EFFICACY OF COMBINED PHARMACOTHERAPY AND PSYCHOTHERAPY

Several reviews of trials of the combination of psychotherapy and pharmacotherapy for patients with mild to moderate major depressive disorder have failed to find the combination to be superior to either treatment modality alone (Depression Guideline, 1993 [E]) Lynch et al. (2003) demonstrated that dialectical behaviour therapy when used as an augmentation treatment with SSRIs, can successfully overcome the vulnerabilities associated w Gerard & Hogarty et al,(1991) added psychoeducational Family Therapy to antipsychotic medication which reduced the relapse rates of such patients. Some studies suggest that both short term and long term improvements as well as more rapid response when both pharmacotherapy and psychotherapy were used ith relapse in chronically depressed elderly patients.

Thus in evidence based mental health treatments, the following general patterns emerge across various mental illnesses:

1. Medications are effective but combined treatments i.e. (medication plus psychosocial interventions) often produce the best results.

2. Some psychotherapies are empirically supported, particularly cognitive – behavioural and interpersonal psychotherapies and have equal efficiency vis–a–vis medication in mild to moderate cases of many conditions.

3. Other psychosocial treatments (e.g. Family education) and services (e.g. assertive community treatment and supported employment for adults; multisystemic treatment for children with conduct disorders) provide advantages of some conditions particularly to promote rehabilitation and recovery in the most impaired individuals.

EFFICACY OF PSYCHOTHERAPY IN SPECIAL POPULATIONS

Geriatric Population

Mohlman et al. (2003) demonstrated that CBT can effectively treat GAD in older adults. In general, certain group therapy intervention, particularly BT Groups, appear promising for use with depressed older adults (Lynch et al., 2003).

Childhood Disorders

Psychotherapy for children and teens is used to address four common problem/disorder clusters (Weiss et al., 2004):
(i) Anxiety related problems and disorders
a) Modeling intervention: Murphy and Bootzin (1973) used two different approaches to live modeling to help children overcome their fear of nonpoisonous snakes. Participant modeling was used by Ritter (1968) with 5 to 11 year old children who were afraid of nonpoisonous snakes.
b) Relaxation training: Laxer et al (1969) used relaxation training to help anxious secondary school students to reduce their test anxiety.
c) Systematic desensitization: Laxer and colleagues (1969) used systematic desensitization to reduce anxiety in children.
d) Reinforced exposure: Muris et al (1998) treated spider fears in 8 to 17 year olds by exposing them to a variety of spiders.
e) Social skills training: Beidel et al (2000) used a program called Social Effectiveness Therapy for Children to treat 8 to 12 year olds who had been diagnosed with social phobia.
f) CBT: Ollendick (1995) used CBT in children suffering from panic disorder with agoraphobia.
(ii) Depressive symptoms and disorders
a) CBT: Cognitive behavioural, psychoeducational, 16-session group treatment called the Adolescent Coping with Depression Course developed by Clark et al. (1990) is the most extensively tested and supported approach to youth depression.
b) IPT: Mufson et al. (1999) reduced depressive symptoms by focusing on common adolescent developmental issues, especially issues bearing on social relationships.
(iii) Attention and hyperactivity symptoms and disorders
a) CBT: Pelham et al. (1998) in their review of evidence based treatments of attention-deficit hyperactivity disorder (ADHD) reported that behavioral parent training and behavioral interventions in the classroom are the best-supported psychosocial treatments for ADHD.
b) Relaxation and biofeedback training: Carmody et al (2001) used a traditional biofeedback approach to treat children with ADHD.
(iv) Conduct related problems and disorders
a) Problem solving skills training: One specific child focused intervention that has shown consistent support across repeated trials is Kazdin’s Problem-Solving Skills Training (Kazdin, 2003).
b) Operant treatment: Autry and Langenbach (1995) succeeded in reducing disruptive behavior by using response cost and time out.
c) Behavioral parent training: Parent Management Training – Oregon (PMTO) developed by Patterson and colleagues, (1982) has been used extensively to treat conduct problems.

NEUROBIOLOGICAL EFFECTS OF PSYCHOTHERAPY

PET: Positron Emission Tomography. SPECT: Single Photon Emission Computed Tomography EEG: Electroencephalography PFC: prefrontal cortex; AC: anterior cingulate.

PROBLEMS IN APPLYING EVIDENCE-BASED PRINCIPLE TO PSYCHOTHERAPY

There are several issues, controversy, obstacles and challenges related to the application of the evidence-based principles to psychotherapy research and in the generality of the findings to clinical work.

1. Variance Among Therapists: There must be individual differences in therapeutics skill among therapists. This means that if different therapies are compared it is necessary to have a good sample of therapists from each type of therapy.

2. Variance Among Patients: It is important to choose representative samples of patients in studies of the effectiveness of psychotherapy.

3. Patient Therapist Interaction: Truax (1963) argued, there might be an interaction between the personal characteristics of a client and therapist that makes for therapeutics success. Some clients may do better with some psychotherapists than with others.

4. Use of Diagnostic Systems: Critics have argued that no system of describing clients is needed, that groupings of clients are impossible because each case is unique, or that diagnosis is dehumanizing (Bohart et al., 1998). In response task force members (Task Force, 1995) have noted that some method for describing client is necessary to enable clinicians to evaluate the likelihood of generalization from research samples for their own practice and to organize data. Without some categorization, synthesis of evidence is extremely difficult, if not impossible. Fonagy and Target (1996) noted that, whatever the limitations of diagnostic systems, critics have yet to suggest a better feasible alternative.

5. Meaning of Recovery: It is difficult to define what is meant by recovery. e.g., is recovery a remission of symptoms, or feeling more cheerful, or a complete change in the way clients view their lives? Actually what is deemed to constitute recovery must depend upon how psychotherapy is conceived. This varies from simple (behaviour therapy) to the complex (psychoanalytic therapies) & to its virtual denial (Smail 1984). Thus behaviour therapy (Eysenck and Rachman 1965) regards neurosis as nothing more than maladaptive responses, say fear of spiders. For therapist of this persuasion, remission of symptoms is recovery. Psychoanalysts consider that a more harmonious balance of aspects of the mind (id, ego and super ego) has to be attained before a client may be deemed recovered. Smail (1984), however, has argued that much psychological distress is not abnormal but is a reasonable response to a wretched life. Clearly what constitutes recovery is no simple matter to decide. This certainly makes for difficulties in trying to compare the results from different kinds of treatments.

6. Spontaneous Remission: In many cases psychological symptoms disappear for no apparent reason. This need to be taken into account in the evaluation of psychotherapy and an untreated control group is required for this purpose.

7. Symptom Substitution: The whole range of subject’s feelings, anxieties and behaviour has to be studied before one can be confident that there is no symptom substitution.

8. Role of Life Events: The effects of other events in the patient's life during the time of psychotherapy should be studied, as life events can affect the course of illness.

9. Economic Concerns: Concerns have been raised that the empirically supported therapy findings can be misused by managed care companies to disenfranchise practitioners of psychotherapies that are not so designated (Silverman, 1996) and can make these same practitioners more valuable to malpractice suits (Kovacs, 1996).

10. Meaning of Therapeutic Change: Several issues have been raised, that even pertain to the most promising treatments in the field of empirically supported treatments the magnitude of therapeutic change is an issue in need of much greater attention. Showing superior effect to no treatment or to other treatments can delineate empirically supported treatments. Yet, without the knowledge about the clinical significance of change, the real importance of this relative superiority may be difficult to evaluate. Moreover, it is important to include measures that assess the impact of change on the client's everyday functioning in real assessed contexts.

11. Maintenance of Change: It may be unrealistic to demand long – term follow – up from all treatment trials, at least data can be collected on two or few occasions after treatment. This in turn may provide excellent information about durability of treatment.

12. Comorbidity: Outcome effects and long – term prognosis are affected by the presence and type of co morbid disorders (Harrington et al., 1991; Kazdin & Crowley, 1997).

13. Psychometric Qualities of Assessment: The qualities that are traditionally considered relevant in psychological testing include reliability and validity.
    a) Reliability: is of particular importance in measuring outcome, because the most common procedure for measuring change involves administering the assessment device before and after treatment and then calculating some kind of change score. The changes of test scores are not only due to the true differences in whatever is being measured but also to error factors that can affect the scores (item sampling, the test taker’s physical and mental state, the test environment, and administrative instructions).
    b) Validity: Because of the limited validity of any specific measure; most researchers recommended the use of multiple measures from multiple perspectives (Coughlin, 1997; Maruish, 1999).

14. Baseline Measurement: To estimate change and symptoms substitution it is necessary to know what individuals were like before the onset of their disorder.

15. Limitation of Randomized Controlled Trials: Although RCTs are invaluable, they frequently fail to meet clinicians’ needs, for several reasons.

    a) RCTs provide information about the average case, whereas clinicians make treatment decision about specific unique cases (Howard et al., 1994).

    b) RCT supported protocols are difficult to use in clinical practice because most currently available protocols guide treatment of single disorders and problems, whereas most patients have multiple disorder and problems

    c) When patients seek treatment for single disorders, the protocols often provide clinicians with little assistance in overcoming common obstacles such as non-compliance and patient- therapist relationship difficulties to following the protocol.

    d) Those who suggest that qualitative research would be more appropriate (Bohart et al., 1998), have rejected it as a poor approach to gaining knowledge

    e) Because cognitive and behavioural approaches have been more often the subject of RCTs than have other forms of psychotherapy, some fear that the criteria does unfair advantage to CBT over other therapies (e.g., Bohart et al., 1998)

    f) Seligman (1995) has argued that, because clients in treatment in the community are not randomly assigned to treatment, empirically supported therapies based on RCTs unlikely to generalize to clinical practice.

16. Limitations of Metaanalysis: primary criticisms of Meta analysis include; mixing of dissimilar studies, publication bias, Inclusion of poor quality studies and lack of standards for conducting and reporting metaanalysis (Sharpe 1997; Matt and Navarro, 1997).

17. Limitations of Manuals:

    a) Some clinicians reacting to a perceived threat to their independence of practice.

    b) Some clinicians have viewed manuals as promoting a workbook mentality (Smith 1995).

    c) Therapists in the community do not follow manuals and thus their use in efficacy research limits generalization (Seligman, 1995; Garfield, 1996).

    d) The use of treatment manual can lead to degradation in the quality of treatment that clients receive (Garfield, 1996, Henry, 1998). The assumptions are 1) Therapist trained in a standardized treatment will not be able to shift flexibly from such protocol when necessary to treat a particular case. 2) That a standardized treatment approach will be less beneficial than a treatment program designed specifically for an individual. Concerning the1st point some authors find that at least under some circumstances (e.g., rupture of therapeutic alliance), greater adherence is related to poorer outcome (Castonguay et al., 1996). Whereas, others have found greater adherence is related to better outcome (e.g., Frank et al. 1991). Concerning the 2nd point; two available studies (Jacobson et al.1989 on behavioural marital therapy, and Emmelkamp et al.1994 on OCD) have not found the superiority of flexible treatments over standardized treatment.

18. Difference between Efficacy and Effectiveness: Many of the treatments supported in the empirical literature may need to evolve considerably before they can fit smoothly into practice settings. The ways in which many of the ESTs have been tested thus far involve clientele, settings, therapists, or treatment conditions that differ in important ways from modal clinical practice (Kazdin, Bas, et al., 1990; Weisz & Weiss 1993). Moreover the exclusion – criteria frequently applied in clinical trials may not be acceptable in clinical cases and this may require changes in manualized procedures to address the problems in treatment.

19. Problems in Dissemination and Implementation: For over fifteen years, researchers have discussed the importance of disseminating empirically supported or evidence-based psychotherapies into community settings (Goldman, 2001; Henngeler & Lee, 2002). Proponents of dissemination have suggested many advantages that these treatments could bring to clinical practice, most prominently the real possibility that they will lead to better outcomes than treatment as usual (Drake et al., 2001; Weersing & Weisz, 2002). Despite the advantages, the rate of transfer of innovative treatments from research clinics to community practice has been very slow. A recent report on mental health by the Surgeon General (2000) found that the majority of clients with severe mental illness do not receive evidence-based treatments. In fact, some psychotherapy with an abundance of research to support their efficacy is not practiced widely in community settings (Goisman et al., 1999). Many researchers and clinicians have warned about the barriers to dissemination efforts (Addis, 2002; Backer et al., 1986; Beutler, et al., 1993). Some of these obstacles include the organizational structure of the adopting agency, negative or suspicious attitudes of administrators and clinicians towards the new treatment, and the labor-intensive training that will be required (Backer et al., 1986). A variety of factors that can affect the amount of time and resources that will be expended in a dissemination effort, include the financial status of the agency, the previous experience of agency staff with adoptions of new treatments, staff turnover rate, and the nature of the intervention that is being disseminated.

20. Disconnection between Psychotherapy Practice and Research: There is a persistent tension in the psychotherapy research literature relating to the perception that therapists do not integrate the findings from psychotherapy research and that researchers fail to study the relevant clinical issue (Stiles, 1992). The research fails to answer basic questions such as: how is a treatment altered when the patient has unusual characteristics? What intervention should the therapist gives if the prescribed treatment is failing? The tension between therapist and researchers has been made all the more strident because of pressures based on both parties to prove cost effectiveness for all psychotherapeutic interventions. Talley et al (1994) has advocated five practices likely to be helpful in creating a rapprochement between researchers and therapists.
    1. Case study should no longer be disparaged, for they have the ability to be scientifically rigorous by testing specific hypothesis.
    2. Wherever possible researchers should endeavor to include clinical vignettes in their published work and emphasize the clinical applicability of specific findings.
    3. Studies must be conducted that determine what type of psychotherapy research is helpful to therapists.
    4. The accessibility of psychotherapy research findings to therapists should be studied with respect to knowledge of new findings as well as understandability.
    5. Training programs must assess students to integrate new research findings, as well as train new generation researchers to ask the clinically significant questions.

METHODOLOGICAL LIMITATIONS OF THE NEUROBIOLOGICAL APPROACH

While neuroimaging procedures can be very useful tools to assess the effect of psychotherapy; they also have a number of limitations:

1. The neuroimaging are much more scientific construct than images of the brain. So it is not all certain that the clinically important phenomena actually correspond to those that show up most colour fully in the images.

2. Neuroimaging gives a static view, i.e., by imaging a single state of mind. It is inadequate to describe the temporal and spatial structure of mental life as a being in the world.

3. A before after paradigm applied in imaging may be helpful for ascertaining effects or constraints on the substrate level, but fails to account for what is really going on during sessions.

EVIDENCE BASED PSYCHOTHERAPY AND INDIA

The evidence-based practice must take into account the individual need and the local circumstances. Hence, the interventions need to be adapted to the community, culture and available resources, as the difference in technology and human resources may limit the applicability of evidence-based principle to different culture and society. But there exist dearth of research on these issues, especially in the developing country like India. Considering our huge burden of illiteracy and poverty, western psychologically oriented psychotherapeutic model would not be much effective here. As compared to western counterpart the Indian patient is more ready to expect and accept dependency relations and less ready to seek intrapsychic explanations. The Indian patient from whatever class he is drawn, more readily alludes to conceptual referrals like Karma, Dharma and traditional figures for orientation and identification than its western counterparts with regard to concepts like conscience, superego or to Greek mythology. Sudarshan Kriya Yoga, a procedure that involves essentially rhythmic hyperventilation at different rates of breathing, has been found to be as effective as imipramine in melancholia (Janakiramaiah et al., 2000) and to decrease blood lactate levels and improve antioxidant status in its practitioners (Sharma et al., 2003). Concerns have been raised about the low visibility of research from developing countries. While (Zielinski, 1995) found that 98% of journals indexed by western services such as Medline are from the developed world, Patel and Sumathipala (2001) reported that 94 % of the articles published in 6 leading psychiatric journals over a 3 year period from Euro- American countries. The advent of Internet has made it possible for authors in developing countries to bypass traditional avenues of scientific publishing, and to post their research directly on their websites. Online journals are easier to publish; the tempo of publishing is accelerated; the articles may contain colored graphs, photographs, PET scans without any additional costs.

FUTURE DIRECTIONS

1. Enhance clinician research collaboration.

2. Study integrated treatments.

3. Design better therapy manuals.

4. Focus on less heterogeneous clinical problems.

5. Identify treatment that can produce harm.

6. Identify moderators of treatment effect.

7. Identify effective ingredients of various therapies.

SUMMARY AND CONCLUSION

• Principles of EBM are being increasingly applied to psychotherapy research.

• Sources of information on evidence-based psychotherapies include RCTs, metanalyses, systematic reviews, and case studies

• Behaviour therapy has been found to be effective in anxiety disorders, like generalized anxiety disorder and phobia as well as in childhood disorders. Both cognitive therapy and cognitive behaviour therapy found to be effective in depression and obsessive – compulsive disorders. Interpersonal therapies are most effective in depression. Group therapy and psychodynamic psychotherapies have been found to be effective in substance use disorders. Family and marital therapies have addressed a wide range of problems ranging from anxiety disorders to schizophrenia. Hypnosis has been found to be effective especially in childhood disorders. Medications are effective but combined treatments i.e. (medication plus psychosocial interventions) often produce the best results. Some psychotherapies are empirically supported, particularly cognitive – behavioural and interpersonal psychotherapies and have equal efficiency vis–a–vis medication in mild to moderate cases of many conditions. other psychosocial treatments (e.g. family education, assertive community treatment and supported employment) promote rehabilitation and recovery in the most impaired individuals.  Psychotherapies have been shown to produce changes in brain function.

• Despite of all the advantages the EBP has in the field of psychotherapeutic practice, it has not been found to be away from its several limitations. Those include the variation among therapist, patient, and difficulty with patients’ diagnosis, comorbidity, and limitations of assessment tool to measure change. The use of RCT and treatment manuals is associated with several methodological limitations. The dissonance between the psychotherapy practice and research, including the difficulties in dissemination and implementation of evidence-based practices, needs consideration.

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