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is President of the Beck Institute for Cognitive Behavior Therapy in Philadelphia and is a Clinical Professor of Psychology and Psychiatry at the University of Pennsylvania. 

Judith Beck, PhD, talks Cognitive Behavior Therapy, clinical tips, and the work of her father, Dr Aaron Beck. 

Applying CBT to Psychiatry 

New research highlights the potential benefits and detriments of treatment strategies for ADHD, which include both pharmacological and nonpharmacological options (

Stimulants are the first line of treatment for ADHD and are typically well tolerated. Although there are potential adverse effects associated with stimulant administration, the most common are usually transient or dose related. One of the more serious effects is stimulant-induced psychosis.

To explore this risk, Moran and colleagues

 examined the records of 337,919 young persons aged 13 to 25 who had an ADHD diagnosis and were newly prescribed a stimulant medication. The researchers found 343 episodes of new-onset psychosis among the 221,846 study-matched population over an 11-year period. The median time from which the first stimulant was dispensed to the psychotic episode was 128 days.

The researchers concluded that the risk of new-onset psychosis was approximately doubled for individuals who received amphetamine compared with those who received methylphenidate. This supported their hypothesis, which was based on the similarities between idiopathic psychosis and the biologic effects of amphetamine. Individuals with primary psychosis have higher presynaptic dopaminergic capacity, which is an index of dopamine release.

Limitations of the study included: unmeasured confounding factors (ie, underreporting of substance use disorder), not knowing if the patients actually took the stimulant medication (there is a high rate of diversion, which is greater for amphetamine than methylphenidate), and the study findings, are not generalizable as the data were only from commercial insurance claims and did not take into account patients with no insurance or public insurance.

While the exact therapeutic mechanism of action of stimulants is unknown, they are thought to increase the availability of dopamine in the postsynaptic cleft by blocking the reuptake of dopamine. Amphetamine blocks the ability of the dopamine transporter to remove dopamine from the synapse, facilitates the reuptake of dopamine across the cell membrane, increases the release of vesicular dopamine (accumulates in the cytoplasm), and inhibits the degradative enzymes monoamine oxidase A and B. Methylphenidate binds to the dopamine transporter in the presynaptic cell membrane, blocking the reuptake of dopamine and, therefore, causing an increase in extracellular dopamine. The difference is that methylphenidate does not promote dopamine release from synaptic vesicles. Moreover, amphetamine induces the release of four times as much dopamine as methylphenidate.

 This increase of dopamine may contribute to adverse effects such as stimulant-induced psychosis.

Cases of stimulant-induced psychosis have been reported as early as 1938.

 However, the first case of a child who experienced auditory, tactile, visual hallucinations, and paranoia after treatment with a therapeutic dose of D-amphetamine for hyperactivity was not published until 1967.

 The 8-year-old child’s symptoms of psychosis resolved after the medication was discontinued. A few years later, similar cases were reported by Lucas and Weiss

 after they observed “psychotic reactions” in two children following a short-term therapeutic dose and in an adolescent after ingestion of excess medication after long-term use of a therapeutic dose of methylphenidate, which had been prescribed for hyperactivity.

It was not until 2007 that the FDA mandated a drug label warning that stimulants may cause psychosis in patients with no prior history. There remains limited data on whether the risk of psychosis differs among the two classes of stimulants.

While the incidence of new-onset psychosis with stimulant treatment for ADHD is small, this can be a frightening experience for the child as well as his or her parent and may negatively impact a parent’s decision to pursue stimulant treatment options. Thus, nonstimulant and non-pharmacological treatment options are often requested. Indeed, many parents continue to search for 

, especially for children with a newly established diagnosis.

 Until recently, there have been no viable nonpharmacological alternatives.

Trigeminal nerve stimulation may offer a nonpharmacological option

With concerns over potential adverse effects of medications, other strategies have been explored for treating ADHD. Preliminary studies using trigeminal nerve stimulation (TNS) to treat ADHD symptoms have peaked interest as a potential alternative or adjunctive treatment to stimulant and non-stimulant medications. TNS is a non-invasive, home administered, well-tolerated approach that has 

 Researchers became interested in TNS for ADHD after observing improvements in concentration and attention on mood disorder rating scales.

The stimulation device is compact and worn on clothing during sleep. Thin wires from the stimulator are attached to adhesive electrode pads that are placed on the forehead bilaterally over the ophthalmic branch (V1) of the trigeminal nerve. A current is sent through the wires to activate the trigeminal nerve, which projects to the nucleus tractus solitarius activating the locus coeruleus and the reticular formation. These play a key component in cognitive functions, particularly in sustaining attention.

The recent double-blind sham control study by 

 looked at cortical activation mechanisms using a quantitative electroencephalogram. The researchers found increased spectral power in the right frontal and frontal midline bands with active TNS, hypothesizing that activation of the frontobasal ganglia network targets hyperactivity and impulsivity. This mechanism of action helps to support the overall findings for improvement in both the inattention and hyperactivity components of ADHD.

During trials, the pattern of improvement on ADHD Rating Scale-IV (ADHD-RS) as well as on the Connor’s rating scale was comparable to that seen with non-stimulant medication.

 In this double-blind sham-controlled study by McGough and colleagues, symptomatic improvement was found to be highest after the first week of treatment; scores continued to improve over the next 3 weeks. While the sham group showed improvement over the first week, it was followed by a flattening response. One week after treatment discontinuation, rating scales were again administered in both the active and the sham groups. In both groups, scores from the ADHD-RS were found to decrease, indicating a recurrence of symptoms. This 4-week trial showed sustained improvement in both hyperactivity and inattention symptoms of ADHD with nightly active treatment.

Unfortunately, there are no long-term studies of mood or ADHD with TNS. Continued trials need to be undertaken to determine long-term outcomes as well as clear parameters for treatment.

The cost of the device used in the study, Monarch-TNS, is just over $1000; it is not currently covered by insurance. Other available TNS devices range between $250 and $450; their efficacy, however, is unknown. It is difficult to compare the cost of TNS versus stimulant and non-stimulant medications, since there is such a wide range in cost. The monthly cost ranges from approximately $8 for a generic stimulant and may exceed $288 for a branded product. Most insurance companies will cover at least some medication costs.

TNS has been well tolerated with high safety and compliance rates. A long-term follow-up study for TNS use in epilepsy demonstrated skin irritation as the main adverse effect from treatment.

 of short-term TNS include headache and eye twitches.

 Based on the 4-week double-blind sham study, the manufacturer of the Monarch-TNS treatment device also noted drowsiness, increased appetite, trouble sleeping, and fatigue as possible side effects. No withdrawal effects have been observed.

 suggest that TNS may be effective for ADHD as an alternative treatment to stimulant and non-stimulant medications given symptomatic improvement in both inattention and hyperactivity symptoms of ADHD. Although direct comparison of TNS to pharmacological treatment has not been undertaken, treatment may be considered in children with parental preference against pharmacological treatment after providing psychoeducation or in children who cannot tolerate psychotropic medications. TNS as an adjunctive therapy may also be considered; however, adjunctive use has not been studied.

Currently, several limitations remain a concern. First, clear parameters (eg, duration of treatment, number of treatments, the need for booster sessions) have not yet been identified. Second, there are no long-term studies for mood symptoms or ADHD, which limits the available data on long-term efficacy for TNS as a treatment. Third, the device itself is available but will come at a high out-of-pocket cost, thereby restricting treatment access.

Based on these limited data, TNS appears to be an effective, safe, well-tolerated option with high compliance rates. Although more studies are needed, this treatment has high potential for use in managing the symptoms associated with ADHD.

Dr Griffin is Assistant Professor of Psychiatry, the Medical Director of Outpatient Child and Adolescent Psychiatry, and the Director of the Child and Adolescent ADHD Clinic at Rush University Medical Center, Chicago, IL. Dr Harari is a first-year Child and Adolescent Psychiatry Fellow at Rush University Medical Center. The authors report no conflicts of interest concerning the subject matter of this article.

 Moran LV, Ongur D, Hsu J, et al. Psychosis with methylphenidate or amphetamine in patients with ADHD. 

 Schiffer WK, Volkow ND, Fowler JS, et al. Therapeutic doses of amphetamine or methylphenidate differentially increase synaptic and extracellular dopamine. 

 Young D, Scoville WB. Paranoid psychosis in narcolepsy and the possible danger of Benzedrine. 

 Ney PG. Psychosis in a child, associated with amphetamine administration. 

 Lucas AR, Weiss M. Methylphenidate hallucinosis. JAMA. 1971;217:1079-1081.

 dosReis S, Park A, Ng X, et al. Caregiver treatment preferences for children with a new versus existing attention-deficit/hyperactivity. 

 Barbaresi WJ, Colligan RC, Weaver AL, et al. Mortality, ADHD, and psychosocial adversity in adults with childhood ADHD: a prospective study. 

 Danielson ML, Bitsko RH, Ghandour RM et al. Prevalence of parent-reported ADHD diagnosis and associated treatment among U.S. children and adolescents. 

 McGough JJ, Sturm A, Cowen J, et al. Double-blind, sham-controlled, pilot study of trigeminal nerve stimulation for attention-deficit/hyperactivity disorder. 

 McGough JJ, Loo SK, Sturm A et al. An eight-week, open-trial, pilot feasibility study of trigeminal nerve stimulation in youth with attention-deficit/hyperactivity disorder. 

New research highlights the potential benefits and detriments of treatment strategies for ADHD, including both pharmacological and nonpharmacological options.

Research Sheds Light on Two Types of Treatment for ADHD

In the past 30 years, a considerable body of research has been amassed regarding the use of psychotherapy to manage suicidal behavior. Much of this research included the premise that suicidal behavior must be dealt with as a problem separate from a primary diagnosis (eg, depression) and that techniques must be used to both manage the risk in the present and prevent recurrences in the future. Most clinicians are not aware that suicide risk should be addressed specifically and separately from the primary psychiatric diagnosis. Practical, evidence-based approaches have been developed that decrease the risk of present and future attempts. We aim to provide a brief synopsis of the research evidence, followed by several examples of strategies that such treatment employs.

Several systematic reviews have analyzed existing data on the effect of therapeutic interventions to reduce suicide risk. In 2008, Tarrier et al

 examined 28 randomized controlled trials (RCTs) involving adults and adolescents. The researchers concluded that cognitive behavioral therapy (CBT)-based interventions demonstrated effectiveness in reducing suicidal behavior. A subsequent systematic review by Mewton and Andrews

in 2016 limited its focus to RCTs examining the benefits of standard CBT in adults. Their conclusion agreed with the observation of Tarrier et al

: Treatment is more effective when directly targeting suicidal thoughts and behavior as opposed to when treatment is designed to address mental illness with the assumption that benefits will also impact suicidal behavior. Hence, the literature underscores the need for specific interventions targeting suicidal behavior.

The meta-analysis by Ougrin and colleagues

 in 2015 supported the effectiveness of therapeutic interventions including CBT, dialectical behavior therapy (DBT), and mentalization-based therapy in reducing self-harm in adolescents. The dearth of independently replicated studies impeded drawing firm conclusions on the comparative benefit of specific therapeutic strategies. Independent trials have looked at the effectiveness of DBT in adolescents who are at high risk for suicide. The RCT by Mehlum et al

 in 2014 and the recently published RCT by McCauley and colleagues

 suggest definite benefits of short-term DBT in adolescents with borderline personality traits who had engaged in prior self-harm and suicide attempts. The latter study also showed superiority of DBT with respect to treatment retention.

Engagement and retention of patients is a significant challenge in managing suicidal behavior. Often, such patients do not seek outpatient therapy and present for emergency care with suicidal crises. The emergency department (ED) must therefore be a key site for intervention. The Emergency Department Safety Assessment and Follow-up Evaluation (ED-SAFE) study by Miller and colleagues

 designed interventions for screening and provision of safety plans with follow-up phone calls to patients and significant others. Stanley et al

 discussed the benefits of such ED-based interventions in reducing suicidal risk. Their comparative cohort study showed that safety-planning interventions coupled with structured follow-up reduced the risk of suicidal behavior by 50% and achieved a twofold increase in the odds of treatment engagement over a 6-month period. The safety-planning intervention consisted of six specific strategies: identifying early warning signs, encouraging internal coping strategies, reaching out to family/friends, identifying other individuals who can provide support during suicidal crises, contacting mental health professionals, and lethal means planning. This large-scale study illustrates a feasible, pragmatic approach to suicidal behavior that does not demand extensive resources and can be easily delivered in an ED setting.

Cognitive behavioral therapy for suicide prevention is another short-term intervention designed to specifically address suicidal behavior that has significant effects in reducing future suicide attempts.

 It is composed of three phases: an initial phase promoting treatment engagement, an intermediate phase focused on cognitive and behavioral strategies targeting suicidal thoughts and mobilizing reasons to live, and a final phase that targets relapse prevention and consolidates the ability to effectively use strategies in the setting of future suicidal crises.

Each of the preceding studies have common psychotherapeutic strategies that may be employed by any clinician. All are rooted in the fundamental principle of the therapist as an empathic partner who forms a strong therapeutic alliance with patients and who acknowledges their suicidal thoughts and behaviors as a response to intolerable pain or acute subjective distress. The patient is enlisted as an active partner in the process of understanding personal risks for future suicide crises and developing remedies for such occurrences.

The following section describes four specific strategies common to these approaches, including lethal means reduction, safety planning, developing reasons for hope, and inspiring delay.

Lethal means reduction is the process of assessing whether patients have access to firearms or other lethal means to commit suicide and then working with them and their support network to restrict access to such means. It is one of the most important and most supported interventions to reduce suicide attempts. Collaborating with the patient by expressing genuine concern about his or her safety, explaining that reducing access will lower the risk of suicidal actions, and then negotiating with the patient and supportive others to make the environment safer is critical for success. In the event that the lethal means available is a firearm, one must assess for multiple firearms and then advocate for removal of all of them. Gunlocks, removal of ammunition, or gun safes are also possible ways to restrict access if the patient refuses to remove the gun(s) from the home.

Methodical inquiry about possible methods and what might limit the ability of the patient/family to remove them is the central task for the clinician. If the patient is hesitant, it helps to assess the pros and cons of restricted access, reminding the patient that this may be time-limited. As in all work with suicidal patients, the more collaboration that is possible with supportive others, the better.

Generally, suicidal behavior occurs as a reflexive response to certain triggers. It is common for patients who engage in such behavior to regard suicide as a means of solving problems that they view as insolvable. Such patients often have significant problem-solving deficits. When patients have no relief from relentless worry or concern about problems, and they think of suicide, the relief it may provide reinforces suicidal thinking and increases the risk for further action. Skill deficiencies that patients have-in problem solving, distress tolerance, emotion regulation, and conflict resolution-may increase their risk for future vulnerability to suicidal behavior.

A particularly good strategy is to plan alternatives that keep the patient safe until skills can be learned or other solutions put into place. Safety planning, as described by Stanley and colleagues,

 is an intervention with which the clinician actively and collaboratively determines with the patient a prioritized and personalized list of warning signs that a crisis is beginning to occur. The clinician then finds coping strategies and internal and external resources that the patient can use at this time. This plan is derived from a risk assessment and the narrative description of the patient’s crisis. It is designed to be over practiced (like a fire drill) so that the plan will be available for use during a suicide emergency. Making a safety plan begins with a chain analysis of the minute-by-minute thoughts, emotions, and behaviors that led to suicidal thoughts or an attempt and the subsequent consequences. The patient must understand that suicidal thoughts are transient and vary in intensity.

The plan provides time for these urges to decrease before permanent harm occurs. The patient is consulted as the expert on his or her own suicidal behavior: “What have you done on your own to decrease suicide urges?” and “How do you get your mind off of it?” If the patient cannot generate options, the clinician may provide suggestions. These may include distracting activities, alternative thoughts, or strategies to decrease painful emotions. After formulating a plan for distractions, the patient is asked to identify two groups of social contacts: a group with whom she or he may be distracted from the suicidal thoughts, and a group that can help with suicidal thoughts. Finally, emergency services are identified that the patient can access if a crisis is imminent.

At each step of the safety planning intervention, the patient is asked about the likelihood of using the intervention, the obstacles he or she anticipates to its use, and those obstacles solved. If the patient cannot solve obstacles or commit to the use of the plan, then more restrictive care is indicated. Once the plan is completed, the written plan is given to the patient and the patient is asked where it will be kept for review and use.

In later sessions, the therapist may provide training in skills that are absent and that increase the patient’s vulnerability to suicide and then mentally rehearse the deployment of those skills in a similar setting in the future. Patients must repeatedly practice new ways of thinking and behavior so that they have other solutions besides suicide available at times of future stress. Patients who develop better ways of coping in a crisis and repeatedly practice such skills (even in their imagination) have greater resilience during stressful circumstances and reduce their reliance on suicide as a solution.

A 45-year-old construction worker sustained a crush injury of his right arm 2 years ago. He has had four surgical procedures and extensive physical therapy, but has continued to experience intractable pain and has been unable to return to work. His family has struggled to make ends meet. He has used opiate pain medication since the accident but never exceeds what is recommended. He needs help with all of his activities of daily living, including dressing.

After his last surgery, he has been more despondent. He meets the full criteria for major depression. He has started to drink to fall asleep at night. His wife brought him to the ED after he told her that he thought she and the family would be better off without him.

After assessing him in the ED, the psychiatrist determines that there are no weapons in the home. The patient indicates that he had plans to overdose on his oxycodone when he got his monthly prescription this week. He and his wife agree that she will keep the pills locked at her place of work and give him access to only a day at a time. The psychiatrist then turns her attention to making a safety plan with her husband. They first discuss all the triggers that produce his intense thoughts of suicide. The patient is asked what would prevent him from using the plan. He says that if he were unable to contact a friend or his wife, he might have trouble. They review professional help that he can contact. He discusses his feeling that this makes him “weak” but eventually commits to doing so.

When asked for reasons to stay alive, the patient says, “My children.” The psychiatrist asks for more detail: “What is important to your children that you do together? What do you value about being with your children? What would you miss in your children’s lives if you died today?” As he describes more about their relationship, he becomes tearful, and the psychiatrist probes further about what he might miss in the future with his children were he to die. He is much more certain about using the safety plan reliably after this discussion.

Most CBT/DBT interventions approach suicidal patients with an eye toward managing hopelessness. A cornerstone of DBT is the idea that the patient must build a life worth living, even when the patient has many life problems and a wish to die. In CBT, a core premise is monitoring and managing hopelessness, because the presence of hopelessness is a significant risk factor for suicide even in the absence of depression.

Methods that improve hopelessness generally connect patients to core values and attachments to inspire the patient to tolerate current pain and stay alive. Making a list of reasons to live generally is a part of the safety plan. The psychiatrist must ask the patient to describe vividly the attachment the patient has to these reasons to strengthen resolve.

Another technique is to build a hope box. This is a tangible collection of items that remind the patient of reasons to stay alive. It may include photographs, inspirational scripture or quotes, poetry, letters, meaningful mementos, and reminders of things that the patient wants to do in the future. These items inspire more emotional connections to the commitment to stay alive. Such items can be actual or virtual (ie, in a phone app) so that the patient has easy access.

Generally, the impulse to suicide is momentary. If the patient can delay action on the impulse, it may be life-saving. Several strategies facilitate delay. First, the patient can be asked to reflect on the things that will be missed if they die, year by year. This brings to light the finality of death and the reality of what the patient will miss. Second, the patient can be asked to commit to “taking suicide off the table.” Many patients who are suicidal are beset with a significant number of psychosocial problems and experience relief when they think about dying as an escape. The patient needs time to begin to resolve these problems. Working with such patients is a challenge because it is impossible to discuss anything except suicide if that is a genuine possibility. Thus, it is often necessary to agree that the patient will commit to a delay to determine if things can improve enough to allow work on psychosocial problems to occur.

These are just a few examples of how it is possible to use psychotherapeutic interventions to more effectively manage the patient with suicidal thinking and behavior. Although these patients are challenging, there are some tools that we know make a difference.

Dr Sudak is Professor and Vice Chair for Education, Drexel University, Philadelphia, PA, and Dr Rajalakshmi is a Resident, Department of Psychiatry, Drexel University, Philadelphia, PA. 

The authors report no conflicts of interest concerning the subject matter of this article.

 Tarrier N, Taylor K, Gooding P. Cognitive-behavioral interventions to reduce suicide behavior: a systematic review and meta-analysis. 

 Mewton L, Andrews G. Cognitive behavioral therapy for suicidal behaviors: improving patient outcomes. 

 Ougrin D, Tranah T, Stahl D, et al. Therapeutic interventions for suicide attempts and self-harm in adolescents: systematic review and meta-analysis. 

 Mehlum L, TÃ¸rmoen AJ, Ramberg M, et al. Dialectical behavior therapy for adolescents with repeated suicidal and self-harming behavior: a randomized trial. 

 McCauley E, Berk MS, Asarnow JR, et al. Efficacy of dialectical behavior therapy for adolescents at high risk for suicide: a randomized clinical trial. 

 Miller IW, Camargo CA Jr, Arias SA, et al; ED-SAFE Investigators. Suicide prevention in an emergency department population: the ED-SAFE study. 

 Stanley B, Brown GK, Brenner LA, et al. Comparison of the safety planning intervention with follow-up vs usual care of suicidal patients treated in the emergency department. 

Cognitive Therapy for Suicidal Patients: Scientific and Clinical Applications

This article provides a brief synopsis of the research regarding the use of psychotherapy to manage suicidal behavior, followed by several examples of strategies that such treatment employs.

Reducing Suicide Risk: The Role of Psychotherapy

Although it is still widely believed that the management of chronic pain usually requires medications or physical interventions such as injections or surgery, a growing body of research has demonstrated the efficacy of psychological therapeutic modalities, most notably cognitive-behavioral therapy.

FOR ANSWERS TO THIS 10-QUESTION QUIZ, PLEASE SEE THE LAST PAGE.

 Cognitive-behavioral therapy (CBT) has only been found to be effective for chronic pain when there is a comorbid mental disorder also present.



There is no evidence that a comorbid mental disorder must also be present for CBT to be effective for the management of chronic pain. However, in patients with chronic pain and comorbid depression, CBT can be beneficial for both.

Although CBT appears to be a promising treatment for chronic pain, as of yet there is insufficient evidence to recommend its use for this.



In its report released in 2018, the task force on pain of the Academic Consortium for Integrative Medicine and Health, an organization of 72 North American academic medicine centers and health systems, found that there is sufficient evidence to recommend the use CBT for chronic pain and to accept it as a valid treatment.

 A recent review of the literature on management of low back pain reported that CBT should be considered a first-line treatment for chronic low back pain (pain lasting for more than 12 weeks).



A comprehensive review of the treatments for low back pain reported that there is sufficient evidence to recommend that CBT be considered as a first-line treatment for chronic low back pain.

When managing chronic low back pain, the recommendation is to:



The comprehensive review recommended that CBT should be considered a first-line treatment for chronic low back pain, NSAIDs should be considered a secondline treatment; that opioids should be considered only for limited use for a select group of patients; and stated that there was insufficient evidence to recommend the use of skeletal muscle relaxants. The only other first-line treatment for persistent low back pain recommended by the review is exercise.

The benefits of CBT for chronic low back pain appear to last for at most a few months.



Studies have found that the benefits of CBT for chronic low back pain are still present at one- and two-year follow ups.

In addition to providing reduction in pain among patients with chronic low back pain, CBT also appears to improve function.



This is an important point as the efficacy of treatments for chronic pain is generally evaluated both on reduction in the level of pain and improvement in function.

 CBT for chronic pain has been studied only in and found to be effective only for certain socioeconomic groups.



CBT appears to be effective as a treatment for chronic pain among all socioeconomic groups and education levels.

To be effective for chronic low back pain, CBT must be provided on an individual basis.



In fact, most of the studies that supported the use of CBT for chronic low back pain employed group therapy.

 Research indicates that for patients with chronic pain who are misusing opioid analgesics CBT may be:


Answer: C. Effective for managing both problems


Although there is only limited research on the efficacy of CBT for patients who have chronic pain and are misusing opioids, findings so far indicate that it may be efficacious for the management of both problems.

Reflecting concerns about the overprescription of opioid analgesics for the management of low back pain, most insurance carriers are not only increasing utilization management of these medications in order to reduce their use but are also promoting the use of non-opioids and non-pharmacologic therapies such as CBT.



Although many insurance carriers including Medicaid, Medicare Advantage, and commercial insurers have instituted policies to try to reduce the amount of opioid analgesics prescribed, there is little evidence that they have done much to promote the use of other treatments including CBT.

 Institute for Clinical and Economic Review (ICER). Cognitive and Mind-Body Therapies for Chronic Low Back and Neck Pain: Effectiveness and Value. 2017. 

https://icer-review.org/wp-content/uploads/2017/03/CTAF_Chronic_Pain_Draft_Evidence_Report_081517.pdf

 Tick H, Nielsen A, Pelletier KR, et al. Evidence-Based Nonpharmacologic Strategies for Comprehensive Pain Care. The Consortium Pain Task Force White Paper. 2017. 

 Foster NE, Anema JR, Cherkin D, et al. Prevention and treatment of low back pain: evidence, challenges, and promising directions. 

 Cherkin DC, Sherman KJ, Balderson BH, et al. Effect of mindfulness-based stress reduction vs cognitive behavioral therapy or usual care on back pain and functional limitations in adults with chronic low back pain: a randomized clinical trial. 

 Thorn BE, Eyer JC, Van Dyke MA. Literacy-adapted cognitive behavioral therapy versus education for chronic pain at low-income clinics: a randomized controlled trial. 

 Van Denburg AN, Vilardaga JP, Shelby RA, et al. Opioid therapy and persistent pain: can cognitive behavioral therapy help? 

 Lin DH, Jones CM, Compton WM. Prescription drug coverage for treatment of low back pain among US Medicaid, Medicare Advantage, and commercial insurers. 

Although it is still widely believed that the management of chronic pain usually requires medications or physical interventions, a growing body of research has demonstrated the efficacy of psychological therapeutic modalities.

The Quiz: Cognitive-Behavioral Therapy and Chronic Pain

 describes cognitive therapy (CT), behavioral activation (which can be administered alone but is also an important component of CT), interpersonal psychotherapy, and problem-solving therapy as having strong evidence of effectiveness in the treatment of major depressive disorder (MDD) using the criteria for evidence-based psychotherapies originally formulated by Chambless and Hollon.

 Short-term dynamic psychotherapy is listed as having only modest evidence of effectiveness.

In contrast, the American Psychiatric Association

 recommends CT, interpersonal therapy, problem-solving therapy, and psychodynamic psychotherapy as effective interventions for depression but limits the recommendation to only mild to moderate depression. Recent evidence on the effectiveness of psychotherapies in the treatment of depression suggests that another look should be taken at these guidelines. There is emerging evidence supporting the effectiveness of CT for severe depression and the effectiveness of dynamic psychotherapy for depression. In this article, I review some of the recent studies and possible changes to the guidelines that should be considered.

The efficacy and effectiveness of CT for MDD has been well established in controlled efficacy trials as well as in real world effectiveness trials.

 Given the substantial pain and suffering experienced by those who will encounter an episode of MDD in their lifetime, the research to date validating the effects of CT justify the time and costs necessary to implement this intervention in outpatient settings.

 demonstrated that CT reduced the risk of relapse after treatment was completed with continuation effects comparable to keeping patients on medication. The trial included only patients with severe depression, which indicates that the APA might reconsider its limited recommendation of psychotherapies for only mild to moderate depression.

In contrast to the solid evidence base for CT in the treatment of depression, there has been substantial debate in the literature over the past 20 years regarding whether short-term dynamic psychotherapy, which targets maladaptive interpersonal patterns as the source of symptomatology, has sufficient research to support its dissemination as an intervention for MDD. Although dynamic psychotherapy has been and is currently practiced worldwide, the research literature across mental disorders is flooded with reviews that debate whether it has adequate evidence of effectiveness.

A comprehensive review concluded that dynamic psychotherapy has large pre-and post-effects that are maintained at 1 year and medium effect sizes relative to control conditions.

 Two trials provide strong evidence that dynamic psychotherapy combined with medication is superior to medication alone in the treatment of depression.

 These studies provide valuable insight into the utility of dynamic psychotherapy in real world practice where psychotherapies are often combined with medication treatment.

A recent trial of longer-term psychoanalytic treatment demonstrated superiority over treatment as usual for treatment-resistant MDD.

 At the 2-year follow-up, 44% of patients in the psychoanalytic treatment no longer met criteria for MDD compared with 10% of those receiving treatment as usual.

In describing the evidence needed to define a psychotherapy as evidence based, Chambless and Hollon² assert that treatment efficacy is best demonstrated in controlled research. They suggest that studies with samples per condition of at least 25 that demonstrate an intervention is not significantly inferior to an already validated intervention can be considered evidence that treatments are equivalent. They warn that the interpretability of equivalence/non-inferiority trials is dependent on trials conducted with strong attention to internal validity.

To add to the emerging evidence supporting the effectiveness of dynamic psychotherapy in the treatment of depression, 2 large-scale noninferiority trials demonstrated that dynamic psychotherapy is statistically noninferior to CT in the treatment of MDD. Driessen and colleagues

 randomized 341 patients in outpatient settings to short-term dynamic psychotherapy versus CT using research methods that included manualized treatments, training protocols, and blind independent assessments. They found there were no differences between treatments at termination or follow-up on either patient rated or observer rated outcome assessments.

My colleagues and I conducted a randomized non-inferiority trial comparing short-term dynamic psychotherapy to CT in the treatment of MDD specifically in the community mental health setting.

 We developed and implemented our randomized noninferiority trial in the community setting with a focus on internal validity, including:

• Expert, intensive, individual and group supervision in each treatment modality on par with the training procedures implemented in efficacy trials

• Blind fidelity ratings to ensure that treatments were delivered adequately and could be discriminated

• Blind expert assessments of the primary symptom outcome

We found that dynamic psychotherapy was statistically noninferior to CT, building on the Driessen trial

 to indicate that dynamic psychotherapy may be broadly effective across settings. Our blind assessments of adherence and competence demonstrated that the cognitive and dynamic psychotherapies could be discriminated and that the CT delivered in the community setting had adherence and competence ratings comparable to those demonstrated in efficacy trials.

Our community trial also demonstrated that patients found both CT and short-term dynamic psychotherapy to be highly sensible, patients were very confident in the treatments, and patients would recommend these treatments to others.

CT focused on both behavioral activation techniques and cognitive restructuring techniques. Based on our blind expert adherence ratings, the specific techniques used most frequently included concrete activities like setting the agenda and assigning homework, as well as cognitive restructuring techniques that included encouraging the exploration of specific thoughts and beliefs and relating feelings to thoughts.

Short-term dynamic psychotherapy focused on both the supportive and expressive techniques described in the manual. Therapists used explicit alliance-enhancing techniques to build the collaborative relationship and used clarifications and interpretations of the relationship patterns interfering with patients’ goals in their current relationships.

Based on our blind expert adherence ratings, the specific interventions used most frequently in our community implementation of dynamic psychotherapy included supportive techniques like using mutual affect, conveying a sense of respect and liking, and using a high level of comments, as well as expressive techniques including exploration of patient wishes towards others, perceived responses of others, and responses.

To date, the evidence supports the effectiveness of both cognitive and dynamic therapies in the treatment of MDD, which suggests that the American Psychological Association should also consider revising their treatment guidelines. At the population level, both treatments offer a reasonable approach to helping alleviate the symptoms of depression. In practice, however, clinicians must decide which treatments are best suited to individual patients.

Despite decades of research on predictors of effectiveness within these treatments, we still do not have reliable indicators of which treatment to provide to which patients.

 conducted innovative studies to evaluate a wide range of possible predictors of treatment effectiveness across CT and medication to build a comprehensive predictive model that could be used to personalize treatment for patients. They found chronicity of illness (more chronic), age (older), and intelligence (lower) were predictive of poor response across both CT and medication. Meanwhile, patients who were married, unemployed, or had higher number of life events had significantly better outcomes with CT compared with medication. The researchers have developed an algorithm that produces a personalized advantage index that indicates which modality might provide better outcomes.

Such predictive models are sorely needed to help practicing clinicians decide which psychotherapeutic interventions are most likely to benefit any given patient. Most studies evaluate no more than a few predictors of treatment effectiveness within single treatment modalities. Since the prediction of which psychotherapy might benefit a specific patient is likely to be complex, studies are needed that can evaluate a range of possible treatment predictors and moderators across multiple evidence based psychotherapeutic approaches. Such a personalized approach to matching patients with psychotherapy may improve patient satisfaction with services and improve outcomes.

As we move forward with research to improve our ability to personalize psychotherapies to meet the needs of specific patients, we also need to think through how best to disseminate the many psychotherapeutic techniques to practicing clinicians. Most training programs remain focused on one school of psychotherapy and many clinicians graduating from these training programs have strong allegiances to a specific psychotherapeutic modality. In spite of this, we have found that clinicians are interested in gaining expertise in a variety of psychotherapeutic techniques.

Despite interest in an eclectic approach to psychotherapy, clinicians are not interested in completely replacing their preferred therapeutic modality. Rather, they prefer to bring in elements of other psychotherapies that may further benefit their patients. As a result, research examining whether briefer focused psychotherapy modules can address treatment personalization needs while meeting the practical needs of clinicians is needed to improve the effects of psychotherapies in clinical practice.

Dr Gibbons is Associate Professor Psychology, Department of Psychiatry, University of Pennsylvania, Philadelphia, PA.
The author reports no conflicts of interest concerning the subject matter of this article.

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In considering how best to disseminate the many psychotherapeutic techniques to practicing clinicians, the author reviews findings and changes to guidelines on depression treatments.

Psychotherapeutic Interventions for Depression: Which Work Best?

It is time for the psychiatric and wider medical world to embrace lessons from the growing science of resilience to treat the wide range of stress-related medical and psychiatric disorders more effectively. Quite often, physicians admonish patients to lower their stress levels, while patients quietly wonder how a lifetime of adversity can be undone, or how to extricate themselves from stressful jobs, relationships, or living environments. In these clinical situations, clinicians need to be prepared to offer concrete suggestions to build protective factors for resilience, rather than presuming that patients can magically get rid of their stressors.

The healing professions can be forgiven for coming late to the science of resilience, since vastly greater research and educational efforts have traditionally focused more on the pathogenic impact of stress and risk factors to generate disease, rather than how to harness the healing potential of biopsychosocial protective factors. It is beyond dispute that specific, well-known adverse childhood events and other developmental factors increase the risk for medical and mental illnesses. When a science of resilience began to emerge in the late 20th century, it became apparent that a subset of high-risk individuals who share a number of biopsychosocial protective factors had relatively healthy life outcomes (

Protective factors include characteristics of the individual and environmental experiences, and may occur at various developmental stages, but all seem to derive from a small handful of fundamental requirements for resilient functioning: a sense of safety, positive social connections, feelings of competence and control, and positive outlooks. Understanding the neurophysiological systems that underlie resilient functioning is crucial to effectively prescribing to the needs of high-risk patients, and to developing innovative ways to more efficiently induce these systems to build resilience.

The human nervous system evolved to serve the fundamental function of modulating behaviors of approach and avoidance so as to optimize the organism’s chances of survival and reproduction. Polyvagal theory observes that humans engage in a continual sensory process of “neuroception,” involving constant surveillance of afferent inputs to ascertain levels of risk, threat, safety, and opportunity to produce behavioral responses that will best serve the needs of survival and reproduction.

 Depending on the valence of afferent signals of neuroception, neurophysiological states are produced that bias our anticipation of novel or unexpected stimuli and result in behavioral and autonomic responses that respond to situations of risk or opportunity.

Understanding how neuroception produces neurophysiological states in the autonomic nervous system is crucial to understanding how resilient individuals cope with stress. With the explication of polyvagal mechanisms in the parasympathetic nervous system, we have been able to move beyond simplistic models of stress response. Based on the interpretation of these sensory inputs through the brain, we not only respond to risk and threat with well-known fight, flight, or freeze mechanisms, but also respond to conditions of safety and opportunity by activating key components of the parasympathetic nervous system to promote rest, relaxation, restoration, and social engagement. The most resilient individuals seem to have an ability to adeptly use these complex neurophysiological systems, to defend or recover from threats and trauma, and to seek or generate opportunities that create a sense of safety, control, and social connection.

Resilient individuals often have exceptional inborn qualities of temperament, personality, and social skills, starting with “easy” infant temperament, developing through childhood into likeability, getting along with others, sense of humor, altruistic tendencies, interpersonal problem-solving, and good emotional regulation-characterized as “emotional intelligence.”

 These social skills typically arise under conditions of safety, from the orchestrated action of the social engagement system (SES), which, when activated, facilitates positive social affiliation, recovery and restoration, and possibly reproductive behaviors. Resilient individuals use their emotional intelligence to calm themselves quickly and effectively in the wake of risk or danger, as well as to attract and maintain loving and supportive social relationships, which in turn assist them in calming their neurophysiological state.

The SES includes the neuromotor pathways responsible for the production of the most important and intimate gestures of facial and vocal expression. Under the optimal conditions of a secure mother-infant attachment relationship, there is extensive interchange of empathic facial and vocal interaction between mother and infant to entrain the SES of the developing infant. The components of the SES, along with the insular cortex, and various other sensorimotor cortical regions interact to generate a “mirror neural system” in humans. Capacities such as empathy, emotional self-awareness, and mentalization, are thought to arise from the mirroring social-emotional interplay of mother-infant attachment. Conversely, if the attachment is insecure, disorganized, or absent, there can be profound deficits in emotional regulation, stress-coping, and social engagement, such as in borderline personality functioning.

In the interest of prescribing resilience, it is crucial to understand that in-born social skills and secure mother-infant attachment are strong protective factors, but their absence does not determine destiny. The adaptive importance of effective social engagement has resulted in significant lifelong plasticity in the SES. For example, meditation favorably alters tonic EEG rhythms and thereby enhances emotional regulation. Yoga and meditation are often recommended to augment the treatment of a variety of psychiatric and medical illnesses, and involve resting or stretching in a place of comfort, quiet, and safety, breathing in a relaxed manner-using a bit of “physiological trickery” to send safe neuroception to the brain that triggers the relaxation response. Frequent or daily “dosing” of such practices seem to effect plastic neurophysiological changes.

 report that teaching emotional intelligence skills to Israeli school children in a war zone decreased the rate of PTSD. Musical tones delivered in the frequency range of intimate social communication may activate the SES in some autistic children.

 Interventions aimed at producing laughter and positive affect have increasingly been shown to improve health.

It is time for the psychiatric and wider medical world to embrace lessons from the growing science of resilience to treat the wide range of stress-related medical and psychiatric disorders more effectively.

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Can We Prescribe Resilience?

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