In general, the goal of treatment is to change thoughts, behaviors, or emotions. This means that in order to consider the possibility of treatment, we must believe that change is possible. For most of human history, the conditions for people suffering from psychological disorders made it virtually impossible for them to improve. Sufferers have been persecuted and subjected to cruel practices; trapped not only in their own minds, but also in physical restraints. Unfortunately, today a large number of mentally ill people remain locked away in penitentiaries, being penalized rather than protected, and tortured rather than treated.

Despite this, treatment is better than it ever has been. As a society, we owe a great debt to early reformers such as Philipe Pinel (1745-1826), who called for exercise, fresh air, and the removal of chains and shackles from the mentally ill in France, and Dorothea Dix (1802-1887), who called for the creation of mental health hospitals in the United States and advocated for more humane treatments for the mentally ill. In the past few decades, stigma has been further reduced and care has been greatly improved, but there is still progress to be made.

Psychiatrists hold an MD (or a DO – Doctor of Osteopathic medicine) and are licensed physicians who specialize in mental health issues. They are able to prescribe medications and usually work in hospitals, institutions, or their own private practices. Neurologists also hold an MD (or DO) and are physicians who specialize in the brain and nervous system. Clinical psychologists hold a Ph.D (or a Psy.D) and specialize in psychotherapypsychotherapyThe use of psychological techniques by a trained therapist to treat emotional, behavioral, and mental disorders.. They do not usually have prescription privileges, though this is beginning to change in some places. Counseling psychologists hold a master's degree or a Ph.D in counseling and usually specialize in mild to moderate mental health issues, providing things like family and couples therapy, grief counseling, or career counseling. Clinical social workers hold a 2-year master's degree in social work and may also have specialized training in certain types of counseling. They may work in a variety of settings including mental health facilities, substance-abuse clinics, veterans' affairs centers, and child welfare agencies.

This may seem like an obvious question, but while psychological disorders are, by definition, distressing to sufferers, this is not the only reason for treatment. Psychological disorders carry many other costs as well, which include costs to the individual (including social, financial, and occupational costs) as well as costs to society in the form of lost productivity, absenteeism, and costs of treatments and institutions. It has been estimated that anxiety disorders alone cost the United States an estimated $42.3 billion dollars each year.

Now that treatment is more humane and more widely available than ever before, it may come as a surprise that many people who are suffering are not currently receiving treatment. Why doesn't everyone get treated?

In some cases, people may not recognize that they need to be treated. Misconceptions about mental illness may cause people to suffer without feeling that they are “bad enough” to need treatment. Or they may believe that their symptoms are personal weaknesses that must be overcome. Of those that do recognize the need for treatment, they may not always be willing or able to receive help and well-trained mental health professionals may not be readily available. Even where help is available, people may not be well-informed of treatment options.

Recognition, availability, and awareness of options are not the only barriers to proper mental health treatment. Stigma still exists, and some potential patients may not seek treatment due to the acknowledgment of mental illness it entails. There are also bureaucratic hurdles which must be overcome, and some sufferers who are willing and able to seek treatment may face wait lists, financial difficulties in paying for treatments or getting insurance, linguistic or cultural barriers, or problems getting appropriate treatments for their particular illnesses.

There are also ethical implications when it comes to considering treatment. Ideally, every person who needed treatment would recognize the need and freely choose to be treated, but unfortunately this is not the case. Should some people be forced to undergo treatment? Thomas Szasz noted that while we might hope to view psychiatrists as agents of the mentally ill, there are situations in which they act as the agents of others; family and friends of the ill, law enforcement, private organizations, or courts.

Though the DSM-5 has slightly reduced the total number of disorders compared to the DSM-IV-TR, critics still claim that it represents a medicalization of daily life which causes otherwise normal aspects of the human condition to be seen as symptoms of illness requiring treatment. Are pharmaceutical companies too eager to push (and profit from) the sale of drugs to an increasingly large number of patients?

For instance, the DSM-5 removed the bereavement exclusion for depression, meaning that previously you couldn't be diagnosed with depression if your symptoms followed the loss of a loved one, but now you can be. Critical psychiatrists have questioned whether we should be attempting to medicate away some negative emotions, regardless of how painful they may be. Which kinds of suffering are the “right” kinds of suffering and which should be treated? Should we make this decision for other people? How do we say that one person's suffering is appropriate and necessary and another's should be chemically blunted? Which of the slings and arrows of life should we be forced to bear, and which should be pharmaceutically excised?

The two main branches of treatment are psychotherapy and biomedical interventions. The term psychotherapy covers a broad range of therapies including psychoanalysis, humanistic therapyhumanistic therapyTherapy emphasizing personal growth, self-acceptance, and the actualization of potential., cognitive therapycognitive therapyBeck's therapy targeting automatic negative thoughts and core dysfunctional beliefs that maintain distress., behavioral therapy, and eclectic therapies, which combine elements of multiple types of psychotherapy (and may also use biomedical treatments). Biomedical interventions include the use of medications, stimulation, and in some cases, surgery.

Freud's psychoanalytic approach to treatment was based on gaining insight into the unconscious. A combination of free associationfree associationA psychoanalytic technique in which the patient verbalizes thoughts without censoring, to reveal unconscious material., dream analysisdream analysisA psychoanalytic technique interpreting the manifest and latent content of dreams to access unconscious material., and interpretation (sometimes called the “talking cure”) was used to resolve conflicts and reduce anxiety, which Freud believed were the source of mental illness. Freud thought that patients may initially show resistanceresistanceIn psychoanalysis, the patient's unconscious blocking of material that would cause anxiety if brought to awareness. to therapy, to avoid confronting the unconscious, but that this could be overcome by “working through” conflict over time. As resistance faded, Freud believed that a process of transferencetransferenceIn psychoanalysis, the patient's redirection of feelings about important people in their life onto the therapist. would occur, in which patients would redirect some strong feelings (love, hatred, etc.) onto the therapist, who could then work to resolve these feelings. Traditional psychoanalysis is not commonly practiced today, though some aspects of it remain, particularly in interpersonal therapy, which focuses on improving relationships.

The humanistic approach grew out of psychoanalysis but emphasized a more positive view of human nature and focused on striving for improvement rather than battling unconscious forces. The person-centered therapy (also known as client-centered therapyclient-centered therapyRogers' humanistic therapy providing unconditional positive regardunconditional positive regardRogers' concept of complete, non-judgmental acceptance of a client — a core condition of effective therapy., empathy, and genuineness to promote self-growth.) of Carl Rogers focused on developing self-awareness and self-acceptance. The goal of therapy was personal growth rather than a “cure” and conscious thoughts were considered to be more important than unconscious influences.

The therapist's role in this humanistic approach was to offer acceptance and genuine reactions to the patient, with the assumption that the patient would realize the correct path toward growth. In order to facilitate this, the therapist would provide empathy and unconditional positive regard, attempting to understand the patient's experience and reflect it back in a positive way. This was accomplished by active listeningactive listeningThe therapist technique of reflecting back and paraphrasing what the client says to show understanding., in which the therapist would listen to clients, then echo, clarify, and acknowledge their views, allowing them to gradually gain greater awareness.

Frederick “Fritz” Perls developed a humanistic approach called Gestalt therapy, which drew inspiration from the Gestalt psychologists of the early 20th century. The goal of gestalt therapy was for a patient to confront thoughts, behaviors, and feelings, take full responsibility for them, and integrate them into a coherent whole (gestalt). This was accomplished using a variety of techniques, most notably the “empty-chair technique”, in which the patient imagined another person (mother, father, etc.) in an empty chair and talked openly, imagining and role-playing responses from that person.

The behaviorist approach to therapy is based on the learning principles of classical and operant conditioning, emphasizing that inappropriate responses can be extinguished and more constructive behaviors can be learned in their place.

Aversion therapyAversion therapyA behavior therapy pairing an unwanted behavior with an aversive stimulus to reduce its appeal. stops problematic behaviors by using classical conditioning. By pairing maladaptive behaviors with punishment, they can be extinguished. For example, the drug Antabuse (don't worry, it doesn't involve abusing ants), or disulfiram, can be used to discourage alcohol consumption. If alcohol is consumed while on Antabuse, this causes nausea and vomiting, even after only one drink. These negative consequences can discourage potential drinkers from breaking their sobriety. While this can be successful in the short-term, it may not be as effective long-term because it doesn't teach coping strategies or reduce cravings for alcohol so users may stop taking the drug to avoid the negative consequences.

Behavioral techniques have greater success when it comes to extinguishing unwanted emotional responses. Exposure therapyExposure therapyA behavior therapy in which clients are repeatedly exposed to feared stimuli until the fear response extinguishes. is an effective intervention for overcoming phobias and anxiety. This therapy involves repeatedly confronting a feared stimulus or situation in order to decrease negative emotional responses to it.

Counterconditioning refers to overcoming a negative response (such as fear) to a stimulus by repeatedly pairing the stimulus with something that evokes a positive response. In 1924, Mary Cover Jones described using this approach to rid a boy named Peter of his rabbit fear but it did not become a widespread therapeutic technique until it was popularized by Joseph Wolpe a few decades later. Wolpe's exposure therapy used a process of systematic desensitizationsystematic desensitizationA behavior therapy technique pairing relaxation with gradual exposure to feared stimuli to extinguish phobias., teaching a person to remain relaxed in the face of increasingly threatening stimuli. In the case of a snake phobia, a person would be taught relaxation techniques, then would practice using these techniques while thinking about a snake, then viewing an image of a snake, then a real snake (known as in vivo exposure), until the person was eventually able to hold a live snake without showing a fear response. Throughout this process the therapist would also serve as a model for appropriate behavior, handling the snake without showing fear.

In vivo exposure is not always practical, so modern exposure therapy also uses virtual reality to simulate situations which are costly or difficult to recreate, allowing patients to learn how to decrease their unwanted emotional responses to situations like combat or airplane travel.

More recent research has demonstrated that the progressive relaxation techniques taught by Wolpe are not essential to this process, and unwanted emotional responses will naturally tend to fade following exposure. Rather than systematic desensitization, some therapists use floodingfloodingAn exposure technique involving immediate, prolonged confrontation with the feared stimulus rather than gradual approach., in which the patient is immediately confronted with a “worst-case” scenario rather than gradually building up the intensity of the stimulus. While jarring, this approach can be effective and may shorten the time needed to extinguish the unwanted emotional response.

Exposure therapy can also be used for other types of disorders by preventing behaviors. In the case of OCD, patients might be exposed to a situation (putting their hands in dirt) but not be allowed to engage in the behavior they would usually respond with (washing their hands). This approach, known as response prevention, forces patients to learn new ways of coping with the anxiety they feel in order to break out of their usual responses.

The principles of operant conditioning can also be used for behavior modification and shaping desired behaviors. In a token economytoken economyA behavior modification program using tokens as secondary reinforcers to reward desired behaviors., people are given rewards (such as tokens) for completing desired behaviors, and these tokens can then be redeemed for other rewards such as television watching, special meals, or trips. This approach can be used to boost social interaction in children with autism, or for skills training that can allow people with disorders or disabilities to become self-sufficient and live on their own. What happens when the token economy is no longer there to reward behaviors? In many cases, the behaviors and skills being taught are designed to be rewarding for their own sake. So when a person has learned how to interact well with others or how to fill out the forms necessary to pay bills or order food, these now have real-life rewards that replace the token economy training.

Cognitive therapy focuses on thinking patterns associated with particular disorders and aims to improve reasoning, self-control, and responses to events, giving patients new ways of thinking.

The goal of Aaron Beck's Cognitive Therapy was to identify distorted views about the self, others, and the world (which Beck referred to as the cognitive triadcognitive triadBeck's model of depression involving negative views of the self, the world, and the future.) then correct these views by challenging the beliefs behind them. Beck taught patients to avoid catastrophizing, or imagining the worst possible consequences of minor events (i.e. “I failed my math test, so I'm not going to get into college, which means my life is ruined”). The role of the therapist was to gradually reveal these faulty thinking patterns, then challenge them, allowing patients to become more aware of their thoughts and how to change them.

Albert Ellis used a more direct approach, and in his Rational Emotive Behavior TherapyBehavior TherapyTherapy applying learning principles — classical and operant conditioning — to eliminate maladaptive behaviors., the therapist would point out errors in a patient's thinking, then work to resolve them. In both cognitive therapy and rational emotive behavior therapyrational emotive behavior therapyEllis's CBT precursor targeting irrational beliefs that cause emotional disturbance — REBT., the goal is cognitive restructuring, getting patients to question their beliefs, assumptions, and predictions about the world, then encouraging them to replace these with more realistic and positive ways of thinking. Modern cognitive therapists may draw inspiration from both Beck and Ellis, in addition to using other techniques such as mindfulness meditation in order to teach patients how to detect cognitive and emotional issues before they become problems.

As the name suggests, Cognitive-Behavioral TherapyCognitive-Behavioral TherapyAn evidence-based therapy combining cognitive restructuring with behavioral techniques — CBT. is a combination of techniques from both cognitive and behavioral approaches, in addition to some unique features. CBT is problem-focused and action-oriented, meaning that it has a narrow focus for which areas of thinking need to be improved and it provides a structured program of behaviors for progress. Programs are flexible and can be tailored to each individual patient, and the purpose of the exercises is made clear to the patient, creating a sense of transparency. The patient and therapist meet with a specific agenda of problems to focus on, then work to restructure thinking in those areas. At the end of a session, the patient is given “homework” assignments to be completed before the next meeting, creating a relationship more like teacher-student than therapist-client. For example, a patient with OCD might work with a CBT therapist to recognize when obsessive thinking patterns occur, then create a list of alternative behaviors designed to interrupt these patterns. This approach can be effective, and PET scans have shown changes in the brain activity of OCD patients over time (Schwartz et al, 1996), reminding us that psychological interventions influence biology.

Some types of therapy are conducted in groups. Couples therapy works with partners to improve communication, deal with sexual dysfunction, domestic violence, or address specific problems that may influence the relationship (such as one person being diagnosed with depression). Family therapyFamily therapyTherapy treating the family system as a whole rather than just the identified patient. considers the system of relationships that has an influence on each of the individual members of a family. These family dynamics may play a role in some illnesses, such as parental pressures or sibling rivalries contributing to a teenage girl's development of an eating disorder.

In group therapygroup therapyTherapy conducted with multiple clients simultaneously — provides social support and shared experience., multiple people work on their own independent problems in a shared setting. This group format encourages social behaviors and social skills and it allows participants to get feedback from multiple people. Group therapy can be beneficial and it provides individuals with an opportunity to relate to others and reduce feelings of isolation or stigma associated with a disorder. In addition, group sessions with a single therapist and multiple participants are more cost-effective, reducing financial strain on individuals.

There are downsides to the group format, however, and all individuals in the group may not have similar needs, so treatments will necessarily be less focused. Group dynamics can also become negative if some members dominate discussions or make others uncomfortable and this may be difficult for a therapist to control. Patients may lose the incentive to improve if some behaviors are now seen as normal in the context of their new group, such as bulimia patients feeling that purging is common or that it is not a big deal because now they know many others who admit to doing it. Patients may also learn negative techniques from others, such as new methods of purging or how other patients with anorexia hid their weight loss from family and friends.

Like formal group therapies, self-help and support groups provide cost-effective and supportive groups for sufferers of specific problems, from alcoholism (AA) and gambling (Gambler's Anonymous) to social phobias (Toastmasters). These groups can provide support, reduce isolation, and foster a sense of community and public commitment to change. Often these group meetings are not run by trained therapists or counselors, which means some advice may be counter-productive, and in extreme cases, groups can become insular, encourage radical views, or even form cults.

One of the earliest biological interventions for the mentally ill was trephining (also known as trepanning) which involved drilling a hole in the skull in order to release the demons or spirits trapped within. Evidence of this practice (skulls with holes that show partial healing and bone growth) dates back as far as 6000BC. We've come a long way since then and psychopharmacology (the study of drug treatments for influencing emotions, thoughts, and behaviors) is far less invasive. Nevertheless, medications shouldn't be thought of as “magic bullets” for treating mental illness and their broad effects come with some costs.

One of the first antipsychotic medicationsantipsychotic medicationsDrugs that reduce positive symptoms of schizophrenia by blocking dopamine receptors. (also known as neuroleptics) for treating schizophrenia resulted from work to develop an antihistamine and was discovered in 1951. The result, chlorpromazine (Thorazine), and the other drugs which followed, thioridazine (Mellaril), and haloperidol (Haldol) would fundamentally change the nature of treatment for psychotic disorders. These medications, which rendered patients euphoric and docile, led to mass deinstitutionalization in the 1950s and 60s, releasing millions of patients and reducing hospitalization for mental illness by two-thirds. Release is not synonymous with cure, however, and many of these former patients were later unable to care for themselves, and ended up destitute and often homeless.

The main way these drugs work is by blocking dopamine activity, which led to the dopamine hypothesis that schizophrenia results from distorted dopamine signaling in the brain. While these early medications were able to reduce positive symptoms such as hallucinations, they weren't effective for negative symptoms such as emotional numbing or social withdrawal. These drugs have side effects which include sluggishness, tremors, twitches, weight gain (with increased risk of obesity and diabetes), and tardive dyskinesia; uncontrollable facial tics and twitches. Some patients experience akathisia (Greek for “unable to sit”), a painful restlessness and agitation which causes them to pace constantly in an effort to reduce pain and which can be severe enough to cause patients to refuse treatment. Newer drugs, known as atypical antipsychotics such as clozapine (Clozaril) risperadone (Risperadil) and olanzepine (Zyprexa), work on both dopamine and serotonin systems, are more successful in reducing cognitive and perceptual distortions, and tend to have fewer side effects.

Anti-anxiety medicationsAnti-anxiety medicationsDrugs that reduce anxiety — benzodiazepines enhance GABA activity; buspirone affects serotonin. (or anxiolytics) help to reduce anxiety and can aid the extinction of learned fears. Benzodiazepines are anti-anxiety drugs which work on the GABA system. Benzodiazepines take effect within minutes to reduce heart rate and anxiety. Side effects include drowsiness and problems with memory and coordination. While effective for reducing arousal and slowing heart rate, these drugs can be dangerous when combined with alcohol (which can lead to a fatal drop in blood pressure) and also carry high risk of addiction, dependency, and withdrawal. Sudden cessation of benzodiazepines results in symptoms of withdrawal that include increased heart rate, shakiness, insomnia, agitation, and anxiety. Common benzodiazepines include diazepam (Valium), lorazepam (Ativan), and alprazolam (Xanax). Due to growing recognition of risks, these drugs are now prescribed more cautiously and in lower dosages than they once were.

Given the side effects and potential for dependence, we may wonder if these drugs really treat anxiety or if they merely mask symptoms. Are people popping pills rather than learning coping strategies? While one could argue that these drugs are helping more people than ever before (prescriptions for anxiolytics doubled between 1995 and 2005) there's a possibility they are being over-prescribed for anxiety that isn't severe enough to warrant drug treatment.

One of the first drugs for depression was iproniazid, a treatment for tuberculosis which had the side effect of making patients euphoric (though it caused higher incidence of hepatitis and was discontinued). Iproniazid was the first of a class of antidepressantsantidepressantsMedications used to treat depression and anxiety — includes SSRIsSSRIsSelective serotonin reuptake inhibitors — antidepressants that block serotonin reuptake, increasing its availability at synapses., SNRIs, MAOIs, and tricyclics. known as monoamine-oxidase inhibitors (MAOIs). Monoamine-oxidase is an enyzme which breaks down monoamines (which include serotonin, dopamine, and norepinephrine), so inhibiting this enzyme may boost levels of these neurotransmitters. Unfortunately, blocking this enzyme also causes a host of side effects, including dizziness, and loss of sexual interest. It also has a dangerous interaction with food containing tyramine (common in fermented foods, cheese, and alcohol) and can lead to hypertensive crisis (extremely high blood pressure), which means that a very strict diet must be followed. Given these side effects and risks, MAOIs are rarely prescribed today.

The next class of antidepressants, introduced in the 1950s, were tricyclic antidepressants (TCAs), which are named for their three-ringed chemical structure and include imipramine (Thorazil) and amitriptyline (Elavil). These drugs block reuptake of serotonin and norepinephrine but they come with a number of side effects (including dry mouth, rash, blurred vision, and increased heart rate) and the potential for fatal overdose. Patients must be gradually weaned off of these drugs to avoid anxiety, headache, nausea, insomnia, and motor disturbances, so these drugs are rarely prescribed today.

The success of early antidepressants lent credence to the catecholamine hypothesis, put forth by Joseph Schildkraut in 1965, contending that depression resulted from a decrease in catecholamines, which include dopamine, epinephrine, and norepinephrine. This later gave way to the serotonin hypothesis, which focused on the possible role of serotonin deficiency in depression.

Perhaps the best-known class of antidepressants are the SSRIs, or selective serotonin reuptake inhibitors which include fluoxetine (Prozac), citalopram (Celexa), paroxetine (Paxil) and sertraline (Zoloft). These drugs block reuptake of serotonin back into presynaptic neurons, increasing the availability of serotonin to postsynaptic neurons. Side effects include nausea, agitation, and sexual dysfunction, and there is also a potential for withdrawal symptoms. The most recently developed class of antidepressants, known as atypical antidepressants, are less focused on serotonin and may also influence norepinephrine or dopamine. These include venlafaxine (Effexor), nefazodone (Serzone), and bupropion (Wellbutrin), among others.

Despite direct-to-consumer advertising implying that antidepressants correct a serotonin imbalance, researchers don't fully understand why antidepressants work (and they don't work for everyone). Effects on neurotransmitter levels occur quickly, but results for patients often don't appear for several weeks after beginning treatment. In addition, depleting serotonin in healthy individuals does not seem to directly lower mood. Imbalance or simple deficiency does not seem to be an adequate explanation for depression and some recent research focuses on the possible role of neurogenesis, the creation of new neurons, in treating depression.

Despite their name, antidepressants are used to treat other categories of illness as well, including anxiety disorders, eating disorders, obsessive-compulsive disorder, and ADHD. Pharmaceutical companies often change the brand name, packaging, and pill colors to avoid consumer associations with antidepressants. So Eli Lilly's drug Sarafem, for Premenstrual Dysphoric Disorder, is actually Prozac and GlaxoSmithKline's smoking-cessation drug Zyban is actually Wellbutrin.

Antidepressants are not prescribed for bipolar disorders, because although they can boost mood they can also trigger manic episodes. Medications for bipolar I and bipolar II are known as mood stabilizers, the most commonly prescribed of which is lithiumlithiumA mood-stabilizing drug used to treat bipolar disorder — reduces frequency and severity of manic and depressive episodes.. Approximately 60-70% of bipolar patients respond to drug treatments, which can prevent manic episodes, reduce depression, and decrease the risk of suicide. Side effects of lithium include nausea and weight gain. Levels of lithium in the blood naturally fluctuate, so patients must use blood monitoring to adjust dosages, as high levels can affect kidney and thyroid function. Lithium is also teratogenic, meaning that it can't be taken during pregnancy due to the potential for harm to the fetus. Valproate, an anticonvulsant drug, can also be used in treating bipolar disorders, though it carries a potential for liver damage.

How should we evaluate drug therapies? Even with medications that have been shown to be effective, finding the correct drug and dosage for each individual patient is a process of trial and error, and in many cases the exact mechanisms of a drug's effects are unknown. Are these treatments correcting problems, or are they merely relieving symptoms? The presence of side effects means drug treatments can be accused of trading one symptom for another, without necessarily addressing the real causes of an illness.

For these reasons, medications shouldn't be seen as standalone treatments. They are often prescribed in addition to psychotherapy in order to help address the underlying causes of symptoms as well as provide patients with greater feelings of control compared to just popping pills and hoping for the best. CBT has been found to be as effective as medication for some disorders, including panic disorder and depression, but effectiveness can be even higher when CBT is combined with medication.

Combining therapies can represent a challenge, however, as it often involves coordinating treatments with multiple practitioners, such as a psychotherapist conducting CBT and a psychiatristpsychiatristA medical doctor who specializes in mental health and can prescribe medications. prescribing dosages for medications. Some areas have adopted rules allowing psychologists to prescribe drugs such as antidepressants even though these psychologists don't have the same medical training as psychiatrists. This is a controversial policy, though we may also worry when we consider that the majority of antidepressant prescriptions come from primary care physicians (who are not specialists in mental illness) rather than psychiatrists.

Medications aren't the only biological methods of treating mental illness, though the following treatments are much less common.

Electro-convulsive therapy (ECT), first used in 1938, is a method of delivering brief electric shocks to the brain. Despite popular depictions as a torturous process (as in the film One Flew Over the Cuckoo's Nest), ECT is administered with muscle relaxants to reduce spasms, and patients are put under general anesthesia before the procedure begins. ECT is mostly used as a treatment for those who have not responded to other treatments. Of these, approximately 80% show improvement with ECT, though the exact mechanism for why this improvement occurs is not clear. It may be that the mini-seizures created by ECT have calming effects on some brain regions, or that they stimulate neurogenesis. Side effects of ECT are generally mild and consist of short-term memory loss, headaches, and muscle aches.

A newer, non-invasive form of brain stimulation is transcranial magnetic stimulationtranscranial magnetic stimulationTMS — a non-invasive technique using magnetic pulses to stimulate or inhibit specific brain regions.. A magnetic coil is used to pass a current through the left or right prefrontal cortex for a short period of time. TMS has fewer side effects than ECT and does not cause short-term memory loss, though it can cause mild headaches and a slight increase in seizure risk. Once again, the exact reason for the effectiveness of TMS is not known, but it may be that TMS helps to increase the likelihood of certain neurons firing, or it may be that it helps to create new neural circuits or improves long-term potentiation (LTP).

Phototherapy uses a box that directs bright light onto the face for 30 minutes each morning. Despite the idea of light healing illness sounding a bit like quackery, this technique actually works for lifting seasonal pattern depression (seasonal affective disorder) by influencing hormone levels.

The leucotomy developed by Egas Moniz and popularized as the lobotomy by Walter Freeman has a terrible reputation which was certainly well-earned, and it is banned in many places. But other types of psychosurgery remain in use, though they are quite rare and because they are irreversible, are only used as last resorts for severe cases. Unlike Freeman's imprecise ice-pick wiggling, modern techniques destroy connections between specific brain areas and include the cingulotomy (which focuses on the area between the cingulate gyrus and the corpus callosum) for depression and OCD, and the anterior capsulotomy (focusing on the caudate nucleus and putamen) for OCD.

Another type of psychosurgery is deep brain stimulation (DBS). Electrodes are implanted in the brain, a pacemaker to control them is implanted in the chest, and stimulation helps to control areas of brain activity. DBS has been used for Parkinson's disease, chronic pain, Tourette's syndrome, tremors, OCD, and even depression.

How do we know when a treatment has worked? This might seem like a simple question (did the patient get better?) but it is actually quite complex and difficult to answer with certainty.

The first problem is that sometimes patients show natural improvement and symptoms of a disorder go away on their own. The illness may have simply run its course (known as spontaneous remission), or symptoms may have gone from their very worst back to average (known as regression to the mean). People tend to seek treatment when they are feeling really bad, so just returning to average may make it seem like a treatment has been effective.

Things get even more complicated when we consider all the aspects of receiving treatment that may play a role in how a patient feels. These are known as nonspecific treatment effects and include things like the doctor or therapist's confidence, feeling a greater sense of control (due to the decision to seek help), avoiding alcohol or changing one's diet (to avoid interactions with medication), or building a warm relationship with a therapist who also wants to see improvement (known as the “therapeutic alliancetherapeutic allianceThe quality of the collaborative relationship between therapist and client — the strongest predictor of therapy outcome.”). All of these factors may play a role in a patient's recovery and make it difficult to assess how much the specific treatment is actually contributing.

Another problem is the placebo effectplacebo effectImprovement resulting from the expectation of treatment, not the active treatment itself., and just believing that one is receiving treatment can be enough to cause improvement. This means that patients receiving medication should be compared to similar patients receiving drug treatments that don't contain any medication. This helps to assess which results are from the medication and which are from believing one is taking medication. Of course, patients can become suspicious and side effects can indicate to a patient that they are getting the “real” drug, distorting results. At the same time, it's possible for patients in the placebo group to experience side effects and this is known as the nocebo effect; an inert substance causing negative effects.

Reconstructive memory can also influence effectiveness. Patients who haven't really improved may falsely remember their symptoms as having been worse before. Patients may be biased to believe that their efforts were worthwhile, convincing themselves they are at least a little better now or that without their therapist or doctor they would have been much worse off. It's also possible that some patients come to depend on the therapeutic relationship and attempt to prolong treatment. Malingering refers to claiming symptoms continue after they have faded, in order to continue receiving care, attention, and sympathy and this can distort the apparent effectiveness of treatment.

You might think that clinicians would be better able to avoid the biases that influence patient perceptions of improvement, but this isn't necessarily the case. Therapists are likely to have a bias toward believing their treatments work. In addition, they may be prone to only counting the positives, hearing and repeating success stories from patients whose lives were turned around, but forgetting those patients who never made progress or stopped treatment. In fact, therapists may think that patients who left treatment and never returned were “cured”, when perhaps these patients simply started seeing other therapists.

All of these effects and biases open the door for pseudo-therapies with true believers, both practitioners and patients. These approaches, from homeopathy and herbal medicines to energy fields and eye-movement desensitization, may be nothing more than nonspecific treatment effects resulting from the misplaced hope and trust of patients and the good intentions and empathy offered by providers.

So how do we establish whether treatments are effective? There are outcome studies, which aim to determine whether patients actually get better, and process studies, which attempt to pinpoint why a treatment works in order to refine it.

Hans Eysenck called out the apparent ineffectiveness of psychotherapy treatment in 1952, noting that while roughly two-thirds of patients improved, two-thirds of those not treated also improved. Treatments have become more effective in the last 6 decades, and the average patient who receives treatment today is likely to be better off than 80% of those who do not receive treatment. While this is good news, keep in mind that this figure can be misleading, since by definition the “average” untreated patient will be better off than 50% of untreated patients. Nevertheless, treatment does provide an advantage, and those who receive treatment tend to improve more rapidly and are less likely to relapse.

Studies which compare treatment, no treatment, and placebo-treatment groups can evaluate the success of interventions. Well-established treatments or “empirically-supported” treatments are those which have repeatedly been shown to outperform placebo treatments, while probably-efficacious treatments are those which have shown some success but may not yet have enough supporting research.

Ideally we could use double-blind placebo studies to assess all treatments, but when it comes to psychotherapy it's difficult or impossible to provide a “placebo” treatment. One way around this is to have a control group of patients who have been diagnosed but who don't receive treatment right away, known as a wait-list control group, which is then compared to patients who did receive treatment during the same time period. This isn't a perfect solution, however, as the anxiety of waiting may contribute to the control group's symptoms, while placebo and nonspecific treatment effects may influence the treatment group.

Placebo studies are easier to conduct with medications, but results have not always been flattering. In 1998, Irving Kirsch and Guy Sapirstein conducted a meta-analysismeta-analysisA statistical technique combining results from multiple studies to determine overall effect sizes. of the effectiveness of antidepressants and found that 75% of their apparent effectiveness was likely due to the placebo effect. When unpublished trials from the FDA were obtained and analyzed, Kirsch and colleagues reported that for most patients, the difference between antidepressants and placebo was too small to have a clinically significant difference in outcome.

Another problem for assessing and comparing treatments is comorbidity. How should we compare the treatment of “pure” and “mixed” cases? How should a therapist or psychiatrist approach the treatment of multiple disorders? Should one disorder be prioritized or should simultaneous treatment be attempted? How will this influence efficacy? Will side effects of one disorder's treatment influence the symptoms of another disorder?

Given just how difficult it is to assess if a single treatment works, it's even more challenging to determine the “best” treatments for any particular disorder, particularly when we consider that the effectiveness of individual therapists using the same approach may vary widely. Nevertheless, when it comes to certain problems we do have some ideas of which treatments are most effective. Phobias and panic disorders tend to respond well to behavioral treatments that teach specific strategies. Moderate depression tends to respond well to CBT as well as medications like SSRIs. Cognitive and behavioral treatments don't seem to be particularly effective for bipolar disorders, which means medication is often a vital first step, and the same is true for schizophrenia and severe depression.

The treatments discussed in this chapter have considered how behaviors, thoughts, and biology can be modified to improve mental health. But these haven't specifically addressed lifestyle factors that may contribute to mental illness. Would we be surprised at the development of physical or mental illness in a sleep-deprived person who feels disengaged at work, socially-isolated at home, and who lives a sedentary lifestyle and eats a poor diet? Might mental illness be a natural response to these negative lifestyle factors?

We can think of positive lifestyle changes as ways of coping with stressful circumstances before they result in illness, as well as ways of combating some symptoms. Many of these habits have been mentioned previously in other chapters, and for good reason. Proper sleep, exercise, a healthy diet, relaxation techniques, and social support can help us to cope with stress and can improve our quality of life.

As previously mentioned, relaxation techniques can boost immune function, and practicing mindfulness meditation may even teach a sort of anti-rumination, allowing us to recognize and redirect negative thoughts when they occur. Aerobic exercise has repeatedly been shown to be as effective as drug treatments for moderate depression and unlike medications, aerobic exercise has side effects which are positive (improved sleep, increased strength and energy, enhanced sex drive, reduced risk of obesity and diabetes, etc.). Exercise has also been shown to be effective at preventing relapse of depression, and a study by Michael Babyak and colleagues (2000) found that an exercise-only group had the lowest rate of relapse, even lower than the exercise + SSRI treatment group.

These lifestyle changes are not a substitute for all treatment and I'm not suggesting that one can jog away schizophrenia or meditate through a manic episode. What I am suggesting is that these behaviors may help to treat some symptoms, and possibly help prevent the development of illness. These strategies can also help to remind us that mental health isn't confined to psychiatric institutions and therapists' offices. Just as infectious diseases can be controlled by inoculating people who aren't sick, mental illness can be addressed by preventing the development of disorders in healthy individuals.

This is not just about encouraging habits to make ourselves healthier or happier. When we understand the factors that increase risk of mental illness, we see that the burdens of poverty, unemployment, homelessness, discrimination, and poor access to healthcare are not just issues of social justice, they are mental health issues too. Helping others to increase competence and control, improve mood and self-esteem, and build resilience doesn't just benefit those individuals, it benefits our society as a whole.