Are Antipsychotic Medications a Helpful Adjunct for Treating Obsessive-Compulsive Disorder?

Among people with whom I work, a practice that’s grown more common in the last few years but with iffy research support is the addition of an antipsychotic medication when an antidepressant medication doesn’t seem to be working. This is done in an attempt to augment the effect of the antidepressant. The practice concerns me because there’s a lot of research evidence showing that the side effects of antipsychotics can be pretty awful (e.g., weight gain, high blood pressure). It concerned me enough that I wrote an editorial about it that the Oregonian published in 2012.

Now new data has been published that clearly suggests antipsychotics should not be added to antidepressants for people with OCD.

Another study showing that CBT does the best with OCD

As I’ve written before, the most effective treatment for OCD is cognitive behavioral therapy (CBT) with exposure and response (or ritual) prevention (ERP).

A 2013 study examined a group of people with moderate to severe OCD who were already taking an antidepressant. They were divided into three groups.

  1. One group received psychotherapy—cognitive behavioral therapy with ERP.
  2. One group was prescribed an antipsychotic—Risperidone—in addition to the antidepressant.
  3. One group was prescribed a placebo (i.e., inactive) pill.

What did they find?—CBT was much more effective

The results are pretty striking. For those that were given an antipsychotic, only 23% of people showed improvement. This might suggest there is some benefit to adding an antipsychotic; however, this finding is not very impressive because those given the placebo (e.g., sugar pill) showed a 15% improvement. Moreover, the researcher found no statistically significant different between the effectiveness of the antipsychotic and that of the placebo. What this means is that, statistically speaking, the antipsychotic was no better than the placebo; that is, the 23% improvement (i.e., antipsychotic) is not more meaningful than the 15% improvement (i.e., placebo).

By contrast to those who received a pill, 80% of people who received cognitive behavioral therapy with ERP showed improvement! This is 3-4x the rate of improvement compared to those taking an antipsychotic—and without the extensive side effects that are common with antipsychotics.

Antipsychotic medication should not be considered for people with OCD

I think this is an important study because it makes it clear that adding antipsychotic medication is unlikely to really benefit someone with OCD. However, that cognitive behavioral therapy with ERP is more effective than medication for OCD is not a new finding

There’s already a solid base of research that suggests the ERP is superior to antidepressant medication for OCD. Giving an antidepressant to someone receiving EX/RP for OCD neither helps nor hinders treatment. This study is evidence that antipsychotics should not be considered for people with OCD.

Anxiety Treatment at Portland Psychotherapy

Research graveyard may come to life

“If enough data is collected, anything may be proven by statistical methods”

Williams and Holland’s Law

It’s an amazing day for scientific research! Hold on, don’t leave me yet. I know I typically try to post things here that are inspiring or at the very least interesting and directly applicable to your everyday life. And the behind-the-scenes politics and procedures of conducting scientific research generally wouldn’t be thought to fall into the “inspiring” category. But trust me, this matters to you!

The All Trials Campaign has organized experts from around the world who are demanding that all unpublished data from clinical medication trials be published and all misreported data be formally corrected. Just this month, the British Medical Journal (BMJ) and PLOS Medicine have taken up the call of the “Restoring Invisible and Abandoned Trials” initiative (RIAT), endorsing the proposal that sponsors and researchers begin publishing the results of their previously confidential clinical trial documents within one year. If they fail to take these actions, RIAT would call for independent scientists to publish those previously confidential trial documents.

To understand why this is such a potentially momentous move, it’s helpful to first understand a bit about how the world of scientific publishing works. At the heart of the problem is the fact that, in general, only studies that find “significant” results get published, and here the word “significant” means that the study found that the particular drug/intervention/treatment being tested was effective. On the surface this practice seems to make sense. I mean, would you sit down to read a newspaper that had a bunch of titles like “Nothing at all happened in Portland last night” and “Nobody did anything of significance in Congress yesterday” (ok, well, maybe that one doesn’t seem like a stretch!). Those of us who read journal articles to get our news about the latest developments in our field want to spend what little time we have reading articles about treatments that actually seem to work. We’re generally less interested in studies that fail to find that a particular treatment works. The result is that studies showing that a treatment doesn’t work, or worse, caused harm, are often unpublished.

However, the problem with state of affairs is that it gives health care providers and the public very skewed information. For every study we hear about that shows a particular drug or treatment supposedly works, we never know about the potentially countless other studies that showed that it didn’t work, or even that it caused harm. And the picture gets even more worrisome when you take into account how most research is funded in the first place.

The vast majority of scientific researchers are only able to do their work through grant funding (though we have a different model here at Portland Psychotherapy for funding our research which you can read more about here). One way this happens is that a researcher, who is very interested in a particular treatment, spends months writing and rewriting a grant application to ask some institution, such as the National Institutes of Health (NIH), essentially asking them for money to study their idea. But even more frequently, it isn’t the NIH or some other arguably unbiased institution that is funding research. As funding from places like the NIH have dropped drastically in recent years, “industry funded research” (e.g. research paid for by a company that is highly invested in its outcome) has soared, with industry-funded research in universities increasing 250% from 1985 to 2005. Increasingly, researchers are paid by a particular company, often a big pharmaceutical company, who has a vested interest in showing that their product (e.g., their drug) is effective.

Now let’s return to the problem of only publishing “significant” findings. If only those studies that show a “significant” result (e.g. that the drug “Y” was more effective than placebo) are going to be published, the company has every incentive in the world to just keep funding study after study until they finally get one that shows the result they want, not because it is a real result, but because of the natural variation and error that is part of research.  And these companies have the deep pockets to do that. So theoretically, they could fund 100 clinical trials and even if they only found a “significant” result in 1 out of 100 studies they ran, that one “significant” finding gets published in a journal, health care providers read about it, the press picks up on it, there are ads in magazines touting the positive findings, and now it’s the new wonder drug. However, the 99 other studies showed that drug “Y” was ineffective were never published.

From a consumer standpoint, would you purchase something if the advertisers told you that 99 times out of 100 it was shown to be completely ineffective? No, we’re more likely to buy (or in the case of health care providers, prescribe them to our patients) products when they are backed by claims like “Clinical studies prove that drug “Y” significantly reduced symptoms of X”. What the RIAT initiative will do is give us a more complete picture so that we can know about the studies that showed that a drug or other product was harmful or ineffective, versus only hearing about the studies that happen to work out.

Unfortunately, the RIAT initiative doesn’t have the ability to force drug companies or researchers to publish their negative findings. However, it does shine light on this incredibly important issue and, if the public demands it, will put new pressure on researchers and the industries to commit to making ALL their data available. This will allow researchers do what they are meant to do, be scientists, rather than being PR machines for companies with very deep pockets.

If I’ve convinced you here that this issue really does impact you and you’d like to read more about this problem of only publishing “significant” findings, you can read this great, in-depth article on the topic published in Scientific America.

You can also sign the petition to support the All Trial Registry here.

CRAFT: Helping Families With an Addicted Love One

Event Brite Link:

http://craftportland.eventbrite.com/

If you have a loved one with an addiction you’ve probably tried everything you can think of to get him/her to stop:  nagging, threatening, ultimatums, bargaining, attending support groups, etc. You may feel like there is nothing that you can do to get them to stop. Don’t give up, there is hope. An approach called CRAFT has been shown in well-designed research studies to get approximately 7 out of 10 loved ones into treatment. Additionally, CRAFT has been shown to improve the well-being of family members. This highly effective approach does not rely on confrontation or detachment. Instead, you will learn about specific actions you can take to free yourself from their cycle of addiction.

Time and date to be determined

Why you shouldn’t buy a light therapy device from Costco (how to find a good light therapy device)

Here in Portland, up to 20-30% of the population suffers from decreased mood and fatigue during the dark and cloudy days of winter. This has been called the “winter blues” and more serious variants of this are typically called Seasonal Affective Disorder.  By a long shot, the most well researched and effective treatment for this kind of seasonal depression is light therapy. Light therapy is fairly simple and typically involves sitting in front of a special kind of light every morning. It works really well and most people respond within in two weeks of beginning the treatment. If you have symptoms of seasonal affective disorder or the “Winter Blues” you should seriously consider getting light therapy device.

Unfortunately, the manufacture and sale of light therapy devices is completely unregulated by the government. This means that there are a lot of people out there buying devices which are not effective and who may end up concluding that light therapy does not work for them, when actually they bought a poorly-made device. It’s not easy to tell scam light therapy devices from legitimate ones, but below I’ll give you some tips that might help.

Typically, a good light therapy device is a little expensive. If someone is selling you a broad spectrum light therapy device for under $150, you should probably be suspicious (though there are some exceptions). It’s likely that it has not been manufactured to the standards used in the research studies and could be ineffective or potentially dangerous for your vision. Tested devices are typically 10,000 lux (a measure of intensity) and should say something about being “broad spectrum” and have shielding from harmful “UV rays.” It’s the UV rays that are put off by fluorescent lights that can harm your eyes.

Unfortunately, one of the biggest sellers of questionable light therapy devices is Costco. I was at Costco the other day and was able to take some shots of the product they are selling:

It would be hard to tell why this device won’t work, unless you know a bit about light therapy devices and also look at the small print below:

Fortunately, they actually specify how much light it is emitting so that you can tell that it won’t work. The light above only provides 4,500 lux at 6 inches from your eyes. A well manufactured device provides 10,000 lux at a comfortable distance (typically 12-24 inches). Who would ever sit with a light only six inches from their eyes? And even if they did, it would still not be strong enough to be effective without spending a lot of time in front of it. If you spend your money on this device, it’s wasted.

So my bottom line recommendation is DO NOT BUY THIS DEVICE. It will not work.

If you would like some advice on products that are worth the investment, here are two recommendations:

#1 – Carex Daylight classic

This device is probably the best one available on a consumer website like Amazon. The benefits are that it is up on a stand, which makes it more likely that the light will be positioned above your eyes, which is key for light  therapy to work. The downside is that the device needs to be about 12″ away from your eyes to be at the recommended 10,000 Lux that has been used in studies. If you carefully follow the directions, and sit with it relatively close to you, then most people get good benefits. This is the device suggested by the Center for Environmental Therapeutics, which is a non-profit dedicated to making light therapy more accessible.

#2 – Philips goLITE BLU 

Like the other light by Phillips, this is a quality product but at a more affordable price tag.  An additional bonus is that this product is better suited for packing up and taking with you. This light is based on newer research about the how blue light affects our eyes and circadian rhythms. It’s not quite as proven as the broad spectrum light above, but is a good alternative to the brighter, white lights if those bother your eyes or you want to try something more portable. Just make sure when you are using it that you are looking at something below the light (the light needs to hit your eyes from above).

Update: Don’t be fooled. Costco continues to sell the Verilux light above, but with a new name. The box for the new light says it’s a bit brighter, but still needs to be 6 inches from your eyes to work. That’s an impractical distance for most people. Don’t buy it. The new name for the questionable device is the “Verilux Happylight Liberty.” Given the poor track record of this company, I’d consider this new device similarly questionable. Avoid it. 


If you’d like some suggestions on other light therapy devices, or general info about SAD, click here.

What do people think is the best treatment for anxiety?

Here at Portland Psychotherapy, we spend a lot of time researching the most effective treatments for problems in living. Too often, though, there’s a disconnect between what the research says works and what is often used in practice. Not only is it difficult to educate the public but even mental health professionals can have difficulty keeping up.

For these reasons, I read this CureTogether post (now associated with 23andme.com) with great interest. CureTogether is a website that collects ratings of treatments. It appears to have an ongoing survey of anxiety treatments. Anyone can log in and rate what worked and didn’t work for them. May 13, 2013, the website posted the results from over 10,900 people who had participated in their survey of anxiety treatments.

What do people think works?

I’ll confess: because there’s so much misinformation out there, I was a little worried about what I’d find. I honestly expected to find evidence-practice lagging behind pop psychology. When I saw the actual rankings, however, I thought to myself, “Not bad.”

Cognitive behavior therapy (CBT)—which arguably has the most impressive research base for addressing anxiety disorders—was number 6. Given that CBT is not as “sexy” as other treatments, I was pleasantly surprised to see it in the top 10. Even Acceptance and Commitment Therapy (ACT), the specific branch of CBT offered at Portland Psychotherapy, was number 11. (This is amazing, actually, as ACT is still new to many professionals.) Even exposure therapy, which has the greatest research support but is especially unsexy, was listed at number 14.

More informal treatments such as exercise (#1), yoga (#3), and meditation (#5) also have some research support for being helpful to people. Not everyone needs to see a therapist for anxiety.

What was more concerning—although not surprising—was the prominence of a class of drugs collectively known as benzodiazepines. These include Xanax (#2), Ativan (#8), and Clonazepam (#9). I say “not surprising” because these are commonly prescribed drugs that calm you down within 20-30 minutes. I say “concerning” because, although they make people feel better in the short-term, benzodiazepines can actually maintain anxiety in the long-term: they are a short-term solution, can be addictive, and can lead to withdrawal effects with prolonged use and rebound anxiety when people stop taking it. Xanax, which is faster acting, is particularly dangerous.

What conclusions can we draw?

I should note that this isn’t an objective research study: it’s simply a summary of what people who filled out an online survey say they’ve tried and decided was helpful. That said, it’s an extremely useful snapshot of the real world treatment of anxiety.

Anxiety Treatment at Portland Psychotherapy