John M. Talmadge, M.D.

A Blog Covering Many Topics

Talk Therapy? Medication?

"We are more than a brain in a jar," Dr. Richard Friedman wrote recently in the New York Times. In his timely article about psychiatry, he goes on to say, "Despite a vast investment in basic neuroscience research and its rich intellectual promise, we have little to show for it on the treatment front." He points out that billions are spent on pharmaceutical research — the quest for the magic pills that will change the way we think and feel — but comparatively little money goes to psychotherapy research.

image of poster about pills

I am an old-timer, and when my generation trained in psychiatry virtually all of us planned on being psychotherapists who were well educated in the use of medication as an adjunct to talk therapy. All psychiatrists I knew back then had been in psychotherapy themselves; personal therapy was considered part of becoming a competent clinician: "Physician, know thyself."

If a psychiatrist has a limited vocabulary, and can't conjugate nouns and verbs, how can they possibly communicate with patients?

Research shows that when psychotherapy and medication are both available, the combination is synergistic. It's like saying 1 + 1 = 3. Today, however, fewer than 10% of psychiatrists are trained and skilled in psychotherapy. My opinion is that this is why a good psychiatrist is very hard to find. I have been teaching young psychiatrists for over thirty years, and I have been a training director in one of our finest medical schools, and I can say with authority that many psychiatrists coming out today get failing grades when it comes to important skills like writing, speaking, and communicating clearly. I'm talking about basic errors in English grammar, syntax, and sentence structure — the stuff most people should learn by the time they enter high school! If a psychiatrist has a limited vocabulary, and can't conjugate nouns and verbs, how can they possibly communicate with patients? This is one reason that psychiatrists today are, in general, poor psychotherapists with little interest in what talk therapy has to offer.

Writing in a medical chart is similar to text messaging. It's easy, and grammar doesn't count. In fact, the modern electronic medical record discourages thoughtful writing, just like text messaging does. A good psychiatrist should not only speak well and write well. A good psychiatrist should be a superior thinker and communicator. Every doctor should have a big sign on the wall behind the chair where the patient is sitting: "DOCTOR, YOUR PATIENT IS TRYING TO TELL YOU SOMETHING!"

Here's Dr. Friedman again: "With few exceptions, every major class of current psychotropic drugs — antidepressants, antipsychotics, anti-anxiety medications — basically targets the same receptors and neurotransmitters in the brain as did their precursors, which were developed in the 1950s and 1960s."

"Sure, the newer drugs are generally safer and more tolerable than the older ones, but they are no more effective."

Prescribing a pill is easier and cheaper than offering the patient psychotherapy. Psychiatrists are paid more to prescribe pills than to counsel with patients. It is understandable, then, that the incentive is to see five patients in a single clinic hour. This saves insurance companies a lot of money. Many insurance companies will not even pay for psychotherapy with a qualified psychiatrist. And think about this: if a patient doesn't like the psychiatrist, there are fewer repeat or return visits. The winners are the insurance companies.

Dr. Friedman is also critical of trends in research, not because they are wrong, but because of simplistic logic. "The doubling down on basic neuroscience research" he says, "seems to reflect the premise that if we can unravel the function of the brain, we will have a definitive understanding of the mind and the causes of major psychiatric disorders." He points to an editorial in May in one of the most respected journals in our field, JAMA Psychiatry, emphasizing the brain but not mentioning the mind, the complexity of mental illness, or anything about how psychotherapy scientifically helps the brain. Friedman believes that "an undertaking as ambitious as unraveling the function of the brain would most likely take many years. Moreover, a complete understanding of neurobiology is unlikely to elucidate the complex interactions between genes and the environment that lie at the heart of many mental disorders."

"Anyone who thinks otherwise should remember the Decade of the Brain, which ended 15 years ago without yielding a significant clue about the underlying causes of psychiatric illnesses."
—Professor and Psychiatrist Richard Friedman

Dr. Friedman's article generated a number of replies, including this one from Christopher Lukas, a noted author:

"Over the years, I have had talking therapy for my depression and post-traumatic stress disorder, and I don’t believe I would be alive were it not for those sessions. I have also taken a whole range of medications for depression and find that psychotherapy outweighs the benefits of any of those drugs.

"Some psychiatrists and some patients think that drugs are better because they work like aspirin: Take two and call me in the morning. But, as Dr. Friedman pointed out, and as I have experienced, other patients find doses of talking therapy can work well if we’re patient and if we understand that many emotional problems may take time to go away.

"Persistence, willingness to give yourself over to the process and willingness to change therapists if the talk isn’t helping you: These are key to talk therapy’s benefits."

The comments by Lukas remind me of something I pointed out to a patient just last weekend. Asking about Alcoholics Anonymous, she wanted to know what it takes to succeed in finding sobriety through AA. "An easy way to think about it," I said, is to remember the three letters H-O-W." The old AA acronym stands for "honesty, open-mindedness, and willingness."

Another writer, who is a physician herself, also agreed with Dr. Friedman:

"For the past 30 years psychotherapy has been given short shrift as drug therapy has become the treatment of choice. There are many reasons for this, but the most powerful are economic.

"Doctors can manage medication for many more patients in a day than they can treat with psychotherapy. More important, pharmaceutical companies, which profit from the drug sales, support research, thus providing funds to psychiatry departments that receive no similar support for psychotherapy research.
Sadly, in the past generation or two there has been a huge loss in professional expertise as fewer psychiatry residency programs provide top-notch psychotherapy education and supervision.

"Twenty-eight years ago I went to medical school planning a career in child psychiatry. My interest had been primed by fascinating conversations I’d heard in high school between my father, a psychoanalyst, and his colleagues.
My medical school psychiatry rotation was a disappointment. There was no attempt to solve the riddles of patients’ emotions and behavior, only the adjustment of medication doses to treat symptoms. Still wanting to solve puzzles, I chose a career in radiology.

"When my father died, I was tremendously moved to hear some of his patients who attended his funeral tell me how the treatment he provided had profoundly changed their lives. Psychotherapy should be an integral part of psychiatric training."

Since I do both — I am a psychotherapist who prescribes medication when appropriate — it's understandable that I agree with Dr. Friedman. It's also true that I practice this way because that approach provides the best care for the brain, the mind, and the whole person.

Genetics, Weird Facts, & Placebos

There are times when the practice of medicine is the most fascinating possible kind of work. For example, consider the placebo effect.

A placebo is anything that seems to be a "real" medical treatment -- but isn't. It could be a pill, a shot, or some other type of "fake" treatment. What all placebos have in common is that they do not contain an active substance meant to affect health. Younger physicians won't remember this, but years ago it was considered okay for doctors to prescribe placebos. Surgeons fairly often would substitute saline (salt water) injections when they worried that patients were asking for too many narcotic shots after an operation. There was a preparation called Gevrabon that was essentially sherry wine with some vitamins added, and it could be given by prescription "for relaxation at bedtime." Over the years, for obvious reasons, experts in medical ethics began to question whether these practices—essentially deceiving patients, but with good intentions—were proper and permissible.

In addiction medicine, I've seen college students come into the emergency room looking drunk, only to discover (with lab verification) that the "drug" they had tried was simply a vitamin pill. Similar findings have emerged at The University of Texas Austin, where one of the research labs has a full-fledged bar (i.e. a saloon) set up to simulate the settings where college students drink. Click here to see the Sahara Bar in the Department of Psychology. Study subjects sometimes get tipsy even when their margarita or manhattan contains no alcohol at all.

In 1996, scientists assembled a group of students and told them that they were going to take part in a study of a new painkiller, called "trivaricaine". Trivaricaine was a brown lotion to be painted on the skin, and smelled like a medicine. But the students were not told that, in fact, trivaricaine contained only water, iodine, and thyme oil – none of which are painkilling medicines. It was a fake – or placebo – painkiller. Read an abstract of the study: Mechanisms of Placebo Pain Reduction. With each student, the trivaricaine was painted on one index finger, and the other left untreated. In turn, each index finger was squeezed in a vice. The students reported significantly less pain in the treated finger, even though trivaricaine was a fake.

In this example, expectation and belief produced real results. The students expected the "medicine" to kill pain: and, sure enough, they experienced less pain. This is the placebo effect.

Placebo medicine has even been shown to cause stomach ulcers to heal faster than they otherwise would. These amazing results show that the placebo effect is real, and powerful. They mean that fake or placebo treatments can cause real improvements in health conditions: improvements we can see with our own eyes. Experiencing the placebo effect is not the same as being "tricked", or being foolish. The effect can happen to everyone, however intelligent, and whether they know about the placebo effect or not.

An article in Harvard Magazine describes Harvard Professor Dr.Ted Kaptchuk’s first randomized clinical drug trial, where nearly a third of his 270 subjects complained of awful side effects. All the patients had joined the study hoping to alleviate severe arm pain: carpal tunnel, tendinitis, chronic pain in the elbow, shoulder, wrist. In one part of the study, half the subjects received pain-reducing pills; the others were offered acupuncture treatments. And in both cases, people began to call in, saying they couldn’t get out of bed. The pills were making them sluggish, the needles caused swelling and redness; some patients’ pain ballooned to nightmarish levels. “The side effects were simply amazing,” Kaptchuk explains; curiously, they were exactly what patients had been warned their treatment might produce. But even more astounding, most of the other patients reported real relief, and those who received acupuncture felt even better than those on the anti-pain pill. These were exceptional findings: no one had ever proven that acupuncture worked better than painkillers. But Kaptchuk’s study didn’t prove it, either. The pills his team had given patients were actually made of cornstarch; the “acupuncture” needles were retractable shams that never pierced the skin. The study wasn’t aimed at comparing two treatments. It was designed to compare two fakes.

Dr. Kaptchuk and his colleagues have found that placebo treatments—interventions with no active drug ingredients—can stimulate real physiological responses, from changes in heart rate and blood pressure to chemical activity in the brain, in cases involving pain, depression, anxiety, fatigue, and even some symptoms of Parkinson’s. His work was also featured in a New Yorker article, "The Power of Nothing," that can be found here.

Here are four fascinating (and weird) facts about placebos and the placebo effect:

1. It doesn't have to be a secret. Some believe that a placebo can only work if the recipient is unaware they are taking one. But there's evidence that people with irritable bowel syndrome who knowingly receive a placebo do better than those who are left untreated.

2. It works better if it's expensive. The pain-killing power of a placebo pill is greater among people who are told they are taking a full-price version, compared to those told that the pill is on sale for a discounted price.

3. It's not just us, animals can get it too. A 2012 study found that between 30 and 40 per cent of rats experienced pain relief when their morphine injections were swapped for inactive saline solution.

4. It has an evil twin. The nocebo effect makes people undergoing treatment more likely to suffer from side-effects if they are warned about them by their doctor.

For the full New Scientist journal article on the subject, click here.

Slowly, over the past decade, researchers have begun to tease out the strands of the placebo response. The findings, while difficult to translate into medicine, have been compelling. In most cases, the larger the pill, the stronger the placebo effect. Two pills are better than one, and brand-name pills trump generics. Capsules are generally more effective than tablets, and injections produce a more pronounced effect than either. There is even evidence to suggest that the color of medicine influences the way one responds to it: colored pills are more likely to relieve pain than white pills; blue pills help people sleep better than red pills; and green capsules are the best bet when it comes to anxiety medication.

Changing the Brain

Current neuroscience reveals that both psychotherapy and psychiatric medications produce positive changes in the brain. Research at UCLA demonstrates that people who suffered from depression had abnormally high activity in the prefrontal cortex.  Psychotherapy patients who improved show more nearly normal brain activity in this hyperactive region. For obsessive-compulsive disorder, OCD, cognitive behavior therapy (CBT) was associated with a decrease in the hyperactivity of the caudate nucleus, and the effect was most evident in people who had a good response to CBT.  In other words, the better the therapy seemed to work, the more the brain activity changed.
People with chronic fatigue syndrome (CFS) tend to have a decrease in a type of brain tissue called grey matter in the prefrontal cortex of the brain.  OCD researchers in the Netherlands provided 16 sessions of CBT, and found significant increases in gray matter volume in the prefrontal cortex.  This seems to suggest that the CFS patients were able to “recover” some gray matter volume after CBT.

The bottom line: Although medication and psychotherapy appear to work their magic in difference places, the results are positive for both. The mechanism of action remains unclear, but studies also show that the combination of psychotherapy and the right medication (getting it right is very important!) is an excellent approach for many individuals. As the brain changes, we see the production of new proteins, which change our brains through neuroplasticity.   In selecting a treatment strategy, sometimes medication works best, sometimes psychotherapy is the best option, and sometimes it’s a combination of the two.