Nature: Psychological treatments: A call for mental-health science

[Firestormm]

Yeah, yeah. Controversial. And no, it doesn't mention ME/CFS. But worth persevering with and thinking about. Though perhaps you've had enough of this already. Still...

Emily A. Holmes, Michelle G. Craske & Ann M. Graybiel
16 July 2014

Psychological treatments: A call for mental-health science

Clinicians and neuroscientists must work together to understand and improve psychological treatments, urge Emily A. Holmes, Michelle G. Craske and Ann M. Graybiel.

How does one human talking to another, as occurs in psychological therapy, bring about changes in brain activity and cure or ease mental disorders? We don't really know. We need to.

Mental-health conditions, such as post-traumatic stress disorder (PTSD), obsessive–compulsive disorder (OCD), eating disorders, schizophrenia and depression, affect one in four people worldwide. Depression is the third leading contributor to the global burden of disease, according to the World Health Organization. Psychological treatments have been subjected to hundreds of randomized clinical trials and hold the strongest evidence base for addressing many such conditions. These activities, techniques or strategies target behavioural, cognitive, social, emotional or environmental factors to improve mental or physical health or related functioning. Despite the time and effort involved, they are the treatment of choice for most people (see ‘Treating trauma with talk therapy’).

For example, eating disorders were previously considered intractable within our life time. They can now be addressed with a specific form of cognitive behavioural therapy (CBT)1 that targets attitudes to body shape and disturbances in eating habits. For depression, CBT can be as effective as antidepressant medication and provide benefits that are longer lasting2. There is also evidence that interpersonal psychotherapy (IPT) is effective for treating depression...

A house divided
But evidence-based psychological treatments need improvement. Although the majority of patients benefit, only about half experience a clinically meaningful reduction in symptoms or full remission, at least for the most common conditions. For example, although response rates vary across studies, about 60% of individuals show significant improvement after CBT for OCD, but nearly 30% of those who begin therapy do not complete it3. And on average, more than 10% of those who have improved later relapse4. For some conditions, such as bipolar disorder, psychological treatments are not effective or are in their infancy.

Moreover, despite progress, we do not yet fully understand how psychological therapies work — or when they don't. Neuroscience is shedding light on how to modulate emotion and memory, habit and fear learning. But psychological understanding and treatments have, as yet, profited much too little from such developments.

It is time to use science to advance the psychological, not just the pharmaceutical, treatment of those with mental-health problems. Great strides can and must be made by focusing on concerns that are common to fields from psychology, psychiatry and pharmacology to genetics and molecular biology, neurology, neuroscience, cognitive and social sciences, computer science, and mathematics. Molecular and theoretical scientists need to engage with the challenges that face the clinical scientists who develop and deliver psychological treatments, and who evaluate their outcomes. And clinicians need to get involved in experimental science. Patients, mental-health-care providers and researchers of all stripes stand to benefit...

You can read more (or not): http://www.nature.com/news/psycholo...alth-science-1.15541?WT.ec_id=NATURE-20140717

 

[A.B.]

I doubt they'll make much progress approaching the problem from a psychological perspective.

Mental health started as failure - doctors in the 19th century couldn't figure out what was wrong with some patients, so they came up with the idea that the mind was creating these problems. Freud, a charlatan, built his misanthropic philosophy on this idea. Out of psychoanalysis, modern psychology was born. Of course they claim to be independent of Freud - but the differences are only superficial. The core idea that the mind creates all sorts of problems which can be solved by treating the mind (mainly via talking) is still the same. That this is actually true has never been proven, despite over a century of time, and (allegedly) an abundance of psychosomatic or mental health problems (30% of all patients visiting the doctor according to some, or even more).

PS: and a study that doesn't include hard facts doesn't deserve to be called evidence based. Questionnaires are opinion. Many questionnaires are just many opinions.

 

[chipmunk1]

according to psychology CBT is effective for everything. Scam.

 

[cmt12]

Mind based solutions have failed up to this point and our current mental health treatments are inadequate - that is true. Understanding the mind is very, very difficult. But just because all of this is true, why dismiss the possibility of any advancements in understanding in that area even as unlikely as it may seem? For me, my desire for a solution is so great that I leave no stone unturned.

 

[A.B.]

Understanding the mind is very, very difficult.

When something is very difficult to understand, sometimes this is just the symptom of operating under flawed assumptions.

 

[anciendaze]

Does anyone reading this have good references on spontaneous remission in mental illness? We have long had researchers finding results roughly consistent with one doctor's opinion 200 years ago: of people admitted to mad houses, 1/3 recovered and resumed previous lives; 1/3 became better, but were not able to resume previous lives; and 1/3 showed no improvement.

I've already mentioned elsewhere that Karl Menninger found a significant increase in admissions to mental hospitals around Boston in the aftermath of the "Spanish flu". Few of these patients were traumatized by WWI or suffered the extreme privations of citizens of France and Germany. Their changes must be attributed to consequences of infection. When he followed up he found that many who were hospitalized, including those with a diagnosis like schizophrenia, later resumed their previous lives. In both instances I mention there was no therapy which would today be recognized as effective. Menninger also found curious cases of schizophrenics who temporarily became lucid while infected with influenza, a clear indication of immune system involvement.

Another indication that mental illness and physical dysfunction go together shows up in shockingly high rates of dementia, with or without classic symptoms of specific psychiatric disorders, among the elderly. Almost anyone in regular contact with elderly people will recognize cases of serious depression, anxiety, aphasia, obsessive-compulsive behavior, delusions and even hallucinations. It is easy to show that immune competence or cardiovascular function often decline as people age, and that decline in mental function parallels these.

Without careful analysis of rates of spontaneous remission, it is impossible to assess the effectiveness of any existing treatment. Lack of clear evidence on this central point makes me wonder how many in the profession really want accurate assessment.

Any readers able to respond? If you are worried about being lambasted in public you can easily reach me by private message. If you are not a member of this forum, you can use my handle here on gmail.

 

[cmt12]

When something is very difficult to understand, sometimes this is just the symptom of trying to make a flawed approach work.

Can't I say the same thing about neuroscience?

 

[alex3619]

Psychiatry will only advance by becoming more scientific. Poor research just sucks up research funds and competes with better research for attention, in a world where too many do not have the time to properly investigate, and that includes bureaucrats and doctors.

Mind based treatments are perhaps an oxymoron. Much of the research in biopsychiatry is moving to focus on inflammation in the brain. If anything comes from psychiatry that is useful in ME for more than palliative help it will be from biopsychiatry.

Any research operating from the basis of mind is embracing the dualist mind-body notion. There is no mind, just body, but there is the physical substance of body, and there is how it functions. What we call mind is a function of brain. Neuoscience, and perhaps neuropsychiatry, have a better position to deal with brain issues than psychopsychiatry. Psychopsychiatry, I predict, will be considered no more than fancy counseling long before the end of the century. Of course I wont be around to be proven right or wrong about that.

A move to putting science back into psychiatry is a good thing. A move to putting evidence back is also a good thing. There are a whole lot of other things needed though.

Surveys and questionnaires are indeed giving data that can be considered evidence. It cannot just be rejected. It can however be investigated, and tested by more objective means. Further, I would downgrade many studies in psychopsychiatry at least two grades in an evidence based review. The first downgrade is for relying primarily on subjective evidence. The second is for an incapacity to have proper double blinded studies. Many would be downgraded a further grade due to the instability and uncertainty of the diagnostic cohort.

PACE for example, is an RCT, but not double blinded. Their primary outcome measure showing efficacy is from SF-36, though they do use a 6MWT. The results from both were really bad, and inadequate to show usefulness, but the walking test was particularly bad and can be completely discounted. That leaves only subjective evidence. That's two downgrades so far. The Oxford criteria is known to contain confounding patients, especially misdiagnosed depressed patients. Its a bad diagnostic criteria for research. Further, the hypothesis that is NOT being tested, and has never been substantiated or properly tested, is the idea that cognition can perpetuate CFS. Failure to do this, and the Oxford cohort, downgrade the study another level.

In a four tiered evidence based ranking the PACE trial would then be at the level of anecdotal evidence. In a five tiered ranking it would be marginally better. It is basically just a very expensive and fancy opinion, without substantive evidence. This is before you get to the myriad mathematical, statistical and reasoning errors.

 

[WillowJ]

If psychology wants to compete on a level of science, they have to use rigorous scientific methods, such as blinded assessments, matched controls (in terms of functional ability and some similarity of symptoms etc., not only demographics), some kind of stand-in for a placebo group with a matched amount of attention (or an actual placebo?), and proper use of statistics.

It also might be wise to use patient-reported outcomes developed in association with the patient community to ensure they reflect outcomes important to the patients themselves.

So far it seems they have most typically failed to use scientific standards. (And indeed it may not actually possible for some things studied, as it's not always possible to define and measure abstract concepts like personality traits or, the example in the article, 'happiness'.) If psychology and psychiatry want better recognition and to keep their standing as scientists, they must actually act like scientists.

Of course the difficulty applying science to studies goes for some of the medical field as well, but it seems to be most troublesome in psychology and psychiatry.

 

[cmt12]

What we call mind is a function of brain.

This is a discussion this forum needs to have so let's have it. What are you basing this statement off of?

 

[alex3619]

This is a discussion this forum needs to have so let's have it. What are you basing this statement off of?

There are whole threads devoted to this. @Hip and I have debated this at length. I am a monist on the theory of mind. I will see if I can find a link or two.

PS http://forums.phoenixrising.me/index.php?threads/mind-body.24076/

 

[cmt12]

There are whole threads devoted to this. @Hip and I have debated this at length. I am a monist on the theory of mind. I will see if I can find a link or two.

PS http://forums.phoenixrising.me/index.php?threads/mind-body.24076/

Thanks for the link. There is no need to discuss the topic any further as long as you acknowledge that your statement is a theory, which wasn't clear to me within the context of your post.

I share the frustrations that you all have about the failures and sometimes dishonesty within psychology and other mind based approaches up to this point. But you guys are doing yourselves a disservice if you are making assumptions about what you think the solution to this illness is going to look like and immediately reject anything that lies outside these parameters.

 

[A.B.]

I share the frustrations that you all have about the failures and sometimes dishonesty within psychology and other mind based approaches up to this point. But you guys are doing yourselves a disservice if you are making assumptions about what you think the solution to this illness is going to look like and immediately rejecting anything that lies outside these parameters.

There is no good reason to believe that theories about the mind causing illness are anything but a mistake. I think many of us came to this conclusion only through experience and study, not prejudice.

The science in support of CBT is weak. I don't think many realize how easy it is to arrive at results that make an ineffective therapy look useful. As anciendaze hints at, a number of patients get better on their own, others get worse. Patients will tend to attribute the change in their health to the therapy they're doing - so people who are getting better will think the therapy is working, whereas people who are getting worse will think it's harmful or not useful. The latter group will tend to drop out of the study early, so patients at the end of the study will be overall healthier compared to the initial patients. Even when the therapy does nothing at all. This is just one way for a therapy to look useful even when it's not.

For problems that just tend to get better on their over time, this is even more true. Post-viral fatigue is a good example. In most cases it just goes away after a while. Meanwhile some of these patients are undergoing CBT, and when the patient is well again, the therapy takes credit for the work done by the body.

Doing studies, having data in support of a hypothesis is not enough. Even creationists can find data to support their hypothesis. One has to take all observations and knowledge into account and critically put the hypothesis to test to see whether it even makes sense.

To me this article reads a lot like plans to find more data to support the hypothesis - not actually putting the hypothesis to a test that it could fail to pass.

 

[chipmunk1]

Most of the CBT studies are not blinded. Generally it has been said that unblinded studies should only be done when changes can be measured objectively. Subjective measurements are known not to be reliable without proper blinding.
.At least in other areas of medicine.

Does anyone reading this have good references on spontaneous remission in mental illness? We have long had researchers finding results roughly consistent with one doctor's opinion 200 years ago: of people admitted to mad houses, 1/3 recovered and resumed previous lives; 1/3 became better, but were not able to resume previous lives; and 1/3 showed no improvement.

Psychoanalysis used the 1/3 rule for predicting the patients outcome.

Basically these were natural disease progressions nothing more.

 

[cmt12]

There is no good reason to believe that theories about the mind causing illness are anything but a mistake. I think many of us came to this conclusion only through experience and study, not prejudice.

The science in support of CBT is weak. I don't think many realize how easy it is to arrive at results that make an ineffective therapy look useful. As anciendaze hints at, a number of patients get better on their own, others get worse. Patients will tend to attribute the change in their health to the therapy they're doing - so people who are getting better will think the therapy is working, whereas people who are getting worse will think it's harmful or not useful. The latter group will tend to drop out of the study early, so patients at the end of the study will be overall healthier compared to the initial patients. Even when the therapy does nothing at all.

For problems that just tend to get better on their over time, this is even more true. Post-viral fatigue is a good example. In most cases it just goes away after a while. Meanwhile some of these patients are undergoing CBT, and when the patient is well again, the therapy takes credit for the work done by the body.

Doing studies, having data in support of a hypothesis is not enough. Even creationists can find data to support their hypothesis. One has to take all observations and knowledge into account and critically put the hypothesis to test to see whether it even makes sense.

To me this article reads a lot like plans to find more data to support the hypothesis - not actually putting the hypothesis to a test that it could fail to pass.

I'm only interested in cures so I agree with you about the limitations of CBT and every other therapy that currently exists, which is why I was forced to attempt to find a solution myself.

What you said is true about making ineffective mind based treatments look effective. It is difficult to apply the scientific method and testing to a mind based solution. Of course, over a long enough period of time things become clear but that could mean a lot of unnecessary suffering up until that point.

 

[chipmunk1]

If you study the history of the so-called mind over matter therapies you cannot ignore that this field is based on wishful thinking and pseudoscience. That doesn't mean that the mind over matter concept is invalid just that the promoters have not much credibility. It's been hundred years and we have gone from one nuttery to another. Personally i don't wish to have anything to do with that mostly because i want stuff that works not something that is based on delusions.

From my understanding some early beginnings of psychotherapy were based on religious beliefs. Then came Freud and others and established the so-called talk therapy based on the psychoanalytic concepts.

I don't think there is any reason to believe that the earlier therapies were based on anything else than wishful thinking. i don't have the impression that the modern therapies like CBT are anything more than wishful thinking. It's just history repeating itself. The concept never seems to have worked well yet it get's revived and revived again.

The concept is in a nutshell:

The mind exists independent of the body.
The mind can cause physical illness but the body can't cause mental illness.
People are causing their illness on their own.
A sick mind can be treated with talking.
People can not think themselves well on their own they need a trained expert of the mind.
People can choose to remain ill or to recover.
If it doesn't work the patient didn't want to get better.

 

[cmt12]

No, CBT is a coping strategy. I provided a theory which introduced the actual mechanism at the root of the continuous stress response, which causes the complete imbalance of the body.

http://forums.phoenixrising.me/index.php?threads/my-understanding-of-cfs-me-and-how-to-heal.31393/

This theory is based on my experiences. Skepticism is necessary, but so is open mindedness.

 

[chipmunk1]

No, CBT is a coping strategy. I provided a theory which introduced the actual mechanism at the root of the continuous stress response, which causes the complete imbalance of the body.

http://forums.phoenixrising.me/index.php?threads/my-understanding-of-cfs-me-and-how-to-heal.31393/

This theory is based on my experiences. Skepticism is necessary, but so is open mindedness.

The most important question is did you get well?

 

[Sidereal]

Does anyone reading this have good references on spontaneous remission in mental illness? We have long had researchers finding results roughly consistent with one doctor's opinion 200 years ago: of people admitted to mad houses, 1/3 recovered and resumed previous lives; 1/3 became better, but were not able to resume previous lives; and 1/3 showed no improvement.

I'm not sure I understand the lambasting comment so I'll bite. The rule of thirds is still basically true in psychiatry although modern pharmacotherapy can temporarily perturb neurotransmission in the brain to make it seem as though things are headed in one direction or another, for a while, but ultimately regression toward the mean is what happens. Psychiatry is no exception among medical specialties. Many medical "treatments" are worthless or harmful.

I don't know about spontaneous remission rates in every psychiatric disorder but in major depression there is some data from a large NIMH study with a long-term follow-up that, among many things, looked at outcomes in people who received no biological treatment for their major depressive episode. The median time to recovery was only 13 weeks.

http://www.ncbi.nlm.nih.gov/pubmed/16699380

 

[alex3619]

Thanks for the link. There is no need to discuss the topic any further as long as you acknowledge that your statement is a theory, which wasn't clear to me within the context of your post.

I share the frustrations that you all have about the failures and sometimes dishonesty within psychology and other mind based approaches up to this point. But you guys are doing yourselves a disservice if you are making assumptions about what you think the solution to this illness is going to look like and immediately reject anything that lies outside these parameters.

I reject nothing outside the parameters I am operating in. I however require evidence, and reason to support them. I require that its not in contradiction with known facts. I require that, for it to be science, it has to be testable. I require that it is not based on folklore but science.

Now things do exist outside science, but even then I require it to be rigorous. I could devote an entire thread to this. Indeed, in my book I will be devoting an entire section.

Too much is waffle dressed up in clothes that sprout labels like "science", "evidence based', "proven" etc. You have to look past the claims to the lack of evidence and the failures in reasoning.

I would love for the existence of mind to be proved. So far there is no such proof. All evidence that I am aware of can be easily explained by brain function, so mind is unnecessary. However I go a step further: mind is what we call brain function. Psychotherapy only has value if it changes brain physiology.

Whether mind exists or not as phenomena, and not as a description of brain function, remains an open question. It is however not necessary to explain anything.

I currently regard "mental health" as just a different way of saying "healthy brain function". PTSD? Brain disorder. Anxiety? Brain disorder. Depression? Brain disorder. Psychogenic illness? Fiction.