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Insight
Matters
Fall, 2004
Thinking
outside the box about psychotherapy
by
Henry A. Nasrallah, MD, Editor
Psychotherapy
is a treatment universally used by psychiatrists and various
other mental health professionals for practically all patients.
Evidence for the beneficial neuroplastic effects of psychotherapy
is growing and perhaps some day, psychotherapy may be regarded
as a biological intervention like pharmacotherapy. So what if
psychotherapy is subjected to the same evidence-based paradigms
that are currently standard requirements for drug development
in psychopharmacology? As I muse about such a scenario, the
following thoughts meandered into my head:
- Can
placebo-controlled psychotherapy trials with a double-blind
design be conducted in a valid and reliable manner?
- Do
various psychotherapies differ in their efficacy profiles
like the various classes of psychotropics? Is psychodynamic
psychotherapy better indicated for certain psychiatric conditions
than cognitive-behavioral therapy and vice versa? Or are psychotherapies
indicated for any psychiatric disorder regardless of the modality?
How is that determined?
- What
is the "right dose" of a given psychotherapy? Why
is 50 minutes considered a "regular" dose while
20 minutes is considered "brief therapy"? Why can't
a psychotherapy session last 3-4 hours or more? Could that
work like a high loading dose of valproate which controls
acute manic symptoms more rapidly?
- What
is the proper dose "schedule" for psychotherapy?
Is once a week really "intensive psychotherapy"
as we define it in Psychiatric Residency Training Programs?
Why not daily (qd) or twice daily (bid) or every other day?
What is the half -life of various psychotherapies anyway?
And what time of day is best for psychotherapy? Before a meal
or after a meal? Is early morning with a rested brain, the
optimal time for psychotherapy? With background music or with
other sound effects related to the patient's background? What
about mid afternoon when cortisol levels are at a peak and
exploring stressful life events and abreactions may be facilitated?
Like psychotropic drugs, perhaps certain psychotherapies are
"stimulating" and should be given in am, while others
are better suited later in the day. In fact, why not do psychotherapy
qhs followed immediately by sleep, and could that approach
have a salutary effect on consolidating the cognitive and
affective processing of psychotherapy? If controlled studies
confirm the above, then evening shift therapists [with house
calls or using bidirectional videoconferencing] may emerge
as a new industry!
- What
are the common side-effects of various psychotherapies? Why
is there so little known about that? Is transference a side-effect??
Is dependency an addictive side-effect like in benzopdiazepine
users?
- Can
some patients "overdose" on psychotherapy? What
is the antidote?
- Can
there be contraindications for certain psychotherapies in
specific individuals? I recall one of my patients who suddenly
became very anxious during behavior therapy (progressive muscular
relaxation). He later did much better with face to face interpersonal
psychotherapy. But the question remains: why are there no
guidelines about the contraindications to psychotherapy?
- Are
there off-label uses of psychotherapy? Sounds funny, but if
evidence-based trials demonstrate that a specific type of
psychotherapy works best for a given symptom or condition,
then is psychotherapy not to be used "off-label"
for other psychiatric symptoms or conditions?
Ok,
enough of the musing and back to reality. As long as psychotherapy
is not a proprietary product patented by a person or a company
and packaged and sold for a profit, then it is highly unlikely
that controlled clinical trials will be conducted. One part
of me says: "What a relief!" but another part of me
laments : "Too bad. We can certainly use scientific methods
to optimize psychotherapy in an evidence-based manner".
Maybe
I should talk about this inner conflict with someone who really
understands . . .
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