In the last couple of weeks, there have been some big announcements from the medical and mental health communities about the wisdom of using drugs over behavioral methods for various disorders. The meds vs. therapy debate has been an active one for a number of years. But these days, some experts and organizations are questioning, more and more, whether popping pills should really be our go-to treatment, based on the literature. And it seems that for some that have historically used meds as the first line of treatment, the evidence for behavioral methods has mounted to the point where recommendations have shifted in their favor. At least for some things.
“Considering behavioral interventions (therapy) prior to medication is a long-overdue recommendation,” says psychologist Shannon Kolakowski, and author of the book When Depression Hurts Your Relationship. “I am thrilled to see this progress, as it reflects what I see in my daily practice. People make tremendous strides with therapy alone. Having therapy be officially recommended as a first line of treatment reduces the stigma about therapy and adds validity to an already established, vetted treatment.”
And research is, as it should be, what’s driving the trend. Studies are making more rigorous comparisons between methods, and learning more about how to determine various measures, like the benefit vs. risk ratio and relapse rate, of each one.
“Over the past two decades, the field of psychology has become a more rigorously tested science, with treatment outcomes measured and reproduced, and therapy guidelines have followed,” says Kolakowski. “This has led to effective, evidence-based treatment people receive in therapy sessions. The changing recommendations are a reflection of how effective therapy is for a host of behavioral and emotional problems.”
Here are a few things for which recent research has prompted changes in go-to treatments.
Behavioral Interventions for ADHD/ADD in Kids
There’s been a big backlash in recent years regarding the advisability of prescribing stimulants like Ritalin and Adderall for children, especially very young ones. The numbers of kids with ADHD have risen markedly in recent years, with many questioning whether this is a true rise in incidence, or it’s a result of diagnosis-eager physicians or even shortcomings in our education system. In any case, the CDC has just released a new recommendation that behavior therapy, rather than medication, should be the first line of treatment for children with ADHD.
“Parents may feel overwhelmed with decisions about their child’s treatment for ADHD, but healthcare providers, therapists and families can all work together to help the child thrive,” said Anne Schuchat, Principal Deputy Director, CDC. “Parents of young children with ADHD may need support, and behavior therapy is an important first step. It has been shown to be as effective as medicine, but without the risk of side effects. We are still learning about the potential unintended effects of long-term use of ADHD medicine on young children. Until we know more, the recommendation is to first refer parents of children under 6 years of age with ADHD for training in behavior therapy before prescribing medicine.”
Cognitive Behavior Therapy for Insomnia
As of this week, the American College of Physicians believes that for insomnia, cognitive behavior therapy for insomnia (CBT-I) should be the first line of treatment, rather than meds, since it has better scientific evidence behind it. And meds can come with all sorts of negative side effects. As per the new recommendations, CBT-I should be used first as a matter of course.
“Cognitive behavioral therapy for insomnia is an effective treatment and can be initiated in a primary care setting,” said ACP President Wayne J. Riley. “Although we have insufficient evidence to directly compare CBT-I and drug treatment, CBT-I is likely to have fewer harms. Sleep medications can be associated with serious adverse effects.”
The experts add if that if the behavioral strategy alone doesn’t work, then the pros and cons of medication can be discussed. And if it’s deemed necessary by both patient and doctor, it can used for four to give weeks, while still doing CBT-I.
Therapy for Depression
The U.S. Preventive Services Task Force recently recommended that everyone aged 12-18 be screened for depression. The first line of treatment for depression is still somewhat up for grabs, but the effectiveness of antidepressants is being called into question more and more, while the research behind the value of behavioral interventions is growing. Last week, a study suggested that mindfulness-based cognitive therapy (MBCT) was as effective in preventing relapse in chronic depression as antidepressants. This is not the first to suggest a similar thing. There are of course certain cases in which medication is absolutely necessary. But in some cases, perhaps in many cases, behavioral strategies should be the first line of treatment instead of medication for certain mood or anxiety disorders. And doctors are beginning to realize that.
“I've noticed that many of my referrals come from physicians and pediatricians, who are now recognizing that therapy should be used for treatment of behavioral issues before they prescribe medication,” says Kolakowski. “This is further evidence of the trend we are seeing, and I see many people in my practice who would not have sought out therapy had not their doctor recommended it as a first line of treatment. The exception is with severe cases, sometimes medication and therapy in conjunction is best. But again, I think medication alone is a disservice.”
So far, the shift in attitude is promising. And insurance companies are slowly beginning to reflect the changing tides. “Mental health parity laws which ensure that therapy is covered by insurance companies just as any medical treatment is covered,” says Kolakowski, “are also in line with the change in recommendations. Parity laws recognize that mental health is a medical condition that affects people as a disease, and should be covered and treated as such.”
Time will tell whether more experts and guidelines recommend behavioral methods as a first treatment for other disorders. If you're dealing with any kind of mental health issue, the most important thing is to talk with a professional, and understand all the pros and cons of each treatment, before making the best decision for your, or your kids', specific situation.
