Clinician's Digest By Garry Cooper
Do Antidepressants Work?
For the second time in six years, a metanalysis led by psychologist Irving Kirsch asserts that antidepressants are no more effective than placebos (see November/December 2002 Networker). Like his earlier analysis, Kirsch analyzes both published clinical trials and the raw data that pharmaceutical companies are required to submit to the Food and Drug Administration. This time, Kirsch asks whether the same antidepressants he studied earlier--Prozac, Effexor, Serzone, and Paxil--work better than placebo on severe depression. The answer, he says, is still no.
Kirsch insists that using the raw data enables him to avoid the well-known bias toward positive results inherent in published studies of antidepressants. A study in the January 17 New England Journal of Medicine, for example, reports that 94 percent of the published trials were positive, whereas only about 50 percent the unpublished studies were. Raw data, unlike published studies, aren't methodologically tweaked to insure positive results.
Like Kirsch's earlier study, the new one, in the February online journal Public Library of Science Medicine, has generated considerable controversy. Much of the criticism focuses on his decisions about what constitutes clinical effectiveness, which his detractors say were arbitrary and ignored the considerable number of individuals who show marked improvement. Using the same data as Kirsch, psychiatrist Eric Turner and psychologist Robert Rosenthal conclude that each drug is indeed superior to placebo in the March 8 online edition of the British Medical Journal.
Nevertheless, in the wake of Kirsch's study, British Health Secretary Alan Johnson has announced plans to train 3,600 more therapists, hoping that with more therapists available, doctors won't reach as quickly for their prescription pads.
Assessing Graduate School Training
How well do graduate schools train students to do therapy? Nicholas Ladany of Lehigh University in Bethlehem, Pennsylvania, who trains therapists and supervisors around the world, says not very well. In last December's Psychotherapy: Theory, Research, Practice, Training, he summarized the findings of four articles that explore the components of effective education for therapists, concluding that a "large percentage of therapists enter graduate school with a low ability for helping . . . and the same large percentage leave it as mediocre to poorly functioning therapists."
Studies of practicing therapists find that learning about psychological theories and principles doesn't significantly improve their clinical outcomes. Only direct experience through such techniques as role-plays and participation in actual therapy (as clients and therapists) develops clinical skills like empathy, active and deep listening, timing, intuition, and understanding of clients, says Ladany. Unfortunately, most graduate programs adhere to what therapy researcher Larry Beutler ironically calls the "germ theory" of learning: they seem to believe that students exposed to concepts will somehow catch the clinical skills.
One way to produce better therapists, Ladany says, is to have graduate programs identify students who have an aptitude for learning clinical skills and divert those who don't to nonclinical tracks. Currently, schools rely on students' own judgments about whether they should become therapists.
Ladany, coauthor of the forthcoming book Practicing Counseling and Psychotherapy: Insights from Trainees, Clients and Supervisors, often runs into professors who challenge his assertions about the inadequacy of graduate psychology programs. He asks them whether they'd refer a close family member to one of their graduating therapists. "About a third of the time," he says, "the answer is no."
Do Cancer Support Groups Increase Survival Rates?
Physicians and therapists have recommended psychosocial support groups for thousands of cancer patients ever since Stanford University psychiatrist David Spiegel's landmark 1989 study found that women with breast cancer who attended a support group had a significantly greater survival rate. …