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End of Treatment Outcomes for Patients with Mood Disorders (2009 – 2017)

Description of the Sample

This analysis includes all patients with a primary diagnosis of a mood disorder who participated in an evaluation followed by a minimum of one therapy session with me between the start of my practice in 2009 and spring 2017.  Given that this is an analysis of end of treatment outcomes, patients who are currently in treatment with me were not included in this sample.

The sample includes 34 individuals (29 females and 5 males) who ranged in age from 12 – 59 years old, with a median age of 20.  The majority of patients in this sample (65%) had a primary diagnosis of Major Depressive Disorder.   Other primary diagnoses included Unspecified Depressive Disorder, Bipolar Disorder, Mood Disorder Not Otherwise Specified, and Persistent Depressive Disorder (formerly known as Dysthymia).

More than half of these patients (56%) had a secondary diagnosis.  The most common secondary diagnoses were anxiety disorders. Other secondary diagnoses in this sample included ADHD, eating disorders, and PTSD.

Approximately 30% of the sample had a history of psychiatric hospitalization, most commonly for suicide attempts or suicidal ideation, prior to staring treatment with me.

Description of Treatment Received

The length of treatment varied dramatically, from one week to 3.7 years.  Number of sessions attended also varied dramatically, from 1 session to 135 sessions.  The broad range of treatment duration and sessions attended reflects the reality that some individuals decided not to proceed with treatment after one or two sessions, whereas other individuals attended sessions off and on, as needed, for the duration of their high school or college years.  The average duration of treatment was 11.9 months and the average number of sessions attended was 28.  So, a typical patient with a mood disorder attended approximately 28 sessions over the course of one year.

The type of treatment received was tailored to the individual patient, based on his or her presenting symptoms, circumstances, age, and preferences.  Forty-one percent of patients received Cognitive-Behavioral Therapy (CBT), 18% received a Dialectical Behavior Therapy (DBT) skills-based approach (NOT a comprehensive DBT program), 30% received integration of CBT and supportive counseling, and 11% interpersonal psychotherapy or supportive counseling.

Level of family involvement varied depending on the patient’s age, presenting symptoms, preferences, and living circumstances.  For the purposes of this assessment, high level of family involvement means that at least one family member attended all or most sessions with the patient.  Moderate level of family involvement means that family members attended some sessions and maintained ongoing communication with me throughout treatment.   Low level of family involvement means that at a family member was involved in the evaluation and/or at least one session, but most sessions were individual.  Among all patients in this sample, 18% had a high level of family involvement, 21% had a moderate level of family involvement, 18% had a low level of family involvement, and 44% had no family involvement.  Degree of family involvement was higher, in general, for adolescent patients than for adult patients, with all patients under age 18 having at least some family involvement in their treatment.  Fifty percent of adolescent patients (under age 18) had a high level of family involvement, while 42% had a moderate level of family involvement and the remaining 8% had a low level of family involvement.

Nearly ¾ of patients saw a psychiatrist and took psychotropic medications during treatment.  Nearly ¼ of patients were hospitalized during treatment, most commonly for suicidal ideation or suicidal gestures.

Treatment Completion and Recovery Rates

Of all patients who began treatment with me for a mood disorder, 15% achieved complete recovery, 24% made significant progress, 41% made some progress, 15% made no progress, and 6% regressed.  For a detailed description of what terms such as “complete recovery” and “significant progress” mean, please see this blog post from 2013.

Eighteen percent of patients completed a full course of treatment with me.  Completing a “full course of treatment” was defined as a mutual ending in which the patient, his/her family (in cases where family was involved) and I mutually agree that treatment goals have been met and treatment is no longer needed.  Of these “treatment completers,” 83% achieved full recovery and the remaining 17% made significant progress towards treatment goals.

The length of time required to complete a full course of treatment varied dramatically from person to person, depending on symptom severity and progress in treatment.  Time required to complete treatment ranged from 1 month to 3 years, with a mean of 16.6 months.  Likewise, number of sessions required to complete treatment varied dramatically between individuals.  Number of sessions attended for treatment completers ranged from 4 – 96 sessions, with an average of 23 sessions.  So, on average, individuals who were most successful in treatment (e.g., those who completed treatment and achieved full remission from their mood disorders) attended an average of 23 sessions over the course of 16 months.

Fifteen percent of patients moved to another geographic location during their treatment (either to attend college or to live elsewhere permanently), prior to completing a full course of treatment with me.  As of their last session with me, 60% of these “movers” had made significant progress in their treatment and the remaining 40% had made some progress.  These individuals were referred to other treatment providers in near their universities or new homes for continued treatment.

The dropout rate for patients with mood disorders was fairly high: 50% of patients discontinued treatment with me prematurely.  As of their last session with me, 18% of these “discontinuers” had made significant progress towards treatment goals, 59% had made some progress, and 24% had made no progress.   On average, individuals who discontinued treatment sooner made less progress, while those who remained in treatment longer made more progress towards their treatment goals.   Three quarters of the individuals who made no progress dropped out of treatment after just one or two sessions, and the remaining one quarter dropped out after 5 sessions.  In contrast, those who made significant progress prior to dropping out of treatment attended an average of 20 sessions.

I do not have data on what happens to patients after they discontinue treatment, so this is purely speculation, but I believe several factors contribute to the high dropout rate among patients with mood disorders.  First, depression frequently interferes with a person’s motivation and ability to carry out tasks, and tends to make people hopeless and pessimistic.  Individuals with these symptoms may have a more difficult time persisting towards a goal, such as scheduling appointments and continuing with treatment over a number of months, and they may feel less hopeful about having a positive outcome in treatment.  Second, some patients and families may be satisfied with “good enough,” and may drop out of treatment after making good progress but before achieving all treatment goals.  In contrast, I have high standards for my patients: I believe that full recovery is possible for most people, and when full recovery does not seem achievable, then a full and meaningful life with well-managed symptoms is an alternative good outcome.  I work diligently with patients and their families in pursuit of these goals.

Eighteen percent of patients with mood disorders were referred to other clinicians who could better meet their needs.  I made these referrals when a patient was not progressing in treatment, and when it did not appear likely that they would make progress in the near future.  As of their last session with me, 17% of referred patients had made significant progress, 33% had made some progress, 17% had made no progress, and 33% had regressed.

Predictors of Treatment Outcome

Not surprisingly, completion of a full course of treatment emerged as a strong predictor of positive treatment outcome.  83% of individuals who completed treatment achieved full recovery, while the remaining 17% made significant progress towards treatment goals.  None of the individuals who discontinued treatment prematurely achieved full recovery.

Another strong predictor of positive treatment outcome in this sample was referral source.  Eighty percent of individuals who achieved full recovery were self-referred (e.g., they found my practice through an online search), while the remaining 20% were referred by word of mouth (e.g., by a friend).    In contrast, none of the individuals who were referred to my practice by their psychiatrist, pediatrician, or another therapist completed a full course of treatment or achieved full recovery, although a number of them made significant progress.  My interpretation of this finding is that individuals who proactively sought my services of their own volition may be especially dedicated to improving their mental health, more invested in their treatment, and thus more likely to persevere through a full course of treatment and achieve recovery.   In the case of self-referred adolescents, their parents were the ones who actually brought their children to treatment.  These parents, on the whole, were particularly attuned to their child’s needs and struggles, researched their child’s symptoms and the variety of treatment approaches available, sought my services proactively, and were especially motivated to help their child recover.  Perhaps this parental conscientiousness, attunement, and empowerment helped facilitate recovery for their children.

Level of family involvement in treatment predicted treatment completion and full recovery for adolescent patients but not for adult patients.  All of the adolescents who completed treatment and recovered had moderate or high levels of family involvement.  In contrast, 75% of the adults who completed treatment and achieved full recovery had no family involvement in their treatment, while the remaining 25% had a low level of family involvement.

Individuals who took psychotropic medication were somewhat less likely to recover than those who did not: 40% of individuals who achieved full recovery were taking medication during treatment, whereas 76% of individuals who did not achieve full recovery were taking medication during treatment.  It is unlikely that taking psychotropic medication caused patients to have a worse outcome.  I believe the most likely explanation for this finding is that taking psychotropic medication is a marker of severity: individuals with more severe forms of mood disorders (e.g., Bipolar Disorder, Severe Recurrent Major Depressive Disorder) are more likely to need medication and are perhaps less likely to achieve complete remission of symptoms.

Hospitalization during treatment emerged as a predictor of less favorable outcome.  None of the individuals who were hospitalized during their treatment with me completed a full course of treatment or achieved full recovery.  It is unlikely that being hospitalized actually caused patients to quit treatment or caused them to make less progress in their treatment.  It is more likely that hospitalization, like taking psychotropic medication, is a marker of severity, and those individuals with more severe illnesses are less likely to experience complete remission of symptoms.

The following variables did NOT predict treatment outcome: age, gender, ethnicity, duration of illness, diagnosis, presence of co-morbid diagnoses, rate paid for services, type of treatment received, or history of hospitalization prior to starting treatment.

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Fighting Stigma: The Gift of a New Generation

Somehow, sometime in the past several years, I crossed some invisible line from “young adult” to simply “adult.”  Polite strangers call me “ma’am” at least as often as they call me “miss.”  Shopping at Forever 21 now seems scandalously inappropriate.  And I can’t remember the last time I was still awake to watch Saturday Night Live.  Now that I seem to be old enough to complain about the younger generation (They think women’s empowerment is posting bikini-clad selfies!  They use social media excessively! Their pivotal relationship conversations take place over text message!), it seems only fair that I also recognize the strengths of this cohort.  And they do have tremendous strengths.

Teenagers and young adults these days, for the most part, have grown up in an era where it is socially acceptable, even encouraged, to speak openly about mental health issues.  Just about every high school and college student who walks into my office has at least a couple of friends with mental health diagnoses.   Most of my patients have one or more members of their extended family, if not their immediate family, who has dealt with a mental illness.   And they know this because they talk openly about it.

And that excessive use of social media I complained about a minute ago?  Well, social media has allowed famous people to speak candidly to a wide audience about their experiences with mental illness, seeking treatment, and ultimately recovering.   Actress Kristen Bell has struggled with depression.   Writer/producer/actress Lena Dunham has received treatment for OCD.  Singer Demi Lovato has spoken openly about her struggles with bipolar disorder and her recovery from an eating disorder.  John Green, author of The Fault in Our Stars, has chronic anxiety which he is able to control with therapy and medication.  Olympic swimmer Michael Phelps has a diagnosis of ADHD.  These individuals have been extremely successful in their professions and have had the courage to speak publicly about their psychiatric problems.

Even more courageous than these celebrities, though, are the regular people who attend school, play sports, hold down jobs, pay bills, raise families, volunteer in their communities, and maintain friendships while also dealing with mental illness.  These are the people who have a lot to lose from the stigma surrounding mental health issues.  These are also the people who have the most to gain from breaking down the stigma.

The younger generation is fighting this stigma.  Australia’s National Youth Mental Health foundation has created an organization called Headspace dedicated to supporting adolescents and young adults with mental illnesses as well as combating stigma surrounding these issues.  In the UK, Prince William, Princess Kate, and Prince Harry have created Heads Together, a charity dedicated to fighting stigma surrounding mental illness and improving the mental well-being of all citizens.  Here in the US, the National Alliance on Mental Illness (NAMI) is running a Stigma-Free campaign.

The message of these organizations is simple and straightforward: mental illness is common and treatable.  Mental health problems are as much a part of the human condition as any other health problem.  Untreated mental illness can have dire effects on the individual, on the family, on the community, and on society as a whole.  People who have psychiatric diagnoses can overcome them and live fulfilling, successful, meaningful lives.  Learn about it.  Talk about it.  Seek treatment when needed, and support others in doing so as well.  Silence and shame help no one.

I can’t recall ever hearing these messages as a teenager or young adult.  If these messages existed at all back in my day, they were eclipsed by the OJ Simpson trial, overshadowed by the Clinton/Lewinsky scandal, drowned out by the Spice Girls and ignored amidst episodes of Friends.  It is an honor and a privilege for me to treat the teens of this generation, who live their lives with more knowledge, understanding, and acceptance than the generation before them.

If you’d like to read an interesting perspective from a highly experienced clinician from a previous generation who has over 40 years of experience treating anxiety and eating disorders, see Dr. Paula Levine’s blog.

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World Eating Disorders Action Day

Today – June 2, 2016 – is the first annual World Eating Disorders Action Day.

In honor of this day, my esteemed colleague, Dr. Tarah Martos, and I hosted the first annual South Florida Parent Summit on Eating Disorders.  The summit provided a unique opportunity for parents of eating disorder sufferers to unite, empower one another, and learn from each other.   We spoke with the parents about envisioning recovery, relapse prevention, and a promising new treatment from Colombia University which involves habit reversal.   The lovely parents who attended the summit, despite having sons and daughters of different ages and with different presentations of illness, felt an instant connection with one another, and a freedom in discussing their experiences with other parents who really, truly get it.

I am proud that World Eating Disorders Action Day exists, and I am honored to be a part of it.   The public health messages surrounding this day have been devoted to increasing awareness that eating disorders are serious but treatable illnesses, caused by a complex interaction of genes and environment, which affect people of all ages, genders, socioeconomic statuses, and ethnic backgrounds.   These are messages I stand behind as a psychologist, as a writer, as an activist, and as a mother of a little girl whom I hope can come of age in a world where the content of these public service announcements is common knowledge.

 

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Exercise and Eating Disorders: It’s Not What You Think

Exercise very often plays a role in the development of restrictive eating disorders, particularly Anorexia Nervosa (AN). Some people view exercise as “a form of purging” or “a way to get rid of calories.” These explanations seem to make sense in light of modern western society’s views on exercise, similar to the theory that people with AN restrict their calories in order to conform to society’s thin ideal. But like the thin ideal theory, the “exercise purging” theory is an erroneous attempt to make sense of a puzzling symptom in the context of modern society.

In AN, excessive exercise, just like food restriction, is a biologically-based symptom, driven by something beyond conscious control or awareness. Patients do not exercise “to burn calories,” although they may insist that burning calories is their motivation. Consider, for example, the fact that even patients who know they are too thin are motivated to gain weight (yes, such patients do exist), often cannot stop themselves from moving unless they are forced to do so. Young children with AN are especially susceptible to the drive to exercise even though they have no idea what calories are or how to burn them.

A little history may help to put this into context. People did not really exercise for the purposes of physical fitness and attractiveness prior to the “exercise boom” of the 1970’s and 1980’s. However, hyperactivity was a symptom of AN long before Jane Fonda’s exercise videos found their way into American living rooms.

The nineteenth-century British Physician William Gull, the first clinician to describe AN medically, was surprised by the seemingly boundless energy that his anorexic patients possessed despite their emaciated state. In his 1874 paper entitled Anorexia Nerovsa, he wrote the following description of a young anorexic girl: “The patient complained of no pain, but was restless and active…it seemed hardly possible that a body so wasted could undergo the exercise which seemed agreeable.” Clearly, this young woman was not motivated by the pursuit of a thinner body, as the idea of exercising to “burn calories” would not emerge until a century later.

Animal research has shown that the hyperactivity commonly associated with AN is rooted in neurobiology and may serve an adaptive evolutionary purpose. For example, activity-based anorexia can be experimentally induced in rats which, like humans, evolved as opportunistic omnivorous foragers. When food-deprived lab rats are given free access to a running wheel, they become hyperactive, lose large amounts of weight, and will often die unless they are removed from these experimental conditions. I highly doubt that these rats were running excessively to purge calories, ward off obesity, or pursue some unrealistic standard of rodent beauty.

So why would AN, which leads to numerous health problems, infertility, and death, remain in our gene pool for tens of thousands of years? Shan Gusinger, an evolutionary biologist and a psychologist, posits that AN has evolved in humans as a means of helping us flee from food-depleted environments. The restless energy, grandiosity, and lack of awareness of one’s starved body allowed prehistoric anorexics to lead their tribes in migrations from food-depleted areas to plentiful ones.

Once the anorexic leader and her tribe arrived in a plentiful environment, the tribe feasted, pressuring the anorexic leader to indulge in food with them. In the absence of modern society’s thin ideal and without our modern obesity hysteria, prehistoric anorexics may have been able to allow their families to feed them, restoring their health and fertility. Even if the anorexic herself died of her condition or was rendered infertile, her close genetic relatives survived and reproduced, thus ensuring the continuity of AN into the next generation.

In our modern world, where children are encouraged to exercise more and make “healthy” (e.g. lower calorie) food choices as early as kindergarten, it is no wonder that AN is still around. During the pre-teen years, when rapid vertical growth and pubertal development demand extra energy, girls and boys are hit hard with the social pressures to be thin (for girls) or lean and ripped (for boys). The rapid weight gain that is necessary for growth and development is feared and despised in these growing children (and often, sadly, in their parents and pediatricians).

Adding add fuel to the fire, the pre-teen years are when intense and time-consuming athletic training begins. Competitive sports provide socially-applauded outlets for the young anorexic’s hyperactivity. No one bats an eye at the 12-year-old dancer who spends hours each evening at her studio in preparation for her next audition, or the 11-year-old boy who plays multiple back-to-back games each weekend with his elite travelling soccer team. Meanwhile, these children are making “healthy food choices,” consuming too few calories and fats to keep up with normal growth, let alone intense daily exercise.

In these vulnerable children, their vertical growth is stunted, their pubertal development is halted, and their intense athletic drive is praised by adults. And before you know it, they have fallen down the rabbit hole and developed full-blown AN. In this way, hyperactivity serves as both a precipitating factor and a perpetuating factor in the development of AN.

In my next post, I will discuss the role of exercise in eating disorder recovery.

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Expanding Our Minds: Towards a Biologically-Based Understanding of Eating Disorders

I read the abstract of a recently published journal article which illustrates one of the major problems in the field of mental health treatment in general, and eating disorder treatment in particular. The article, authored by Jim Harris and Ashton Steele and published in the latest issue of Eating Disorders: The Journal of Treatment and Prevention is provocatively titled Have We Lost Our Minds? The Siren Song of Reductionism in Eating Disorder Research and Theory.

The authors state that, over the past decade, “the focus of eating disorder research has shifted from the mind to the brain.” I disagree with this assertion on two levels. First, the statement implies that the mind and the brain are separate entities. They are not. The “mind” is simply a range of conscious functions which are carried out by the brain: for example, thoughts, beliefs, emotions, intentions, motivations, and behaviors. These mental functions originate in the brain, are executed in the brain, and are interpreted by the brain.

Indeed, recent developments in genetics and neuroimaging techniques have allowed scientists to study the structure, function, and circuitry of the brain in far greater detail than was possible before. Researchers have utilized this new technology to generate and test novel hypothesis about the biological underpinnings of eating disorders. The results of these studies have indicated that eating disorders are genetically inherited, biologically-based brain disorders, similar to bipolar disorder and schizophrenia.

However, while research in the area of genetics and neuroimaging has proliferated in the eating disorders field, there has been no shortage of research on psychosocial factors or non-medical treatments for eating disorders, such as FBT and DBT. Contrary to Harris and Steele’s assertion, we have not “lost our minds.” We’ve simply expanded our minds and deepened our realm of investigation to study the biological underpinnings of mental functions as new technology has allowed us to do so.

Harris and Steele assert that the brain disorder model of eating disorders necessitates that treatment targets the underlying neurobiological abnormality; namely, medication. The authors then conclude that the brain disorder model of eating disorders is misguided because no pharmacological intervention has been shown to significantly benefit patients with anorexia nervosa.

This simplistic assumption and its corollary reflect a lack of basic understanding of the relationship between the brain and the symptoms of psychiatric illness. The authors fail to recognize the fact that certain non-medical interventions HAVE been consistently shown to benefit patients with biologically-based brain illnesses.

For example, it is widely accepted amongst medical and psychological professionals, as well as the general public, that autism is a biologically-based brain illness. There are no medications which have shown to consistently benefit children with autism. The gold-standard of treatment for autism is early intervention with applied behavior analysis (ABA), which is a form of behavior therapy focused on skills building, parent training, and modifying environmental contingencies. Most children with autism do extremely well with this type of treatment, and many of them can be mainstreamed in classrooms with typically developing children.

Sound familiar? It should, because that is precisely what is happening in the world of eating disorder treatment. The treatment approaches which have shown the most promise in the world of eating disorders are psychological and behavioral treatments such as Family-Based Treatment (FBT) for anorexia nervosa and Cognitive-Behavioral Therapy (CBT) and Dialectical Behavior Therapy (DBT) for bulimia nervosa.

There are a number of misconceptions about these types of treatments. For example, many people believe that FBT is merely re-feeding. This is not so. FBT is a psychological and behavioral treatment – a form of psychotherapy – and parental control of re-feeding is but one component of the first phase of this three-phase treatment model.

As another example, some people believe that CBT and DBT are merely “learning skills.” Again, this is a misconception. CBT and DBT are forms of psychotherapy which involve a relationship with a therapist who instills hope, provides support and feedback and accountability, promotes awareness of thoughts and feelings, and teaches adaptive skills for managing life’s challenges.

Contrary to popular belief, psychotherapy does not consist of lying on a couch and talking about your mother. That myth stems from psychoanalysis, an antiquated form of treatment commonly practiced in the mid-20th century which has no evidence base. Modern evidence-based psychotherapy is entirely different: it is active, directive, and believe it or not, effective.

I get a bit irritated when uninformed people make sweeping generalizations on either side of the fence, such as “psychotherapy doesn’t work for eating disorders,” or, on the flip side, “psychotherapy is the best way to treat eating disorders.” The truth is more specific: evidence-based psychotherapies are effective in the treatment of eating disorders.

From my perspective, focusing on the biological basis of psychiatric illnesses does NOT mean:

• That the illness can only be treated with a pill
• That psychological and social factors are irrelevant
• That environment doesn’t matter
• That the patient can’t do anything about it
• That the psychologist’s job is obsolete

Focusing on the biological basis of eating disorders DOES mean:

• That eating disorders are illnesses, no different from cancer or diabetes or schizophrenia
• That patients do not, and in fact cannot, choose to develop eating disorders
• That eating disorders are not caused by family dynamics or social pressures
• That prevention efforts aimed at improving body image are unlikely to be effective
• That a person must have a certain genetic predisposition in order to get an eating disorder
• That biological relatives of eating disorder patients are at risk for developing the disorder themselves
• That medication can be helpful, though not curative, in some cases
• That full nutritional restoration, and thereby correcting the brain-based symptoms of starvation, is a necessary first step in treatment
• That psychotherapy focused on resolving underlying issues or gaining insight into the origins of one’s illness is unlikely to be effective in resolving eating disorder symptoms
• That behaviorally-based psychological treatments focused on symptom management and skills building can be very effective, in large part because they change the brain
• That last century’s theories about the causes of eating disorders are inaccurate

I wish that Harris and Steele, and all professionals involved researching or treating eating disorders, could grasp these points. If the general population had this basic understanding of eating disorders, then patients and their families would be viewed with compassion and understanding rather than judgment or smug clichés (e.g. “she needs to learn to love herself;” “it’s all about control”).

The past decade represents a monumental shift in the way expert clinicians view eating disorders. In fact, it will be 10 years ago this fall that I saw my very first eating disorder patient. As a bright-eyed graduate student hungry for hands-on clinical experience, I chose a training rotation at an adolescent eating disorders clinic. On my first day at the clinic, not much older or wiser than the teenagers I was about to start treating, I was introduced to “the Maudsley Approach,” a promising new treatment method from the UK. And the rest, as they say, was history.

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Sleep and Mood Disorders: Implications for Mental Health Care

Getting enough sleep is important for everyone. Well-rested bodies and brains are healthier, more resilient, and more energetic. For those with depression and other mood disorders, getting plenty of sleep must be a priority. In fact, research has demonstrated that people with insomnia are ten times more likely to develop depression than those who get sufficient sleep. Further, new research has shown that sleep disturbances can trigger psychiatric illnesses in those who are vulnerable.

Sleep is every bit as important as medication and therapy in the treatment of mood disorders. For this reason, I make a point of discussing and monitoring sleep patterns with my patients, and I integrate sleep hygiene into their treatment plans.

A recent study financed by the National Institute of Mental Health and published in The New York Times found that a psychological treatment called CBT-I (Cognitive-Behavioral Therapy for Insomnia) doubled the effectiveness of antidepressant medication in the treatment of depression.

This was not surprising to me. I was trained in CBT in graduate school and I have seen cognitive-behavioral techniques work wonders in many of my patients. But the implications of this study, and the fact that the results have made it into the popular media, are quite significant.

One of the most disturbing and unfortunate trends in mental health care in recent years has been the overuse of psychotropic medication and the corresponding underuse of behavioral and psychological interventions. This trend is especially bothersome to me because I am keenly aware – thanks to my training and experience as a psychologist – that certain evidence-based psychological treatments are as effective, if not more effective, than medication for treating certain illnesses.

Unfortunately, most people outside the field of psychology don’t know this. Americans are bombarded daily with advertisements for psychotropic medication on television, online, and in print. It’s only natural, then, that consumers who are suffering from depression or anxiety would request medications from their doctors, even when they have a problem that can be successfully treated by other means.

Don’t get me wrong – I am by no means anti-medication. I am thankful that we have effective, relatively safe medications on the market now that can help people effectively manage serious illnesses which were once disabling. Indeed, psychotropic medication can be extremely helpful – even life-saving – for many people. My concern is that psychotropic medications are prescribed too frequently to people who may not need them, often without the necessary monitoring, and often without the corresponding psychological and behavioral interventions that have been proven effective.

As a psychologist who practices said psychological and behavioral interventions, rather than a psychiatrist who prescribes said medications, am I biased? Well, obviously. I believe in what I do and I chose this profession for a reason. But still.

My hope is that, with articles such as this one, the general public will learn that evidence-based psychological treatments exist which can reduce their suffering and improve their quality of life. I would like people to be fully informed about their options when it comes to mental health treatment. I look forward to the day when people experiencing psychiatric symptoms routinely ask their primary care physicians for referrals to psychologists who practice evidence-based treatments, rather than, or in addition to, asking for prescriptions.

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Correlates of Treatment Outcome for Patients With Mood Disorders

In my last blog post, I described end-of treatment outcomes for patients with mood disorders. Here, I will elaborate on factors that were correlated with treatment outcome for these patients. Please be advised that these results are specific to my practice and my patients, and should not necessarily be generalized to other clinicians or populations.

Diagnosis
Type of mood disorder diagnosis was strongly correlated with treatment outcome. Patients with Depressive Disorder NOS (DDNOS; n = 3) fared best. Two-thirds of these patients (n = 2) completed treatment and achieved full remission. The remaining one-third (n = 1) attended treatment for two months and made significant progress before quitting prematurely.

Patients with Mood Disorder NOS (MDNOS; n = 4) had varying outcomes. Half of them (n = 2) completed treatment; of these, one achieved full remission and the other made significant progress. Of the remaining MDNOS patients, one quit prematurely after making some progress and the other regressed and was referred to a higher level of care.

Both of the patients in this sample with Dysthymic Disorder also had a diagnosis of Major Depressive Disorder (MDD). For statistical purposes, I am subsuming these individuals under the category of MDD, as that is the more severe of the two diagnoses. Patients with Major Depressive Disorder (MDD; n = 11) had varying outcomes. Eighteen percent (n = 2) completed treatment and achieved full remission; 9% (n = 1) quit treatment after making significant progress; 45% (n = 5) either quit treatment or moved away after making some progress; and 27% (n = 3) were referred to other providers.

The presence of both dysthymic disorder and MDD (n = 2) did not have a consistent impact on treatment outcome – one of these individuals completed treatment and achieved full remission, while the other regressed and was referred to a higher level of care.

None of the patients with bipolar disorder (n = 3) completed treatment or achieved full remission. However, one of the patients with bipolar disorder remained in treatment for over a year and made significant progress, but was eventually referred to another treatment provider to address other treatment needs.

Comorbidity
Presence of a co-morbid diagnosis was a negative prognostic factor. Only 18% (n = 2) of the patients with comorbid disorders completed treatment, and only 9% (n = 1) achieved full remission, while the remaining 9% (n = 1) made significant progress. In contrast, 40% (n = 4) of patients without a comorbid diagnosis completed treatment, and all of these patients achieved full remission.

Medication
Patients who did not take psychiatric medication during treatment with me were more likely to make progress in treatment and more likely to achieve remission than those who took psychiatric medication. All of the patients who did not take medication (n = 8) made at least some progress in treatment. In contrast, 30% of those who took medication either made no progress (n = 2) or regressed (n = 2) during treatment. Half of the patients who did not take medication (n = 4) achieved remission by the end of treatment, compared to 8% (n = 1) of those who took medication.

My hypothesis is that patients who took medication had poorer outcomes not because their medication didn’t work or made them worse, but rather because taking medication is confounded with severity of mood disorder and with comorbidity. In other words, those with more severe mood disorders and/or comorbid conditions were more likely to require medication in order to function, whereas those with mild to moderate mood disorders were less likely to need medication.

Age and Family Involvement
Younger age was a significant predictor of treatment completion. Patients who completed treatment ranged in age from 16 – 29, with an average age of 19.7. Those who did not complete treatment ranged in age from 12 – 59, with an average age of 28.6.

Being under 18 years old was a protective factor. None of the adolescents under 18 quit treatment prematurely. Of the 6 adolescents in this sample, 50% (n = 3) completed treatment and attained full remission, 33% (n = 2) were referred to other treatment settings after a year or more of treatment with me due to other needs, and the remaining 16% (n = 1) engaged in treatment as a 17-year-old and made some progress, but quit shortly after his 18th birthday. I suspect that the high level of parental involvement that I require for adolescent patients is the primary reason why they are likely to remain in treatment and have positive outcomes. In addition, younger patients tend to have shorter duration of illness compared to adult patients, and early intervention is also predictive of positive outcome.

For patients over 18, family involvement often included spouses and significant others instead of parents, based on the patient’s living situation and relationship status. Sixty percent (n = 9) of the patients over 18 in this sample had no family involvement whatsoever, 27% (n = 4) had a low level of family involvement, and 13% (n = 2) had a moderate level of family involvement. None of the patients over 18 had a high level of family involvement.

Importantly, amongst the adults in this sample, family involvement was not necessary in order to make progress in treatment or attain remission. None of the adults who attained full remission (n = 2) had family members involved in their treatment. Likewise, 67% (n = 2) of the adults who made significant progress in treatment had a low level of family involvement and 33% (n = 1) had no family involvement at all.

None of the patients over age 30 (n = 5) completed treatment. I hypothesize that there are several reasons for this: 1.) Older patients had a longer duration of illness, which means that their illness was more entrenched and more difficult to treat; 2.) The majority of these patients (80%; n = 4) had no family support at all; 3.) All of these older patients paid reduced rates for my services, which indicates that they were of lower socio-economic status, and which may suggest that they value my services less than those who pay full price; 4.) I saw all of these patients during my post-doctoral year, when I was less experienced and not yet fully licensed. Therefore, it is reasonable to assume that the quality of my services was somewhat lower back then than it is now that I am fully licensed and more experienced; and 5.) I prefer working with child and adolescent patients and find that I tend to be more effective with them. For these reasons, particularly #5, I no longer treat adult patients beyond their mid-twenties.

Gender
Average duration of treatment was comparable for males and females (6.8 months vs 7.4 months, respectively). Rates of remission were similar between males and females. Twenty percent (n = 1) of males completed treatment and achieved remission, compared with 25% (n = 4) of females. However, amongst those who did not achieve remission, females were more likely to make significant progress than males. Twenty-five percent (n = 4) of females made significant progress, compared with none of the males.

Hospitalization
Hospitalization during treatment with me predicted regression in treatment. Of the patients who were hospitalized during treatment with me, 67% (n = 2) had regressed by the end of their treatment with me. In contrast, none of the patients who were not hospitalized during treatment had regressed as of their final session with me.

I hypothesize that patients who remained out of the hospital during treatment with me were responding well to treatment, which would explain why they were more likely to achieve remission or at least make significant progress. In contrast, being hospitalized during treatment may have been an indication that the patient was not responding well to treatment, which explains why they were likely regressed as of their last session with me.

Surprisingly, history of hospitalization before entering treatment with me was not related to outcome. Of the 8 patients who had been hospitalized previously, 25% (n = 2) achieved remission, 25% (n = 2) made significant progress, 38% (n = 3) made some progress, and only 12% (n = 1) regressed in treatment with me. These percentages are comparable to those of the 13 patients who had not been hospitalized before beginning treatment with me: 23% (n = 3) achieved remission, 15% (n = 2) made significant progress, 38% (n = 5) made some progress, 15% made no progress, and 8% (n = 1) regressed.

I would have suspected that history of hospitalization would be confounded with illness severity, and therefore would predict poor treatment outcome. However, it is possible that the individuals who had been hospitalized before entering treatment with me had not been given appropriate outpatient treatment, hence the escalation of illness need for hospitalization. Perhaps these patients were able to benefit from their treatment with me, and it is possible that, in some cases, hospitalization could have been avoided if they had received effective outpatient treatment sooner.

Attendance at Therapy Sessions
Attendance at therapy sessions was correlated with treatment retention as well as treatment outcome. Sixty-seven percent (n = 4) of those who completed treatment attended all of their appointments, while the remaining 33% (n = 2) had only one missed appointment. Eighty percent of patients who attained full remission (n = 4) had perfect attendance in therapy; the remaining 20% (n = 1) missed only one appointment. None of the patients who missed more than one appointment completed treatment or achieved full remission.

I suspect this relates to the old adage: “You get out of it what you put into it.” A patient who frequently misses appointments probably places little value on their mental health, which may explain why they tended to drop out of treatment prematurely. Those who were diligent about their treatment prioritized their mental health and worked hard in therapy. Those who were conscientious and responsible about attendance were, most likely, conscientious and responsible about completing therapy homework, taking their medication consistently, and making positive life choices in general. Thus, it is natural that these individuals had better treatment outcomes.

Fee for Services
Payment of full fee for services was a predictor of treatment completion and achieving full remission. Sixty-seven percent of patients (n = 2) who paid my full rate completed treatment, compared with only 22% of patients (n = 4) who paid a reduced rate. Given that so few patients in this sample paid my full rate (n = 3), it is difficult to draw any conclusions about how these individuals differ from those who pay a lower rate.

However, in my practice, the correlation between payment of full services and better treatment outcome has been consistent across diagnoses, regardless of the number of clients in the sample. As I have noted in recent posts, individuals who pay lower fees are, by definition, of lower socio-economic status (SES). These individuals may have more financial stressors than those of higher SES, and may have other life obstacles in general (limited access to healthcare, transportation difficulties, unemployment, single parent families) which interfered with their ability to progress in treatment.

In addition, those who pay reduced rates were much more likely than those who pay full rate to no-show for sessions or to cancel at the last minute. This finding suggests to me that, on average, individuals who paid reduced fees placed less personal value on their sessions, had less respect for my time, did not prioritize their recovery, and/or were generally irresponsible, compared with individuals who paid full rate.

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Brain-Based Language and Eating Disorders (by guest blogger Carrie Arnold)

The following is a guest blog post from Carrie Arnold, science writer and blogger, who attended the International Conference on Eating Disorders with me earlier this month.

Language is a funny thing.

I’m a writer–every day, I see (and use!) the power of words to explain very esoteric subjects, to comfort a friend, and even to entertain. The language we use to talk about eating disorders is also important. It was refreshing to have a psychotherapist describe me not as “an anorexic,” but as “someone with anorexia.” Anorexia was a diagnosis. It wasn’t me.

The issue of language in eating disorders goes far deeper than whether or not to use anorexic or bulimic to describe someone. It cuts right to the heart of how we understand eating disorders and how we treat them. One of the sessions at the 2012 International Conference on Eating Disorders in Austin, Texas discussed the use of brain language in regards to eating disorders. Laura Collins, founder and executive director of FEAST, spoke about how the biological language can be empowering to parents and sufferers. Brett Deacon, a psychologist from the University of Wyoming, spoke of the power of the biopsychosocial model of mental illness, and the potential dangers of biological language. Anne Becker, an anthropologist and ED expert from Harvard University, talked about how language affects our perception of EDs. Lastly, Kelly Klump, a behavioral geneticist from Michigan State University, asked the crucial question: is it time for new language or new data?

First, a mini-history lesson. As neuroimaging techniques and other brain science has advanced in recent years, scientists studying mental illness have begun to use these tools to explore the biology of mental illness. Without these tools, researchers could only look at the psychosocial factors that contributed to mental illness, and they accumulated a mass of very important data on the subject. But neuroimaging and other techniques have allowed scientists to probe biological variations that might contribute to mental illness. Leading psychiatrists and psychologists like Tom Insel, director of the National Institute for Mental Health, have argued that these significant biological differences mean that “mental illness” should be renamed “brain disease.”

To some, a brain disease by any other name surely doesn’t smell as sweet. To me, the use of “brain disease” or, an alternative, “biologically-based mental illness” seems obvious. Depression, schizophrenia, and eating disorders affect the brain. That’s where they start. Deny that, and you may as well call them Big Toe Disorders or something equally ludicrous. If they’re not brain disorders, then what are they? I’m not asking a rhetorical question-I really would like an answer.

One potential answer that Dr. Deacon suggested was the biopsychosocial model. Mental illnesses are really biopsychosocial illnesses. Which is accurate. My problem with that term is that every disease, from eating disorders to cancer to diabetes, has biological, psychological, and social components. It’s like taking cows, sheep, goats, horses, dogs, and cats and putting them in a barn and trying to tell them apart by figuring out which have four legs.

I don’t know of anyone out there who can support the assertion that EDs are only biological. Genes matter, yes, but so does environment. Laura presented statements from families around the world that biological language like “brain disorder” gave them a way to move forward. Looking for blame didn’t really matter anymore. They could reframe their loved one’s behavior: instead of being a willful teen refusing to eat, they had a sick adolescent who wasn’t able to eat.

One of the main concerns with the biological language is the potential for stigma. If your genes caused your illness, then you’re screwed. After all, your genes are your genes, and they’re not changing unless you stand in front of some gamma rays. Which I wouldn’t recommend. Basically, then, it’s easy to see how biology would support the view of “Once an anorexic/bulimic, always an anorexic/bulimic.” Recovery was a hopeless endeavor.

While it’s true that you’re stuck with the genes you’re born with, your biology isn’t written in stone. To paraphrase biologist PZ Myers, biology isn’t rigid. It’s a bunch of squishy processes making do. Your genes don’t change, but their expression does. It’s a process known as epigenetics, whereby genes are regularly activated and silenced by various environmental factors. It’s entirely possible that the negative energy balance (that is, burning more calories than you’re consuming) that typically precedes anorexia activates genes that perpetuate the food restriction. It’s also entirely possible that nutritional rehabilitation silences these genes or activates other ones that help the brain and body return to normal.

The problem, then, isn’t with the biological language per se, but rather our culture’s generally abysmal level of scientific literacy. These concepts are difficult for even PhD scientists to understand. But as society’s awareness of the biological contributions to brain diseases/ mental illness grows, perhaps the understanding of the complex biology will improve as well. In fact, a study by Cindy Bulik and colleagues at UNC found that biological language actually decreased the stigma of anorexia, rather than increasing it.

Saying things like “brain disease” also doesn’t mean that the only solution is a pill. Although I do benefit from medication, I’m hardly a shill for Big Pharma. Psychotherapy remains one of the best ways to reliably change the brain long-term. Researchers found significant brain changes when a group of people with spider phobia underwent a course of cognitive-behavioral therapy. The authors conclude that “These findings suggest that a psychotherapeutic approach, such as CBT, has the potential to modify the dysfunctional neural circuitry associated with anxiety disorders. They further indicate that the changes made at the mind level, within a psychotherapeutic context, are able to functionally “rewire” the brain.”

At some point, however, all of this “language talk” makes me want to throw up my hands in frustration. Aren’t we just wasting loads of time playing at semantics? Call it Rainbows and Kittens for all I care!

Except that language really does matter. A recent study in the American Journal of Psychiatry found that people were significantly more likely to believe that someone needed treatment when they were diagnosed with social anxiety disorder versus social phobia. In the state of New Jersey, it was legal for health insurers to deny paying for anorexia treatment because it wasn’t a biologically based mental illness. A recent class action law suit caused this provision to be overturned and anorexia and bulimia treated on par with depression, bipolar disorder, and schizophrenia. Language matters, and it matters a lot.

The talk at ICED didn’t necessarily settle the matter, but then it wasn’t meant to. The most important thing was how it provided a better understanding of what we all mean when we say things like brain disease or biopsychosocial. What I mean when I say brain disease isn’t necessarily what other people mean. I know that talking about the biology of eating disorders doesn’t mean that environment is irrelevant as is psychotherapy. But that’s not necessarily what other people think. Perhaps what the field needs to do is clarify what their terms mean and how they use them in a sentence. Only then can we start to have a meaningful dialogue that will move the field forward.

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A New Awareness

Tomorrow, National Eating Disorders Awareness Week (NEDAW) begins.

NEDAW is a public health initiative designed to educate people about eating disorders. While I applaud the good intentions and effort that go into planning and executing NEDAW, I will not be participating in any of the events. I do not believe that the messages conveyed during NEDAW are particularly helpful: instead of correcting the myths and misconceptions associated with eating disorders, NEDAW just seems to perpetuate them.

For example, the National Association of Anorexia Nervosa and Associated Disorders (ANAD) posted the following on their website in under the heading Eating Disorders Awareness Week 2012:

“Through intentional activities, conversations and events we can all help create an environment that redefines outdated thinking, reduces the stigma associated with weight, body shape, or size, and inspires someone to reconsider an unhealthy attitude or behavior.”

There are several assumptions imbedded in this sentence:
• The environment causes eating disorders by making people feel dissatisfied with their bodies.
• People develop eating disorders because they are insecure, vain, shallow, appearance-focused, or overly influenced by the media.
• By altering the messages people receive from their environment and eliminating the “thin is in” culture, we can prevent or cure eating disorders.
• Overcoming an eating disorder is about reconsidering unhealthy attitudes or behaviors.
• If you have a friend or family member suffering from an eating disorder, you should try to inspire him/her to reconsider his/her unhealthy attitudes and behaviors.
• The unhealthy attitudes and behaviors associated with eating disorders are willful and consciously chosen.

Of course, none of these statements are explicit, but they don’t need to be – the public will draw these conclusions on their own.

I wholeheartedly agree that our culture is toxic and that the messages we receive about body image, beauty, food, and sexuality are horrific and damaging. I do not object to these principles at all – quite the contrary – but I do object to focusing on these messages during National Eating Disorders Awareness Week.

The current public health message associated with eating disorders awareness week is something akin to “Girls are dying to be thin, so let’s all love our bodies!” The themes of NEDAW revolve around thinness, body image, and the media. The concept of psychiatric illness is lost. Of course, it does not help that most eating disorder treatment professionals, eating disorder organizations, tabloid magazines, and recovering eating disorder patients espouse the same body-image centered messages.

I would like to change the public health mantra to something along the lines of “Eating disorders are highly heritable brain-based illnesses with severe psychiatric and medical symptoms.” My ideal public health message for EDAW would also contain the following points:

• Most symptoms of anorexia nervosa and bulimia nervosa are triggered or perpetuated by malnutrition. For those who are biologically vulnerable, dieting can trigger a cascade of self-perpetuating symptoms which lead to life-long psychiatric disability or death.
• Body dysmorphia is a symptom, not a cause, of an eating disorder. It is not present in all eating disorder patients, and it bears little relation to the typical woman’s body image distress.
• Early, aggressive intervention offers the best hope for full recovery.
• An eating disorder is a brain disease, not a weight problem.
• There are a variety of methods for treating eating disorders. Most of the eating disorder treatment available is NOT based on current science or evidence-based practice. Patients and parents must be proactive in finding effective treatment.
• Anosognosia – a neurologically-based inability to recognize one’s illness – is a symptom of Anorexia Nervosa. Therefore, patients should not be expected to “want to get well.” It is up to the patient’s loved ones and clinicians to ensure that he/she gets appropriate treatment as soon as possible.

These are the points that the public needs to hear. These are the points that will truly change the way eating disorders are perceived.

There are many eating disorder treatment professionals out there who will participate in a NEDAW walk or rally, or wear a “Love your body” T-shirt, or attend a screening of “America the Beautiful,” and then head to the office to practice outdated, ineffective treatment.

Next week, I will be promoting eating disorders awareness by providing my patients with the most current, evidence-based information and treatment, and by spreading scientifically-sound information through my blog and through my conversations with people. Please join me!

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Attachment to Theories

It is human nature to concoct theories in attempt to explain various phenomenon. As human beings, we have the capacity to problem-solve, to think critically and creatively about issues which impact us. For centuries, people have constructed theories as a means of “making sense” of things.

The need to create theories arises most often when the reason or cause of an event or circumstance is not readily apparent. For example, in ancient Greek mythology, the god Apollo rode his chariot across the sky every day, carrying the sun from east to west. Now we have modern science to explain the earth’s rotation on its axis every 24 hours, thus creating the appearance of the sun moving overhead from east to west, so the myth of Apollo is no longer necessary.

In modern times, science has replaced mythology and theory as our means of understanding various phenomena. While modern science has helped us understand many phenomenon, we still do not know what happens to us after death. This explains the popularity of major world religions which offer theories to answer these questions, such as heaven in Christianity or reincarnation in Hinduism.

In contrast to physics, chemistry, and biology, which have existed for millennia, psychology is a relatively new science. Relatively little is known about the causes of, and effective treatments for, mental illnesses. Therefore, numerous psychological theories have been proposed over the past century in attempt to explain psychological disorders. For example, in the 1950’s mental health professionals believed that autism and schizophrenia were caused by emotionally frigid “refrigerator mothers.”

With the advent of better science in recent decades, we have learned that parenting style plays no role whatsoever in the development of autism nor schizophrenia. While the precise causes of these brain disorders are unknown, we do know that autism and schizophrenia are neuro-biological disorders with strong heritability components, and that the patient’s parents can be extraordinarily valuable resources in treatment if they are given the right professional support.

While our current understanding of mental illness is in its infancy, recent scientific research has shed some light on factors that influence the development of mental illnesses. We also have some scientific data demonstrating that certain types of treatment are more effective than others for certain populations. In light of our current understanding of the etiology and effective treatment of mental illness, I am profoundly disappointed when I read about well-meaning but misinformed psychologists who cling to antiquated theories of mental illness and practice antiquated treatments.

For example, psychologist and author Judy Scheel, Ph.D., LICSW, believes that eating disorders are rooted in unhealthy or disrupted attachments to parents. In her recent Psychology Today blog post, she writes:

“For many individuals, eating disorders are attempts to fix externally what is internally vulnerable in an individual. Yet the cause of an eating disorder can often be traced back to attachment patterns that are weak or failing in childhood, which leave someone vulnerable to a whole host of self-esteem, self-worth and relationship issues later in life.”

This theory has a familiar odor. It reeks of refrigerator mothers, castration anxiety, and unconscious conflicts. In 1950, this was all we had. But now, in 2011, we know so much more.

Why do some psychologists cling to antiquated theories which have been disproven? Similarly, one may ask why many people cling to the theory of creationism when we have solid scientific evidence to support evolution. For some people, the notion that “we came from monkeys” is insulting and offensive and clashes with their existing belief system. The story of creationism is a foundation of Judeo-Christian religions, and (at least in its literal interpretation) is incongruent with Darwin’s theory of evolution.

The same is true with psychological theories. Many people who have been trained in psychodynamic or relational approaches feel that the new science runs counter to everything they have been taught and undermines the type of treatment they practice. They cling to their theories and defend them with religious fervor. The new science threatens their religion.

The problem here is that psychology is not a religion; it is a science. In the United States, we all enjoy freedom of religion – the freedom to believe whatever we wish and practice any religion we choose without persecution. We should not have freedom of science. As experts in the field of psychology with doctoral-level degrees, we should not have the freedom to write and publish whatever we happen to believe, and practice whatever method of treatment we wish, without accountability.

I was a graduate student relatively recently (2001 – 2008), and I was taught many things in my training that I no longer believe to be accurate. This is not a failure of my training; this is a reality of an evolving science. New developments occur in medicine all the time, and physicians who have been in practice for 20 years have had to learn and re-learn new ways of practicing as the science of medicine has evolved. This is expected. It is taken for granted by most patients.

As psychologists, we have a responsibility to educate ourselves about the latest scientific developments in our field and utilize our expertise to help people in need. Clinging to unproven theories, in the face of new science, is irresponsible, lazy, and potentially harmful. When challenged on their ideas, many old-school psychologists will use phrases such as “everyone’s opinion is valuable” or “can’t we agree to disagree” or “there is no right way to treat eating disorders” or “I feel unsafe.”

Here is the problem – this is not group therapy. We cannot sit around and validate one another’s feelings and hold hands and sing Kumbaya. Yes, all people are equal, but all ideas are not equal. Some ideas are supported by reliable scientific evidence and others are not. There may not be one right way to treat eating disorders but there are many wrong ways, and there are methods and techniques which clearly work better than others for most people.

We must let go of unhealthy, dysfunctional attachments to old ideas. Clearly, these attachments to antiquated theories contribute to the development of unhelpful psychotherapy. Perhaps today’s unhelpful psychotherapy is an attempt to validate one’s early training.