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How we treat is more important than the treatment!

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In medicine and psychology, we tend to argue about what treatments work best rather than which physicians or therapists work best and with which patients. University of Toronto psychiatrist Benoit Malsant, with whom I worked in Pittsburgh, writes that only psychiatrists help only about 30 to 40% of the patients they see who are depressed (Archives of General Psychiatry, 2002; 59: 729-33). He believes we should do much better. He also points out that we hurt quite a few people we treat. He believes success comes from being enthusiastic about what we do. He believes that 90% of people with depression will get better if they don't give up and stay with one doctor for a year, even if they have to go through three or four treatment trials. Benoit believes in antidepressants. I'm not as enthusiastic, preferring therapy, especially those that lead to what is called behavioral activation, in which people actually do things they haven't been doing that they would do if they weren't depressed. Benoit says, "the secret to high treatment response rates in geriatric depression is to persuade the person to fill the prescription, take the drug as prescribed, and stay on it despite initial side effects or lack of efficacy." Filling a prescription and taking a drug as prescribed represents a kind of behavioral activation. A study in The Lancet of beta-blockers in heart failure showed that taking pills as prescribed is more effective than taking active medication. Something about following instructions is activating.

Benoit quotes a randomized, clinical trial of citalopram in geriatric depression which showed that where a patient gets treated matters more than what they receive. He interprets this as referring to how the psychiatrists use the drug, which I would interpret as reflecting all the non-specific aspects of treatment (how we treat). In this 15 site clinical trial, the response rate to citalopram varied from 18% to 82%, while the response rate to placebo ranged from 16% to 80% (American Journal of Psychiatry, 2004; 161: 2050-9). This shows to me that how we interact is more important than what we give. I saw this recently on our inpatient service. We had a patient who believed that she couldn't eat because her bladder had filled up her entire abdomen, leaving no room for food. She couldn't eat until surgery shrunk her bladder. If we were Ibn Senna, a Persian physician from the 12th century, we would have done sham surgery with her and pronounced her cured. Sham surgery was shown tremendous helpful for knee problems in a large study of 180 patients at the Houston Veterans Administration Hospital. We had to do something because she was starving to death. Much debate ensued on whether or not we could treat her against her will. Finally it was decided that we could. We started an injectable antipsychotic drug and by the next morning she was much better. She was fixing her hair and eating. Drugs don't work that quickly. What worked was that we changed our attitude and she felt it. Our new attitude was definitive and assertive. We were going to do whatever was required for her to get better. I believe that her feeling this shift in stance on the part of her doctors and nurses helped her improve.

Ibn Senna is worth mentioning because he did whatever was required to help the patient and worked within the patient's narrative. In a famous story, he was brought to see the sultan's son who thought he was a cow. The son was refusing to eat or drink and was demanding to be sacrificed and fed to the people who were hungry. Ibn Senna agreed that he was a cow, but pronounced him a scrawny cow he could hardly feed anyone. Ibn Senna said he could be sacrificed if he would put on some weight so that he would make a decent meal. Ibn Senna came every day to feed the prince and to administer the various medicines of the day. At some point, the prince informed Ibn Senna that he was no longer a cow and could get back to being a prince and find other ways to feed the people. I imagine how shocked and surprised Ibn Senna must have feigned being to learn that the prince was not a cow.

Psychotherapy outcome studies repeatedly show that the non-specific factors of treatment (unrelated to what is done) are the most important, accounting for 60 to 85% of the improvement that people make. Medicine has forgotten this. Some of it comes from how we are trained. Resident physicians rotate through various services in usually one-month blocks. While they have some continuity clinics in which they can see the same patients over time, their schedules have their clinic times constantly changing and patients can't always figure out when their doctor might be available. Moreover, we are not training residents in the art of sitting with people and listening. We are training them to do things. The beauty of psychotherapy is that it requires us to sit and listen and build a relationship with someone.

Psychotherapy has fallen out of favor in medicine. Nevertheless, therapy or counseling or just seeing people frequently and listening, might be our most important medicine. Neuroscience increasingly underscores the powerful effects that experience has on changing the wiring patterns of our brains (neuroplasticity) and the genes that are being expressed in any given moment (epigenetics). These factors might be more important than medications and more long lasting. Especially in psychiatry, we know that the brain adjusts to medications and compensates so as to return to its pre-medication state. In psychiatry, we know that medications often stop working after about 18 months and have to be changed. This is because the brain has compensated. This is also what makes it so difficult to get off psychiatric drugs.

Psychoanalyst and psychiatrist Lawrence Blum does an admirable job in explaining what is happening in both psychotherapy and medicine. A patient starts, he says, by telling the story of his life and his suffering. Gradually the doctor or the therapist becomes incorporated as a character in the story. When that happens the story is taking place in the office and is susceptible to modification in a process sometimes called co-authoring. The doctor or the therapist provides a rare opportunity (in this culture) to figure out what the story is about. Rarely do we have the opportunity to reflect on the plots interwoven through our lives. Mostly we automatically move from situation to situation, relationship to relationship. Dialogue allows us to become aware of what it is we think we want and the strategies we are using (plots) to achieve those wants. Then we can "write" better stories that improve our self-world interface, reducing the friction, helping us to achieve our wants easier, or to change our wants to being more achievable. Mark Twain said the easiest way to be happy is to be content with what you have, a basic principle of both Buddhism and dialectical behavior therapy (DBT).

Doctoring or therapy allows us to participate in the stories of our patients' lives, sometimes as fellow traveler, sometimes as narrator, sometimes as stand-ins for other characters from the patient's past. As we get to know the parts we are being asked to play, we can feed back to the patient information about the roles he is asking us to play, a process through which he or she can learn about the roles he or she is casting in other compartments of life. Awareness of plot and characters allows us to change our stories.

I'm arguing that doctors do have time to do this work and should make more time. It's more effective than failing to help someone recover from depression. It's especially important in geriatrics in which the story is seeking an adequate ending. Geriatrics provides one of those ideal times in which people are already reflecting upon the story of their lives in order to making meaning, to feel like they made a difference, mattered to someone, or did their part to improve the world. Depression comes from the judgment that we didn't matter, that we didn't improve the world, and maybe even made it worse. America is harsh that way. A study in China found that most people thought the best age to be was 80 because of how much one was respected. In the United States, people thought it was 20 because one was young and healthy with so many choices ahead. The United States is a youth-focused culture, and older people can feel disrespected, cast aside, and unimportant. Their stories are sometimes not even known to their grandchildren or great-grandchildren.

Doctors can bring the story back into focus, for the patient and for the family. Time spent doing so is time well spent, perhaps even more than time spent prescribing drugs and arranging screening tests. Let's reclaim time with patients from the financial managers. Let's find ways to do what has been called "ultra-brief therapy for an ultra-long time" or to actually to general practice psychotherapy for some part of our workweek.

Of course, physicians can't counsel everyone and we also need behavioral health specialists, but research also exists to show that inter-professional collaboration works best when everyone shares the skill sets of the others. When doctors spend even half a day counseling, they work so much better alongside the behavioral health specialist who may be seeing the bulk of the patients.

Let's embrace the non-specific aspects of treatment, whether it be medicine or psychology, and work toward life change in positive directions. Let's bring the story back into medicine.

 

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Lewis Mehl-Madrona graduated from Stanford University School of Medicine and completed residencies in family medicine and in psychiatry at the University of Vermont. He is the author of Coyote Medicine, Coyote Healing, Coyote Wisdom, and (more...)
 

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