 2013:
http://www.nytimes.com/2013/12/15/health/the-selling-of-attention-deficit-disorder.html?pagewanted=all&_r=0
I am not meaning this post to be a discussion of the controversies of ADHD diagnosis. Instead, this post will focus mainly about ADHD medication. I think the rising rate of ADHD diagnosis, and the rising rate of stimulant prescription, is a very concerning trend, particularly if these diagnoses and treatments are offered without attending adequately to other biopsychosocial factors, and particularly if these treatments are being offered under the influence of un-recognized biases due to the financial power and influence of the manufacturers.
On the other hand, the rising awareness and acceptance of ADHD can allow those children, adults, and families who are dealing with ADHD-related issues to feel less stigmatized, judged, and unfairly treated. In families, knowledge and acceptance of ADHD can help child-rearing practices to be adapted, so as to avoid a harshly punitive stance towards those children with attention problems.
The newer ADHD medications are, not surprisingly, very popular, frequently prescribed, are often touted as being better than the older medications, and are listed first on medication advice guideline sheets (such as the CADDRA recommendations).
Here is a comparison of costs per day between the different ADHD drugs, looking at a typical full therapeutic dose for an adult. These cost estimates come from a site called "Pharmacy Compass" which searches for the best local prices for medications at pharmacies.
1. Newer drugs (CADDRA considers these to be the only "first line" medications):
Adderall XR 30 mg:$3.91 per day
Biphentin 80 mg:$4.36 per day
Concerta 72 mg:$5.92 per day
Vyvanse 60 mg: $5.14 per day
Strattera 100 mg: $5.51 per day
2. Older drugs (CADDRA considers these "second line"):
Dexedrine spansules 40 mg: $3.59 per day
Ritalin (methylphenidate) 60 mg: $0.81 per day
Ritalin SR 60 mg $0.66 per day
So we see that the least expensive option is methylphenidate or methylphenidate SR. Dexedrine is over 5 times as expensive. Concerta and Vyvanse are about 8 times as expensive, per day.
I mention these expense differences not necessarily in an effort to favour the cheaper medication, but rather to heighten your anticipation that there could be bias in any research results regarding these medications--especially if the research is sponsored by the manufacturers-- due to the huge profit motives involved.
It would be fair to look for studies which carefully and prospectively treat ADHD patients with Ritalin vs. one of the newer medications, in randomized comparisons.
1) Vyvanse vs. Ritalin. Almost no studies in the literature! In one study, all they looked at was whether patients stuck to a dosing regimen, in which case the Vyvanse group did "better." (http://www.ncbi.nlm.nih.gov/pubmed/23937642 ) But this measure had nothing to do with the patients actually feeling better or improving more!
A better study compared Vyvanse with Oros-MPH, a long-acting version of Ritalin (though not plain old Ritalin itself!)
[ http://www.ncbi.nlm.nih.gov/pubmed/23801529]
In this study, at first glance it certainly appears that Vyvanse is better! But looking carefully, one finds statements such as this: "At endpoint, the difference between lisdexamfetamine and OROS-MPH in the percentage of patients with an ADHD-RS-IV total score less than or equal to the mean for their age was not statistically significant." (p.747) This statement was tucked into the results section but left out of the conclusion. Looking at side-effects, we find a lower total rate of adverse effects in the Ritalin group. Reduced appetite, insomnia, and nausea were more common in the Vyvanse group. Notably, there is a long list of conflicts of interest at the end of this paper, including some of the authors being employees of the Vyvanse manufacturer, and owning stocks in the company!
In conclusion here, there is no doubt that Vyvanse is an effective medication for ADHD. The dosing regime is very convenient, which may be particularly effective and helpful for many. But it is not necessarily superior to much cheaper alternatives. For some people (including many patients I have seen), regular methylphenidate (Ritalin) allows better fine control of symptoms during the course of the day, without being "stuck" with a continuous sustained-release effect. For others, they certainly do prefer the Vyvanse. I just think that Vyvanse should not be assumed to be better, as the evidence is very weak that it is, while it is 8 times more expensive than Ritalin!
2) Concerta vs. Ritalin
http://www.ncbi.nlm.nih.gov/pubmed/11389303
This is a good early study, directly comparing the two medications, published in Pediatrics in 2001. Here is the authors' concise summary: "On virtually all measures in all settings, both drug conditions were significantly different from placebo, and the 2 drugs were not different from each other." The reason to choose Concerta over Ritalin would be convenience. The authors do point out that "compliance" is more likely on a long-acting formulation. But remember that "compliance" is a very, very indirect, and possibly irrelevant, measure of health and well-being!! Why is it important that there be better "compliance?" Should the only criteria not be well-being? Certainly this is not a reason to classify Concerta as "better" or "first line". Concerta is 9 times more expensive than Ritalin!
3) Adderall vs Ritalin
http://www.ncbi.nlm.nih.gov/pubmed/10103335
In this study, published in Pediatrics in 1999, Adderall comes out as looking better than Ritalin. But, once again, the study was sponsored by the manufacturer. On a close look, a couple of problems: first, the doses of the medications were fixed. The ritalin doses appear too low, so as not to match the equivalent doses of Adderall given. At this point, one would usually give Ritalin doses at least twice that of Adderall (i.e. 100% higher) but in this study the Ritalin dose was only 40% higher than the Adderall dose. In accordance with this under-dosing, the Adderall group not surprisingly had more side effects such as insomnia.
In conclusion, there is no doubt that Adderall XR is a good medication for ADHD. Many of my patients have preferred it over other alternatives. But it is not fair, once again, to assume that it is better. It does not deserve to be considered "first line" while a similarly-effective alternative that is one-sixth the cost is considered "second line."
4) Meta-analytic comparison:
Faraone and Glatt (2010) have published a good meta-analytic review paper, which is worth reading in detail, with particular attention to the data tables and graphs: http://www.ncbi.nlm.nih.gov/pubmed/20051220
In the conclusion of this paper, the authors state that they "found no significant differences between short- and long-acting stimulant medications."
Addendum: a recent Cochrane review, published in February 2016 by Punja et al., concludes that there is a lot of evidence that amphetamines reduce core symptoms of ADHD, but cause a variety of problematic side-effects. They note that there was evidence of a lot of bias in the studies they looked at, with the quality of evidence being low to very low.
Here is a direct quote from their conclusion: "This review found no evidence that supports any one amphetamine derivative over another, and does not reveal any differences between long-acting and short-acting amphetamine preparations."
Friday, February 19, 2016
Do Higher Doses of Antidepressants Work Better?
It is common practice in psychiatry to increase the dose of an antidepressant if the standard dose is not helping enough. Sometimes doses are increased before even finding out if the lower dose is working.
But it is interesting to consider evidence that higher doses actually do not necessarily work better:
Ruhé et al. (2009-2010) have published research on this issue, and conclude that SSRI dose increases do not improve effectiveness. Their explanation for this is quite simple: serotonin receptors are already well-occupied at standard doses, and this does not change with dose increases:
http://www.ncbi.nlm.nih.gov/pubmed/18830236
http://www.ncbi.nlm.nih.gov/pubmed/20862644
In general, it is indeed interesting to see scanty evidence that increasing antidepressant doses lead to improved effectiveness, even for treatment-resistant cases.
This issue came to my attention upon reading Lam's recent article about using light therapy to treat non-seasonal depression ( http://www.ncbi.nlm.nih.gov/pubmed/26580307). Their medication groups used only 20 mg of fluoxetine, without the possibility of increasing the dose. They cited some old, dated references to support this, such as Altamura et al (1988), and Beasley (1990):
http://www.ncbi.nlm.nih.gov/pubmed/2196623
A better, more recent article reviewing antidepressant dose vs effectiveness is by Berney (2006):
http://www.ncbi.nlm.nih.gov/pubmed/16156383
In many studies, higher doses may appear to work better, mainly because the dose was increased before the lower dose had a chance to work fully. The lower dose may well have worked just as well as the higher dose. Controlled studies comparing different doses do not support the belief that higher doses work better.
So it should not be routine practice to increase antidepressant doses beyond a standard "full dose" which is usually one tablet or capsule daily. In many cases, the different dosage regimes are likely to be equivalent. It is relevant to consider that higher doses mainly benefit the pharmaceutical companies, since they are selling more product despite the effectiveness being the same. Therefore, presentations of research data about antidepressant effectiveness may be biased in favour of higher doses. An extremely common research design in antidepressant studies is to have "flexible dosing," usually leading to the antidepressant group averaging about twice the standard dose in the end. This design, even when treatment effects are shown, biases the reader to have the specious conclusion that higher doses are better.
However, there are certainly many individual case reports of higher doses being more useful. So dose increases may have a role in some cases.
The key point is to question dose increases as a reflexive, routine management strategy for inadequate antidepressant effects. Alternative strategies include giving the lower dose a longer try, switching to something else, or using some form of augmentation.
Addendum:
Just days after posting this, I see there is a new meta-analysis by Jakubovski et al. in The American Journal of Psychiatry (173:2,pp. 174-183) which suggests that SSRI antidepressants do actually work slightly better at higher doses, peaking at 2.5 times the standard dose (e.g. 50 mg fluoxetine). They admit that the data show a trade-off between slight improved effectiveness at higher doses, but accompanied by worsened tolerability.
Yet, it is important to consider that higher doses could reflect a greater placebo effect; some of the research about active placebos show that agents which cause more side effects are likely to have a larger impact on symptoms than inert placebos. Because antidepressants at higher doses have more side effects, there would be more of this "active placebo" effect. See my previous post on this subject: http://garthkroeker.blogspot.ca/2009/03/active-placebos.html
It's hard to know what to make of this, other than to probably remain open-minded about the issue. I think that a better study design for this type of issue is to look at dose comparisons within individual clinical trials, rather than to amass data meta-analytically. Active placebo comparison groups would also be useful. For example, agents which would cause very mild side-effects could be used instead of a totally inert placebo, so as to improve the blinding of the studies. In many individual clinical trials of antidepressants (both new and old) which compare doses or dose ranges within the studies themselves, there are no significant differences in effectiveness.
Another issue, which the authors point out, is that most antidepressant studies have strict inclusion criteria which usually do not match the type of cases one would tend to see clinically most often. Many studies require a major depressive disorder diagnosis, with limited comorbidities allowed, and with limited past treatment trials, etc.
Meanwhile, it remains reasonable to give a baseline dose of antidepressants an adequate length of time to work, without reflexively increasing the dose on a routine basis. Dose increases remain an option, with some evidence-based support, but switching or augmentation could often be preferred, depending on patient preference and side-effects.
But it is interesting to consider evidence that higher doses actually do not necessarily work better:
Ruhé et al. (2009-2010) have published research on this issue, and conclude that SSRI dose increases do not improve effectiveness. Their explanation for this is quite simple: serotonin receptors are already well-occupied at standard doses, and this does not change with dose increases:
http://www.ncbi.nlm.nih.gov/pubmed/18830236
http://www.ncbi.nlm.nih.gov/pubmed/20862644
In general, it is indeed interesting to see scanty evidence that increasing antidepressant doses lead to improved effectiveness, even for treatment-resistant cases.
This issue came to my attention upon reading Lam's recent article about using light therapy to treat non-seasonal depression ( http://www.ncbi.nlm.nih.gov/pubmed/26580307). Their medication groups used only 20 mg of fluoxetine, without the possibility of increasing the dose. They cited some old, dated references to support this, such as Altamura et al (1988), and Beasley (1990):
http://www.ncbi.nlm.nih.gov/pubmed/2196623
A better, more recent article reviewing antidepressant dose vs effectiveness is by Berney (2006):
http://www.ncbi.nlm.nih.gov/pubmed/16156383
In many studies, higher doses may appear to work better, mainly because the dose was increased before the lower dose had a chance to work fully. The lower dose may well have worked just as well as the higher dose. Controlled studies comparing different doses do not support the belief that higher doses work better.
So it should not be routine practice to increase antidepressant doses beyond a standard "full dose" which is usually one tablet or capsule daily. In many cases, the different dosage regimes are likely to be equivalent. It is relevant to consider that higher doses mainly benefit the pharmaceutical companies, since they are selling more product despite the effectiveness being the same. Therefore, presentations of research data about antidepressant effectiveness may be biased in favour of higher doses. An extremely common research design in antidepressant studies is to have "flexible dosing," usually leading to the antidepressant group averaging about twice the standard dose in the end. This design, even when treatment effects are shown, biases the reader to have the specious conclusion that higher doses are better.
However, there are certainly many individual case reports of higher doses being more useful. So dose increases may have a role in some cases.
The key point is to question dose increases as a reflexive, routine management strategy for inadequate antidepressant effects. Alternative strategies include giving the lower dose a longer try, switching to something else, or using some form of augmentation.
Addendum:
Just days after posting this, I see there is a new meta-analysis by Jakubovski et al. in The American Journal of Psychiatry (173:2,pp. 174-183) which suggests that SSRI antidepressants do actually work slightly better at higher doses, peaking at 2.5 times the standard dose (e.g. 50 mg fluoxetine). They admit that the data show a trade-off between slight improved effectiveness at higher doses, but accompanied by worsened tolerability.
Yet, it is important to consider that higher doses could reflect a greater placebo effect; some of the research about active placebos show that agents which cause more side effects are likely to have a larger impact on symptoms than inert placebos. Because antidepressants at higher doses have more side effects, there would be more of this "active placebo" effect. See my previous post on this subject: http://garthkroeker.blogspot.ca/2009/03/active-placebos.html
It's hard to know what to make of this, other than to probably remain open-minded about the issue. I think that a better study design for this type of issue is to look at dose comparisons within individual clinical trials, rather than to amass data meta-analytically. Active placebo comparison groups would also be useful. For example, agents which would cause very mild side-effects could be used instead of a totally inert placebo, so as to improve the blinding of the studies. In many individual clinical trials of antidepressants (both new and old) which compare doses or dose ranges within the studies themselves, there are no significant differences in effectiveness.
Another issue, which the authors point out, is that most antidepressant studies have strict inclusion criteria which usually do not match the type of cases one would tend to see clinically most often. Many studies require a major depressive disorder diagnosis, with limited comorbidities allowed, and with limited past treatment trials, etc.
Meanwhile, it remains reasonable to give a baseline dose of antidepressants an adequate length of time to work, without reflexively increasing the dose on a routine basis. Dose increases remain an option, with some evidence-based support, but switching or augmentation could often be preferred, depending on patient preference and side-effects.
Thursday, February 18, 2016
Mental Health Care Organization & Advocacy
A grave problem in the world today is the lack of timely access to mental health care.
The roots of this problem are located in basic societal factors, such as poverty, political oppression, crime, and lack of educational opportunity.
These social factors influence the prevalence, severity, and prognosis of mental health problems. Mental health problems still occur frequently, even in affluent, safe, free environments, but it is important in health care to address the core societal needs as the first, most important, and most powerful rung of care.
These issues are very "political," since changes in poverty and social freedoms, etc. require the involvement of a community's leadership on all levels.
What is the role of the existing community of therapists and other mental health workers to improve quality and timely access to mental health care?
A common pathway nowadays is to employ a type of "corporate" model to improve efficiency. In industry, it is very clear that an assembly line is much more efficient, to produce the largest quantity of goods, with good quality control, in a very consistent, standardized way, with the least possible amount of money and time. Such an approach requires teams of workers, supervised by managers, with each individual worker having a particular area of specialization.
In many corporations or businesses--such as banks--there are also regular efforts to evaluate employee performance, so as to enhance productivity. There may be performance reviews done by management, or perhaps quotas to meet, or quantified analysis of productivity which is then reviewed regularly.
The mental health analogy of an assembly line would be a type of corporate structure, with various members of a team involved in care. So one might deal with a clerical worker to organize appointment times, a social worker, an occupational therapist, a nurse, a primary care physician, a clinical counselor, and a psychiatrist. Even prior to entering this structure, one could deal with friends, family, peer support volunteers, or in a university setting it could be professors, residence workers, etc.
In order for such a system, with multiple rungs of care involved, to work smoothly and helpfully, there would need to be a sense of warm, harmonious collaboration, allowing the experience of being supported by a community.
The risk of such a system, particularly if it is not running smoothly, is that a person could feel like their care was divided or pigeon-holed. It could indeed feel like interacting with a corporation, in the negative sense of the word. (For a particularly critical set of insights about this, I am reminded of the documentary book and film by UBC law professor Joel Bakan, entitled The corporation).
Performance reviews often could lead to a dramatic reduction in morale in an organization, even if the short-term goal of increased "productivity" is reached. Generally it is stressful for workers to feel scrutinized in a hierarchical system. Another consequence of a highly monitored work environment could be subtle changes in the pattern of practice: workers may avoid more difficult, chronic cases, since these would be more likely to lead to negative "productivity ratings." Creative initiatives in the workplace could become inhibited, since it would be "safer" from a productivity point of view to stick with established practices. Also, this type of environment would lead to a type of natural selection process, in which workers with a greater tolerance for such scrutiny and stress would become more abundant in the worker population. Those workers with less tolerance for this would become less prevalent in this system, due to burnout, and due to such a person not wanting to apply for work in such a system.
In some parts of the world, psychiatry is reserved only for "medication consultation," thus leading to atrophy of clinical skills among psychiatrists, as well as overuse of medications, all in rushed, highly medicalized brief appointments.
While I applaud efforts to improve efficiency, I am aware of serious risks.
I see a rise in bureaucratic activities in health care. I see more people, including talented, warm-hearted clinicians, spending their time in front of computers, attending meetings, doing research, or doing some kind of administrative task, instead of dealing on a personal level with people in need. More people are hired, while a smaller proportion of workers' time is spent helping people on a personal level.
Some types of bureaucracy are unavoidable, and necessary for excellence. For example, in hi-tech manufacturing, we absolutely must cooperate with specialists, many of whom across the world, to share the task of creating something amazing or world-changing. The creation of a modern computer or airplane requires hundreds of highly specialized steps, starting from the mining and processing of rare earth metals, to metallurgical processing, to specialized manufacturing of countless components, to involvement of mathematicians, physicists, engineers, and other designers. The finances for such projects need to be organized by people with expertise in commerce and business.
Mental health care does have some aspects in common with airplane manufacturing! But in many ways I believe that it is quite different.
Most patients I see have not really benefited from bureaucratic involvements, but rather have been stressed by them. Hi-tech therapeutic "tools" have often been tried, ranging from trials of "manualized" therapy to computer apps, to sophisticated combinations of medications.
I do not claim that such "tools" are unimportant (actually I think many of them are interesting, clever, imaginative, and uniquely helpful for many), but rather that they must not become the sole focus of a network of health care, that is becoming increasingly impersonal, bureaucratized and corporatized.
The foundations of mental health care are personal empowerment, through economic and educational freedom, followed by the opportunity to have a reliable, stable personal relationship with a helping figure if desired. Physical treatments should be available but not pushed upon people as a default approach, or because personal care was not an option.
If the system is preoccupied with technical and bureaucratic aspects of care, at the expense of personal relationships, then I believe we are facing a steep decline in the quality and availability of mental health care for those most in need.
A particularly insidious part of this problem would be that an assembly-line type of mental health care bureaucracy could most certainly allow more people to be seen, to shorten wait lists, etc. This could lead an external observer to assume that the system had improved. But the decline in quality -- which could risk becoming part of a cultural norm, just as fast-food restaurants or donut shops have become a community norm -- may not be noticed or addressed.
In order to protect the quality of mental health care, I encourage those who have had a positive experience of their own care to be sure to speak up, to offer feedback and advocacy if possible, so as to guide the system towards providing similar positive care experiences for others.
Personal care is expensive to society, in terms of time and money. Bureaucratic care is undoubtedly less expensive, at least in a shorter-term view. At present, many people in dire need have no care at all. Arguably, economically efficient bureaucratic care is preferable to no care at all.
But another option is for our society to invest much more attention and time to offer high-quality, personal care for everyone. For this to occur, or to continue, it is likely that advocacy is needed.
Reference:
Bakan, J. (2004). The corporation: the pathological pursuit of power and profit. New York: Free P.
Thursday, February 4, 2016
CBT Therapists prefer Psychodynamic for themselves
Last summer a professional colleague quoted a research finding, that CBT therapists, if they had to choose a style of therapy for themselves personally, preferred psychodynamic therapy. I haven't been able to locate the exact source of this finding-- perhaps it was a survey at a conference.
Here, by "psychodynamic" I mean an open style of therapy, which is based on empathy, exploration, reflection, consideration of interpersonal patterns, consideration of existential issues, building insight, and particularly on attending to the relationship between therapist and patient or client. Psychodynamic therapy is much less focused on symptom questionnaires, "psychoeducation," prescription of exercises, reviewing worksheets, etc.
During a subsequent discussion I had with a leading CBT specialist, this theme recurred--about how meaningful and helpful it was for that person to have had a long-term personal experience with psychodynamic therapy.
CBT is a very much more "data-driven" style. Psychodynamic styles are less so. While I find CBT approaches extremely important, it is also true that because they are "data-driven" it will be naturally much easier to generate certain types of data from trials of CBT. There would be a built-in bias favouring CBT in research. Those therapists who are very inclined towards "data gathering" would likely be much more inclined towards CBT, and in turn would probably be more inclined to spend time publishing in research journals. Psychodynamic therapists, on average, are simply less interested in publishing research papers.
Those studies comparing CBT with other styles of therapy sometimes show advantages of CBT -- but many do not. And most comparative studies are very brief in duration.
The meaningful, positive elements of psychodynamic styles of therapy are likely to require longer periods of time to evaluate. Such long time periods are more difficult to measure in a study, due to technical limitations.
The inefficiencies of psychodynamic therapies, as manifest in some of the research, have often stemmed from applying old-fashioned psychoanalytic ideas in a dogmatic or highly passive way, and from offering long-term psychodynamic therapies to all patients, without any attention to shorter-term CBT-style work. A "blended model" could involve attending to CBT ideas with most patients, but also offering longer-term psychodynamic therapies at the same time, according to patient wishes. This type of blending is already a natural part of the approach of most therapists on both sides of the "CBT vs. psychodynamic spectrum." The key feature which is required, in any case, is for the therapist to be kind, patient, empathic, engaging, and available.
Another related factor, emerging in society in general, is that much of CBT is simply psychoeducational. Ideas about basic psychological self-care tactics are a major part of every formal CBT course or manual. The thing is, it is becoming much more prevalent now that people are already educated about CBT ideas.
Therefore, to offer only CBT would be, more commonly, to offer educational material that more and more people are already well-versed and experienced in.
I completely support the idea of increasing the availability of CBT, and of fostering education about self care based on these ideas, starting in childhood. A lot of CBT could be "taught" as a university or high-school style course. The manuals for them are similar in size to the workbooks for a typical 3 month course.
But the role of psychodynamic styles is likely to become even more important with time, since more people will already have been well-versed in CBT.
Here, by "psychodynamic" I mean an open style of therapy, which is based on empathy, exploration, reflection, consideration of interpersonal patterns, consideration of existential issues, building insight, and particularly on attending to the relationship between therapist and patient or client. Psychodynamic therapy is much less focused on symptom questionnaires, "psychoeducation," prescription of exercises, reviewing worksheets, etc.
During a subsequent discussion I had with a leading CBT specialist, this theme recurred--about how meaningful and helpful it was for that person to have had a long-term personal experience with psychodynamic therapy.
CBT is a very much more "data-driven" style. Psychodynamic styles are less so. While I find CBT approaches extremely important, it is also true that because they are "data-driven" it will be naturally much easier to generate certain types of data from trials of CBT. There would be a built-in bias favouring CBT in research. Those therapists who are very inclined towards "data gathering" would likely be much more inclined towards CBT, and in turn would probably be more inclined to spend time publishing in research journals. Psychodynamic therapists, on average, are simply less interested in publishing research papers.
Those studies comparing CBT with other styles of therapy sometimes show advantages of CBT -- but many do not. And most comparative studies are very brief in duration.
The meaningful, positive elements of psychodynamic styles of therapy are likely to require longer periods of time to evaluate. Such long time periods are more difficult to measure in a study, due to technical limitations.
The inefficiencies of psychodynamic therapies, as manifest in some of the research, have often stemmed from applying old-fashioned psychoanalytic ideas in a dogmatic or highly passive way, and from offering long-term psychodynamic therapies to all patients, without any attention to shorter-term CBT-style work. A "blended model" could involve attending to CBT ideas with most patients, but also offering longer-term psychodynamic therapies at the same time, according to patient wishes. This type of blending is already a natural part of the approach of most therapists on both sides of the "CBT vs. psychodynamic spectrum." The key feature which is required, in any case, is for the therapist to be kind, patient, empathic, engaging, and available.
Another related factor, emerging in society in general, is that much of CBT is simply psychoeducational. Ideas about basic psychological self-care tactics are a major part of every formal CBT course or manual. The thing is, it is becoming much more prevalent now that people are already educated about CBT ideas.
Therefore, to offer only CBT would be, more commonly, to offer educational material that more and more people are already well-versed and experienced in.
I completely support the idea of increasing the availability of CBT, and of fostering education about self care based on these ideas, starting in childhood. A lot of CBT could be "taught" as a university or high-school style course. The manuals for them are similar in size to the workbooks for a typical 3 month course.
But the role of psychodynamic styles is likely to become even more important with time, since more people will already have been well-versed in CBT.
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