Neurological Changes During Psychotherapy: Does it really matter if drugs work better than psychotherapy?

Obsessive-compulsive disorder (OCD) is an anxiety disorder characterized by persistent, intrusive thoughts or impulses (obsessions) and repetitive behaviors (compulsions) (1).  Obsessions generally revolve around a central theme, the most common of which are contamination, symmetry and order, and safety and harm (2).  Compulsions are thought to arise as a mechanism for reducing the anxiety produced by unwanted obsessions.  Every time a compulsive behavior is performed, anxiety decreases, and the behavior is negatively reinforced, increasing the likelihood of a person performing the ritualistic behavior again.

There are a number of theories about the origin of depression.  The most relevant to our topic are the cognitive theories, which focus on the negative thoughts that are involved in creating and maintaining a depressive state.  Aaron Beck’s theory of depression involves negatively distorting thoughts about the self until such negative cognitions are automatic and persistent, invading every aspect of a person’s life (3).

Both OCD and depression are most common treated pharmacologically with selective serotonin reuptake inhibitors (SSRIs).  There is some question as to the efficacy of these drugs, especially in relation to a particularly strong placebo effect in treating depression.  Still, SSRIs are prescribed at an ever-increasing rate for both depression and OCD.

Cognitive behavioral therapy (CBT) is the most common type of psychotherapy used to treat both OCD and depression.  It is a very structured and directed method of psychotherapy, with a short time course (typically about 10 weeks) and a good deal of practicing outside of therapy sessions.  The theory behind CBT involves several assumptions about cognitive processes.  First, it assumes that some stimuli elicit thoughts that distort reality.  For example, a depressed person may be turned down for a job and think “I’m completely incompetent.  I can’t succeed at anything I do,” instead of thinking something more realistic, such as “There were probably a lot of very qualified applicants for this position.  I’ll find something else.”  Second, behaviors often lead to the reinforcement of these distorted thoughts.  Avoidance of situations which produce negative thoughts (in this case, a job interview) doesn’t allow an individual to confront the distortions and change their opinion.  These distorted thoughts can lead to psychological distress, which impacts one’s emotional states.  Finally, CBT posits that individuals are capable of becoming aware of their distorted thoughts and behaviors and actively changing them.  CBT sets as its goal helping patients become aware of their maladaptive thoughts and behaviors and replacing them with more realistic thoughts and possible actions (3).

CBT for OCD is most often in the form of Exposure and Response Prevention.  This type of therapy focuses mostly on extinguishing compulsive behaviors from a patient’s repertoire.  Over 20-30 sessions, the patient is exposed through visualization, controlled experiences in a therapy setting, and finally in real life to anxiety-producing situations.  The patient is taught to refrain from engaging in compulsions during or after exposure to these situations.  When there are no catastrophic consequences to being exposed to an anxiety-producing situation and not engaging in a ritualistic behavior to reduce it, the compulsions and the anxiety that comes along with these situations become extinguished (4).

In depression, CBT involves three different components.  The first is cognitive restructuring, in which the therapist helps the patient identify and correct distorted thoughts that may be causing depressed emotions.  The second is behavioral activation, in which the patient is encouraged to gradually reengage in activities that were once pleasurable, or to find new activities in which to participate.  Finally, patients are given instruction on problem solving skills, so that problems that seem completely unmanageable at first glance can be broken down into small steps that are easier to deal with (3).

The topic of psychotherapy becomes much more interesting when recent studies elaborating on the neurological changes associated with successful CBT treatment are taken into account.  Functional neuroimaging studies have shown that, in OCD, CBT is associated with a decrease in activity of the caudate nucleus, similar to the results seen for patients treated with SSRIs (5).  In depression, studies show that both antidepressants and CBT decrease activity in the prefrontal cortex and increase activity in the basal ganglia as compared to before treatment (6).  Studies seem to agree that although the results of CBT and pharmacotherapy are often similar, they seem to work through different neurological mechanisms.  Drugs seem to work from a bottom-up pathway, affecting primarily subcortical structures, whereas psychotherapy may have a top-down mechanism, affecting mostly cortical structures (7).

Although the results of neuroimaging studies are fascinating, the actual activity patterns in the brain are not as important as the implications of the results.  One of the most interesting things that came out of our discussions was just how deeply ingrained people’s opinions on the merits of psychotherapy versus drugs in the treatment of depression are.  Even comments that were seemingly unrelated to a comparison of the two treatment options were laden with value judgments.  Two distinct camps seem to exist – those who prefer psychotherapy because it seems to be a more “natural” first option and those who believe that medication is the better option because it’s “easier”.

Among those who support psychotherapy was our guest speaker, Dr. Yadin, who, being a cognitive behavioral therapist herself, spoke in with great conviction about trying CBT first in order to let the brain, the most plastic organ we have, heal itself.  Several people echoed this belief in the forums after our discussion, which seemed mostly to be in the form of a strong gut reaction that psychotherapy is “more ‘natural’ and therefore ‘better’” (8).  Others see psychotherapy as an alternative that can be tailored much more easily to vast individual differences that exist among people currently being treated for psychological disorders.  The fact that CBT “addresses the person’s experience rather than their neurochemistry” (9) makes this approach much more appealing to many people.  Although some students might not agree with psychotherapy as a first line of treatment, it was argued that people may be more willing to try psychotherapy in the future, with our culture pointing the way towards natural alternatives such as organic foods and hybrid SUVs (10).

On the other side of the spectrum are those who made comments supporting pharmacotherapy as a first attempt at treatment.  This group argued both that drug treatment is easier and that psychotherapy is too self-selecting in its target population to be widely successful.  Most of us agree that American culture is incredibly focused on quick fixes and solving problems with the least possible amount of effort.  It’s also been argued that in an age where drug commercials are more common than almost any other kind of advertisement, there is almost no stigma associated with taking medication to treat a psychological disorder anymore (11), whereas psychotherapy is still looked down upon as something only “crazy” people need.  Because much of the efficacy of treatment for disorders like depression involves the patient’s expectations, then the mindset that drugs are the only socially acceptable way to treat a disorder may make antidepressants a better option than psychotherapy.  The last common argument for drug therapy is actually an argument against psychotherapy, which has been criticized as being highly self-selective.  Because psychotherapy, and CBT in particular, requires so much self-motivation and self-healing, many people believe that its applicability is highly limited to a group of people with a certain personality type (12).

Our discussions, both in class and on the forum, suggest that there are a number of unresolved issues in the debate about psychotherapy and pharmacological approaches to treatment of mental disorders.  While the arguments on both sides of have numerous merits and faults which could be expanded upon, the most prudent way to advance our conversation may be to stop worrying about which type of treatment is better and start using all of the data we have to actually learn more about depression (13).

I agree that which kind of treatment for depression is “better” is an irrelevant argument for a number of reasons.  Most importantly though, there is no treatment currently in use that is successful in treating everyone with depression.  Drugs work for some people; CBT works for some people; a combination of the two is most successful for others.  There are even some people for whom neither of these options provides any relief.  Instead of continuing this debate, it would be more beneficial to invest our effort into creating new and more effective neuroimaging techniques that can give us more information about what is actually happening in the brain that causes depression, in addition to what happens when the brain spontaneously recovers from depression, or recovers due to a specific form of treatment.  With a better idea of the neural mechanisms of depression in humans (there is a vast but not highly applicable body of literature about animal models of depression), we can move on to finding forms of treatment that benefit more people.  Even more ambitious would be progress towards differentiating between the subsets of depression that must exist, given the variability in response to treatment.  From here, we could more easily predict the type of treatment that will work best for each person diagnosed with depression and avoid the unnecessary prolonging of pain and suffering that come along with such a disorder.  With a shift away from thinking that either drugs or psychotherapy as they stand are the ultimate method of treating depression, it’s very likely that someday there will be a greater understanding of the umbrella of depressive disorders and more comprehensive methods for treating them.

References

(1) http://www.nimh.nih.gov/health/topics/obsessive-compulsive-disorder-ocd/index.shtml Obsessive-Compulsive Disorder
(2) http://psychcentral.com/lib/2006/a-list-of-common-obsessions/ A List of Common Obsessions
(3)http://en.wikipedia.org/wiki/Cognitive_behavioral_therapy Cognitive Behavioral Therapy
(4) http://en.wikipedia.org/wiki/Exposure_and_response_prevention Exposure and Response Prevention
(5)http://query.nytimes.com/gst/fullpage.html?sec=health&res=9B0CE3DA1239F936A25751C0A960958260 Psychotherapy Found to Produce Changes in Brain Functions Similar to Drugs
(6) http://www.forensic-psych.com/articles/artNYTTalkTherapy8.27.02.html Like Drugs, Talk Therapy Can Change the Brain
(7) http://pn.psychiatryonline.org/cgi/content/full/39/9/34 Brain Data Reveals Why Psychotherapy Works
(8) Felicia, Psychotherapy
(9) krosania, Individual Differences
(10) ebitler, Psychotherapy thoughts…
(11) aamen, I also thought this was an
(12) ehinchcl, Individuality…
(13) Paul Grobstein, Depression and Exuberance