Some Nice Endorsements

Some Nice Endorsements

Hi web visitors,

I have received some very kind comments recently, and wanted to share a couple of them them with you! I hope it won’t sound like excessive self-promotion. Be assured I occasionally get some harsh and disturbing emails as well from individuals who don’t take kindly to some of the views I post. I do encourage criticism, since I am often off base, but sometimes the tone of the criticism can be painful and somewhat shocking. So I guess I am trying, perhaps, to balance that with samples of large numbers of heartwarming emails I receive from so many of you!

As an aside, I also just received a phone call from a patient I had not spoken to in 40 years. In my book, Feeling Good, I described him, and the very intense challenges he presented to me as a young and enthusiastic cognitive therapist, just feeling my way along. I often presented him in the weekly Aaron Beck seminar I attended, where I’d get guidance on especially difficult and disturbing therapeutic dilemmas. But we persisted, and he recovered, and became a leader in the Recovery Incorporated movement, which I have always supported.

Recovery Incorporated is a free of charge self-help group started by Abraham Lowe in the 1930s, and it still serves many individuals throughout the United States. Much like AA, but for depression, in many cities you can attend daily meetings.

Well, it was wonderful touching base again, and he was in tears with gratitude. What a gift that phone call was! He said I changed his life, and I pointed out it was mutual, and that I had gained an enormous amount from the work we did together!

David

Hi Dr. David

Just a quick email to say I am reading your book, When Panic Attacks, again. Just like your first book, Feeling Good, this book on anxiety is a very interesting read and makes a ton of sense! Absolutely fantastic! You are a gifted doctor and author.

Thank you very much,

Kind regards

Shane

Hi Shane,

Thank you! I appreciate your kind note, and I’m sure my daughter will as well. She was my editor, and really helped a lot on the writing.

David

Hello Dr. Burns,

I wanted to send you a quick email to let you know that I truly appreciate your book Feeling Good. I have read several chapters several times and will for years to come! I’m sure I didn’t understand depression before reading Feeling Good, and now I realize that I had been suffering from depression and anxiety pretty much since puberty.

I initially bought the book to help my wife. She has also gone through years of emotional, psychological, spiritual and physical abuse and it has brought her from feeling hopeless every day to feeling good most days. Upon reading it with her, I realized that I also had irrational thoughts which were causing me to miss out on happiness in my life.

I’ve always been very interested in psychology. I’ve listened to a lot of lectures which are available online and I’ve gone through researching the history of psychotherapy, most of which horrifies me because of the unbelievable amount of harm caused. Your methods are by far the most effective I’ve found.

It’s refreshing to see effective talk therapy succeeding in a system which seems to think that pumping people full of anti-depressants (without talk therapy) will correct years of abuse and neglect.

I appreciate your work and your value as a person. Your work has helped at least 10 people I personally know who were suffering. I’ve bought your book for a few of my friends, and all of them said it’s helped their marriages and happiness.

I saw you were in Calgary in November and I really wish I could have come to see your workshop, but hopefully you will be in the area again and I can shake your hand and thank you in person.

Much love from Canada,

Harold

Hi Harold,

Thank you for your kind comments. It is deeply meaningful to hear from someone who has been helped by one of my books. That’s terrific!

You mentioned that you missed me in Calgary. Actually, I will be in Calgary on November 27th of this year (2017) for the large trauma conference sponsored by Jack Hirose and Associates. I will be giving a morning keynote address, followed by a four-hour afternoon workshop, and will illustrate the new, high-speed TEAM-CBT treatment methods for trauma patients who are struggling with depression and anxiety disorders. I will also deliver a two hour evening presentation for the general public (as well as mental health professionals) on Skills, Not Pills for Depression and Anxiety. You can get more details on my workshop page if you CLICK HERE.

If you plan to attend any of my presentations, make sure you come up and say hello so we CAN shake hands!

David

Hi Dr. David,

I’m not expecting a response, nor do I necessarily expect that you read all the messages that come your way, but I feel like I owe you a lot at this point. My dissertation was on reciprocity, and while I do not suffer from too many “should” thoughts directed at others, I do like to practice what I’ve studied.

I consider myself fairly intelligent, generally logical, and have an undergraduate degree in Psychology. All of which made me even more surprised with how much the first couple of chapters of “Feeling Good” resonated with me after suffering pretty badly for a year and a half following a very painful breakup. I feel silly for convincing myself I could never be happy again because I would never find someone to be with. Unproductive at research, a series of non-starting romantic endeavors, “wishing” I didn’t have kids so suicide was an option, not wanting to leave my house, dwelling on what I could have done differently so that I wouldn’t be alone the rest of my life.

I just finished the book after finally picking it up last week (my therapist recommended it a year ago). I realized that these cognitive distortions have been with me throughout my life – not that I’ve been depressed my whole life (although I probably would have claimed that 2 weeks ago). My cause is clearly a love addiction, but I’m not contacting you for therapy!

I’m contacting you because I wanted to say thank you. I feel like I have a strong understanding of the cognitive distortions that have plagued me any time I’ve faced real sad events in my life and I now have tools to combat this now and in the future. I purchased copies of your book for my ex-wife, a recent failed romantic interest, my father, my brother, and I am going to have my 17 year old daughter read through the first three chapters to see if it resonates with her as well.

I never wanted to admit that I might suffer from depression. I kept putting off facing it, even though my mother suffered from depression her whole life. My father is a retired Marine and I was raised to believe that you should be strong enough to overcome challenges “on your own”. That put me at a disadvantage in some ways, but I’m optimistic that my copious notes and highlighting in your book will be with me the rest of my life – or that I’ll never need them after I practice some of the techniques.

Anyways, this is way longer than I intended! Thank you for showing me that the dark mood spirals I’ve experienced throughout my life are treatable and not uncommon. I wish I would have realized this long ago… but I’m trying to avoid “should” thinking, so I don’t let that thought persist!

Don

Hi Don.

Thank you so much for contacting me. Greatly appreciated. And thanks, too, for permission to post your wonderful note!

All the best,

The Placebo Effect

The Placebo Effect

Hi web visitors,

Recently I have referred to the fact that many of the current schools of therapy have only a placebo effect in the treatment of depression and anxiety, and this has drawn some skeptical, and arguably angry, responses from a couple visitors to the website who did not take kindly to the idea that I may be challenging the validity of their favorite school or method of therapy. In addition, I have mentioned recent researchers such as Dr. Irving Kirsch from Harvard, who have concluded that the chemicals called antidepressants may have few, if any, clinical significant effects above and beyond their placebo effects. This has also annoyed some visitors.

In fact, one reader has called me a quack and asked to be removed from the mailing list for my posts! In all fairness, this has just been a couple folks, and I get many heartwarming and wonderfully positive comments from you every day. I really appreciate your support!

But I thought it might be useful to publish an excerpt from my psychotherapy eBook, Tools, Not Schools, of Therapy in order to present some of my thinking in little more depth, because the placebo effect can be confusing to people. The material I am publishing below is a portion of the chapter entitled “The Clinician’s Illusion.” The chapter highlights ways that practicing mental health professionals sometimes developed inflated ideas about their clinical effectiveness.

Although my book is primarily geared for clinicians who want to improve their therapy skills and effectiveness, the material I am publishing here could be of potential of interest to lay individuals as well who are keenly interested in mental health issues. As an aside, if you are interested in ordering a copy of my eBook, CLICK HERE.

I want to emphasize that the placebo effect is not necessarily a bad thing. A placebo effect is a real effect, and might involve, for example, a complete elimination of the symptoms of depression or anxiety, or even a physical ailment of some type. A placebo effect simply means that the recovery the patient has experienced does not result from the specific mechanism you thought, but rather from your belief that the treatment would help.

It is important to understand the placebo effect, both from the perspective of research and clinical work as well, because it creates profound confusion in both arenas.. My goal in publishing this excerpt is to provide an overview of an important phenomenon which has always been an important part of medical and psychiatric healing.

I am an optimist, and feel that the future of psychotherapy is bright. But I also believe the future will belong to clinicians who are practicing empirically based, data-driven therapy, and that is why I have developed TEAM-CBT. In TEAM-CBT we measure the patient’s symptoms with brief, sensitive scales at the start and end of every session, with no exceptions. That way, clinicians can assess their effectiveness, or lack of effectiveness, at every single therapy session. This is like having a psychiatric X-ray machine for the first time, giving clinicians precise and accurate information that can guide the therapy for the first time.  This treatment breakthroughs has allowed us to develop superior treatment techniques that can lead to high-speed recovery from depression and anxiety, effects that are far more powerful than a simple placebo effect. But the placebo effect will always be a welcome and important component of medical and psychiatric treatment..

Please remember that I am posting my thoughts and experiences as part of my outreach work for therapists and for the general pubic. When I write, I try to express myself in crystal clear language, but am sometimes disheartened when I see that some people may not grasp what I am saying, and may even to jump to conclusions that are the opposite of what I am suggesting. It is not my goal to upset visitors to FeelingGood.com, and it breaks my heart to see some people becoming upset by my posts. If you find my writing disturbing, then this might not be the website for you. But if you hang in there and share your ideas and criticisms with me, I’ll usually do my best to respond.

Please remember that I can only express my best thinking, for better or worse, and that I am often wrong or off-base in my conclusions. My beliefs are subject to error as well as bias, so please feel free to disagree with me and even to reject my thinking.

YMy opinions may not be valid, but I don’t think I can qualify as a quack who’s just talking off the top of his head, saying things for effect. I began my career doing research on brain chemistry at the University of Pennsylvania School of Medicine, working specifically on the chemical imbalance theory of depression and anxiety for several years. During that time, I won one of the world’s top awards, the A.E.Bennett award, for basic research on brain serotonin metabolism.Some early investigators speculated that a defiicient of brain serotonin is the cause of depression–that IS the chemical imbalance theory. But I could find no convincing evince for this theory, in my published research or in my review of the world literature.

I say that to let you know that I am not an outsider throwing stones, but an psychopharmacology insider. I have personally prescribed antidepressants on more than 13,000 occasions, although I treated most of my patients without them. So I do have considerable experience behind my words. In addition, in this blog I will provide you with references to specific studies, so you can do your own research and come to your own conclusions. One book I would recommend for the serious reader is Irving Kirsch’s book, “The Emperor’s New Drugs: Exploding the Antidepressant Myth,” available as a paperback on Amazon and a good and easy read!

The table below describes why clinicians, including those who start new schools of therapy, frequently conclude that their treatment methods are substantially more effective than they really are. I call this problem “The Clinician’s Illusion.” I discuss all of these problems in Chapter 6 of my eBook, but will only publish the material on the Placebo Effect here.

How Clinician’s Fool Themselves

1.   The Placebo Effect. You attribute your success to your theory and methods when the improvement was actually a non-specific placebo effect. 5.   Therapeutic Solipsism. You assume you know how your patients are thinking and feeling, and you’re not aware that your perceptions may be off base.
2.   Self-Fulfilling Prophecies. You feel so certain that something will happen that you subconsciously make it happen. Then you conclude you were right all along. 6.   Therapeutic Arrogance. You assume that your theories and methods are valid a priori, and that you don’t really need to test them empirically.
3.   Sample Selection Bias. You generalize about the effectiveness of your treatment based on your experiences with a highly-selected group of patients who seek you out, as well as those who continue to work with you, forgetting those who dropped out. 7.   Coupling. You couple a new technique, such as EMDR (eye movement desensitization and reprocessing), with an established method, such as exposure therapy and cognitive therapy, and attribute the improvement you observe to the new technique.
4.   Selective Recall. You selectively remember the patients who respond well to your interventions, and selectively forget or discount those who don’t. 8.   The Confirmation Paradox. You assume that your theories are valid because they’re consistent with your clinical observations.

The Placebo Effect

from Tools, Not Schools, of Therapy
by David Burns, MD *
Copyright © 2017 by David D. Burns, MD

Imagine this scenario: a man who’s been feeling worthless and discouraged for several months seeks treatment from his family physician, or from a local psychiatrist. The doctor explains that he’s suffering from an episode of depression that results from a chemical imbalance in his brain. The doctor reassures him and gives him a prescription for an antidepressant that will correct the imbalance.

Four weeks later, the man reports that he’s feeling much better. He’s sleeping better, his mood has lifted, and he’s productively involved in life again. He and his psychiatrist attribute his dramatic improvement to the antidepressant medication. Is this sound reasoning? Can we reasonably conclude that:

  • His depression resulted from a chemical imbalance in his brain?
  • The antidepressant corrected this chemical imbalance?
  • He responded to the antidepressant?

Although many health professionals and patients do draw these kinds of conclusions, his rapid improvement does not provide convincing evidence for any of them. All we can say for sure is that he was depressed and now he’s feeling better. That’s great, but we don’t know what caused his depression or what triggered his improvement. His improvement could have resulted from the passage of time, unexpected events that lifted his mood, the fact that he became more active, the medication, or other factors, including the placebo effect.

What is the placebo effect, and why is it so important? We know that our expectations can have powerful influences on the way we think, feel, and behave. If you’re convinced that something will help, there’s a good chance that it will help, even if it has no real effects at all.

Let’s say that you and I work as marketing executives for a pharmaceutical company. One day, at a press conference, we announce the synthesis of a wonderful new antidepressant called “Placebin.” We emphasize the superior antidepressant effects of Placebin and explain that it has few or no side effects, and virtually no toxic effects. In fact, we’re so excited by this new breakthrough that we’re going to give Placebin to a million depressed people absolutely free of charge in a huge, nationwide clinical trial. There’s tremendous enthusiasm for Placebin and our stock goes up by more than a billion dollars overnight.

Of course, we don’t tell anyone that our new drug is just a placebo, with no active chemical ingredient. How many of the million depressed patients who take Placebin will recover?

Numerous research studies have shown that if you give an inert placebo to people who are suffering from depression, 30% – 50% of them will recover. The precise percentage will depend on how severe or refractory the patients are. This means that within a few weeks, 300,000 – 500,000 of the patients in our clinical trial will have recovered. They’ll swear by the drug and tell all their friends about it. Some may even appear on national television and give glowing testimonials about how Placebin totally cured them and changed their lives. Tens of thousands of people will rush to their doctors to get prescriptions for this remarkable new medication, and controversial books will appear, asking whether it’s ethical to prescribe “happiness pills.”

But of course, Placebin didn’t really do anything for anyone. It was the patients’ expectations, and not the pills, that got them better. The patients actually healed themselves, but didn’t realize it.

Why are placebos so powerful? A few possibilities jump to mind:

  • Hope. Hopelessness is one of the cardinal symptoms of depression. The belief that things can’t change acts as a self-fulfilling prophecy, because the patient gives up. Then nothing changes, so the patient concludes that she or he really is hopeless.Hope works in the opposite way. If you expect to get better, you’ll become more productive and your outlook will change, so you’ll start to feel better. That’s why patients who believe in any new “treatment” for depression or anxiety have such a good chance of recovering, even if the treatment only has placebo effects. In many cases, the belief that you’ll recover, and not the treatment itself, causes the improvement. Hope is the most potent antidepressant in existence.
  • Warmth and empathy. Positive correlations between therapeutic empathy and recovery have been reported in more than 100 psychotherapy outcome studies (Orlinsky, Grawe, & Parks, 1995). Patients who perceive their therapists as warm and understanding recover more rapidly than patients who do not feel accepted or understood by their therapists. Of course, a correlation does not necessarily imply causality. However, my own research, using Structural Equation Modeling techniques, suggests that the correlation results from a direct causal effect of therapist empathy on recovery from depression (Burns & Nolen-Hoeksema, 1992).

Hope and empathy are important keys to recovery, but these variables create confusion about how and why therapy works. You can test any kind of kooky therapeutic intervention you want, and if you can convince people that your treatment will be effective, it probably will be reasonably effective, even if it involves blatant quackery. Whatever we do will be somewhat effective for some of our patients, and amazingly effective for a number of them. As a result, we may conclude that our theories are valid and that our treatments have specific antidepressant or anti-anxiety effects. We’ll attribute the positive outcomes we observe to our theories and to the methods we’re using, and not to the placebo effect. We’ll tell ourselves, “Bob recovered because of the antidepressant I prescribed,” or “the EMDR I used,” or “the family of origin work we did,” or whatever method we tried.

This is not a trivial concern, because new treatments for depression and anxiety emerge all the time. Many of the new schools of therapy attract large numbers of followers, especially if they’re skillfully marketed.

I don’t mean to imply that the placebo effect is a bad thing, or that it’s unimportant. It’s been one of the physician’s strongest medicines for thousands of years, and it deserves more research. If we can learn more about how the placebo effect works, we can develop more potent placebos. But if you had a ruptured appendix, wouldn’t you want the help of a skillful surgeon? If the surgeon had a warm, reassuring bedside manner, so much the better, but you’d need more than just the placebo effect to save your life.

Now, you may be thinking, “Well, this is all rather academic, because we do have empirically validated treatments for depression and anxiety. Drugs and psychotherapy have been proven to be effective.”

In fact, the situation isn’t so clear-cut. Recent studies suggest that antidepressants may have very few real therapeutic effects, if any, above and beyond their placebo effects. For example, in a well-controlled, multi-university study funded by the National Institute of Mental Health, 320 patients with major depression were randomly assigned to treatment with St. John’s wort, sertraline (Zoloft), or placebo. As you can see in the chart below, 32% of the patients who received placebo recovered, as compared with only 25% of the patients who received sertraline and 24% of the patients who received St. John’s wort (Hypericum depression trial study group, 2002).

slide3

This study clearly showed that St. John’s wort has no real antidepressant effects above and beyond its placebo effects, a result that was widely publicized by the pharmaceutical industry. However, they didn’t publicize the fact that the antidepressant didn’t fare much better than St. John’s wort! The authors of the study concluded that “the overall response to sertraline on the primary measures was not superior to that of placebo, an outcome which is not uncommon in trials of approved antidepressants” (NIH, 2002).
These results are not consistent with the widely held notion that the chemicals called “antidepressants” have strong, specific antidepressant effects. In fact, based on their review of the world literature, as well as the data that has been submitted to the FDA by drug companies over the past several decades, Kirsch and his colleagues have concluded that at least 75% – 80% of the effects we attribute to antidepressant medications clearly result from their placebo effects (Kirsch & Sapirstein, 1998; Kirsch, Moore, Scoboria, & Nicholls, 2002).

Below, you can see a figurethat represents the kinds of results you’ll find in the most favorable drug company studies that have been conducted. This figure represents almost 20,000 patients who were tested in drug company studies of the SSRI antidepressants, like Prozac, and includes every known SSRI at every known dose. As you can see, in drug company studies, they typically select patients with scores averaging 25 on the Hamilton Rating Scale for Depression (HRSD), indicating moderate or severe depression.  Then these patients are randomly assigned to treatment with placebo versus an antidepressant.[*] Of course, they tell the patients that they won’t know whether they are getting the antidepressant or the placebo.

A 25-point reduction in HRSD scores would be needed for full recovery. As you can see, the patients who received the antidepressants experienced a 10 point reduction in HRSD scores, while the placebo group experienced an 8.5 point drop.

slide1There are two striking things about these results. First, the difference between the drug and placebo groups was only 1.5 points. This is the most improvement you could attribute to the drug itself, and it’s small, especially when you consider the fact that a 25 point reduction is needed for full recovery.

A number of recent researchers have suggested that such a tiny effect may not justify prescribing antidepressants, given the significant side effects, toxic effects, and hazards associated with these agents (Antonuccio, Danton, & DeNelsky, 1995; Antonuccio, Danton, DeNelsky, Greenberg, & Gordon, 1999; Kirsch, Moore, Scoboria, & Nicholls, 2002). I would strongly agree with that. In fact, I have developed more than 75 psychotherapy techniques to help patients who are depressed or anxious. And using the new TEAM-CBT, I often see a complete or near-complete elimination of symptoms in a single, two hour therapy session.

if there was a psychotherapy technique that only caused a 5% or 6% in 12 to 16 weeks of treatment, it would not make my top 1000 list, much less my top 75 list, and I would tell my students not to bother with it.

The second potentially important point is that roughly 8.5 of the 10 points of improvement in HRSD scores in the drug group, or 85%  of their improvement, resulted from the placebo effect, and not from the drug itself. In other words, if the people in the drug group had been in the placebo group instead, they still would have improved by 8.5 points.

Keep in mind that the figure we just reviewed represents the best studies that drug companies published. However, drug companies suppress the results of many studies that don’t come out in the “right” way. If you look at the next figure, you’ll see the results of many unpublished studies in which there were no differences  between the antidepressant and the placebo. Drug insiders will tell you that studies like this are common, but the results are never published. As a result, there’s a highly misleading pro-drug bias in the world literature. This leads to false perceptions about the efficacy of these agents.

slide2

Recent researchers have argued that the tiny differences between antidepressants and placebos in even the most “favorable” outcome studies may result from flaws in the way drug companies conduct these studies (Antonuccio, Burns, & Danton, 2002; Antonuccio, Danton, & DeNelsky, 1995; Antonuccio, Danton, DeNelsky, Greenberg, & Gordon, 1999; Kirsch, Moore, Scoboria, & Nicholls, 2002). One problem is called the “placebo washout” period. Prior to randomizing patients to the drug or placebo group, drug companies put all the patients on placebos for a one to two-week period. During this phase of the study, they carefully monitor the patients’ depression scores. Any patients who improve are selectively removed from the study. At the end of the “placebo washout” period, the researchers randomly assign the remaining patients to the placebo or drug groups. In this way, they stack the deck in favor of their new drug.

In case this did not jump out at you, think about it this way: the have removed the placebo responders from the study! In cards, this is called “stacking the deck.”

Can you imagine what would happen if they set the study up in the opposite way? Suppose they put everyone on their new antidepressant for one or two weeks, and then removed all those who began to improve before randomly assigning the remaining patients to the placebo versus drug conditions. The drug companies would cry foul, because you’d be biasing the study against their drug. But that’s exactly what they do when they selectively remove the placebo responders from their studies.

Why do drug companies do this? In a cynical moment, one might argue that their motives could be financial financial rather than scientific. If they can come up with two studies that demonstrate a statistically significant difference between their new drug and a placebo, they’ll receive FDA approval to market the new drug. As a result, their stock will probably increase in value by a massive amount overnight. And they executives of the drug company may get bonuses based on increases in stock value.

They use other tricks they may use to try to stack the deck in their favor as well. For example, patients who enlist in a drug company study of a new antidepressant are informed that they’ll either receive the new drug or a placebo. They’re also informed that the placebo will be chemically inactive and will have no side effects. However, if they receive the new antidepressant, there will be certain side effects they should expect. For example, if they receive Prozac, they may experience upset stomach, diarrhea, nervousness, a loss of sexual drive, and so forth.

Once the study begins, patients who experience the anticipated side effects usually conclude they got the new drug. In contrast, patients who don’t experience any side effects usually conclude that they’re in the placebo group. Studies indicate that if you ask patients which group they’re in, they’ll be correct as often as 80% to 90% of the time.

So the studies aren’t really “double blind” at all, because the patients know very well whether or not they’re receiving the new “antidepressant.” This flaw tends to bias the results because the patients who think they’re getting the new antidepressant become more hopeful and optimistic, thinking they’re getting a wonderful new medication for depression, so they improve because of feeling greater hope and optimism. In contrast, the patients who think they’re only getting the placebo may feel disappointed, so their depression scores can get worse. This artifact can create statistically significant differences between the drug and placebo groups, even when no differences exist in reality.

Another problem is the use of badly flawed assessment instruments like the HRSD. This scale is one of the worst psychometric instruments ever developed and it boggles my mind that anyone would take it seriously, much less use it in research! There are many fatal flaws with this instrument, including the fact that it focuses almost exclusively on non-specific somatic symptoms, which are poor indicators of depression.

For example, three of the 16 items on the HRSD ask about insomnia. As noted earlier in the book, many factors other than depression can cause insomnia. Furthermore, any medication with sedative properties will cause an apparent “improvement” on the HRSD, even if the medication has no antidepressant properties at all! This is not a trivial problem, because many antidepressants have significant sedative side effects.

These flaws are particularly egregious because all these problems are easily solvable from a research perspective. For example, you could simply ask patients what group they think they’re in soon after the study begins, and control for this variable when you analyze the data. Or, you could use active placebos rather than inactive placebos. For example, if the drug being tested causes sedation, you could use an antihistamine like Benadryl for the placebo, since this medication causes sedation. Or, if the drug causes stimulation and diarrhea, like Prozac, you could use caffeine for the placebo.

But drug companies refuse to use more refined assessment instruments or implement any corrective strategies because they know they’ve got a good thing going and don’t want to rock the boat. In fact, the only studies in the world literature that have used active placebos have failed to show any differences whatsoever between placebos and antidepressants (Kirsch & Sapirstein, 1998). Clearly, drug companies don’t want to wander into this territory!

Recent reports have dealt even stronger blows to the psychopharmaceutical industry. Investigators have shown that all the new antidepressants, including the SSRIs, appear to cause substantial increases in the rates of successful suicide in children (Garland, 2004; Jureidini et al., 2004; Whittington et al., 2004) and in adults (Healy, 2003).Below, you can see the rates of successful suicide in depressed adults who were randomly assigned to SSRIs (such as Prozac) or placebos in drug company studies. If these were true antidepressants, why would they cause an increase in suicide rates?[2]

slide4

Many people find these studies hard to swallow, and simply cannot believe them at first. We all know someone who’s said, “Prozac worked for me. It saved my life. The effect has to be real!” But remember that 30% – 50% of the people who receive a placebo will say exactly the same thing.

My reading of the literature, as well as my clinical experience over the years, has led me to conclude that true antidepressant medications may not yet exist. We have chemicals with side effects that are called “antidepressants,” such as Prozac and Paxil, but the antidepressant effects of these kinds of drugs appear to be underwhelming at best.

I don’t want to throw too many stones at the drug companies, because a critical reading of the psychotherapy outcome literature reveals similar problems. Many forms of psychotherapy do not seem to have any strong or specific antidepressant effects above and beyond their placebo effects, either in the short-term or the long-term. This suggests that most of the effects we attribute to each “brand” of therapy may be non-specific placebo effects as well.

Where do we end up? One potentially important conclusion is that the needs of science clash with the needs of marketing. When someone is selling a product, their research needs to be considered with considerable scrutiny, because all human beings are subject to corruption, especially when huge amounts of money are involved. But this is equally true in psychotherapy as in psychopharmacology. If someone has staked his or her career on promoting this or that new brand of psychotherapy, it may be just as difficult for that person to acknowledge or publish research showing that the new treatment has few or specific antidepressant effects above and beyond the placebo effect.

So they first question is–are the chemicals know as antidepressants significantly more effective than placebos? The conclusion I have come to, through clinical experience and my reading of the research literature, is–probably not.

And the second question is–are most psychotherapists, and most schools of psychotherapy, more effective than placebos in the treatment of depression?  The conclusion I have come to is the same–probably not.

This is not necessarily bad, because the placebo effect is quite strong, and helpful to 50% of the individuals who seek treatment for depression. But the reason why I’ve created TEAM-CBT is to try to find answers for the other 50%. I’m optimistic we’re doing that, but we’ll have to wait for the result of current research studies to find out for sure!

David

[*] This table, and some of the others in this chapter were adapted from Preskorn, S. H. (1997). Clinically relevant pharmacology of selective serotonin reuptake inhibitors: an overview with emphasis on pharmacokinetics and effects on oxidative drug metabolism. Clinical Pharmacokinetics, 32 Suppl. 1: 1-21.

[2] The increase in suicide may result from the stimulating effects of these antidepressants. Some patients become more agitated and anxious or even experience akathisia when taking SSRIs, and this may trigger suicidal feelings. Another possibility is that the lack of antidepressant effects may make some patients feel more desperate. They may reason, “Even this powerful new drug isn’t helping me. I must be a hopeless case.”

References

Antonuccio, D.O., Burns, D., & Danton, W.G. (2002). Antidepressants: A triumph of marketing over science? Prevention and Treatment, 5, Article 25. You can read this article online:

http://journals.apa.org/prevention/volume5/toc-jul15-02.htm

Antonuccio, D.O., Danton, W.G., & DeNelsky, G.Y. (1995). Psychotherapy versus medication for depression: Challenging the conventional wisdom with data. Professional Psychology: Research and Practice, 26, 574-585.

Antonuccio, D.O., Danton, W.G., DeNelsky, G.Y., Greenberg, R., & Gordon, J.S. (1999). Raising questions about antidepressants. Psychotherapy and Psychosomatics, 68, 3-14.

Burns, D.D., & Nolen-Hoeksema, S. (1992). Therapeutic empathy and recovery from depression in cognitive-behavioral therapy: A structural equation model. Journal of Consulting and Clinical Psychology, 60(3), 441-449.

Garland, E. J. (2004). Facing the evidence: antidepressant treatment in children and adolescents. Canadian Medical Association Journal, 170, 489-491.

Healy, D. (2003). Lines of evidence on the risk of suicide with selective serotonin reuptake inhibitors. Psychotherapy and Psychosomatics. 72, 71-79.

Hypericum depression trial study group. (2002). Effect of Hypericum perforatum (St. John’s wort) in major depressive disorder: A randomized, controlled trial. Journal of the American Medical Association, 287, 1807-14. You can read a summary online at: www.nih.gov/news/pr/apr2002/nccam-09.htm

Jureidini, N., Doecke, C.J., Mansfield, P.R., Haby, M.M., Menkes, D.B., & Tonkin, A.L. (2004) Efficacy and safety of antidepressants in children and adolescents, British Medical Journal, 328, 879-883.

Kirsch, I., Moore, T.J., Scoboria, A., & Nicholls, S.S. (2002). The emperor’s new drugs: An analysis of antidepressant medication data submitted to the U.S. Food and Drug Administration. Prevention and Treatment, 5, Article 23. You can read this article online:

http://journals.apa.org/prevention/volume5/pre0050023a.html

Kirsch, I., & Sapirstein, G. (1998). Listening to Prozac but hearing placebo: A Meta-Analysis of Antidepressant Medication. Prevention and Treatment, 1, Article 0002a. You can read this article online:

http://journals.apa.org/prevention/volume1/pre0010002a.html

Krupnick, J.L., Sotsky, S.M., Simmens, S., Moyer, J., Elkin, I., Watkins, J., & Pilkonis, P. (1993). The role of the therapeutic alliance in psychotherapy and psychotherapy outcome: Findings in the NIMH treatment of depression collaborative research program. Journal of Consulting and Clinical Psychology, 64(3), 636-643.

NIH (April 9, 2002). NIH News Release. http://www.nih.gov/news/pr/apr2002/nccam-09.htmOrlinsky, D.E., Grawe, K., & Parks, B.K. (1995). Process and outcome in psychotherapy–Noch einmal. Chapter 8 in A. E. Bergin, & S. L. Garfield (Eds.), Handbook of Psychotherapy and Behavioral Change (pp. 270-376). New York: John Wiley, & Sons, Inc.

Preskorn, S.H. (1997). Clinically relevant pharmacology of selective serotonin reuptake inhibitors: an overview with emphasis on pharmacokinetics and effects on oxidative drug metabolism. Clinical Pharmacokinetics, 32, Supplement 1, 1-21.

Whittington, C.J., Kendall, T., Fonagy, P., Cottrell, D, Cotgrove, A, & Boddington, E. (2004). Selective serotonin reuptake inhibitors in childhood depression: systematic review of published versus unpublished data. The Lancet, 363, 1341-1345.

 

Photos from Our Sunday Hike

Photos from Our Sunday Hike

Hi web visitors,

I am attaching eight photos from this week’s Sunday hike, which included two hail storms. I hope you like the photos! One of our newest Tuesday group members, Maryam, took them.

As you can see, spring is in full swing here already. There is so much beauty and majesty in these photos, taken with a cell phone. You will see that some of the trees are already covered with white or pink blossoms. The tree with white blossoms is a really old plum tree. If we have enough bees, it may produce a large volume of fabulous plums. But it is a race with the birds and squirrels as to who gets them first! Usually we lose that one.

Danny, the other man in the photos,  drove something like two or three hours to hike with us on Sunday. That’s real commitment! The house in the photo is one we passed on the hike.

We had to avoid most of the trails which were excessively muddy due to all the rain we’ve had, but it was a terrific hike in spite of having to be on roads part of the time. The main hiking adventure is internal, at any rate, so the weather and trails are not overly important.

There were only three of us, due to the rain, and we were working, as usual, on personal relationship issues, which seems to be a popular topic among therapists who come to the Sunday hikes. The hikes provide an opportunity for therapists to work on their own issues, and also to learn and practice psychotherapy techniques, so we can improve the work we do for our patients / clients. It was an interesting and productive  hike, I think.

We focused on questions like how do you get to know someone? What’s the best approach when you are meeting someone who may interest you? Web visitors also ask these kinds of questions. In fact, one of them is a man who has asked for tips on flirting. I may devote a blog on that, if folks are interested, and encourage all of you to post their your tips and suggestions, as their are so many radically different theories about this!

 

David

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Treatment of Hypochondriasis / Health Anxiety

Treatment of Hypochondriasis / Health Anxiety

Hi Dr. Burns,

I have read feeling good and listened to all your podcasts as of today. I have a history of hypochondria and depression and your book helped me tremendously in overcoming my anxiety. I am beyond happy that I can finally have control over my emotions.

I used to go to psychotherapy sessions with multiple different psychotherapists and more often than not the solutions they offered were along the line of “keep as busy as possible not to give in to the thoughts” or “imagine the obsessive thoughts as a spoiled brat that you should not give into” which all failed dramatically. And believe me when I say they even made it worse than before!

Recently I was listening to some your anxiety podcasts in which you introduced the exposure technique. You described how it worked in the case of Pedro, the young man with OCD who was having intrusive thoughts of Jesus having sex with Mary in all the positions of the Kama Sutra. And the harder he tried to control these forbidden thoughts, the more intense they became!

You also described the Experimental Technique you used in your panic attack patients. I was wondering if these techniques can be helpful in the case of patients dealing with health anxiety.

I read a research paper of a psychiatrist treating her hypochondriac patients with exposure techniques. For example, in my case, if I’m always scared of contracting HIV, I might volunteer to work with HIV positive patients so I could confront my fear. I was wondering if that could help with the urge to get tested very often and if there are any other techniques you specifically find useful in this case.

I used the exposure technique successfully to eliminate my frightening thoughts of slitting my wrists or throat with a razor. These thoughts used to give me a tremendous amount of anxiety and I would always try to eliminate them from my mind as soon as they appeared, almost automatically thinking that’s the way to protect myself. That didn’t work! But now they are completely gone as I spent a full half-day just repeating those images in my mind, over and over again. I tried to imagine all the graphic details until I was completely bored with them! I would like to thank you for reaching out and sharing your knowledge and expertise with people despite the fact that you don’t practice anymore.

And by the way that jumping jacks story with your patient who thought she was about to die during a panic attack has become an inside joke between me and my husband!

Sincerely,

Mona

Hi Mona,

Thank you for your kind comments about the Feeling Good podcasts! I know that my host, Fabrice, will be thrilled to hear that you like them and find them helpful!

There are so many things I appreciate about your wonderful email that I’m not sure where to begin. I do want to emphasize that I cannot treat anyone or give medical advice in this medium, so my answer, as always, will consist of general teaching.

First, I resonated when you described previous therapists who gave you advice, thinking that would help. To my way of thinking, an awful lot of “psychotherapy” consists of schmoozing behind closed doors with the occasional piece of advice thrown in, and in most cases, that just doesn’t get the job done. In fact it can make people feel worse, because it is often sounds patronizing.

Second, I have a current series of several Feeling Good podcast on the treatment of anxiety using four models that are all described in my book, When Panic Attacks. They are the Motivational Model, the Cognitive Model, the Exposure Model, and the Hidden Emotion Model. All four models have tremendous healing power, and I integrate all four into my treatment of each individual with anxiety, because you never know which one, or which combination, will give you the “ah-ha” moment when the anxiety suddenly disappears completely. You can listen to those podcasts right now if you like, either on iTunes or right here on my website, feelinggood.com.

In the treatment of OCD, the Exposure Model usually has two components: Exposure and Response Prevention. So if a person has an irrational fear of HIV, as you described in your email, they could use Cognitive Exposure or Classical Exposure. Cognitive Exposure might involve fantasizing dying of HIV until the fantasy becomes totally boring. Classical Exposure might involve volunteer work with HIV patients, as you mentioned.

In therapy, I work with the patient to figure out what type of Exposure will be the most effective. The Exposure has to be anxiety-provoking, or it won’t be helpful. And, as you say, the goal of exposure is not to control the anxiety—which makes it worse—but simply to flood yourself with the anxiety until it finally loses its power over you.

Response Prevention would mean, in this case, refusing to give in to the urge to get repeated blood tests, if that’s what you are doing to deal with your fear of HIV. But the Response Prevention has to be tailored to your compulsion. Let’s assume that you had OCD with a handwashing compulsion, so you are washing your hands repeatedly all day long to get rid of the imagined “contamination.” Response Prevention would mean refusing to give in to the urge to wash your hands repeatedly. The anxiety will increase for several days, but if you refuse to give in, the compulsion will generally diminish and disappear. This is a bit like drug withdrawal, actually.

But Exposure is just one of four effective treatment models. I treated a medical student with severe OCD who also had the fear of HIV, and Exposure and Response Prevention were only somewhat helpful, and definitely not curative. In his case, the Hidden Emotion Technique ruled the day. If you are interested, you can read about that fantastic technique in my book, When Panic Attacks, and of course, one of the Feeling Good podcasts on anxiety will focus on this technique.

I have treated many patients with health anxiety / hypochondriasis and the Hidden Emotion Technique almost always contributed greatly to their (frequently rapid and complete) recovery. But in therapy, I use more than 75 techniques to help folks—it just isn’t the case that you can have one “formula” that works for everyone, since we are all individuals and our negative thoughts and feelings will be unique—so that requires an individualized approach to treatment, namely TEAM-CBT. (That’s my commercial message!)

All the best,

David

Photos from this Week’s Sunday Hike

Photos from this Week’s Sunday Hike

Hi web visitors,

Here are some photos from our hike this Sunday. We had five hikers! It is one of the highlights of the week, and a nice way to hang out because most folks work on deeply personal issues, so you get to know someone in a real way, not like chit chat at a cocktail party! Way more fun!

One of the photos is an Adobe Creek waterfall we discovered by going down a hidden path, the road less traveled by for sure!

The photos also show the early emergence of spring here. Lots of the trees are bright pink or white with flowers, although not shown in these pictures.

Thanks to Maryam, a new member of the Tuesday group, for the great pics!

David

Thanks!

Thanks!

Hi everybody! I will now be sharing many posts from my website on FB and Twitter, and maybe other sites eventually.

My colleague, Lisa Kelley, urged me to thank all of you who are reading my blogs and supporting my efforts–so thank you! I am trying to get as many people as possible signed up on my website, so please spread the word. There are tremendous free resources for you on http://www.feelinggood.com, including my free weekly Feeling Good Podcasts with Dr. Fabrice Nye. We are getting loads of kind and positive comments, so check it out!

Also, she said many people send me emails on Facebook, but I rarely go to my FB page. I would encourage you to come to http://www.feelinggood.com if you want to comment or send me an email that you want me to respond to. There is a convenient sign up button there too, to make it easy for you to subscribe to my posts. And at the bottom there will always be a button if you want to share any specific post with your friends and colleagues.

That’s all for now!

David