Wednesday, March 12, 2014

How Psychotherapy Changes the Brain

By Serina Deen, MD MPH

When I first see patients for evaluation, they often tell me that they’ve debated starting a “biological” treatment such as medication, versus a “psychological” treatment such as psychotherapy. I’m happy to report that as brain imaging technology advances, we’re finding that this distinction may be obsolete. 

Psychotherapy is also “biological” in that it can lead to real functional and structural changes in the brain.   In fact, sometimes psychotherapy and medication produce surprisingly similar changes in the brain.  We still have a lot to learn about the topic, but below are some examples of what researchers have been finding so far.
Functional Changes in the Brain:
In one study, researchers at UCLA found that people who suffered from depression had abnormally high activity in an area of the brain called the prefrontal cortex.  Those who got better after they were treated with a type of therapy called interpersonal therapy (IPT) showed a decrease in activity in the prefrontal cortex after treatment.  In other words, IPT seemed to “normalize” brain activity in this hyperactive region.

Another study looked at people who have obsessive compulsive disorder (OCD), who tend to have an overactive area of the brain called the caudate nucleus.  Treatment with a type of therapy called cognitive behavior therapy (CBT) was associated with a decrease in the hyperactivity of the caudate nucleus, and the effect was most evident in people who had a good response to CBT.  In other words, the better the therapy seemed to work, the more the brain activity changed.
Changes in Brain Volume:
People with chronic fatigue syndrome (CFS) suffer from debilitating fatigue.  People with CFS tend to have a decrease in a type of brain tissue called grey matter in the prefrontal cortex of the brain.  Researchers in the Netherlands gave people with CFS 16 sessions of CBT, and found significant increases in gray matter volume in the prefrontal cortex.  This seems to suggest that the CFS patients were able to “recover” some gray matter volume after CBT.
Similarities and Differences to Medications
Psychotherapy sometimes seems to work in similar ways as medications, and other times appears to have different mechanisms of action.
In the study mentioned previously about people with depression, both IPT and the antidepressant paroxetine (Paxil) showed a decrease in prefrontal cortex activity.  And with OCD patients, both CBT and the antidepressant fluoxetine (Prozac) produced similar decreases in activity in the caudate nucleus. 
However in a different study, the antidepressant Venlafaxine (Effexor) produced changes in different parts of the brain than IPT in depressed patients.  This shows that there is variability in how different treatments work in the brain.
How Psychotherapy Produces Brain Change
We now know that the brain keeps changing, even after we become adults.  Learning leads to the production of new proteins, which in turn can change connectivity in our brains in a process called neuroplasticity.   Indeed, researchers in Germany showed that certain neurochemicals involved in neuroplasticity increased in depressed patients who got better after a course of interpersonal therapy. 

Picking a Treatment that Works Best for You
Even though we know that both medication and psychotherapy can change our brain, we still have a long way to go in learning exactly how that happens and when to use what treatment. Given a specific mental illness, sometimes medications work best, sometimes psychotherapies are the best option, and sometimes it’s a combination of the two.  In addition, there are different types of psychotherapies that work for different illnesses, just as there are many different types of medications.  If you’re considering seeking help for mental illness, it would be helpful to talk with a trained professional about what would work best for you. 

Read tips on what to expect during your first visit with a psychiatrist  
"Let's Talk Facts" brochure on Psychotherapy
Brain Awareness blog post from NIMH Director Tom Insel, MD

Six tips for talking to your doctor about medication

For more information about psychotherapy







Wednesday, February 5, 2014

Effective Addiction Treatments are Available

By John Renner, MD and Frances Levin, MD

We are all saddened by the death of Philip Seymour Hoffman and the many other individuals who have died because of overdoses of heroin or pain medications.  For all of those individuals who struggle with opioid use problems, it is important to realize that help is available and that effective treatment can restore them to productive lives.  Some 4.7 million people in the U.S. have used heroin at least once in their lives.  It is estimated that nearly a quarter of people that use heroin become dependent on it.

Whether it be through mutual support programs such as NA, long-term residential treatment, or addiction pharmacotherapy with buprenorphine, methadone or ER naltrexone, no individual need fear that their condition cannot be treated.  Friends and family members also need to be educated in the use of intra-nasal naloxone for the reversal of opioid overdoses.  

APA has long fostered the development of addiction focused training
programs for psychiatrists.  Many psychiatrists have been specifically trained to provide office-based addiction pharmacotherapy and to manage the co-occurring psychiatric disorders that often complicate recovery from substance use disorders.  

More information:
·         Information on addiction
·         Opioid Overdose Prevention Toolkit (SAMHSA)
·         Substance use treatment locator (SAMHSA)
·         Buprenorphine Physician and Treatment locator (SAMHSA)
·         For psychiatrists:  Providers Clinical Support System for Medication Assisted Treatment

Blog contributors:

John Renner, MD
Member, APA Council on Addicition Psychiatry (Past Chair)
Director of Addiction Fellowship Program,

Professor of Psychiatry,  Boston University School of Medicine
Associate Chief of Psychiatry, VA Boston Healthcare System

Frances Levin, MD
Chair, APA Council on Addiction Psychiatry
Kennedy-Leavy Professor of Psychiatry, Columbia University Medical Center
Director, Addiction Psychiatry Fellowship,
New York Presbyterian Hospital
New York State Psychiatric Institute

Friday, January 10, 2014

Need a New Year’s Resolution? Try Exercise!

By Ahmed Raza Khan, MD, MPH
Child and Adolescent Psychiatry Physician at Stanford University School of Medicine

Most people know that exercise is beneficial for cardiac health and is prescribed by physicians for the prevention and alleviation of various medical complications. But what if I told you exercise can also significantly benefit your mental health in more ways than one? Let’s take a look at some of the ways exercise can improve mental health and how to incorporate this into your new year’s resolution list!
Exercise and Depression Prevention:More than 350 million people in the world suffer from depression and it is the leading cause of disability worldwide.  Exercise has often been considered as a supplemental tool in treating depression, but recent evidence points to exercise playing a role in the prevention of future depressive episodes. These recent findings show that even low levels of physical activity (e.g., walking less than 150 minutes a week) can prevent future depression. There has been significant research in the last few years that links cardiovascular health’s role in the origin of depression. This would certainly be a plausible explanation for why exercise may prevent depression.

Alzheimer’s Disease Prevention:Alzheimer’s disease is a chronic, degenerative disease of the brain that affects over 25 million people in the world. This illness leads to a progressive mental decline, steering its victims to dependence on caregivers and, eventually, death. Amyloid plaques are abnormal clusters of protein fragments that are found in the brains of patients with Alzheimer’s disease and are thought to play a major role in its progression. Recent studies have found that people who exercised at or above the levels recommended by the American Heart Association had significantly lower numbers of amyloid plaques than those who exercised less. This was the case for even those who carried the APOE-e4 gene variant, which is an established risk factor for Alzheimer’s disease. When people with the APOE-e4 gene variant were compared, those with higher levels of exercise had lower levels of amyloid plaques.

Improving Cognitive Functioning:Exercise has been shown to increase cognitive functioning in rats. As rats get older, their memory tends to diminish and this appears to be due to a drop of nerve synapses in the hippocampus, the memory center of the brain. But after 12 weeks of voluntary running, both memory and hippocampus nerve synapses were restored in these rats.

Consistency in Exercise:Recent neuroscientific studies have shown that the cognitive benefit of exercise may have a window of time. In fact, rats that improved their cognitive functioning by exercise, had this improvement dissipate in 3-6 weeks of inactivity. This is similar to what is seen with muscle mass or heart rate when exercise is withdrawn. This evidence intimates that exercise is beneficial for the brain and should be performed consistently.

The American Heart Association is a great resource for planning the amount and type of exercise one needs. They recommend at least 30 minutes of moderate-intensity aerobic activity at least 5 days a week for a total of 150 minutes or at least 25 minutes of vigorous aerobic activity 3 days a week for a total of 75 minutes. An easy target to remember: 30 minutes a day, 5 days a week.

Tuesday, November 19, 2013

APA Releases List of Five Uses of Psychiatric Medication to Question

Continuing the Conversation about Choosing Wisely: The American Psychiatric Association Releases List of Five Uses of Psychiatric Medication to Question

Joel Yager, MD, 
Professor, University of Colorado School of Medicine
Chair of the APA Council on Quality Care

Recently the APA released a list of “Five Things Physicians and Patients Should Question” in Psychiatry as part of the Choosing Wisely® campaign, led by the ABIM Foundation. The list identifies five specific evidence-based recommendations that can help physicians and patients make wise choices about their care.

The APA list contains the following five recommendations:
  • Don’t prescribe antipsychotic medications to patients for any indication without appropriate initial evaluation and appropriate ongoing monitoring.
  • Don’t routinely prescribe two or more antipsychotic medications concurrently.  
  • Don’t prescribe antipsychotic medications as a first-line intervention to treat behavioral and psychological symptoms of dementia.    
  • Don’t routinely prescribe antipsychotic medications as a first-line intervention for insomnia in adults.   
  • Don’t routinely prescribe antipsychotic medications as a first-line intervention for children and adolescents for any diagnosis other than psychotic disorders.
Why was this list created?
This list was created to help clinicians and patients reduce the number of times that certain medications are routinely prescribed in situations where other initial treatments might be preferable, and where risks of these medications’ harmful side effects could be decreased or avoided. 

Does this list apply to the care of children or adolescents?
For any indication and for any patient, the potential harms of treatment must be weighed against the potential benefits. For the Choosing Wisely campaign, the APA recognizes that for some young patients in some circumstances an antipsychotic medication may turn out to be an appropriate choice of treatment if the clinical benefits are judged to outweigh potential harms after the patient receives appropriate initial evaluation and will receive ongoing monitoring. However, the APA advises physicians and patients to question the routine use of antipsychotic medications in children and adolescents for clinical circumstances where these medications are not endorsed by available clinical practice guidelines or lack explicit FDA approval indications for their use.

Why the Choosing Wisely Campaign?
The facts driving the Choosing Wisely effort are well known: Current health care practices in America spend too much money on unnecessary tests and procedures that do not benefit patients and that may even cause unintended harm. According to a report from the Institute of Medicine, up to 30 percent of health care delivered in the United States is wasteful. Providers and economists agree that these costly unnecessary practices threaten America’s ability to provide the highest quality of care possible to all patients.

Choosing WiselyThrough the Choosing Wisely campaign and by publishing this list, the APA hopes to spark conversations between its members and patients about whether certain tests and treatments are really necessary or the best ones to choose. The APA joined the campaign because it recognizes that physicians have professional, moral and ethical responsibilities to take the lead in addressing these challenges.

While the APA has taken a bold step in identifying and developing the list, our work doesn’t stop here. Over the coming months and years, the APA will be working with the ABIM Foundation, Consumer Reports, and a variety of other Choosing Wisely campaign stakeholders to raise awareness of these lists and to make them available to patients and the public at large.     

Learn more about Choosing Wisely and read all the lists released to date at

Monday, October 28, 2013

Cyberbullying: an Update on Intimidation in the Digital Playground

By Arshya Vahabzadeh, M.D.
American Psychiatric Association Leadership Fellow

Resident Physician in Child and Adolescent Psychiatry at MGH/McLean/Harvard Medical School

What is cyberbullying?
Cyberbullying is bullying, intimidation, and harassment that happens with the aid of electronic technology. Cyberbullying can happen through text messaging, social media, and emails. The boundaries of cyberbullying continue to expand as new communication technologies emerge.
Cyberbullying is emerging as a major problem, with new research from the Bureau for Justice Statistics revealing that 9% of teenagers aged 12-18 have reported being cyberbullied in a given year.
Female students are more likely to experience cyberbullying. The most common forms of cyberbullying include harassment by text or instant messaging, or the posting of hurtful information on the internet. Despite the high levels of cyberbullying, an adult is notified in only a quarter of cases.

How is cyberbullying different than traditional bullying?
Cyberbullying can continue 24 hours a day and is not dependent on location. While traditional bullying often requires the physical presence of a bully, a child can be cyberbullied at anytime and anywhere they are in contact with communication technology, including their own cell phone. There may be no “safe” zone and this may intensify the level of distress that the cyberbullying can produce.

Material such as digital pictures, text messages, or social media posts designed to hurt an individual can be rapidly distributed to a large group of people. Often it is difficult to find out the source of the information, giving a degree of anonymity to the cyberbully.
Harassing and intimidating material, once distributed through digital means are also much more difficult to remove. Often videos or pictures may stay indefinitely available through digital means.

What are the effects of cyberbullying?
People who are cyberbullied are thought to be at risk of the same consequences of traditional bullying. These effects include increased depression, decreased self-worth, hopelessness, and loneliness. There is some evidence to suggest that being cyberbullied may result in suicidal feelings in 20% of teenagers, a higher rate than in traditional bullying.

What can we do about cyberbullying?
Promote Good Digital Habits
  • Keep your children informed about the risks of the technology they are using.
  • Engage your children in a discussion on how to best deal with cyberbullying by formulating a plan for dealing with text messages or other digital content that is upsetting to them. Children should be made to feel as comfortable as possible in discussing their experiences with trusted adults.
  • Review and teach them about privacy settings for digital media. Talk to them about limiting the amount of private information they share about themselves.
  • Tell children to keep their passwords safe and not to share them with friends or people they don’t know.
Take Action
  • Approach a child if you notice signs of changing behavior, especially if it is happening when they are using the computer, their cell phone, or any other communication device.
  • Consider discussing the situation with the suspected bullies’ parents, the child’s school, and other organizations they may be involved in.
  • Identify and archive the cyberbullying material, it may be useful when contacting the Internet service provider, cell phone company, or in severe circumstances, the police.
  • Consider closing down targeted social media accounts or changing cell phone numbers.
  • Some cyberbullies thrive on obtaining a reaction, avoiding replying to messages or engaging with the cyberbully may also be useful in some situations.
Public Service Announcement:
f"> Where can I get more information?
More on cyberbullying from and  and

More on bullying