Pharmacotherapy or Psychotherapy?It Doesn't Have to Be Either-Or

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In the movie “Analyze This,” Robert De Niro plays a mobster so plagued by an anxiety disorder that he seeks out a psychiatrist — played by Billy Crystal — and demands therapy to cure him of his inner turmoil within two weeks, in time for a big mafia meeting. Hilarity, of course, ensues. In the midst of De Niro’s psychoanalytic tirades with Crystal — like the one where he begins talking about “closure” and winds up shooting a pillow — it might occur to the viewer to wonder, “Why doesn’t this doc just put the Godfather on Prozac and call it a day?”

For starters, it wouldn’t make a very interesting movie — but more to the point, the fact is that despite all the attention received by psychiatric drugs like Prozac, Paxil and Zoloft, psychotherapy (or “talk therapy”) is still alive and well in America. Sometimes used on its own to treat psychiatric conditions like depression and anxiety disorders, and sometimes used in concert with medications, psychotherapy has undergone major changes since the days of Sigmund Freud, and even since the days when everyone’s image of psychotherapy was a Woody Allen-style neurotic lying on a couch obsessing about his mother.

One of the most commonly used forms of psychotherapy today is a method called cognitive behavioral therapy (CBT), which has proven very successful in treating many psychiatric conditions, including depression, anxiety and phobias. It’s based on the idea that our thoughts determine our feelings and our behavior — and the patient can become aware of distorted thoughts and behaviors, and work toward changing them. Psychiatrists practicing CBT help their patients recognize destructive patterns of thinking and responses — for example, thinking “I’m such a loser, I can’t do anything right” — and replacing those negative patterns with more realistic and positive ones.

CBT is more than just sitting in a therapist’s office for an hour every week talking about your feelings. According to the American Institute for Cognitive Therapy, the “homework” that might go along with such a treatment plan could include “keeping track of your moods, thoughts and behaviors, scheduling activities, developing goals, challenging your negative thoughts, collecting information, changing the way you communicate with others, and other assignments.”

For example, someone who is depressed might have a difficult time starting the day on a good note, because they find that they wake up in a bad mood. They can work with their therapist to create an “action plan” that helps them give their day a positive start, like doing yoga or eating breakfast with a friend. They’re encouraged to identify and overcome possible obstacles (such as feeling too tired to do yoga or the friend being out of town), and then write daily progress reports on how well they’ve met their goals.

For a person with obsessive-compulsive disorder on the other hand, CBT might involve teaching them to recognize compulsions — like constant hand washing — as the obsessive urges they are. They then learn to refocus their attention away from the compulsion and help it to pass by participating in an activity that they enjoy and that engages them, such as needlepoint or working on a crossword puzzle.

So how well does all this actually work? Some studies have shown that CBT is as useful as antidepressant medication in treating mild to moderate depression, and can even be superior in preventing a relapse. A meta-analysis (published in the Journal of Affective Disorders in 1998), which included eight studies, showed that 29.5 percent of patients treated with cognitive therapy relapsed, compared with 60 percent of those treated with antidepressants.

The best evidence of CBT’s effectiveness is in unipolar depression, but it has been shown to be successful in treating other psychiatric conditions, such as anxiety disorders, phobias and post-traumatic stress disorder. It’s even shown promise as a complementary treatment for schizophrenia.

In addition to CBT, there are other types of psychotherapy, ranging from family therapy to interpersonal therapy (which focuses on improving troubled personal relationships) to play therapy (often used with children). These kinds of psychotherapy can either be used alone, or in combination with medication, depending on a person’s needs. (Some people, with particularly severe or complex psychiatric conditions, will always need to be managed with medications no matter what additional therapies they receive.)

In fact, various forms of psychotherapy have even been shown to alter brain chemistry and function. For example, a study that appeared in the journal Psychological Medicine in September 2007 found that brief eclectic psychotherapy not only led to clinical recovery in people with post-traumatic stress disorder, but it actually appeared to modulate the functioning of specific PTSD-related sites in the prefrontal cortical regions of the brain.

And that’s not an isolated example — a review in Acta Neuropsychiatrica, published in 2006, cataloged multiple studies that found significant effects of psychotherapy on the brain, showing that therapies like CBT can “modify activity in dysfunctional neural circuitries linked to the development of various psychopathological conditions.” Some studies have even found that psychotherapy leads to more of these positive changes in the brain than medication alone.

So maybe De Niro’s crazy mobster wasn’t so crazy after all (although shooting the pillows probably wasn’t the best idea). Psychotherapy requires a lot of work and commitment on the part of the patient, and it may not take effect as quickly as medication can, but then again it won’t have the side effects that medication can. And evidence clearly shows that for many people, it’s more than worth the effort.

About the Author

Gina Shaw is the medical writer for The Washington Diplomat.

Last Edited on July 9, 2014