We need to put more effort and resources into developing a better understanding of how psychological therapy — “one human being talking to another” — is able to alter brain activity and cure or help ease the symptoms of many mental disorders, according to a commentary published Thursday in the British science journal Nature.
“It is time to use science to advance the psychological, not just the pharmaceutical, treatment of those with mental-health problems,” write Emily Holmes, a clinical psychologist and program director of the Medical Research Council Cognition & Brain Sciences Unit in Cambridge, England; Michelle Craske, director of the Anxiety Disorders Research Center at the University of California, Los Angeles; and Ann Graybiel, a neuroscientist at the McGovern Institute for Brain Research at the Massachusetts Institute of Technology (MIT).
As the three researchers point out, “Psychological treatments have been subjected to hundreds of randomized clinical trials and hold the strongest evidence base for addressing” many mental-health conditions, such as post-traumatic stress disorder (PTSD), obsessive-compulsive disorder (OCD), eating disorders, schizophrenia and depression.
Yet, “for many people, psychological treatments still conjure up notions of couches and quasi-mystical experiences,” the researchers add.
Some treatments still ‘in their infancy’
That’s not to say that psychological treatments always work.
“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,” Holmes, Craske and Graybiel point out. “For example, although response rates vary across studies, about 60% of individuals show significant improvement after [cognitive behavioral therapy] for OCD, but nearly 30% of those who begin therapy do not complete it. And on average, more than 10% of those who have improved later relapse. For some conditions, such as bipolar disorder, psychological treatments are not effective or are in their infancy.”
To better understand why certain psychological therapies work for some people and not for others and to improve the treatments’ outcomes so that they help more individuals, much more scientific research is needed, say the commentary’s authors.
“Neuroscience is shedding light on how to modulate emotion and memory habit and fear learning,” they add. “But psychological understanding and treatments have, as yet, profited much too little from such developments.”
Too much professional isolation
A big part of the problem is that neuroscientists, clinical psychologists and psychiatrists tend to work in their own academic and research silos, and thus “meet infrequently, rarely work together, read different journals, and know relatively little of each other’s needs and discoveries,” say Holmes, Craske and Graybiel.
That “culture gap” must be bridged, they stress.
In addition, they say, research on psychological treatments is “scandalously under-supported”:
Mental-health disorders account for more than 15% of the disease burden in developed countries, more than all forms of cancer. Yet it has been estimated that the proportion of research funds spent on mental health is as low as 7% in North American and 2% in the European Union.
Within those slender mental-health budgets, psychological treatments receive a small slice — in the United Kingdom less than 15% of the government and charity funding for mental-health research, and in the United States the share of National Institute of Mental Health funding is estimated to be similar. Further research on psychological treatments has no funding stream analogous to investment in the pharmaceutical industry.
This Cinderella status contributes to the fact that evidence-based psychological treatments, such as CBT, [interpersonal therapy], behaviour therapy and family therapy, have not yet fully benefitted from the range of dramatic advances in the neuroscience related to emotion, behaviour and cognition. Meanwhile, much of neuroscience is unaware of the potential of psychological treatments.
‘Enormous promise’
Holmes, Craske and Graybiel offer a multi-step process for fixing this problem, including building much stronger professional links between clinical and laboratory researchers.
In addition, they urged mental-health charities work harder to get national funding organizations “to reconsider the proportion of their investments in mental health relative to other diseases.”
“The amount spent on research into psychological treatments needs to be commensurate with their impact,” they stress. “There is enormous promise here. Psychological treatments are a lifeline to so many — and could be to so many more.”
You can read the commentary in full on the Nature website.
One problem is
that very little research has a good placebo control (a sham treatment provided by someone who doesn’t know that it’s a sham).
Lacking this we don’t know what proportion of the subjects would have recovered without ANY treatment (I’ve seen estimates in the 30% – 40% range). The treatment may even be iatrogenic (actually produce the problems that it’s intended to cure).
And then there’s the question of how improvement and cure are measured. In most cases it’s simply a survey of the opinions of care providers and patients (and the care providers typically estimate a higher cure rate than the people that they are treating).
Let’s not forget
that the qualities of the therapist are a key consideration. Most find no relief from their first medication trial. Why would we expect patients’ experiences with therapists to be any different?
In both cases
we may be seeing an artifact of spontaneous remission.
If a significant number of cases ‘cure themselves’ (improve without any treatment),
we may simply be seeing people bounce from treatment to treatment until (possibly by coincidence) they improve. They then attribute the improvement to finding the right treatment, even though it is possible that they would have eventually gotten better with no treatment.
There’s also the possibility of regression to the mean (these statistical phenomena are easily Googled). People usually seek help when things are at their worst. This makes it likely that the normal variability of human behavior will result in their more likely feeling better than worse after time passes.
Anecdotes cannot sort these things out — only a carefully controlled experimental design.