Working with a Psychiatrist Effectively

Working with a Psychiatrist EffectivelyIf you are a psychiatrist, sometimes you have an opportunity to experience a response to treatment that seems like a miracle. But when miracles don’t happen, what are strategies for working with a psychiatrist effectively?

Early in my career, the serotonin re-uptake inhibitors SSRIs) were released, and I had a chance to see a number of people who had given up hope of leading a normal life and had dramatic responses to Prozac (and then Zoloft). 

It was an experience that was something like the experience described by a famous neurologist (Oliver Sacks) when the dopamine agents were discovered for treating Parkinson’s. People suddenly “awoke” as if from a deep sleep or coma.

Much of psychiatry, indeed almost all of it, does not involve miracles. It involves hard work and the careful addition of treatments, any one of which, by itself, achieves only partial effects.

The key in this case is to be able to identify what is actually happening in response to a medication. You need to help your psychopharmacologist identify the responses to the medications. Even if these responses are not desirable, knowing what the effects of the specific medication is allows a psychiatrist to choose the next step and leads more quickly to the desired outcome.

However, we can get fixated on the wish for a miracle, anything short of that and we say that the medication “isn’t working.” Unfortunately, this bimodal assessment of medication response (“working” or “not working”) is not that useful, indeed, it can lead to giving up on a medication too early.

As a psychopharmacologist, what I want to know is not whether a medication is “working” but what are the effects that it’s having.

For that reason, I ask my patients to fill out questionnaires to help me assess a broad range of symptoms and responses, and I also often use standardized tests like the Inventory for Depressive Symptomatology, which allows me to get a much clearer picture of how things change over time.

When patients use these tools, they get at least a 50% boost in response to medication. And there is much less chance that a potentially useful medication will be passed over, delaying a positive response to treatment for months or even years. 

Does Psychiatric Treatment Work?

psychiatric treatmentHow well do psychiatric treatments work? Aren’t psychiatric medications just placebos? Does psychotherapy really do anything?

These are the kind of questions that mental health clinicians run into all the time.

Dr. Maximilian Huhn and colleagues from the Munich Technical Institute (Huhn – reference 1) have conducted a major review of the data. They evaluated results from 852 clinical trials involving 137,126 patients with 21 psychiatric disorders.

They looked at the “effect size” of treatments. Effect size is a way of summarizing the magnitude of the benefit. Comparing the group that got treatment with the group that didn’t get treatment what is the nature of the difference in outcomes? Jacob Cohen proposed that effect sizes could be considered small, medium or large. A “moderate” effect size means that the effectiveness of the treatment should be “easily visible.”

They found that, in general, psychiatric treatments had  medium effect sizes (0.50). Interestingly, psychotherapy had a somewhat higher effect size than pharmacotherapy for acute treatment (ESs, 0.58 for therapy and  0.40 for medications).  [The authors suggested that this could be due to the fact that the psychotherapy studies tended to be done with smaller numbers of people in the study and thus there might be more bias in the results.]

How does this effect size compare with the effectiveness of non-psychiatric medications?2014-06-15_7-00-49

The same group at the Munich Technical Institute (Lucht – reference 3) earlier published the results of their systematic review of data on effect sizes for non-psychiatric medications.

The white dots show the results of clinical trials of medications used for treating common medical problems like hypertension, heart disease, high cholesterol, etcetera. The blue dots show the results of the clinical trials of psychiatric medications. The further up the chart the larger the effect size.

As you can, there were not big differences in effectiveness. In fact, psychiatric medications, in general, were somewhat more effective than non-psychiatric medications.

Other findings from Huhn’s study were that combination treatment (medications and therapy) generally worked better than one type of treatment alone (especially for more severe conditions).  Of 12 meta-analyses of combinations of pharmacotherapy and psychotherapy (range of study participants, 23–2131), 7 found that combination treatment was more effective than either therapy type alone.

They also found that acute treatment was somewhat less effective than maintenance treatment. In other words, psychiatric treatments were not as good at taking care of an acute depression as they were at preventing a recurrence of depression once you were better. 

Citation(s):

  1. Huhn M et al. Efficacy of pharmacotherapy and psychotherapy for adult psychiatric disorders: A systematic overview of meta-analyses. JAMA Psychiatry 2014 Apr 30; [e-pub ahead of print]. (http://dx.doi.org/10.1001/jamapsychiatry.2014.112)
  2. Correll CU and Carbon M.Efficacy of pharmacologic and psychotherapeutic interventions in psychiatry: To talk or to prescribe: Is that the question? JAMA Psychiatry 2014 Apr 30; [e-pub ahead of print]. (http://dx.doi.org/10.1001/jamapsychiatry.2014.301)
  3. Lucht S et al. Putting the efficacy of psychiatric and general medicine medication into perspective: review of meta-analyses.
    The British Journal of Psychiatry (2012)200: 97-106 doi:10.1192/bjp.bp.111.096594