How does it work? CBT vs anti-depressants
November 18, 2014 1:34 PM   Subscribe

Cognitive behavioural therapy is the best-studied form of psychotherapy. But researchers are still struggling to understand why it works (Single Link Nature.com).
People with depression tend to have detectable differences in two primary brain systems: the prefrontal cortex, which is responsible for complex mental tasks such as self-control and planning, and the limbic system — including the amygdala — which is involved in emotional processing. In healthy people, the prefrontal cortex can inhibit amygdala activity, keeping emotions in check. But imaging shows that in many people with depression, the prefrontal cortex seems to be less active. “Depressed people have what you might think of as a trigger-happy amygdala.”
posted by spamandkimchi (37 comments total) 71 users marked this as a favorite
 
...and married people seem to benefit more from cognitive therapy than from medication.

Well that's just weird.
posted by smartyboots at 1:40 PM on November 18, 2014


...and married people seem to benefit more from cognitive therapy than from medication.

Well that's just weird.


Perhaps that's because intimate partners can help reinforce healthier ways of thinking, being privy to their partners problems and the means being used to ameliorate them.
posted by clockzero at 1:46 PM on November 18, 2014 [16 favorites]


I've found the CBT technique of Thought Stopping (choosing an alternate item to focus on and practicing) to be critical to managing the symptoms of depression. The relationship between client and therapist is critical, though; some research has pointed to recovery rates being about even between all therapies; I've been hoping for some more critical analysis of personality type vs. type of therapy. My personal opinion is that different types of people need different types of interventions, that cultures have to be taken into account, and that family and social influences are much larger than we tend to assume - but that's based on a limited sample of clients and me being me. There is sufficient evidence that what therapists do is sometimes different from what we think we do that I can't assume my assessment of therapy-overall is valid.

I know I'm incredibly eclectic because each client is a new world and different tools are needed; I use a lot of CBT but I use it heavily modified to fit a client, using the words they might use or quite simplified down. I also use a lot of questions - which I think triggers the pre-frontal cortex; I've had clients who begin to work with me who can't tolerate a simple question about how they feel who become much more comfortable with questions over time, and then that skill generalizes to other people. I think thought monitoring (mindfulness/etc...) can work similarly, building skills of self-awareness and situation labeling that operate out of the pre-frontal cortex.

I feel like it's important to mention here - by and large we believe this area of the brain is the last to develop, and I think the situations people are raised in have a large effect of when and how. I was raised practicing critical analysis from literally my childhood, and so it comes very naturally to me, but that is not the case for the majority of people I know.

One other thought is that I think we find the "placebo effect" (read: results because the client believes there should be results) folded into therapy and it would be nearly impossible to remove it.
posted by Deoridhe at 1:47 PM on November 18, 2014 [30 favorites]


Okay, I'm sorry but this is the Internet, and when I first read that title I was like "wait CBT, holy fuck, in what way is that comparable that to Prozac?"
posted by trackofalljades at 2:07 PM on November 18, 2014 [23 favorites]


A thought - any thought - is a neurochemical event. What CBT does is give a person strategies for coping with negative thoughts that create negative realities - i.e. cognitive distortions. CBT addresses this reality in ways that few prior therapies had. The most accessible introductions I've yet seen on CBT, for potential users are Feeling Good and Feeling Good Together (CBT for troubled realtionships of all kinds) - both written by David D. Burns, MD, on faculty at Stanford University.

Dr. Burns' books have been translated into more than 20 languages; his books have been prescribed by thousands of therapists, worldwide. the impact of the prociples and activities based on CBT have been so successful that the term "bibliotherapy" has been coined to describe the impact of Burns' application of CBT for depressed patients.

Here are some quotes from Dr. Burns

Last, the cognitive distortions described by CBT (derived from research) aresomething that even healthy people should be aware of. Everyone engages cognitive distortions from time-to-time, even if they are not depressed. Thus, CBT's principles could also help our general - non-depressed - population.
posted by Vibrissae at 2:09 PM on November 18, 2014 [14 favorites]


...and married people seem to benefit more from cognitive therapy than from medication.

>>> Well that's just weird.


Relationships are such a laboratory for acting out all our assumptions, healthy and unhealthy, about ourselves and other people. Shifting some of those unhealthy assumptions can really dramatically improve people's feelings of helplessness or depression.

Plus, relationships tend to like homeostasis, even when things are bad. If one partner starts taking medication and feeling better, it generally throws the whole system out of balance. If there's not some individualized outside support during that upheaval, then the process of the partner getting better can make the relationship worse, reinforcing the depression.
posted by jaguar at 2:09 PM on November 18, 2014 [3 favorites]


Okay, I'm sorry but this is the Internet, and when I first read that title I was like "wait CBT, holy fuck, in what way is that comparable that to Prozac?"

I pay Mistress for an hour of antidepressants each week and she calls me a filth worm as she prescribes them
posted by Greg Nog at 2:11 PM on November 18, 2014 [31 favorites]


Tips to manage the cost of counseling or therapy (if there is a cost):

Private services are available and are covered by some insurance plans. The cost for private counseling or therapy can range from $50 to $240 for a one-hour session.

Wellbutrin: Dosing with WELLBUTRIN XL should begin at 150 mg/day given as a single daily dose in the morning. If the 150-mg initial dose is adequately tolerated, the dose of WELLBUTRIN XL should be increased to the 300-mg/day dose after 1 week. If the 300-mg dose is not adequately tolerated, the dose can be reduced to 150 mg/day. The usual adult target dose for WELLBUTRIN XL is 300 mg/day, given once daily in the morning.

150mg × 60 pills $1.50 $89.95. So a two week supply.

I like the science and nature.com is quite credible but this really isn't affordable to most of the world. And that makes me grumpy.
posted by vapidave at 2:11 PM on November 18, 2014


I wonder if it works well for relationships because some of the toxic thoughts get said out loud, which makes them much easier to spot. When they're just inside your head, they can slip past quickly and be hard to catch and think through.
posted by clawsoon at 2:19 PM on November 18, 2014 [5 favorites]


Okay, I'm sorry but this is the Internet, and when I first read that title I was like "wait CBT, holy fuck, in what way is that comparable that to Prozac?"

I've had that reaction, in both directions. "Oh that's cool, this porn site is offering help to users who suffer from depression..."
posted by ThatFuzzyBastard at 2:33 PM on November 18, 2014 [3 favorites]


“Depressed people have what you might think of as a trigger-happy amygdala.”

I was at a workshop the other day and the trainer told us about a client of his who had severe anger issues as a result of trauma. He described it to the client as it being "irritable" rather than "trigger-happy". The client was pleased to have a concrete reason for what was going on with him, and told him next session that he had announced to his family: "You're not to be giving me a hard time. I have an irritable amygdala."
posted by billiebee at 2:54 PM on November 18, 2014 [13 favorites]


Incidentally, CBT has a lot in common with Buddhist mindfulness meditation (though arguably with different aims and theory behind it).
posted by saulgoodman at 3:02 PM on November 18, 2014 [12 favorites]


Yes, and mindfulness meditation has the added benefit of being free.
posted by haricotvert at 3:35 PM on November 18, 2014 [4 favorites]


You can get CBT for free on the NHS in the UK

jus sayin
posted by memebake at 3:37 PM on November 18, 2014 [4 favorites]


vapidave: 150mg × 60 pills $1.50 $89.95 .... this really isn't affordable to most of the world.

In "most of the world," medicines often cost less than in America, because those governments understand that negotiating prices down is their job.
posted by Harvey Kilobit at 3:38 PM on November 18, 2014 [9 favorites]


This book on the stoic philosophy underlying CBT is really a fascinating read.
posted by mmmbacon at 3:44 PM on November 18, 2014 [8 favorites]


CBT is really kind of like having lessons in thinking--or maybe it's more like feeling. Most people happen to be naturally fairly good at having feelings. If you don't have a brain that's naturally pretty good at feelings, then it's going to take you more practice to be competent at feeling. Private lessons are very, very useful for this. Having people to help you is useful. Practice on your own, in a pinch, still helps more than not doing anything at all. I'd still rather work with a professional, but I'm not going to stop working on it because that's not feasible at the moment.
posted by Sequence at 3:45 PM on November 18, 2014 [4 favorites]


If differences in brain chemistry can change the way you think, it should be no surprise that changes in the way you think can effect your brain chemistry.
posted by straight at 4:06 PM on November 18, 2014 [6 favorites]


This dude Epictetus figured a lot of this stuff out in around 70 A.D.
posted by johngoren at 4:10 PM on November 18, 2014 [6 favorites]


...and married people seem to benefit more from cognitive therapy than from medication.

Well that's just weird.


I'm guessing that those might be married people who are also in therapy. In that case it might also be a case of breaking out of the loops and negative feedback that people can get stuck in.
posted by carter at 4:34 PM on November 18, 2014


I LOOKED UP THE OTHER MEANING OF CBT AND NOW I CANT NOT READ IT ANY OTHER WAY PLEASE HEP ME
posted by Joe in Australia at 5:04 PM on November 18, 2014 [16 favorites]


The more I think about it, the more I wonder if for married people, the medication side effects might be more inclined to cause relationship/self-esteem problems that would offset their emotional benefits.
posted by Sequence at 5:23 PM on November 18, 2014


How well does psychodynamics compare with CBT?
posted by Apocryphon at 6:15 PM on November 18, 2014


How well does psychodynamics compare with CBT?

Studies overall seem to show not much difference between therapy types ("modalities" is the fancy word). One of the reasons so many studies show the effectiveness of CBT is that it's a modality that can be very regimented, so it's easier to set up studies because the therapists in the trial can really be doing very close to the same thing with each and every client, which is not often as easy with other modalities.

So one of the reasons there are so many studies about CBT is that CBT is generally easy to study.
posted by jaguar at 6:37 PM on November 18, 2014 [6 favorites]


Telling my therapist what CBT stands for online got my biggest laugh out of him yet. (CBT never worked for me however and isn't the be all and end all of therapy if you are reading this and feeling hopeless at it not fitting you.)
posted by kanata at 6:39 PM on November 18, 2014 [5 favorites]


Wait, the other meaning of CBT isn't "Computer-Based Training"?

...checks Wikipedia...

Oh..........I see.
posted by McCoy Pauley at 8:03 PM on November 18, 2014 [5 favorites]


I'm purposefully not going to find out what the other meaning of CBT could be. Happy world. Safe space.

More on topic, I once read something arguing that there are something like nine different clinical symptoms which you only need need to present four of to be diagnosed with depression. In other words, depression is a huge catchall category so it makes sense that somebody presenting some symptoms may profit better from different treatment. This doesn't even touch the misdiagnosis, or partial diagnosis. Yes, this patient is depressed, but that's got more causes in their undiagnosed chronic fatigue syndrome, provide ways for managing that condition and you'll do more for them.

From personal experiences with my friends who have been depressed their whole lives, compared to those who move in and out. It's not a simple topic. For people who can't take med and for who find no relief in CBT the world is a very hard place.
posted by Braeburn at 1:02 AM on November 19, 2014 [1 favorite]


you were warned
posted by thelonius at 2:55 AM on November 19, 2014


You can get CBT for free on the NHS in the UK

True, and I love the NHS. However, getting a referral for CBT (or any kind of psychotherapy) is a long process for Brits, particularly those suffering from conditions that don't include psychosis as a symptom. Also, unless the therapist makes a case for urgent, continued care, typically you will only receive six sessions, and you rarely have a say or a choice with regards to which therapist or approach you'd like to try (unless you're willing to wait, or to go private).

I'm not saying this to bash the NHS at all; the NHS is the single greatest thing about the UK. I'm saying that we have a long way to go in terms of advocacy and lobbying for better mental health provision on the NHS. Thankfully, as of next year waiting times for mental health referrals will finally be brought in line with physical health referrals.
posted by dumdidumdum at 3:02 AM on November 19, 2014 [5 favorites]


I've found the CBT technique of Thought Stopping (choosing an alternate item to focus on and practicing) to be critical to managing the symptoms of depression.

So wait. "Think about something else and snap out of it" actually does work?
posted by DU at 3:43 AM on November 19, 2014


CBT vs anti-depressants

How about CBT + anti-depressants?
posted by Thorzdad at 4:57 AM on November 19, 2014 [4 favorites]


A few years ago I stepped on the train and had a panic/anxiety attack. Out of nowhere, nothing to trigger it. I had NO idea what it was - just that it was the most terrifying fight-or-flight horror I'd ever experienced. I thought I was going to pass out or have a fit. I worked out it was a panic attack, and started to live in fear I'd have another one. So of course I did, and a terrible feedback loop started. I was having trouble on the train or bus, in crowds, I couldn't even go to a concert. Flights were the worst. I had never had any problem with any of these scenarios in the past and suddenly I could barely handle them.

So a few months of that and I decided to try CBT, having never done therapy before. I figured I'd give it a go before I tried meds. It made all the difference in the world, teaching me to accept the panic if it hit and how to disrupt the harmful mental-loop I was in. And it gave me tools for when it did hit, how to bring myself back down.

It's been about three years since I finished up CBT. I have not had a panic attack in that time. I still get a bit edgy in certain scenarios, but CBT pretty much saved me.
posted by Windigo at 7:16 AM on November 19, 2014 [7 favorites]


I see patients with tinnitus that ranges from mildly annoying to debilitating. For those with severe, incurable tinnitus, CBT can work wonders and it is a recommended treatment in the American Academy of Otolaryngologists' official tinnitus guidelines.
posted by robstercraw at 9:54 AM on November 19, 2014 [3 favorites]


robstercraw: For those with severe, incurable tinnitus, CBT can work wonders

Huh. How does that work?
posted by clawsoon at 10:12 AM on November 19, 2014 [1 favorite]


How about CBT + anti-depressants?

There are at least two good studies showing that the two together are more likely to be effective than either one alone.
posted by straight at 11:30 AM on November 19, 2014 [3 favorites]


MoodGYM - a free website at the Australian National University that helps you to learn CBT skills.
posted by obiwanwasabi at 8:53 PM on November 19, 2014 [3 favorites]


How well does psychodynamics compare with CBT?

In my experience, CBT works well when you have a relatively straightforward problem and many opportunities for practice. I had a case with someone where one issue was never looking IN things for wanted items, so the items ended up all being set out in sight. We did a simple CBT practice of putting one often-looked-for thing in a drawer and practiced looking for it; did the trick pretty quickly. It's also good for intrusive thoughts and building cognitive skills. The biggest behavioral trick I keep is a focus on positive reinforcement for desired behavior - people underestimate the power "I like it when you do that" can have.

Psychodynamics varies a lot by situation and type of dynamics. Family dynamics can be critical when dealing with people who have complicated or abusive family histories and situations. Dream analysis is a good way of getting into complicated things using a pictorial language one's own brain produces. Discussions of id/ego/super-ego can be useful for people struggling with a lot of internal conflict about what they should or shouldn't do, and can come in handy when dealing with self-hatred. So can discussion of the shadow. When peoples' problems are more socially based, I tend to bring in discussions of the persona and different personas and how to make them and when to set them aside. Gendered issues can be addressed more easily through an analysis of anima/animus experiences - taking gender out of a human form and abstracting it for ease of study. Etc... etc... Unfortunately, studying this kind of thing in an experimental sense is the opposite of easy.
posted by Deoridhe at 7:19 PM on November 20, 2014 [3 favorites]


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