Conference Coverage
VA/DOD elevate psychotherapy over medication in updated PTSD guidelines
MIAMI – Should trauma-focused psychotherapy supplant medication for first-line treatment?
So often in clinical practice, guidelines and directives about psychiatric treatments lag behind the results we see every day in our offices. Such is the case with cognitive-behavioral therapy.
Earlier this summer, the departments of Veterans Affairs and Defense deemed trauma-focused psychotherapies, such as CBT, as first-line treatments for posttraumatic stress disorder over medication management. Was I surprised by these findings? Absolutely not. Likewise, last year, the American College of Physicians released a guideline recommending CBT as first-line treatment for chronic insomnia disorder in adults. Surprising? Again, not in the least.
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Pierre Janet, PhD, MD, the French psychiatrist, psychologist, and neurologist, more than a hundred years ago in his L’Automatisme Psychologique, advanced the idea that thoughts can be challenged and that perceptions leading to mental problems can be reversed. Dr. Janet completed his pioneering work, including an exploration of the power of hypnosis, even though the psychoanalytic movement was in full force and many parallel ideas about treating mental disorders were barely recognized.
By the middle of the 20th century, Albert Ellis, PhD, developed rational emotive behavior therapy, which focused on thoughtfully restructuring irrational beliefs into rational ones that led to improved skills and behaviors. A decade later, the great Aaron T. Beck, MD, developed a true form of CBT. Over the years, Dr. Beck went on to develop controlled clinical trials showing CBT to be more effective in treating a variety of psychiatric disorders, including depression, panic attacks, anxiety disorders, obsessive-compulsive disorders, various phobic disorders, and PTSD.
Yet, despite the effectiveness of CBT, too few young psychiatrists and mental health professionals learn how to use it, and fewer appear to practice it. Traditional psychiatric training, by and large, continues to rely on more psychodynamic approaches, which do have value but take longer to get results than does CBT.
Clearly, partnering with patients and helping them learn new constructs can lead to positive results. More and more research shows that CBT is efficacious for patients across many age and demographic groups.
In one randomized, controlled study of 96 Latino patients with depression, for example, researchers at the University of California, Berkeley, found that group CBT administered in a primary care setting led to a significant decrease in depressive symptoms as measured by the Spanish-language version of the Patient Health Questionnaire (PHQ-9) (Cog Behav Prac. 2017 Apr 17; doi: 10.1016/j.cbpra.2017.03.02). Of the 96 patients, 92 completed the PHQ-9 at least once, and 76 completed a baseline measure of the questionnaire on day 1 of group therapy, the researchers reported. At baseline, the average PHQ-9 score was 13.88, which points to the high end of moderate depression, moving toward moderately severe depression. For every week the patients were enrolled in the therapy, PHQ-9 scores fell by 0.15 points.
The spin on CBT that I created – which I call the learning, philosophizing, and action (LPA) technique – helps patients think through problematic issues and come away with new narratives. I developed and used the LPA technique as part of a smoking-cessation program I ran for many years at the New York University Langone Medical Center. In turn, that program developed into a short-term psychotherapy program with a focus on CBT and hypnosis/relaxation techniques.
Dr. Robert T. LondonCBT sessions usually are well focused. Homework also can be given after each session as a way to continue to challenge thoughts and behaviors that are not working and change them into more acceptable thinking and behaviors. Clinicians who use CBT to treat patients often leave open times for return visits if and when future “tune-ups” are needed. Interestingly, a review of the types of psychotherapies available show that they number in the hundreds, and some say regardless of the type of psychotherapy used with patients, the results are the same. That’s just not true, and finding the right therapy for each patient is critical. Clearly, a small number of therapies, including CBT, are most effective in problem resolution and patient care.
We need better codification and organization on what kinds of therapies are and are not suited for specific diagnosable problems. It is hoped that a clearer understanding of genetics, laboratory testing, and imaging, as emphasized by the National Institute of Mental Health’s Research Domain Criteria, will better equip us to decide what works best. Again, for now, helping patients learn and relearn new ways of thinking and behaving, as developed through CBT, is among the best treatments available for many mental health problems.
Dr. London, a psychiatrist who practices in New York, developed and ran a short-term psychotherapy program for 20 years at NYU Langone Medical Center and has been writing columns for 35 years. His new book about helping people feel better fast is expected to be published in fall 2017. He has no disclosures.