Controversies

www.heartandsoulofchange.com 4/3/2011

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Controversies of the Day

Barry Duncan,Barry Duncan, Psy.DPsy.D. www.heartandsoulofchange.com. www.heartandsoulofchange.com954.721.2981954.721.2981 www.whatsrightwithyou.comwww.whatsrightwithyou.com

[email protected]@comcast.net

Threats to Our Identity


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Take Clients at Face ValueBut Nothing Else


Several issuesthreaten our identity

Bottom Line: Look atit yourself and draw

your own conclusions

Several issuesthreaten our identity

Bottom Line: Look atit yourself and draw

your own conclusions

Controversial Issues and ThreatsGotta Dig Deeper

Controversial Issues and ThreatsGotta Dig Deeper

Third PartyReimbursement Trends

Evidence Based Practice

PsychotropicMedications

Psychotherapy and theMedical Model

Third PartyReimbursement Trends

Evidence Based Practice

PsychotropicMedications

Psychotherapy and theMedical Model


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Therapists and Mangled CareWhine, Whine, Whine

Therapists and Mangled CareWhine, Whine, Whine

Things are relative…WhenCHAMPUS started, such outrage.

Paid less than others & had theaudacity to require a tx plan atsession 24! Many could not workfor such measly pay or with suchunreasonable demands.

To any therapist today, whatCHAMPUS paid then with suchlimited oversight, would be todie for.

Things are relative…WhenCHAMPUS started, such outrage.

Paid less than others & had theaudacity to require a tx plan atsession 24! Many could not workfor such measly pay or with suchunreasonable demands.

To any therapist today, whatCHAMPUS paid then with suchlimited oversight, would be todie for.

All Downhill From ThereAll Downhill From There

We didn’t work w/ 3rd partypayers to address costs, wedemonized them.

They deserve their DarthVader status. But we didn’toffer alternatives. Mainlyresponded with righteousindignation.

But not going away… Instead of fighting, join

them at the table; data canhelp us be “players”

We didn’t work w/ 3rd partypayers to address costs, wedemonized them.

They deserve their DarthVader status. But we didn’toffer alternatives. Mainlyresponded with righteousindignation.

But not going away… Instead of fighting, join

them at the table; data canhelp us be “players”


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Stepping UpReturn on Investment

Stepping UpReturn on Investment

Conversant in the language(proof of value, return oninvestment); responsibility forcost & effectiveness.

Managed care has reason forconcern: dropout, therapistand treatment variability.

Collecting data & usingfeedback solves concerns.

These advantages can bebargaining chips. Efficiencyshould increase the value ofour services.

Conversant in the language(proof of value, return oninvestment); responsibility forcost & effectiveness.

Managed care has reason forconcern: dropout, therapistand treatment variability.

Collecting data & usingfeedback solves concerns.

These advantages can bebargaining chips. Efficiencyshould increase the value ofour services.

Darth Vader Is Still Darth VaderHow Will They Use the Data

Darth Vader Is Still Darth VaderHow Will They Use the Data

Some will employ thedata to improveoutcomes, i.e., provideimmediate feedback soyou can adjust tobenefit your clients.

Giving you feedback toimprove your servicesspeaks to an interest inthe quality of theservices delivered.

Some will employ thedata to improveoutcomes, i.e., provideimmediate feedback soyou can adjust tobenefit your clients.

Giving you feedback toimprove your servicesspeaks to an interest inthe quality of theservices delivered.


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Other PurposesOther Purposes

Clinician profiling, removingtherapists from providerpanels or limiting referrals.

Or, to steer referrals or payhigher rates—or “P4P”

Client welfare often invokedas an explanation—clientssteered have best chancefor success. But even thebest don’t benefit up to athird of their clients. P4Pdoes not address clientsreceiving services now.

Clinician profiling, removingtherapists from providerpanels or limiting referrals.

Or, to steer referrals or payhigher rates—or “P4P”

Client welfare often invokedas an explanation—clientssteered have best chancefor success. But even thebest don’t benefit up to athird of their clients. P4Pdoes not address clientsreceiving services now.

P4P Doesn’t WorkWet Blanket

P4P Doesn’t WorkWet Blanket

P4P Threatens OurIdentity; Puts Us InCompetition w/EachOther—Advantage Gainedat Someone’s expense

Kills the Spirit…EverybodyCan Get Better

We are motivated bygetting better at what wedo…

P4P Threatens OurIdentity; Puts Us InCompetition w/EachOther—Advantage Gainedat Someone’s expense

Kills the Spirit…EverybodyCan Get Better

We are motivated bygetting better at what wedo…


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Bottom LineBecome a Player

Bottom LineBecome a Player

Become a player.

Collect data, takeresponsibility, learn thelanguage of business, &negotiate higher rates.

Oppose collection ofdata w/o feedback.Voice concerns that P4Pwill kill the spirit ofoutcome management.

Become a player.

Collect data, takeresponsibility, learn thelanguage of business, &negotiate higher rates.

Oppose collection ofdata w/o feedback.Voice concerns that P4Pwill kill the spirit ofoutcome management.



Two approaches: ESTsor EBTs and EBP

One establishes criteriabased on RCTs andcreates lists

Other describesprocess of applyingevid. & incl. participants

Two approaches: ESTsor EBTs and EBP

One establishes criteriabased on RCTs andcreates lists

Other describesprocess of applyingevid. & incl. participants


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Evidence Based PracticeWhat’s the Hubbub?

Evidence Based PracticeWhat’s the Hubbub?

All approaches have validways to help clients.Makes sense to learnmultiple ways.

Also makes sense to be“evidence based”

In truth, no one says,“Evidence, smevidence!”

Like not believing in Momor apple pie. So what isthe controversy about?

All approaches have validways to help clients.Makes sense to learnmultiple ways.

Also makes sense to be“evidence based”

In truth, no one says,“Evidence, smevidence!”

Like not believing in Momor apple pie. So what isthe controversy about?

Evidence Based PracticeA Little History: EST to EBP

Evidence Based PracticeA Little History: EST to EBP

1993 apa guidelines Magic bullets to counteract

magic pills: ESTs & Div 12;increased rec. therapyefficacy, but

Promulgated grossmisinterpretations and nowoften wielded as amandate for competentand ethical practice.

That’s the controversy.Intent is not to demonize

1993 apa guidelines Magic bullets to counteract

magic pills: ESTs & Div 12;increased rec. therapyefficacy, but

Promulgated grossmisinterpretations and nowoften wielded as amandate for competentand ethical practice.

That’s the controversy.Intent is not to demonize


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Be SkepticalLike My Little Friend

Be SkepticalLike My Little Friend

Can be tedious

Worth it to countermandates & practiceaccording to clientpreferences and benefit.

ESTs suggest a therapistidentity based on technicalacumen in administeringmanualized, cookie cutterinterventions

Can be tedious

Worth it to countermandates & practiceaccording to clientpreferences and benefit.

ESTs suggest a therapistidentity based on technicalacumen in administeringmanualized, cookie cutterinterventions

No Data Supports Such EdictsThe Question: Is It a Fair Contest

No Data Supports Such EdictsThe Question: Is It a Fair Contest

Dodo: most replicated; nospecific effects; efficacy overplacebo, sham, or no tx isnot differential efficacy.

In few claiming superiority:Is it a fair contest?

Comparing 2 approachesintended to be therapeuticadministered in = amts bythose who believe in whatthey are doing & equallysupported—from same pool?

Dodo: most replicated; nospecific effects; efficacy overplacebo, sham, or no tx isnot differential efficacy.

In few claiming superiority:Is it a fair contest?

Comparing 2 approachesintended to be therapeuticadministered in = amts bythose who believe in whatthey are doing & equallysupported—from same pool?


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Whose Evidence Is It?Allegiance Effects

Whose Evidence Is It?Allegiance Effects

At least 40% of anyobserved effect isattributable to the beliefin (allegiance to) theapproach by theresearchers…TDCRP

Even meagerEven meagerdifferences disappeardifferences disappearwhen researcherwhen researcherallegiance isallegiance iscontrolled…controlled…

At least 40% of anyobserved effect isattributable to the beliefin (allegiance to) theapproach by theresearchers…TDCRP

Even meagerEven meagerdifferences disappeardifferences disappearwhen researcherwhen researcherallegiance isallegiance iscontrolled…controlled…

PMTO(Ogden & Hagan, 2008)

PMTO(Ogden & Hagan, 2008)

PMTO effective in reducingparent-rep. child externalizingproblems, improving teacher-rep. social competence, &enhancing parental disciplineover TAU.

“The findings thus indicate thatPMTO is an effective treatmentprogram…and moreover thatan evidence-based treatmentprogram can be transportedsuccessfully…” (p. 617).

PMTO effective in reducingparent-rep. child externalizingproblems, improving teacher-rep. social competence, &enhancing parental disciplineover TAU.

“The findings thus indicate thatPMTO is an effective treatmentprogram…and moreover thatan evidence-based treatmentprogram can be transportedsuccessfully…” (p. 617).

Ogden, T., & Hagen, K.A. (2008). Treatment effectiveness of ParentManagement Training in Norway: A randomized controlled trial ofchildren with conduct problems. Journal of Consulting and ClinicalPsychology, 76(4), 607-621.


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The DataPMTO v TAU

The DataPMTO v TAU

16 measures—only 4 found adifference

On 1 of 4 (CBCL Total), thedifference was 1.92 points.

On CBCL Ext., difference was1.53 points. Clinical significancequestionable at best.

Differences by age. Superiorfinding for PMTO on 4/16measures for 7 & younger only.None on 15/16 measures for 8& older; 1 favored TAU.

16 measures—only 4 found adifference

On 1 of 4 (CBCL Total), thedifference was 1.92 points.

On CBCL Ext., difference was1.53 points. Clinical significancequestionable at best.

Differences by age. Superiorfinding for PMTO on 4/16measures for 7 & younger only.None on 15/16 measures for 8& older; 1 favored TAU.

In Addition to These UnderwhelmingResults…Unfair Contest

In Addition to These UnderwhelmingResults…Unfair Contest

PMTO therapists: 18 monthstraining & ongoing sup. duringstudy: TAU therapists received notraining, support, or sup.

Dose favored PMTO 40 v. 21 hrs.

No findings on 12/16 measures,no effects children 8 & over,combined with differential training& support of the 2 therapistgroups & unequal doses of tx castdoubt on this study’s conclusions.

PMTO therapists: 18 monthstraining & ongoing sup. duringstudy: TAU therapists received notraining, support, or sup.

Dose favored PMTO 40 v. 21 hrs.

No findings on 12/16 measures,no effects children 8 & over,combined with differential training& support of the 2 therapistgroups & unequal doses of tx castdoubt on this study’s conclusions.


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Trauma Focused CBTUnfair Contests

Trauma Focused CBTUnfair Contests

Child Centered Treatment(CCT), the comparison tx is nota fair comparison—therapistsdid not see the kids & parentstogether, TF-CBT therapistssaw kids and parents together3 x out of the 12 sessions. Notreasonable care…

CCT condition did not provideadvice or suggestions to kids orparents. Not a real tx.

Reactive measures; 5 of 13

Child Centered Treatment(CCT), the comparison tx is nota fair comparison—therapistsdid not see the kids & parentstogether, TF-CBT therapistssaw kids and parents together3 x out of the 12 sessions. Notreasonable care…

CCT condition did not provideadvice or suggestions to kids orparents. Not a real tx.

Reactive measures; 5 of 13Cohen, J. A., Deblinger, E., Mannarino, A. P., & Steer, R. A. (2004). A multisite, randomized controlled trial for children with sexualabuse-related PTSD symptoms. Journal of the American Academy of Child and Adolescent Psychiatry, 43(4), 393-402.

APA Definition of EBPAPA Definition of EBP

Evidence-basedpractice is theintegration of the bestavailable research withclinical expertise in thecontext of clientcharacteristics, culture,and preferences(American Psychologist,May 2006).

Evidence-basedpractice is theintegration of the bestavailable research withclinical expertise in thecontext of clientcharacteristics, culture,and preferences(American Psychologist,May 2006).


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APA RecommendationsAPA Recommendations

Decisions should be made incollaboration with the client,based on the best evidence

Most effective whenresponsive to the client’sstrengths, cultural context,and preferences.

Responses are variable.Therefore, ongoingmonitoring of client progressand adjusting as needed isessential

Decisions should be made incollaboration with the client,based on the best evidence

Most effective whenresponsive to the client’sstrengths, cultural context,and preferences.

Responses are variable.Therefore, ongoingmonitoring of client progressand adjusting as needed isessential

EST/EBTs offers choices forclients—but are merelylenses that may or may notfit the client’s frame andprescription. Methods andmodels are neither deitynor demon, but are usefulmetaphorical accounts ofhow people can change.

But any mandates…

EST/EBTs offers choices forclients—but are merelylenses that may or may notfit the client’s frame andprescription. Methods andmodels are neither deitynor demon, but are usefulmetaphorical accounts ofhow people can change.

But any mandates…

No Silver Bullet Cures


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A Mountain of ManureA Mountain of Manure

Lopsided ContestLook for YourselfLopsided ContestLook for Yourself

I have never seen anadvantage of anyapproach over another

(or TAU) that wasn’t alopsided contest

that had its winnerpredetermined.


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DBTShould It Be Prosecutable?

DBTShould It Be Prosecutable?

Using vague,unstandardizedmethods to assisttroubled clients ‘shouldbe prosecutable’ insome cases, said Dr.Marsha Linehan (Carey,2005, p. 2).

Linehan, M. et al (2006) Two-Year Randomized Control Trial and Follow up of DBT.Archives of General Psychiatry, 63, 757-766.

•NIMH funded study of DBT:• Compared DBT to servicesoffered by “community-nominated” treatment experts;• Community experts:

•Received no training, supervision, orconsultation;

•No control of type, amount, or qualityof services .

•Provided significantly less directservice than DBT therapists.

•DBT therapists:•Received 45 hours of specializedtraining;

•Pre- and during-study supervision.

•Gave 95 (38 x 2½) more hours ofcontact dedicated to keeping peopleout of the hospital

DBT:DBT:What do the data say?


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The Truth Is in the Tables

Smoke and MirrorsReal World Applications

Smoke and MirrorsReal World Applications

DBT for “BPD”

In a large CMHC servingSPMI clients: Of 382eligible by dx, only 25(6.5%) thought it was forthem; 25% of thosedropped out beforeprogram started; another25% dropped out…is itworth the cost?

DBT for “BPD”

In a large CMHC servingSPMI clients: Of 382eligible by dx, only 25(6.5%) thought it was forthem; 25% of thosedropped out beforeprogram started; another25% dropped out…is itworth the cost?

Haynes, M. (2006). Real world applications of evidence based practice.Heart and Soul of Change 3. Bar Harbor, ME.


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APA Conclusions and theBottom Line…

APA Conclusions and theBottom Line…

Outcome not guaranteedregardless of evidence

Challenge statements thatuse EBTs to mandate orreimburse.

Know about dodo verdict &unfair contests in research.

Educate others about APAdefinition & importance ofmeasuring client response.

Outcome not guaranteedregardless of evidence

Challenge statements thatuse EBTs to mandate orreimburse.

Know about dodo verdict &unfair contests in research.

Educate others about APAdefinition & importance ofmeasuring client response.

Mandatesdon’tmakeempiricalsense

NOT ANTI-EBT or ESTNOT ANTI-EBT or EST

Calling for a more sophisticated clinician whochooses from a variety of orientations andmethods to best fit client preferences andcultural values. Although there has not beenconvincing evidence for differential efficacyamong approaches, there is indeed differentialefficacy for the client in the room now—therapists need expertise in a broad range ofintervention options, including ESTs.

Calling for a more sophisticated clinician whochooses from a variety of orientations andmethods to best fit client preferences andcultural values. Although there has not beenconvincing evidence for differential efficacyamong approaches, there is indeed differentialefficacy for the client in the room now—therapists need expertise in a broad range ofintervention options, including ESTs.


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Reminds Me ofAnimal FarmReminds Me ofAnimal Farm

Some therapiesare more equalthan others

Some therapiesare more equalthan others

The Medical Model EquationThe Medical Model EquationIs It Your Identity?Is It Your Identity?

The Medical Model EquationThe Medical Model EquationIs It Your Identity?Is It Your Identity?

DiagnosisDiagnosis

++

Prescriptive TreatmentPrescriptive Treatment

==

Cure or SymptomCure or SymptomAmeliorationAmelioration

DiagnosisDiagnosis

++

Prescriptive TreatmentPrescriptive Treatment

==

Cure or SymptomCure or SymptomAmeliorationAmelioration


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The Medical ModelFighting the Borg?The Medical Model

Fighting the Borg?

MM is not the Borg, nor amI Captain Picard.

Psychotherapy, however, isnot a medical, it isrelational.

Never challenged on that.

Yet, MM rules as adescription of what we do.Ironically, its assumptionsand practices are notsupported by the data.

MM is not the Borg, nor amI Captain Picard.

Psychotherapy, however, isnot a medical, it isrelational.

Never challenged on that.

Yet, MM rules as adescription of what we do.Ironically, its assumptionsand practices are notsupported by the data.

DiagnosticDiagnostic DysDys--OrderOrder

Poor ReliabilityPoor Reliability

Unknown ValidityUnknown Validity

Does not predict LOS or outcomeDoes not predict LOS or outcome

Little help in treatment selectionLittle help in treatment selection

Surveys consistently find that MHPsSurveys consistently find that MHPsdo not like it or find it useful…do not like it or find it useful…

Kirk, S.A., & Kutchins, H. (1992). The selling of DSM: The rhetoric of science in psychiatry. New York: AldineDuncan, B., Miller, S., & Sparks, J. (2004). The Heroic Client. San Francisco: Jossey-Bass.


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“Psychotherapy is the only form of treatmentwhich, at least to some extent, appears to createthe illness it treats” Jerome Frank (Frank, 1961,p. 7).

Reliability: “To say that we've solved thereliability problem is just not true…It's beenimproved. But if you're in a situation with ageneral clinician it's certainly not very good.There's still a real problem, and it's not clearhow to solve the problem" Robert Spitzer, leadeditor of DSM III (Spiegel, 2005, p. 63).

Validity: “There is no definition of a mentaldisorder. It’s bullshit. I mean, you just can’tdefine it… these concepts are virtuallyimpossible to define precisely with bright lines atthe boundaries.” Allen Francis, lead editor ofDSM IV (Greenberg, 2010, p. 1).

Quotable Quotes about Diagnosis

•Creates the Illness•Reliability not good•It’s bullshit

DiagnosisFinal Comment

DiagnosisFinal Comment

Remains a fixed part ofgraduate training programs,a prominent feature of ESTs,and a prerequisite forfunding in most mentalhealth and substance abusedelivery systems—allengendering an illusion ofscientific aura & clinicalutility that far overreachesthe DSM’s deeply flawedinfrastructure.

Remains a fixed part ofgraduate training programs,a prominent feature of ESTs,and a prerequisite forfunding in most mentalhealth and substance abusedelivery systems—allengendering an illusion ofscientific aura & clinicalutility that far overreachesthe DSM’s deeply flawedinfrastructure.


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The Beat Goes On: MH ParityGood But

The Beat Goes On: MH ParityGood But

Just like FOC leg. enslaved us toreimbursement by dx & themedical way we talk, paritypromises further bondage.

Payers still set fees. Have tocover the costs of equal accesssomehow: reducing profit?

Negotiating based on benefit, ora fixed no. of sessions in returnfor better rates & autonomywould be moot. Parity does notaddress outcome.

Just like FOC leg. enslaved us toreimbursement by dx & themedical way we talk, paritypromises further bondage.

Payers still set fees. Have tocover the costs of equal accesssomehow: reducing profit?

Negotiating based on benefit, ora fixed no. of sessions in returnfor better rates & autonomywould be moot. Parity does notaddress outcome.

Medical Model: Doesn’t Fit Me, MyExperience, or the Data

Medical Model: Doesn’t Fit Me, MyExperience, or the Data

Not pts with illnesses requiringtx from experts w/powerfulinterventions. Not bestdescribed by Killer Ds. Therapyis not model & technique.

Identity lies outside dx,prescriptive tx, cure, &reflects the interpersonalnature of the work & theconsumer’s perspective of thebenefit & fit of services.

Not pts with illnesses requiringtx from experts w/powerfulinterventions. Not bestdescribed by Killer Ds. Therapyis not model & technique.

Identity lies outside dx,prescriptive tx, cure, &reflects the interpersonalnature of the work & theconsumer’s perspective of thebenefit & fit of services.


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Data Could Help Here TooData Could Help Here Too

National data base couldreevaluate funding models& MM assumptions.

As evidence emerges redx, ESTs, LOS, & outcome,the real predictors maycome to light (alliance &early change).

Reimbursement based onbenefit

National data base couldreevaluate funding models& MM assumptions.

As evidence emerges redx, ESTs, LOS, & outcome,the real predictors maycome to light (alliance &early change).

Reimbursement based onbenefit

Bottom LineCollect DataBottom LineCollect Data

Nothing wrong with MM.But not empiricallysupported nor an aptdescription. Collect data &use it to introduce newconventions forunderstanding our services.Parity is fine but clientbenefit should be in themix.

Nothing wrong with MM.But not empiricallysupported nor an aptdescription. Collect data &use it to introduce newconventions forunderstanding our services.Parity is fine but clientbenefit should be in themix.


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Raving LunaticPsychotropicsRaving LunaticPsychotropics

Same as EBTs—whether anyapproach should be privilegedabove others, predictors, clientpreferences. None earned thatempirical respect.

Evidence: Meds should never beconsidered more than 1 optionamong many—never automatic.

Identity threat compelling: Justlike I am not a technicianadministering one size fits allinterventions, I am not a lowertiered way to help clients.

Same as EBTs—whether anyapproach should be privilegedabove others, predictors, clientpreferences. None earned thatempirical respect.

Evidence: Meds should never beconsidered more than 1 optionamong many—never automatic.

Identity threat compelling: Justlike I am not a technicianadministering one size fits allinterventions, I am not a lowertiered way to help clients.

Medication, Like All Treatments,Work Sometimes

Medication, Like All Treatments,Work Sometimes

Very studies purporting tosupport major classes ofdrugs reveal: limited efficacyof antidep. over placebo, theunderwhelming results ofantipsy. and their pervasiveintolerability, and a lack ofmeaningful benefit of combingtherapy and meds.

Regarding children, the datais even less compelling

Very studies purporting tosupport major classes ofdrugs reveal: limited efficacyof antidep. over placebo, theunderwhelming results ofantipsy. and their pervasiveintolerability, and a lack ofmeaningful benefit of combingtherapy and meds.

Regarding children, the datais even less compelling


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The APA Working Group on PsychoactiveMedications for Children and AdolescentsThe APA Working Group on PsychoactiveMedications for Children and Adolescents

For most of the disorders reviewed herein,there are psychosocial treatments that aresolidly grounded in empirical support as stand-alone treatments. Moreover, the preponderanceof available evidence indicates thatpsychosocial treatments are safer thanpsychoactive medications. Thus, it is ourrecommendation that in most cases,psychosocial interventions be consideredfirst. (p. 16.)

For most of the disorders reviewed herein,there are psychosocial treatments that aresolidly grounded in empirical support as stand-alone treatments. Moreover, the preponderanceof available evidence indicates thatpsychosocial treatments are safer thanpsychoactive medications. Thus, it is ourrecommendation that in most cases,psychosocial interventions be consideredfirst. (p. 16.)

Sparks, Duncan, Cohen, & Antonnucio,Fatal Flaws

Sparks, Duncan, Cohen, & Antonnucio,Fatal Flaws

Given the infiltration ofindustry influence,discerning good sciencefrom good marketingrequires a willingness toengage primary sources

Flaws cast doubt on claimsthat medication should be afirst line, a priori solution toany client problem.

Given the infiltration ofindustry influence,discerning good sciencefrom good marketingrequires a willingness toengage primary sources

Flaws cast doubt on claimsthat medication should be afirst line, a priori solution toany client problem.


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Five Fatal Flaws of Drug Studies

•Compromised blind

•Client versus clinician measures

•Time of measurement

•Conflicts of interest

•Minimization of risks

#1 Compromised Blind

DB foundation of RCT

Inactive placebos make itpossible to know txstatus (side effects)

Many experienced withmedications, and manyactively seek todetermine their status

Double blind integrity notmonitored


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#2 Client versus Clinician Ratings

Clients & clinicians differ onimpressions of improvement

Outcome measures are mostoften clinician-rated

When client ratings areused, no difference results

If clients don’t know they’rebetter, how much better arethey?

Doctor knows best!Doctor knows best!

#3 Time of Measurement

Medications are neverprescribed for shortperiods of time

8-12 week trialsinadequately determineeffect; differences startto dissolve by 16 weeks

Drug trial time frames:logistics or strategy?


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#4 Conflicts of Interest

When money speaks, the truth keepssilent.

Russian Proverb

#5 Minimization of Risks

Lack of standardizedmeasures for adverseevents; mostly fromspontaneous report

Lack of clarity of AEterminology

Failure to publishunfavorable studies

Rhetoric obscures data Conclusions for

tolerability and safetydo not reflect findings

This won’t hurt a bitThis won’t hurt a bit


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Flaws in Action: TADS(Treatment of Adolescent Depression Study)

Flaws in Action: TADS(Treatment of Adolescent Depression Study)

Multicenter, randomized,masked, effectiveness trialfunded by NIMH. N = 432

Short term (12-weeks) andlong-term (36-weeks) of 4tx for adols. dx MDD

Prozac, placebo, CBT,Prozac + CBT

Primary measures: CDRSand dichotomized CGI-I

Multicenter, randomized,masked, effectiveness trialfunded by NIMH. N = 432

Short term (12-weeks) andlong-term (36-weeks) of 4tx for adols. dx MDD

Prozac, placebo, CBT,Prozac + CBT

Primary measures: CDRSand dichotomized CGI-I

. . . a landmark government. . . a landmark government--financed study has found that Prozac helps teenagersfinanced study has found that Prozac helps teenagersovercome depression far better than talk therapy. But a combination of the two treatments,overcome depression far better than talk therapy. But a combination of the two treatments,the study found, produced the best result.the study found, produced the best result. NY Times, June 2, 2004NY Times, June 2, 2004

"The medication is addressing"The medication is addressingthe chemical imbalances in thethe chemical imbalances in thebrain while the psychotherapy isbrain while the psychotherapy isaddressing the behavior and theaddressing the behavior and thethoughts," said Dr. Timothythoughts," said Dr. TimothyWilens, a child psychiatrist atWilens, a child psychiatrist atMassachusetts General Hospital,Massachusetts General Hospital,who reviewed some of thewho reviewed some of thepreliminary results for ABCpreliminary results for ABCNews.News.

"The take"The take--home message is thathome message is thatmedication works, that suicidemedication works, that suiciderisk is minimal and that therisk is minimal and that thepositive effects of the medicinepositive effects of the medicineoutweigh the risk," saidoutweigh the risk," saidKoplewicz.Koplewicz. ABC News, June 2ABC News, June 2

Prozac effectiveProzac effective

The study's findings so far indicate that patientsThe study's findings so far indicate that patientsbecame less suicidal as the study advanced,became less suicidal as the study advanced,Emslie said in an interview. Nevertheless, theEmslie said in an interview. Nevertheless, therisk of suicide attempts was greater among thoserisk of suicide attempts was greater among thosetaking Prozac than those on placebo or talktaking Prozac than those on placebo or talktherapy: Five people on Prozac and one ontherapy: Five people on Prozac and one onplacebo made a suicide attempt, he said. Heplacebo made a suicide attempt, he said. Headded that the number of patients in the studyadded that the number of patients in the studywas too small to establish whether an increasedwas too small to establish whether an increasedrisk actually exists.risk actually exists. Newsday, June 3, 2004Newsday, June 3, 2004

"This study will help"This study will helpput the argument toput the argument torest," Emslie said.rest," Emslie said.


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TADSA Tad Short on Evidence


Flaw #1: No active placebo; No placebocomparison for Comb.; CBT and Comb.knew tx status (no difference withplacebo).

Flaw #2: Primary measures clinician-rated. Secondary measures have limitedpsychometric credibility. 1 of 2 clinician-rated scales (CGI-I) at 12-weeks showsdifference. Primary measure shows nodifference. No effects client measures

Flaw #3: 12-week trial with limitedmasking; beyond 12 weeks, allparticipants knew treatment status. Nodifference at 30 weeks

Flaw #1: No active placebo; No placebocomparison for Comb.; CBT and Comb.knew tx status (no difference withplacebo).

Flaw #2: Primary measures clinician-rated. Secondary measures have limitedpsychometric credibility. 1 of 2 clinician-rated scales (CGI-I) at 12-weeks showsdifference. Primary measure shows nodifference. No effects client measures

Flaw #3: 12-week trial with limitedmasking; beyond 12 weeks, allparticipants knew treatment status. Nodifference at 30 weeks



Flaw # 4: Leadinvestigator, John March:support from Eli Lilly–extensive ties; Emslie andother researcher:consultants, speakersbureau, and researchsupport from Eli Lilly.

Flaw # 5: 6 suicideattempts out of 200 Prozactakers compared with 1 outof 200 non-Prozac takers.


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This Doesn’t MeanThat Meds Are Not Helpful

This Doesn’t MeanThat Meds Are Not Helpful

Just means thatmed. is no moreviable thananything else,client preferenceis paramount, notany empiricalmandate.

Just means thatmed. is no moreviable thananything else,client preferenceis paramount, notany empiricalmandate.

Penn, Schoen, & Berland Associates(2004). Survey for the APA. unpublishedpaper.

Prescription PrivilegesWell Intentioned but Dangerous

Prescription PrivilegesWell Intentioned but Dangerous

Psychiatrists weretrained as therapists.Despite lack of data &under the influence ofmassive marketing &increased income, mosthave become pillpushers. Arepsychologists different?

Psychiatrists weretrained as therapists.Despite lack of data &under the influence ofmassive marketing &increased income, mosthave become pillpushers. Arepsychologists different?


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Consider a Monitor FeatureThe Ability Not To PrescribeConsider a Monitor FeatureThe Ability Not To Prescribe

Thinking about how being able toprescribe has improved patientcare, he mentions a patientdiagnosed with bipolar disorder.Fain put him on acombination of medicationsno one had tried with himbefore. The medications broughtrelief from his manic symptomsfor the first time, Fain says.

"He tells me every time, he patsme on the shoulder and says,'You saved me.'"

Thinking about how being able toprescribe has improved patientcare, he mentions a patientdiagnosed with bipolar disorder.Fain put him on acombination of medicationsno one had tried with himbefore. The medications broughtrelief from his manic symptomsfor the first time, Fain says.

"He tells me every time, he patsme on the shoulder and says,'You saved me.'"

The Ability NOT to PrescribeThe Ability NOT to Prescribe

Such medication cocktails,SOP for psychiatry, areneither empirically supportednor FDA approved. Success ofthis client will likely lead tocontinue unsupported andunapproved poly-pharmaceutical solutions justlike psychiatrists—paving theway for the diminishment ofpsychotherapy as a first lineof action and furthermarginalization.

Such medication cocktails,SOP for psychiatry, areneither empirically supportednor FDA approved. Success ofthis client will likely lead tocontinue unsupported andunapproved poly-pharmaceutical solutions justlike psychiatrists—paving theway for the diminishment ofpsychotherapy as a first lineof action and furthermarginalization.


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Conclusions and DiscussionSparks et al

Conclusions and DiscussionSparks et al

When clinical trials are criticallyexamined…psychiatric drugtreatments should not be privileged.And when effects to tx are noted, whoprovides the tx, the quality of thealliance, and the clinician andrecipient’s expectations for successprovide a better explanation than anyspecific effects due to the medication.

Knowing that there is no irresistiblejustification to medicate, therapistsare free to put other options on thetable & draw in the voices of theirclients—to engage in an informedrisk/benefit analysis to choose txs inconcert with client values,preferences, & cultural contexts

When clinical trials are criticallyexamined…psychiatric drugtreatments should not be privileged.And when effects to tx are noted, whoprovides the tx, the quality of thealliance, and the clinician andrecipient’s expectations for successprovide a better explanation than anyspecific effects due to the medication.

Knowing that there is no irresistiblejustification to medicate, therapistsare free to put other options on thetable & draw in the voices of theirclients—to engage in an informedrisk/benefit analysis to choose txs inconcert with client values,preferences, & cultural contexts

Therapyshouldbe firstoption

Date post:	18-Dec-2014
Category:	Education
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