I've written before about the the failure of basic neuroscience research to advance neuropharmacology (at least, it's been a failure so far), but it's nice to see Eric Kandel, my old mentor (and one of my scientific heroes), make the same argument. Kandel began his scientific career as a Freudian psychiatrist - he was soon turned off by the blatant the lack of empiricism - so his recent interest in the biological benefits of talk therapy, and ways of rigorously measuring those benefits, provides an interesting snapshot on the state of neuroscience.
On the one hand, it's sobering that talk therapy remains the most effective treatment for a wide variety of illness, from chronic back pain to depression. Alas, this says more about the failure of pharmacology than it does about the therapeutic value of talk therapy. On the other hand, science is finally beginning to understand the anatomical mechanisms that allow talk therapy to work. We can see how mere words and conversation profoundly influence the activity of the brain. Here's Kandel, writing for the Dana Foundation:
The other thing that has impressed me is that in the last 20 years we've had no advances in pharmacotherapy. We started off with interesting antipsychotic agents, interesting antidepressants, but they really have progressed very modestly. Selective serotonin [re]-uptake inhibitors--each company's copying from the other using exactly the same assays to develop it. Twenty years, and there's general agreement that there is no difference between most of the selective serotonin [re]-uptake inhibitors and no improvement either. A drug sells not because it's any better than any other but because there are major names associated with it.In schizophrenia, the issue is even worse, because for 45 years there probably hasn't been a better drug. There are drugs that have better side effects, but there have not been major developments in drugs.
The one thing that has become better is the legitimacy of psychotherapy. There are several behavioral therapies out there--interpersonal therapy, cognitive behavioral therapy--that have been shown in rigorous control studies, in depression, for example, to be at least as good as selective serotonin [re]-uptake inhibitors for mild and moderate depression and to be synergistic with drugs in severe depression.
Moreover, we've beginning to identify--particularly in depression--certain areas of the brain that function abnormally. For example, [Emory University psychiatry professor] Helen Mayberg showed that [Brodmann] area 25--the subgenual cingulate cortex--is hyperactive in depression. This area connects to the amygdala; the amygdala also is hyperactive in depression. When patients respond to psychotherapy, those abnormalities reverse. So for the first time we not only have a psychotherapy that works but we have an independent, biological measure, an assay, and we can see to what degree this works.
Thanks Ted!
Brain & Behavior
Comments (842)
From the clinical trials point of view, each SSRI helps about 2/3 of patients taking each drug. That doesn't equate to no differences among them. As patients and clinicians will attest, there can be profound differences in efficacy and in tolerabiity for individuals, which is all that matters for the patient.
For the scientist and the psychopharmacologist, mechanisms of action matter more, as each new type of compound reveals something new about the brain. As much as I am loathe to disagree with Dr. Kandel, the locus of "better" is the patient, and not the pharma company or researcher's name. Prozac, Paxil, and Effexor sell, while Serzone was taken off the market.
Posted by: Howard | December 30, 2008 10:52 AM