In this video I discuss comparing effectiveness of treatments as well as comparison with placebo, wait-list, and no treatment conditions. I also describe how lifestyle factors may play a role in mental illness and how positive lifestyle changes can help to reduce or prevent symptoms. Disclaimer: This channel is for educational purposes only and is not intended as medical advice for the diagnosis or treatment of psychological disorders.

Video Transcript

Hi I’m Michael Corayer and this is Psych Exam Review. In the previous video, I talked about some of the challenges of trying to assess the effectiveness of treatments for mental illness. And in this video, I’d like to continue this topic by looking at treatment studies and how we can try to compare the effectiveness of different approaches to treatment.

So how do we establish which treatments are actually effective for patients? Well, one way we can do this is through what are called outcome studies and outcome studies are just looking at whether or not patients improved after receiving a particular treatment. Now, as we saw in the previous video, understanding why this improvement occurred is much more complicated, but we can simply ask, okay, if these people received, let’s say, an antidepressant medication and this group of people all received cognitive behavioral therapy, and this group of people all received a placebo pill, we can say which group improved more, and that might indicate to us which treatment is more effective.

And then we also have what are called process studies and process studies are trying to understand why a treatment is working. So might say, okay, this treatment appears to be effective for these patients. Now we do some studies to try to figure out why that is. Can we break it down? What is it about that treatment that’s relieving certain symptoms?

Now, controversies about which treatments are effective and whether or not certain treatments are effective for certain disorders go back quite a long way. And we can go back to the 1950s when Hans Eysenck wrote about psychotherapy and he pointed out that psychotherapy appeared to be effective because about 2/3 of patients improved after receiving psychotherapy. But what was important to know is that two thirds of people who didn’t receive psychotherapy also improved. And this suggested that psychotherapy wasn’t really doing anything. It wasn’t helping to alleviate the problems that people were having, because people not receiving psychotherapy also had their symptoms go away over time. And this relates back to the things I talked about in the previous video about spontaneous remission and regression to the mean.

Now today, things are better, and we can say that the average treated patient is better off than 80% of untreated patients Now, the first thing to note about this is that it does mean that 20% of untreated patients are actually going to be better off than the average treated patient. And we also have to remember the starting point. And what that means is the average untreated patient is already better off than 50% of untreated patients, because the average is going to be in the middle of the distribution. So right away, when we’re talking with the average untreated patient, we’re talking about somebody right in the middle. Half of untreated people are already worse off than that person. And so that distorts the picture a little bit. We have to keep that in mind when we say that we’re talking about 80%. So that’s just an improvement from doing better than 50% to doing better than 80%.

But that does mean the treatment is providing an advantage. And you know, getting treatment is, for most of the time, is going to be better than not getting treatment. Not for every patient, it’s not guaranteed. But we can say that treatment does seem to be doing something. There is a benefit to it. Now, we can also think about the different types of treatments that we can get and try to compare effectiveness across those treatments to determine which is best for a particular disorder.

Now, generally speaking, we’re comparing effectiveness across 3 groups. We compare the treatment to people who don’t get the treatment and then to people who get a placebo treatment. So we have, let’s say, a medication, a group that doesn’t get anything and then a group that gets a placebo pill. And we want to see which of those three groups is improving the most. Now, hopefully the group getting the treatment is showing the most improvement, the placebo may show some improvement, but not as much. And the no treatment group may not show nearly as much improvement as either of those two groups.

Now, if we have that case where a treatment is repeatedly shown to be more effective than no treatment and more effective than the placebo treatment, then it becomes what’s called a well–established treatment. This means it’s empirically supported, and it’s repeatedly been shown to outperform placebo treatment. Now, we also have a category of probably efficacious treatments. And these are treatments that have shown some success, but they don’t yet have enough supporting research to make them well-established.

Now, one of the challenges that we have here is that it’s a little bit easier to establish effectiveness for medications than things like psychotherapy. And the reason for that is it’s really hard to do placebo treatment when it comes to psychotherapy. The patients often are going to know, am I receiving therapy or not? And especially in the case of trying to do a double blind study, you know, it’s easy to have a patient who receives a pill, a real medication or placebo, and they don’t know which one they’re getting. And then the doctor evaluating that patient also doesn’t know, are they getting the real pill, or are they getting the placebo? But when it comes to psychotherapy, you really can’t do that. We can’t have a psychotherapist who believes that he’s giving a real established psychotherapeutic treatment to this patient, when, in fact, he isn’t. Or for a patient to know whether or not they’re receiving actual therapy or not. And so this makes it very challenging for certain approaches to treatment to reach that well established treatment threshold, because they can’t do these types of placebo studies.

Now, one way we can try to get around this for psychotherapy is to use what’s called a waitlist control. And so this is where we have patients who received a diagnosis, but they’re told that treatment is not yet available to them. And so they’re on a waiting list. And the idea is, I can compare, let’s say I have a group of patients that receive the diagnosis, and then half of them start their treatment right away. The other half are put on the waiting list. And then, let’s say, 8 to 12 weeks later, I can look at both of these groups and see who’s doing better. And if the group getting the therapy is doing better than the group that’s just waiting, that suggests the therapy is helping. It’s doing something.

Now, there are some ethical issues with this, because we’re essentially withholding treatment from people who might need it. And that’s not necessarily a good thing. And then we also have problems of anxiety. Maybe it’s the case that people who are put on the waiting list, this increases their anxiety. It worsens some of their symptoms. They think, you know, I know I have this diagnosis now. Why can’t I be getting this treatment? I’m going to be getting worse. Things are going to be, you know, out of my control. And maybe those are going to make their symptoms worse, or it’s going to make it harder for them to recover. And so we have to keep that in mind when we compare these groups. And even if we do show that the group getting the treatment is better off than the wait list, we still have the question of why that is happening. Is it simply the placebo effect? They know that they’re receiving maybe a psychotherapeutic treatment, or is it the nonspecific treatment effects that I talked about in the previous video, things like their relationship with the therapist, the warmth and empathy that’s provided, the feeling that they’re taking control over their disorder. All these things might be part of the reason they’re improving, rather than the therapy itself.

Now, even when it comes to these well-established medical interventions that are easily tested in these randomized controlled placebo trials, even in these cases, we have some controversy, some difficulty establishing well, how much are these actually improving the symptoms for patients? And this brings us to some research by Irving Kirsch and Guy Sapirstein, who looked at a number of studies on antidepressants. They looked at a large number of trials, they did a meta analysis of trials on antidepressant medications. And what they found was that the apparent effectiveness of these antidepressants may mostly be due to the placebo effect. That people are getting better when they’re taking antidepressants, but a large part of that improvement might simply be the placebo effect because they believe they’re getting a treatment and that expectation and belief can influence their symptoms

And a related idea here is the role of publication bias. So they included trials that were published and then also data that was unpublished. And part of the reason why they needed to include unpublished data is that sometimes these studies are done, they don’t find an effect and then it never gets published, right? And so the idea of publication bias is that it’s easier to get published if you find an effect of a medication. So yes, the SSRI is more effective than placebo it’s easier to get that paper published than one that says there’s no difference between SSRI and placebo, or the placebo group happened to do better in this. So we might wonder how much publication bias is playing a role here and whether or not some of the studies showing that the SSRI group does significantly better than the placebo group might just be false positives. They may just be coincidences that it just so happened that the people in that treatment group got a little better than the people in the placebo group.

And a related idea here is even if we do have a real positive difference with a medication versus a placebo, we might wonder whether it’s clinically significant. And so the difference here is between statistical significance and clinical significance. And the way you can think about this is, let’s say that the placebo group improves and the treatment group improves. So we have improvement in both groups and the difference in improvement might be large enough to be statistically significant.

So let’s imagine that we have two groups of patients here, let’s say this represents their mood, they’re suffering from depression. And so the placebo group gets the placebo pill and because of the placebo effect, they show some improvements. So their symptoms, the severity of their depression, well, okay, let’s say that their mood increases. So their mood is elevated a bit by getting placebo and then the group that’s getting the real medication they also improve and they improve a little bit more than the placebo group. So this might be a statistically significant difference between these two groups. In other words, the gap between these 2 improvements is statistically significant, but it may not be clinically significant. What that means is if you’re a patient in either of these two groups, how you feel and your improvements in mood are really not any different, it doesn’t matter. You could have just been getting the placebo and you’d feel almost as good, not statistically quite as good, but it would be insignificant in terms of the effect on you and your symptoms, how well they’re alleviated.

And so then the question is, well, if it doesn’t matter which group you’re in, you know, the real medication group or the placebo group, let’s say both of those groups feel better. Well, then you might wonder, what are the tradeoffs of getting that slight improvement by being in the treatment group? What if you’re also suffering from a number of side effects that come with getting the real medication? Maybe you’d be better off just getting a placebo pill, believing you’re getting an SSSRI and getting that improvement in your mood the reduction of certain symptoms and not having all those side effects. And so that’s something we have to think about even when we look at these statistically significant differences between things like a treatment and a placebo. How much does that really matter for the patient?

Now we also have some additional challenges that go into this that I didn’t get a chance to discuss in the previous video. And one of these is comorbidity. So you might recall that comorbidity is suffering from multiple disorders at the same time. And this is quite common in mental illness. I pointed out in a previous video that prevalence rates are not additive. If they were, then it would appear that everybody has a mental illness. But what we find instead is that it’s a smaller number of people who often have multiple disorders at the same time. So we have comorbidity being a large issue in mental health. And then we might wonder, how does this relate to assessing the effectiveness of treatments? How do we compare pure versus mixed cases? Meaning, how do we compare somebody who’s only suffering from major depression versus somebody who’s suffering from depression and an eating disorder? How should we go about assessing the improvements in certain symptoms? And maybe they show slight improvements in both disorders, or maybe they only show improvement in one disorder and not the other.

So how should we approach this? And how should we approach this treatment of these multiple disorders at the same time? Should we try to treat both disorders simultaneously? Should we be trying to reduce symptoms in both types of disorders? Or should we try to prioritize a certain disorder? Maybe we deal with the depression first and then we deal with an eating disorder symptoms later. Well, how do we go about doing that? Can we actually do that? Can we separate the symptoms so neatly? And what do we do if there’s side effects of a treatment? Maybe those are influencing the symptoms of another disorder. So maybe I give you an SSRI, and maybe that’s actually going to cause some side effects that might worsen some of your symptoms of some other disorder that you’re suffering from. And so this makes things very messy, and it makes it really hard for us to figure out the effectiveness, even if we have an effective treatment.

So, well, maybe it’s improving certain symptoms of one disorder, but only in patients who have sort of the pure form of that disorder. And if it’s comorbid with something else, maybe it’s not so effective now. This makes it almost impossible to try to figure out what the best treatments are. And as I mentioned before, there’s often a sort of trial and error process with each individual patient trying to work out what sort of things will help them the most.

And in the case of something like psychotherapy, we have the problem of the same approach to psychotherapy is going to be different when it’s conducted by different therapists. It’s not a one size fits all thing. And so even though they’re both practicing cognitive behavioral therapy, let’s say it’s not exactly the same treatment for their patients. And of course, patients also differ from one another. And so a patient receiving a treatment for a particular therapist might not find much benefit. But perhaps if they got the same type of treatment from a different therapist, they would show a different level of improvement.

Now all that said, all these challenges in mind, we still have some approaches that do seem to work well for certain disorders. So we can say that certain approaches to treatment are generally effective for certain types of disorders. So for example, if we look at phobias and panic disorders, we find that behavioral interventions are often very effective. So things like exposure therapy that I talked about in previous video, you know, using that to treat something like a specific phobia is generally pretty effective. And many patients will respond well to that. And if we look at something like moderate depression, we find that SSRIs are about equally effective as cognitive behavioral therapy for treating moderate depression. And most effective is to combine these treatments. So SSSRIs plus cognitive behavioral therapy is often the most effective treatment. And there’s a number of meta-analyses showing that.

And then for severe symptoms of things like depression, or schizophrenia, or bipolar disorders, it’s generally considered the best practice to go with medication first, not cognitive or behavioral treatments. And this makes sense if you think about the severity of symptoms. If you have somebody who’s, you know, in a severe episode of schizophrenia, the ability to. sit down with them and engage in psychotherapy. I mean, that’s generally going to be very difficult, if not impossible. And so you start with medication, hopefully bringing the symptoms away from that most severe point. And then from there, maybe you can integrate some other approaches later on in the treatment.

And lastly, we’ll look at lifestyle factors and the role that these may play in mental illness. So if I were to describe a person to you and say this is somebody who’s, you know, they feel disengaged at work, they’re not motivated, they feel they’re socially isolated, they don’t have many or any friends or family to help support them. They live a sedentary lifestyle, they’re not getting much activity. They’re not exercising and they eat a poor, unhealthy diet. Now, would you be surprised if this person developed a physical illness as a result of this lifestyle? And in most cases, people say, of course, we know that these factors play a role in a number of physical illnesses. So what about the probability this person would develop a mental illness if they have all of these lifestyle factors that we know are associated with physical illness? Well, this is probably going to play a role in their mental health as well. And so we can think about how these factors are influencing people and how they might relate to the symptoms that people are suffering from.

And this brings us to the role of positive lifestyle changes as a part of treatment, ways of coping and dealing with stress, dealing with anxiety that can help to prevent the development of certain types of symptoms and hopefully also reduce symptoms for some patients. So these aren’t really any major surprises. There’s positive lifestyle changes people can make things like improving their sleep habits to help regulate their circadian rhythm. We know this is going to influence hormone levels in the body and this is going to play a role in not just physical illnesses, but also mental illnesses. We know that, we know that exercise can be effective, getting a healthier diet, encouraging people to find time for relaxation and encouraging them to find social support. We know that these are ways to relieve stress and these can improve quality of life and they can also help to reduce the symptoms of mental illness. So we also can think about some of the reasons why these approaches can be effective.

One of these is relaxation and mindfulness, things like meditation. These not only help people to relax, but they help to boost immune function. And so this can help them to be less likely to get physically sick, but also they can be less likely to develop symptoms of mental illness. And one way that this is believed to work is through what’s called anti–rumination. So I talked about rumination in a previous video, this is the idea where people have repetitive unwanted negative thoughts that keep coming to mind. They feel they don’t have control. They keep obsessing over certain things they can’t seem to stop bringing it to mind. And so a practice like mindfulness can help people to recognize when that’s starting to occur and with practice they can learn to redirect some of those negative thoughts and some of their unwanted emotional responses.

So they find certain thoughts coming to mind and they can say “okay I recognize this is happening and I can shift my attention to somewhere else and I can hopefully prevent this from falling into that cycle of rumination” in that sort of downward spiral where it keeps occurring over and over again. And when we look at things like exercise, we can see that exercise is as effective as medication or cognitive behavioral therapy for some patients suffering from things like moderate depression and in this case we can say even if it’s as effective in some ways that makes it better because we don’t have the negative side effects that might come along with something like taking an SSRI. And so the side effects of exercise are improvements in sleep, improvements in energy, improvements in sex drive, whereas in the case of things like SSRIs we’ve seen problems with sex drive, problems with sleep habits. And so these are generally positive side effects rather than negative side effects and people getting exercise either in combination with other treatments or by itself show lower relapse of things like depression.

Now this is not to suggest that exercise or some of these lifestyle changes are substitutes for treatment and that all someone needs to do is just exercise and they’ll be fine. I’m certainly not saying that. There are many symptoms that are not going to be responding to these lifestyle factors. I’m not suggesting that you can jog away a schizophrenic episode or that you can meditate through a manic episode or something like this. That’s not the case and we don’t want to think that way about people who are suffering and that they just need to go for a jog or something. But what we can say is these lifestyle factors can reduce certain symptoms and they can help people to cope with the symptoms that they’re experiencing. And in healthy people they can also help to prevent the development of symptoms and this is sort of similar to thinking about inoculation when it comes to physical illness. One of the ways that we approach the public health issues for certain diseases is we say, well, we want to prevent people who are healthy now from developing the disorder or the disease in the future. And we can think about these lifestyle factors for mental health as well, that if we can encourage people to engage in these positive lifestyle behaviors that we can actually prevent the development of disorders in the future, we can inoculate them from certain types of mental health symptoms. And in doing that, we’re helping everyone. So anytime we can reduce the symptoms of mental illness, whether it’s in somebody who’s healthy who might develop them, or in somebody who’s suffering from those symptoms already and we can help to relieve some of that, we’re making things better off for everybody.

OK, so I hope you found this helpful. If so, please like the video and subscribe to the channel. And this is actually the last video in this series “Intro Psych Tutorial”, there’s 245 videos covering a very broad range of topics in psychology. And so in the future, I’ll be starting some video series on some other topics. And if you have some ideas that you’d like to see covered, maybe things that aren’t necessarily covered in an introductory psychology class, then let me know in the comments below. So thanks again for watching and I hope you’ve enjoyed this video.