What Underlies Psychopharmacology? Part 2

Part 2

by Allan M. Leventhal

The 20th century witnessed the development of three quite divergent explanatory systems to account for mental illness, each offering a distinctly different approach to treatment: psychoanalytic theory and treatment by psychoanalysis and its variants; a genetic theory of chemical imbalances of neurotransmitters in the brain, with treatment by prescription of psychiatric drugs; and a behavioral learning theory, offering treatments designed to eliminate the behaviors that characterize the mental disorders. Enough time has now passed to allow for a good reading as to the value of these different systems.


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Part 1 here
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Comparative effectiveness

How successful is behavior therapy? Behavioral treatments have been applied to all of the mental disorders.²⁴ How does the effectiveness of behavior therapy compare with drug treatment?

Research funding to develop behavior therapy has been miniscule compared with the investment that has been made studying psychiatric drugs. Nevertheless, outcome studies for a wide range of disorders show behavior therapy to be at least the equal of drug treatment. Studies have shown behavior therapy is more effective in the treatment of depression (less than half the relapse rate),²⁵ obsessive-compulsive disorder,²⁶ and borderline personality disorder.²⁷ Studies indicate no difference in effectiveness for drugs versus behavior therapy in the treatment of some other disorders, for example, in the treatment of phobias²⁸ and generalized anxiety disorder.²⁹

The playing field, however, is not level. An artifact built into double blind studies favors drug treatment. Many patients in double blind studies have had prior experience with the drugs being studied and recognize if they are on the drug or the placebo because of the presence or absence of side effects (they become unblinded). Those who recognize they are on the drug are inclined to rate their experience positively, those who realize they are on the placebo to rate their experience negatively, inflating the apparent effectiveness of the drugs. In addition, outcome measurements are generally taken after three months of treatment when placebo effects are robust; when measured long term, drug treatment is more likely harmful than helpful.⁸,¹⁵,³⁰ Perhaps most revealing, the studies that have used active placebos (placebos with side effects) have found that the drug effects reported in studies using inert placebos (the far more common practice) disappeared.³¹ Given that the placebo effect plays a larger role when measuring the effectiveness of drug treatment, and that drug treatment, unlike behavior therapy, raises safety concerns, a case can be made for behavior therapy being the more trustworthy choice even when research results appear to show parity.

Correction of avoidance behavior often is central to behavior therapy. If there is a unifying theory for behavioral treatment, correction of avoidance behavior has primacy. For example, elevator phobic patients are trapped in their fears because of the relief they experience when they choose not to take an elevator. OCD patients who repeatedly check the stove to be certain the gas jets are turned off derive immediate relief from fears of asphyxiation by checking. Depressed patients become inactive because they fear being incapable of replacing what has been lost. Socially anxious patients, by staying away from social situations, feel spared social failure. Sometimes a behavioral understanding of these problems discloses behavioral deficits needing attention or cognitive distortions needing to be corrected and these goals are built into the treatment, but the primary task of the behavior therapist generally entails elimination of avoidance behavior and promotion of more functional behaviors. Avoidance behavior by these patients occurs automatically and is governed by the principle of negative reinforcement because in each case avoidance behavior terminates an aversive situation. Effective behavioral treatments have been developed to remedy avoidance behavior.

Constructive change in behavior therapy occurs by means of specifying the dysfunctional behaviors that comprise the patient’s problems, identifying the interactions with the environment that trigger these behaviors, and progressing through programs designed to remedy these learned dysfunctional behaviors. Through a collaborative process, hypotheses are generated to account for the problems and to promote positive steps, which are tested by keeping track of the results of behavioral changes and by discussing problems encountered in this process. Rather than having “insight” as a goal (as is the case in psychoanalytically-oriented psychotherapy), the goal is arriving at an understanding of the contingencies controlling problematic behaviors and identifying the specific new behaviors necessary for positive change. Basic to the treatment is teaching the patient how to analyze and correct problems when they arise in the future.

Unfortunately, while there are many behavior therapists well trained in how to deliver behavior therapy within a learning theory framework, they still are too few in number. Great Britain’s national health service, recognizing the greater value of this approach to treatment and the need for more therapists with behavioral training, has embarked on a large-scale training program to address this need. A similar program should be established in this country.

Behavior therapy is far from a fully developed treatment. To give some examples: Studies are needed to determine the most effective means of conducting the assessment phase, which sets the stage for treatment. The centrality of cognitive versus strictly behavioral variables is disputed. There also are outstanding questions about the optimal length of the treatment. For example, in studies comparing behavioral versus drug treatment for moderately to severely depressed patients, outcome typically is measured after two to three months of treatment. Not only does this bias the outcome in favor of drug treatment (because measuring outcome after two to three months of treatment capitalizes on the placebo effect for those on drugs), it also probably represents a too limited amount of time for behavior therapy to produce lasting change for at least some patients. While patients in behavior therapy for three months have been found to have less than half the relapse rate of those treated with drugs for a year,³² this does not answer the question of how long behavior therapy should continue for more robust, longer lasting results. Questions such as these make it plain additional research on behavior therapy is needed to improve the effectiveness and efficiency of this form of treatment.

Today

Finally, some comment is called for with regard to how these three models are represented today. The chemical imbalance theory and treatment by pharmacological methods dominates the treatment of mental disorder. And this preference is rising. A survey in 2006 reported the number of Americans taking antidepressants had doubled in a decade from 13.3 million to 27 million. The use of antipsychotic drugs to treat children and adolescents for problems such as aggressive behaviors and mood changes increased five fold from 1993 to 2002. A 2009 survey found that 73% more adults and 50% more children were using psychiatric drugs than in 1996.

This acceptance has been a marketing triumph for psychiatry and the pharmaceutical industry. Psychiatric leaders have carefully managed what information about drugs makes it into print and what is disseminated to the public. A combination of psychiatry fully embracing drug treatment, drug promotion and obfuscation sponsored by the drug companies, and patient and parental time constraints and wishful thinking have prevented the truth about the ineffectiveness of these drugs to register on doctors or the public.

An eclectic approach to psychotherapy dominates the talk therapies. Psychoanalytic theory and treatment for the most part has evolved into an eclectic form of psychodynamic psychotherapy, which retains some core psychoanalytic concepts, discards many others, and incorporates ideas from other theoretical orientations. While behavior therapy usually is available and has had a significant impact on treatment, not infrequently it takes place primarily as an adjunct, one of a number of arrows in a quiver made use of within this general approach to psychodynamic treatment. And unfortunately, therapists who lack sound behavioral training often misapply the procedures of behavior therapy reducing the effectiveness of these techniques.

Basic psychoanalytic concepts are now so ingrained in how we think about personality and the dynamics of daily life that a psychodynamic therapy relying on these ideas is very consumer friendly. Science writers and novelists regularly write in this fashion, as if psychoanalytic ideas correctly describe and account for human behavior. But face validity and validity rarely are synonymous. Behavior therapy is based on a very different kind of explanation for human behavior that fits the data better but includes concepts less familiar to many people and requires more explanation. In the hands of a skillful therapist, therapeutic practices derived from this approach readily become accepted as they demonstrate their usefulness.

Most patients are seeking help for ordinary problems in living and are suffering from behaviors that may be making them miserable but are not necessarily debilitating. Because these problems often are transitory, drug treatment is accepted as beneficial by doctors and their patients. The eclectic talk therapies often are helpful, most certainly when the problems are less entrenched. Eclectic talk therapy has a success rate equivalent to or better than drug treatment since its success is less attributable to a placebo effect. Its strengths are that it offers support and helps patients to construe their situation more constructively. Psychodynamic therapy is at its best when in addition to giving “insight” it enables patients to be more active and successful agents in their own behalf.

There are inherent problems, however, with this approach to treatment. When successful, the eclectic format makes it impossible to know what it is in the therapy that is responsible. And when the treatment is unsuccessful or only partially successful, the usual response is to refer the patient for drugs, which is the sanctioned treatment and excuses the therapist for the psychotherapy’s lack of success. The reality is that this referral is nothing more than bucking the problem to someone else to solve who has even less to offer. And, if the patient is then prescribed a drug while continuing in psychotherapy, even though the great likelihood is that the patient will have abandoned taking the drug after enduring several months of aversive side effects, everyone feels pretty good about the combined treatment having worked – at least for a while. In the absence of a treatment based on a functional analysis of the contingencies governing the problem, too often the patient leaves therapy without having learned the tools needed to address problems when they arise in the future.

An important purpose served by having a clear theoretical model, with methods derived from it empirically, is that purity enables specific tests of effectiveness. Eclectic psychotherapies presently serve a worthwhile purpose for people in need, but if we are to determine what methods are effective, we must view this approach as a temporary measure while we invest in research aimed at isolating the ingredients responsible for successful treatment. Of the three systems described in this article, learning theory and behavior therapy, despite having been relegated to a secondary role, offers a more promising outcome for conceptualizing and treating mental disorder successfully.

Favorable results have been obtained for behavior therapy despite a paucity of research support in comparison with the funding of studies related to drug treatment. It is vital that we as a society invest a lot more in perfecting behavior therapy, but the NIMH, our primary public funding source (the drug companies now fund the great bulk of the research), has shown insufficient interest in making the deserved investment in behavior therapy.

The NIMH

Since psychiatry’s transformation to a biological orientation the NIMH has been committed to the pharmacological treatment of mental disorder and has led the way in establishing drugs as the treatment of choice even when the results of outcome studies are inconsistent with this choice.

A prime example of NIMH’s determined advocacy for drug treatment and the chemical imbalance theory, regardless of evidence to the contrary, is amply revealed in the institute’s handling of the STAR*D study, discussed earlier in this paper. The STAR*D study was funded for 35 million dollars, making it one of the most costly studies ever conducted by NIMH, and was designed to examine the guidelines for antidepressant treatment of moderate to severe depression. Although double blind studies had found antidepressants to be no better than placebos, STAR*D’s experimental design included no control groups. Nevertheless, as reviewed earlier, STAR*D’s results for antidepressants, short-term, were identical to what double blind studies have found for placebo. The long-term results for antidepressants, which rarely have been measured, were shockingly poor. Thus, STAR*D’s results were hardly an endorsement for treating depression by antidepressant drugs. But that is not how the results were reported:

1. The main result reported in STAR*D publications was a remission rate of 67% for antidepressant treatment, which the researchers claimed gave solid support for treating depression with antidepressant drugs. This figure was arrived at by summing across trials, a calculation the researchers admitted having failed to meet the conditions required for its use. They then went ahead and used it anyway and greatly compounded the misrepresentation of their results by declaring this bogus figure to be the prime outcome of the study. The calculation is spurious, highly misleading, and part of a pattern of unwarranted manipulations of the data that inflate the reported effectiveness of antidepressants.³³, ⁸

2. As their tables show, the actual long-term results for antidepressant treatment were that by the end of a year’s time all but 108 of the 4,041 patients had either relapsed or dropped out of treatment (a 3% success rate). Nowhere in STAR*D’s publications of results is there any mention in the text of this outcome. Rather than being an endorsement of the treatment guidelines, the results call for a change in the guidelines.

3. In the short-term (measured at three months), STAR*D’s actual results are remission rates of 25-30%. These results are precisely what double blind studies have found as the outcome for placebos, indicating the short-term benefit for antidepressants is a placebo effect. No mention is made of the similarity of these findings to the results of placebo controlled studies or that these results also are in close agreement with the findings of NIMH’s first depression treatment study, published 17 years earlier, which found no difference between antidepressant drugs and placebo. In the short run, antidepressants perform no better than sugar pills; these results also call for a change in the guidelines.

4. In fact, the results are even worse because STAR*D researchers violated their own admission and remission protocol criteria by changing measures mid-stream. These changes had the effect (easily shown in their data) of inflating the apparent effectiveness of antidepressants by several percentage points.

5. STAR*D’s researchers nonsensically claim their results support the latest chemical imbalance theory (that different drugs are necessary and successful for different conditions) despite the fact that drugs with different neurochemical actions were equivalent in their ineffectiveness.

Absent these manipulations of the data, STAR*D’s results are a clear-cut repudiation of the psychiatric guidelines calling for treatment of moderate to severe depression by antidepressant drugs. Yet the NIMH has presented the findings to the public as if they were an endorsement of the current guidelines, encouraging people to choose antidepressant drugs to treat depression. With regularity, this fictitious reporting of results is repeated in the media, considerably expanding the likelihood that treatment choices will be influenced by this erroneous information. This biased reporting needs to be publicized if misrepresentations of this kind are to be corrected.

The NIMH’s mishandling of the 35 million dollar STAR*D study (that’s our money, folks) is a prime example of what the medical journal editors (cited earlier) have warned is taking place as a consequence of various forms of payment made to doctors and researchers by the pharmaceutical industry. But in this instance it is the NIMH, the agency mandated to protect the public, that is manipulating the data not a drug company. How can one fail to conclude the NIMH is more determined to promote what is deemed to be of value for psychiatry than what is good for the public?

Psychiatry and Big Pharma

Psychiatry’s adoption of the chemical imbalance theory for mental illness rescued the profession. Establishing a model that required a medical degree gave psychiatry a competitive advantage and the economic success of this strategy undoubtedly exceeded the wildest imaginings of those who engineered the change. Psychiatry’s transformation to treatment by prescription of drugs not only filled all the empty hours in psychiatrists’ weekly schedules, it increased their hourly income by 40%. The pharmaceutical industry made this conceptual change possible by partnering with psychiatry in establishing acceptance of allegedly effective psychiatric drugs as the preferred treatment for mental disorder and Big Pharma has been rewarded royally. Yet concealed behind today’s continuing complacent promotion of the chemical imbalance theory and prescription of psychiatric drugs is the absence of empirical evidence for the theory or the treatment. The NIMH plays a central role in promoting this system by the choices the institute makes in the allocation of funds for research and through dissemination of slanted information and advice to the public.

Psychiatry and Big Pharma are in a symbiotic relationship with one another where neither could function profitably without the other. Working together they have benefited enormously and they have huge financial incentives to maintain current practices. A behavioral model offers meager financial returns compared with the bonanza associated with a biological model and reliance on drug treatments. Given the self-interest of these businesses for maintaining the current model, the power and credibility accorded to psychiatric opinion by the general public, and the practically unlimited resources of the drug companies for marketing their products, the truth about which treatments for mental disorder work and are safe and which treatments don’t work and are unsafe is largely unknown by doctors and the public.

In short, while the biological revolution in psychiatry shows little evidence of being beneficial for patients, it has been very good for business for psychiatrists and extraordinarily profitable for the pharmaceutical industry. The situation is analogous to the alliance of Wall Street bankers and traders, who with the help of some esteemed economists, established acceptance of a rationale for a financial system of great benefit to them personally. In the end the one-sided nature of the transactions led to an economic crash causing great financial losses for the public. Similarly, psychiatry and Big Pharma have perpetrated a utopian pharmaceutical mythology that serves their interests very well but has served the public very poorly. Drug treatment has not yet crashed, but there are ominous signs that we may be headed toward widespread mental disability as a consequence of this misguided treatment of mental disorder. In contrast, behavior therapy is safe and more effective. Given the superior substantive base and the greater promise offered by treatments based on a behavioral approach, more support is warranted for training behavior therapists and for pursuit of basic behavioral research. As a society we need to invest far more in developing this model for treating mental disorder.

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Allan M. Leventhal, Professor Emeritus of Psychology at American University in Washington, DC, co-authored (with Christophe Martell), The Myth of Depression as Disease, Praeger, 2006. Read other articles by Allan.