cognitive behavioral therapy


For Depression, Computer-Assisted Therapy Offers Little Benefit, Study Finds

It’s unlikely that your therapist will be replaced by a computer program anytime soon.

That’s the takeaway of recent study out of Britain looking at the effectiveness of computer-assisted therapy for depression.

The bottom line: The computer programs offered little or no benefit compared to more typical primary care for adults with depression. That’s largely because the patients were generally “unwilling to engage” with the programs, and adherence faltered, researchers conclude, adding that the study “highlighted the difficulty in repeatedly logging on to computer systems when [patients] are clinically depressed.”

In an accompanying editorial, Christopher Dowrick, a professor of primary care medicine at the University of Liverpool, stated what may seem obvious: Many depressed patients, he wrote, don’t want to interact with computers; rather, “they prefer to interact with human beings.” He noted that the poor result “suggests that guided self help is not the panacea that busy [primary care doctors] and cost conscious clinical commissioning groups would wish for.”

(Lloyd Morgan/Flickr)

(Lloyd Morgan/Flickr)

As part of the study, published in the BMJ, 691 patients suffering from depression were randomly assigned to receive the usual primary care, including access to mental health care, or the usual care plus one of two computer-assisted options that offer cognitive behavior therapy (CBT), a form of therapy that encourages patients to reframe negative thoughts. Patients were assessed at four, 12 and 24 months; those using the computer programs (one called “Beating the Blues” and the other “MoodGYM“) were also contacted weekly by phone and offered encouragement and technical support.

The context of all this is that demand for mental health services generally exceeds supply around the globe, and health systems are seeking ways to bridge the gap. According to the new paper, demand for cognitive behavioral therapy, for instance, “cannot be met by existing therapist resources.” So, the thinking goes, maybe a computer can ease some of the caseload. And in some cases, it works. Indeed, Britain’s National Institute of Health and Care Excellence (NICE) guidelines recommend computerized CBT as an “initial lower intensity treatment for depression….” based on studies that showed it can be effective.

However, results of this latest study may nudge clinicians and policymakers to rethink the computer’s role in therapy.

Here are the results, summed up in BMJ news release:

Results showed that cCBT offered little or no benefit over usual GP care. By four months, 44% of patients in the usual care group, 50% of patients in the Beating the Blues group, and 49% in the MoodGYM group remained depressed…. Continue reading

Darker Days: Talk Therapy May Be More Durable Than Light Treatment For Seasonal Affective Disorder

For me, it’s already started: As the darkness descends around 5 p.m., my mood starts to sink too. And it’s not even Thanksgiving.

Victims of SAD, or seasonal affective disorder, a form of depression marked by a dip in mood during the darker winter months, take note: Light therapy may help, but talk therapy may be more “durable” in the long-term.

Researchers at the University of Vermont report that light therapy (essentially, simulating sunrise by sitting in front of a device upon waking that emits high intensity artificial light, around 10,000 lux, for at least 30 minutes) was comparably effective as cognitive behavioral therapy for addressing acute episodes of SAD.

(Lloyd Morgan/Flickr)

(Lloyd Morgan/Flickr)

However, the researchers found that after two subsequent winters nearly half the subjects in the light therapy group reported a recurrence of depression, compared with just over one-fourth of those in the cognitive behavioral therapy (CBT) group.

Lead researcher Kelly Rohan, Ph.D. a professor in the Department of Psychological Sciences at the University of Vermont in Burlington, said in an interview that after two winters: “The CBT [patients] maintained their gains better, and we found a more enduring effect of the CBT treatment two years out. Fewer had recurrences of depression and, as a whole, their depressive symptoms were fewer and less intense than people with light therapy.”

Over 14 million Americans suffer from SAD, the researchers report, based on extrapolating a national number from a smaller U.S. sample; prevalence ranges from 1.5 percent of the population in southern states like Florida to over 9 percent in the northern regions of the country.

“There’s no argument that light therapy is a very effective treatment that can substantially improve winter depressive symptomsunder acute conditions, Rohan said in the interview. “But there’s an assumption that people stick to it, and interventions that require effort from people face compliance issues over time.”

The study’s bottom line, she said, is:

“I think the data show that consumers have choices — light therapy is very effective — the question is, ‘Am I willing to stick with it long term and then continue on through the whole winter and pick it up next fall through the winter?’…if so, more power to you. However, if you are willing to consider an alternative, that is CBT, it might be more durable  — you can carry it into the future like a toolbox, you’ve got coping techniques you can use over time.” 

(Full disclosure: Dr. Rohan receives book royalties from Oxford University Press for the treatment manual for the cognitive-behavioral therapy for SAD intervention.)

So how does CBT for SAD differ from therapy for general depression? Rohan says the approach is similar — with a bit of custom tailoring. For instance, the therapist might say something like: “‘We know the dark days are a big contributor to the onset of your symptoms and we can’t control that — we can’t control the sunrise and sunset. But we can control your reaction, and what you think and what you do in response to these light and temperature changes.’ ”

In general, CBT for this condition hinges on reframing the patient’s thinking about the approaching winter — away from a negative attitude about the shorter, darker, freezing, snowbound days, and toward a more positive approach, for instance: What kind of fun, frolicking things can I get out and do in the cold?

“Instead of hibernating and becoming more socially withdrawn,” Rohan said, “we try to get people more engaged in fun winter activities.”

And if you think escaping to the Caribbean will solve your problem, think again: “We don’t endorse jumping on a plane — that’s avoidance, that’s pretending it’s summer when it’s actually winter,” she said. “And dialing the heat up in your home or going to a tanning bed, we don’t advocate for that either — that’s denial, that’s never an adaptive coping strategy. We want people to take winter by the horns.”

Personally, sunshine-filled vacation therapy in winter has worked for me, but Rohan pushed me to rethink this strategy. “When you come back from a trip like that, re-entry can be really jarring,” she said. “Patients feel great when they’re there, when they come back to reality it can really bite.”

Here are some more specifics on the study, published online in the American Journal of Psychiatry, from the UVM news release:

In the study, 177 research subjects were treated with six weeks of either light therapy – timed, daily exposure to bright artificial light of specific wavelengths using a light box – or a special form of CBT that taught them to challenge negative thoughts about dark winter months and resist behaviors, like social isolation, that effect mood. Continue reading

High Anxiety: How I (Sort Of) Overcame My Fear Of Flying

Screen shot 2013-08-01 at 9.39.48 AM

Imagine this tense scene at Logan International Airport’s Terminal E earlier this summer:

A woman with two young children rummages through her medication bag while awaiting an overnight flight to Europe. She pulls out a bottle of pills, then grabs her phone to text her therapist:

Woman: How early can I take half a Xanax? Flight at 8:20. Getting shaky.

Therapist’s response: You can take it now. You can do this!!!!

The scene, sadly, is all too real; that frantic woman is me.

I hate flying. Just writing the word ‘flying’ gives me a pang of dread, twinges of imminent diarrhea and the feeling that I might choke on my own fear.

I’m like Woody Allen on the plane in “To Rome With Love,” a death-grip on Judy Davis’ arm when turbulence hits. “I can’t unclench when there’s turbulence,” he says. “I don’t like this, the plane is bumpy, it’s bumpy… I don’t like when the plane does that… I get a bad feeling.”

In my case, to avoid this excruciating feeling, I have cancelled family trips at the last minute, pretended to be ill, and dragged my children on a 30-hour train ride from Boston to Orlando.

This summer, I’d finally had enough of my fear and its invasive grip on my life. But could I overcome it? I honestly wasn’t sure.

(Before I go on, let me say clearly that mine is definitely a “first-world problem.” There’s no poverty, abuse or major life-threatening illness going on here — just a “problem bred of privilege,” as one friend put it. Still, it’s fairly widespread, and worse since 9/11. Though precise prevalence numbers don’t exist, a 2008 study published in the Journal of Anxiety Disorders says fear of flying is “estimated to affect 25 million adults in the United States and nearly 10–40% of the adults in industrialized countries.” Similarly, a 2007 New York Times report quotes an NIH estimate that about 6.5 percent of Americans fear flying so intensely that it qualifies as a phobia or anxiety disorder.)



Russian Planes With Duct Tape

It wasn’t always this way for me. As a single, childless reporter, I flew all over: to Africa and Vietnam, to Cuba on a Russian-made plane lined with duct tape and in China on a domestic flight on which the pilot told everyone to move to the left side of the plane for “balance.” I flew in tiny, private planes across Washington state in bad weather, and to Provincetown on a little 9-seater.

Then, while walking to work across the Brooklyn Bridge on September 11, 2001, I saw the second plane hit the World Trade Center.  A year later, when I was pregnant with my first child, my flying anxiety suddenly took hold.  When the baby was six months old, I rescheduled a family trip abroad to avoid heavy rain. After that, for the next 10 years, I never took a flight more than three hours long.

I said “no” to weddings, work trips and excursions with my husband to romantic locales. I always had a good excuse not to travel, but in reality, avoiding these trips was all about my fear.

Flying Coffins And Familial Anxiety

There are likely genetics at play here: anxiety is a family trait, and several of us have suffered with flying fears. Years ago, a close relative freaked out on a flight from D.C. to San Francisco and, after a scheduled layover in the midwest, refused to get back on the plane. Instead, he took a train home. For a while, my father called planes “flying coffins,” and took a heavy dose of Klonapin, usually prescribed for seizures and panic attacks, before flights. Continue reading

Psychology Versus Psychiatry: Do The New Depression Guidelines Take Sides?

New guidelines on how to treat depression stress medication over talk

In our post-Freudian, post-Prozac-crazed era, you’d think the fierce debate over what works better — psychiatry (drugs) or psychology (talk, lots of it) might have quieted. Most professionals I interact with these days take a more pragmatic, mash-up approach to mental health, trying to figure out what combination of therapeutic talking, behavioral retraining, and (conservative) medicating, offers relief to each individual patient.

But on the front lines of mental health, the debate still rages, according to Time Healthland, which has a niece piece today on the new American Psychiatric Association guidelines for treating depression, and why all these various mental health providers can’t just get along. The bottom line? In this latest battle, at least, the psychiatrists (or is it the drug industry?) won.

According to the new guidelines — which will govern treatment for the 200,000 in-patient psychiatric patients in the U.S., as well as the 20 million or so who get out-patient treatment — the No.-1 preferred approach is drugs. Just drugs. The guidelines don’t mention psychological approaches like cognitive-behavioral therapy until No. 3, just after electroshock therapy. Ouch.

The new guidelines underplay an enormous body of data from the past decade showing that even the best psychiatric drugs work better than sugar pills only when the drugs are used in conjunction with psychological therapies that help patients change how they behave and how they form their thoughts. Neither a strictly psychiatric approach (just drugs) nor a strictly psychological approach (just talk therapy) works much better than a placebo pill on its own. But when used in combination, the psychiatric and psychological treatments help a majority of people get better.

Medscape offers a less pointed analysis of the new guidelines.

Clearly, the questions raised here aren’t going away soon. An accompanying story reports that 1 in 10 Americans, or 9 percent, suffer from depression and 3 percent suffer from major depression.