{"id":39953,"date":"2013-09-12T20:24:15","date_gmt":"2013-09-13T00:24:15","guid":{"rendered":"http:\/\/1boringoldman.com\/?p=39953"},"modified":"2013-09-12T20:40:19","modified_gmt":"2013-09-13T00:40:19","slug":"an-aside-2","status":"publish","type":"post","link":"https:\/\/1boringoldman.com\/index.php\/2013\/09\/12\/an-aside-2\/","title":{"rendered":"an aside…"},"content":{"rendered":"\n
Back in the late 1970s when the cry for evidence based proof was in its youth and psychiatry was changing, there was a lot of talk about this topic. Cognitive Behavior Therapy was kind of new, and all the rage. Beck was a clear thinker and he won us all over first with "depressive thinking" and then with the more general CBT. There were a raft of papers with CBT, CBT+Drugs, Drugs, and Placebo. They always played out the same way – CBT+Drugs came up the winner. CBT was the darling of the new psychiatry in part because it was time limited, also Aaron Beck renounced his psychoanalytic-ness, it was amenable to psychometric study, and it helped in many cases. Psychodynamic types racked their brains to find a way to do similar studies, but they never got off the ground for a bunch of reasons. After the DSM-III and the changes in third party payment, the topic kind of slid off the radar:<\/div>\n
\n
The Efficacy of Cognitive-Behavioral Therapy and Psychodynamic Therapy in the Outpatient Treatment of Major Depression: A Randomized Clinical Trial<\/font><\/strong><\/div>\n
by Ellen Driessen, Henricus L. Van, Frank J. Don, Jaap Peen, Simone Kool, Dieuwertje Westra, Mariëlle Hendriksen, Robert A. Schoevers, Pim Cuijpers, Jos W.R. Twisk, and Jack J.M. Dekker,<\/div>\n
American Journal of Psychiatry<\/font><\/strong>. 2013 170:1041-1050.<\/div>\n


<\/strong><\/u><\/p>\n

Objective<\/font><\/strong><\/u>: The efficacy of psychodynamic therapies for depression remains open to debate because of a paucity of high-quality studies. The authors compared the efficacy of psychodynamic therapy with that of cognitive-behavioral therapy [CBT], hypothesizing nonsignificant differences and the non-inferiority of psychodynamic therapy relative to CBT. <\/div>\n
Method<\/font><\/strong><\/u>: A total of 341 adults who met DSM-IV criteria for a major depressive episode and had Hamilton Depression Rating Scale [HAM-D] scores ><\/u> 14 were randomly assigned to 16 sessions of individual manualized CBT or short-term psychodynamic supportive therapy. Severely depressed patients [HAM-D score ><\/u> 24] also received antidepressant medication according to protocol. The primary out-come measure was post-treatment remission rate [HAM-D score <<\/u> 7]. Secondary outcome measures included mean post-treatment HAM-D score and patient-rated depression score and 1-year follow-up outcomes. Data were analyzed with generalized estimating equations and mixed-model analyses using intent-to-treat samples. Non-inferiority margins were pre-specified as an odds ratio of 0.49 for remission rates and a Cohen’s d value of 0.30 for continuous outcome measures. <\/div>\n
Results<\/font><\/strong><\/u>: No statistically significant treatment differences were found for any of the outcome measures.The average post-treatment remission rate was 22.7%. Non-inferiority was shown for post-treatment HAM-D and patient-rated depression scores but could not be demonstrated for post-treatment remission rates or any of the follow-up measures.<\/div>\n
Conclusions<\/font><\/strong><\/u>: The findings extend the evidence base of psychodynamic therapy for depression but also indicate that time-limited treatment is insufficient for a substantial number of patients encountered in psychiatric outpatient clinics.<\/div>\n<\/blockquote>\n
For a recovering lab denizen like me, dynamic psychotherapy drew me like a magnet. I wanted to know why people did things that backfired over and over [myself included]. There were and are plenty of patients who wonder the same things, and were looking for someone to join in the search, and that’s what I did with my time. I hasten to add that I think mental health care is always eclectic, and I’ve rarely encountered an approach that didn’t have something to contribute. With me, CBT was one of those things – but more conceptually than formally. <\/div>\n

This study actually points out the difficulty of psychotherapy research. These patients had been somewhat refractory, they were chronically ill, and we know nothing of their motivation. They were selected by symptom [depression] and the therapy choice was random, not tailored to the patient. It was short [16 weeks]. The population was ‘take-all-comers.’ The results reflect all of those things. CBT and Dynamic Psychotherapy were "non-inferior" to each other sure enough, but that meant that the outcome wasn’t very good for either.  If there are things to say from the results, it’s that psychotherapy isn’t for everyone; that assignment by symptom isn’t optimal; and that the venerated place of CBT may well have been an artifact of the times. Oh yeah, there’s an accompanying full text editorial by Michael Thase online [Comparative Effectiveness of Psychodynamic Psychotherapy and Cognitive-Behavioral Therapy: It’s About Time, and What’s Next?<\/a>]. No comment.<\/p>\n

I was on my own as a practitioner, but after retirement I volunteered in a child and adolescent clinic for four years with people of other disciplines, all of whom had been "trained in CBT." We had a lot of fun, because they were an unusually talented lot. Their version of CBT meant doing the same thing I did. We laughed about that some. Adolf Meyers would have approved. I was better at hearing the patients’ back stories, but they weren’t half bad. They tended to lean on learning theory and give "homework," but it wasn’t often. The experience reinforced what I always thought – that good psychotherapists are "naturals" who pick up on any and everything useful that comes their way, particularly the lessons the patients teach us, and incorporate it into their maturing approach.<\/p>\n

I expect that there will always be psychotherapists, though how many are physicians remains to be seen. But I would doubt that psychotherapy research of this type will ever yield much satisfying – too many variables and an infinite number of psychotherapist-patient pairs. These days, most psychiatrist psychotherapists I know are in the pool with the multidisciplinary psychotherapy community at large rather than the neuroscience-based psychiatric community…<\/div>\n","protected":false},"excerpt":{"rendered":"

Back in the late 1970s when the cry for evidence based proof was in its youth and psychiatry was changing, there was a lot of talk about this topic. Cognitive Behavior Therapy was kind of new, and all the rage. Beck was a clear thinker and he won us all over first with "depressive thinking" […]<\/p>\n","protected":false},"author":2,"featured_media":0,"comment_status":"open","ping_status":"closed","sticky":false,"template":"","format":"standard","meta":{"_bbp_topic_count":0,"_bbp_reply_count":0,"_bbp_total_topic_count":0,"_bbp_total_reply_count":0,"_bbp_voice_count":0,"_bbp_anonymous_reply_count":0,"_bbp_forum_subforum_count":0,"footnotes":""},"categories":[2],"tags":[],"class_list":["post-39953","post","type-post","status-publish","format-standard","hentry","category-politics"],"_links":{"self":[{"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/posts\/39953","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/users\/2"}],"replies":[{"embeddable":true,"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/comments?post=39953"}],"version-history":[{"count":9,"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/posts\/39953\/revisions"}],"predecessor-version":[{"id":39962,"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/posts\/39953\/revisions\/39962"}],"wp:attachment":[{"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/media?parent=39953"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/categories?post=39953"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/tags?post=39953"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}