Thursday, July 23, 2009
OMG!!! That's What They Said! Relapse
"The goal of treatment was to maximize the number of patients achieving clinical remission because this would then render them eligible for the mood challenge." [italics added]
The winners of this month's Omgodthat'swhattheysaid Award are Segal, Kennedy, Gemar, Hood, Pedersen, and Buis in "Cognitive Reactivity to Sad Mood Provocation and the Prediction of Depressive Relapse," Archives of General Psychiatry 63:7 July 2006.
They wanted to answer a question I asked in my last post, why does depression come back? Cognitive Behavioral Therapy (CBT) says that automatic negative thoughts cause depression. CBT is designed to make people aware of these thoughts, to interrupt and reframe them. It is often as effective as antidepressants in treating mild and moderate depression, and better in terms of relapse rate. Nevertheless, people treated with CBT do relapse. One explanation is that CBT addresses the cognitive processes that dominate during a depressive episode, but there are underlying and ingrained thought processes that persist even in remission. Give people a list of adjectives, ask them which apply to them, and those who have been depressed but are in remission will nonetheless pick out more negative words than those who have never been depressed.
The authors theorize that there remains a tendency, even in remission, to revert to a depressive style of processing information under conditions that provoke vulnerability. They hypothesized that the treatment modality, antidepressants or CBT did not matter. What would predict relapse risk would be the level of that residual reactivity.
To overcome methodological limitations of previous studies, this group decided to start with subjects who were currently depressed, then treated to remission by a standard protocol for the study, either CBT or antidepressants, and then submitted to a mood provocation exercise that would allow the researchers to test their residual reactivity.
Okay, I have problems with an experiment that involves provoking depressive thinking in people who are at risk of relapse. But that is an ethics of design issue. Let's get to this month's Omgodthat'swhattheysaid Award, which is awarded for the use of language.
Under the conditions for the experiment, people who did not achieve remission after two drug trials were eliminated from the study. And here again is the winning quote: "The goal of treatment was to maximize the number of patients achieving clinical remission because this would then render them eligible for the mood challenge."
Get it? They want to make people feel bad. The goal of treatment for a disease with a 15% mortality rate is to provide subjects, or should we say rather objects for an experiment designed to make them feel bad. That's what they said.
Here is their recipe for creating a bad mood. Listen to Prokofiev's "Russia under the Mongolian Yoke" at a slow speed, while remembering a time in your life when you felt very sad. "This type of provocation (combining elements of music associated with sad mood and autobiographical recall) has been found to be effective in bringing on transient dysphoric mood states." I'll say it's effective. My therapist used to play a particular Enya cd in the waiting room to cover voices in her office. After the fifth time it made me too depressed to talk, she broke it. Of the 127 people who reached remission in this experiment, rather than submit to the mood provocation, fifteen of them evidently thought this experiment was whacked, took their good health and bolted for the door.
I suppose the mood provocation could be justified, ethically speaking, by the fact that these people are bound to experience mood provocation out in the real world anyway, as my experience in my therapist's office demonstrates. In fact, my massage therapist used to play the same cd. But I learned to ask her to take it off! Part of trying to maintain my health includes avoiding situations that threaten it, which explains why my therapist broke the cd that wasn't even hers, it was her office partner's. While the dysphoric state is said to be transient, if it does indeed cause the subject to revert to depressive thinking, it would reinforce harmful tendencies. The effects of that reinforcement might not be so transient, even after the conscious mood passed. It seems to me, they know their experiment causes harm. They want to find out how much harm.
In any case, the quote for which they won the award reveals their own underlying and ingrained thought processes. The purpose of treatment was not so that sick people would get better. It was so that the researchers could obtain subjects/objects for their experiment.
Following mood provocation both groups, those who were treated with CBT and those treated with antidepressants became about equally sad. They were then tested for cognitive reactivity -- the tendency to think negatively. Those treated with meds became more reactive in their thinking, immediately following the mood provocation. Oddly, the CBT group became less so. The researchers suggest that this might be because the experience triggered their CBT skills.
Eighteen months later, both groups had relatively equal relapse rates, the CBT group slightly less. The greatest indicator of relapse risk was an individual's number of previous episodes, confirming what is well known about MDD. Controlling for medical history, those who had become more reactive following the mood provocation did have a higher relapse rate, regardless of their treatment modality.
One explanation is that there is an underlying and unconscious cognitive structure in the person in remission, waiting to be activated by a sad mood. Alternately, the cognitive structure could be masked because it is suppressed; the sad mood places an additional load on the effort to suppress it, and eventually too great a load to be maintained. Myself, I would testify that this monitoring of thoughts is exhausting, and I cannot maintain it.
Okay, I will give them this credit, they are investigating what leads to relapse, about which there has not been much research. They are also peeking behind the veil of Cognitive Behavioral Therapy. I like the idea of a nonmedical treatment option for depression, but I do suspect that the "behavioral" part of the therapy is more significant than the "cognitive" part, i.e., that what changes is how the patient reports his/her thoughts, not what is going on inside the skull, that CBT does not go deep enough into the mind to affect the brain. And I note that this research could be cited to demonstrate an issue in my last post, that the mind has feedback loops that tend toward homeostasis, just like the brain. Relapse is all about the mind and the brain both maintaining homeostasis.
If this research leads to an improvement in the therapy, then perhaps that improvement justifies the suffering provoked by the research. Nevertheless I challenge the authors to look at their own underlying thought patterns and cognitive structures in relation to their subjects, as evidenced by their language. What do you think?
And do you have nominations for next months OMGod! Award?