Thursday 22 February 2018

What do talking therapies do to the ever-changing brain?

Mind and meaning....

A new study has shown a 28% rise in the prescription of antidepressants to children.
A new study has shown a 28% rise in the prescription of antidepressants to children.

Patricia Casey

The use of antidepressants has rocketed in recent years despite the ambivalence that many people have about taking such medications. The same holds true for anti-anxiety medication.

These have been the mainstay of treatment for the most common psychiatric disorders, i.e. depressive illness and generalised anxiety.

But, increasingly, people are opting instead for talking and behavioural therapies such as cognitive therapy, mindfulness and supportive counselling. The thinking is that these are natural and do not affect the brain, in contrast to what some mistakenly refer to as the 'chemical straitjacket' that medication imposes.

Nobody questions the mechanism by which talking therapies impact on symptoms such as low mood, poor self-confidence and worthlessness. Rather it is assumed that some mysterious 'psychological' mechanism brings this about. So the dichotomised thinking, that psychological treatments are for psychologically-based disorders and medications are for those that are biologically based, prevails. There is a firm belief among extreme and ardent adherents to the anti-psychiatry model of mental disorders that all psychiatric conditions, even schizophrenia and bipolar disorder, should be managed using psychotherapy.

The brain is the most difficult organ in the body to study; it is also the most complex. Access to it is very limited as it is encased in bone and if tampered with can result in serious physical incapacity and even death. Developments in neuroimaging over the past 20 years have made it increasingly visible and accessible for study. The tools that allow this utilise scans of various types.

Some focus on the structure of the brain itself and others on the cells within it. An MRI scan tells us what the brain looks like while functional MRI (fMRI), PET and SPECT scanning tells us how the brain is functioning based on changes to blood flow and metabolism in its cells.

Studies using these tools show us that the brain is a 'plastic' organ. In other words, it constantly changes. Since mental processes all derive from activity within the brain, it follows that the more accessible it is, the more we can learn about the range of normal and abnormal activities as well as the factors, such as treatments, that impact upon it.

There are now over 20 published studies on brain changes after psychotherapy for depression, anxiety disorders and emotionally unstable personality disorder (previously called borderline personality disorder), beginning in 1992.

They show that various talking therapies alter brain function in patients suffering from major depressive disorder (MDD), obsessive-compulsive disorder, panic disorder, social anxiety disorder, specific phobias, post-traumatic stress disorder and emotionally unstable personality disorder. Most have shown similar changes with psychotherapy and medication demonstrating that both interventions work in parallel.

But a few studies have shown that these therapies result in changes to different areas of the brain. For example, a 2004 study by Dr K Goldapple from the Rotman Research Institute in Toronto reported on the impact of cognitive therapy and an antidepressant (paroxetine) on people with major depression.

The response to CBT was associated with increases in metabolism in certain parts of the brain and these differed from the areas which the antidepressant appeared to target. Similar findings were found in a study of psychodynamic psychotherapy compared with fluoxetine (also known as Prozac).

Based on a number of studies showing that cognitive therapy changes the prefrontal cortex, the part of the brain responsible for higher-level thinking, it is possible that in those with major depression, cognitive therapy leads to physical changes to the parts of our brain relating to our perspective (higher level thinking) as well as our emotions. However, we know that not everybody responds to these treatments and identifying the underlying mechanisms for these treatment failures is hugely important also.

All these studies, however, have investigated the brain changes on the whole brain systems level. To understand the more basic mechanisms related to psychotherapy, possible molecular and cellular changes should also be studied.

Two Finnish studies have been reported, one using psychotherapy only and the other comparing psychotherapy with an antidepressant. Changes to the density of the receptors concerned with serotonin were found in both following successful treatment.

Studies in this area are in their infancy but they may provide enormous possibilities for enriching our understanding of how treatments work and, also, fail to work. We are now at a stage in our knowledge where we can no longer simply say an intervention is exclusively 'psychological' or 'biological'.

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