Treatment of Psychological Diseases and Disorders

According to the most recent Diagnostic and Statistical Manual of Mental Disorders (DSM-IV), there are nearly 400 different psychological disorders. Some of these disorders fit the definition of “disease,” a problem that impairs functioning and that mostly stems from biological causes.  Common examples include bipolar disorder and schizophrenia. Other “disorders” impair functioning but are determined by a more diverse array of causes, some of which are psychological and social / cultural in nature. In this sense, these conditions are not true “diseases.” Examples include anxiety disorders, depression, eating disorders, and substance use disorders.

The distinction between “diseases” and “disorders” helps to suggest appropriate treatments. In general, diseases require biological intervention. Research suggests, for example, that medication is very successful in helping individuals to manage symptoms that accompany bipolar disorder and schizophrenia. Although it may encourage them to take their medication regularly, manage stress effectively, and help with emotional struggles, research shows that psychotherapy generally does not help people overcome the symptoms of these diseases without biological intervention.

Biological treatments also may help people with disorders in some cases. For example, in one of the largest and most rigorous studies ever conducted on the treatment of clinical depression, researchers in the late 1980s found that antidepressant medication helped manage the symptoms of severe depression (which I would define as involving significant suicidal thinking, that often recurs, or that is chronic) more than other treatment options, at least during the time span in which individuals were taking the medicine.

On the other hand, decades of carefully controlled clinical studies have shown that medication often is not the best treatment for many disorders. For instance, a recent meta-analysis found that antidepressants generally perform no better than a sugar pill in the treatment of depression that is mild or moderate in severity (read more at http://jama.ama-assn.org/cgi/content/short/303/1/47?home). Often times, any symptom relief that medication provides ends when individuals stop taking them.

Increasingly, I also see researchers skeptical of the underlying pharmaceutical claim that “chemical imbalances” of serotonin explain why some people struggle with emotional disorders. Apparently, some of the best evidence that there is a chemical imbalance of serotonin involved in disorders such as depression is that antidepressant medications sometimes help. However, this is akin to saying that if Tylonol sometimes helps you overcome a headache, then headaches must be caused by a “Tylonol imbalance.” This doesn’t necessarily take away from the fact that antidepressant medications can be helpful in some circumstances, but it does suggest, at least, that the mechanisms by which antidepressants sometimes work are in question by many in the scientific community.

Approximately 5% of all American men and approximately 10% of all American women are taking an antidepressant medication for some reason. Many of these individuals suffer from significant side effects from the medication. Others believe that they are being helped by the medicine and thus do not work to resolve the underlying issues that are at the “root” of the problem. In fact, much of the therapeutic effect of medicine likely stems from psychological factors such as cathartic release of telling their doctor about their problems, the relationship between them and their doctor, or the faith or hope they experience from the treatment. Of course, there are other ways to treat psychological disorders that may provide these factors without needing to take a pharmacological substance.

The best treatment option for many people who struggle with disorders is psychotherapy. Several forms of psychotherapy – cognitive therapy, behavioral therapy, interpersonal therapy, and psychodynamic therapy – have been found to successfully treat many disorders, including disorders with severe symptoms.  Furthermore, compared with the effects of medication, psychotherapy often seems to provide better treatment in the long-term. Perhaps one of the reasons why psychotherapy is so helpful in many cases is that it gets at the “root” causes of people’s problems. Furthermore, although psychotherapy seems unrelated to biology, research shows that biological changes happen through this treatment just like it does when medication is helpful.

Available research suggests that there is not necessarily one kind of psychotherapy that is better than the rest (the main exception being that exposure based treatments seem to work better than all other treatments for anxiety disorders). Rather, it seems that there are certain “common factors” involved in good treatment, including a trusting relationship with a treatment provider, client factors such as motivation to follow suggestions, and the faith and hope that the treatment will help. Based on this, individuals struggling with depression would do well to seek a referral to a good therapist and “try them out” to see how they “click” with them. Usually, someone can tell after the first session whether they like the therapist. If the first therapist one tries doesn’t work out, another provider might work better.

There also are other activities that might help people with disorders. Some of these might be encouraged by a therapist, and include working through self-help materials (see David Burns’ books “Feeling Good” and “When Panic Attacs” for books shown to work in comparative research), regular aerobic exercise, keeping an emotions journal in which one writes about difficult emotions, keeping a gratitude journal in which one records what one is most thankful for, engaging in pleasurable activities, talking with a trusted friend about one’s problems, performing random acts of kindness, getting lost in nature, and managing stress through effective coping techniques. Although these kinds of activities haven’t really been established as successful treatments in themselves, they are linked with mood in various ways. In fact, I wouldn’t be surprised if many of these lifestyle-based approaches someday are shown to perform at least as well as – if not better than – conventional treatments available today.

In conclusion, people struggling with a mental illness should know that there is hope. Almost all conditions can be managed effectively through the right combination of treatment options. Many disorders can be overcome long-term without the use of medicine. Probably the most difficult step in treatment is acknowledging that you have a problem and taking the first step to seek help. However, with this humility and courage, people can experience relief and improvement.

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