Dedicated to the Amazing Houdini
American stunt performer (March 24, 1874 – October 31, 1926)
The start of Chapter 3 of the famous book Feeling Good by David D. Burns1 on cognitive behavioral therapy (CBT) hit me, “Depression is not an emotional disorder at all! Every bad feeling you have is the result of your negative thinking.” In this paper, I intend to give this conclusion some good natured trouble.
CBT has become rooted as a proven dogma in the treatment of depression in spite of large problems remaining in the methods of CBT clinical trials and the logic of how CBT works. In this paper, I would like to discuss 4 major problems. (“Depression” in this article is defined as DSM-IV major depressive disorder [MDD]2).
1. The premise of CBT that negative cognitions are the cause of MDD is the only instance in all of medicine and psychiatry where a symptom of an illness is also construed to be the cause.
The diagnosis of MDD includes negative cognitions as a symptom (ie, feeling worthless or excessive or inappropriate guilt2), and it is known both in clinical practice and in research, that negative cognitions may resolve either with antidepressant medications or with cycling out of the depression.3
Negative cognitions as a symptom can also make depression worse, however, asthmatic coughing as a symptom of asthma may also make asthma worse. If we make a therapy that helps to decrease coughing in asthma, we might conclude the therapy was efficacious in asthma. Is that really true? It depends on whether you state that therapy helped asthmatics to feel and function better (true) versus if you state that the therapy is the fundamental treatment of asthma (false).
2. The statement that CBT clinical trials are “randomized and controlled” obfuscates that the studies are not double-blind (ie , neither subjects nor therapists in psychotherapy studies are blind to the type of treatment).
No CBT study (no psychotherapy study) can be a double-blind study. They may be single-blinded, the rater may not know the treatment the patient received, but neither the patients, nor the therapists, can be blinded to the type of therapy given (two out of three of the persons involved in the trial, ie, all of the persons involved in the treatment, are unblinded). Moreover, the patient must be an active participant in correcting negative distorted thoughts, so they are quite aware of the treatment group they are in.
While a drug study can use a double-blinded placebo control, psychotherapy arms that are called controls are not a blind-placebo, the therapist is also likely a believer in the therapy approach and may transmit this hope to the patient in some way, and large uncontrolled bias is the result in these studies.
In addition, MDD studies are known to have large random error because subjects with a variety of mildly low mood are included, investigator and patient preference, non-perfect rating instruments, etc. Bias can then lead to a result very far from the true value, Figure 1.4 A study on bias in treatment outcome studies concluded that the results of unblinded randomized clinical trials (RCTs) tended to be biased toward beneficial effects if the RCTs' outcomes were subjective (as they are in psychotherapy studies) as opposed to objective.5
A recent meta-analysis examined the effectiveness of CBT when placebo control and blindedness were factored in.6 Pooled data from published trials of CBT in schizophrenia, MDD, and bipolar disorder that used controls for non-specific effects of intervention were analyzed. This study concluded that (1) CBT is no better than non-specific control interventions in the treatment of schizophrenia and does not reduce relapse rates; (2) CBT is not an effective treatment strategy for prevention of relapse in bipolar disorder; (3) CBT treatment effects are small in treatment studies of MDD. For MDD, the authors note that the pooled effect size was very low at 0.28 (Hamilton Depression Scale) and 0.27 (Beck Depression Inventory). Remember, these studies are still not double blind making the findings of even small efficacy questionable.
Dr Berger is in private practice in Japan and consults on clinical trials with pharmaceutical companies. He reports this article received no support or grants, and that he has no conflicts of interest concerning the subject matter of this article. His website is at www.japanpsychiatrist.com.
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