Private or NHS therapy can be good or bad and everything in between. In May 2023, among many things I explored ‘What biological treatments are known to psychiatry?‘ I did not focus much of non-chemical therapies. I do so now.
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Depression is one of the most common mental disorders. In general depression of the mild and lower end of moderate varieties, are best not treated with antidepressants. Psychological or non-chemical interventions are often more effective and durable. One or more of them may be appropriate depending on individual circumstances and assessment:
- Psychotherapy: This is a broad category that includes cognitive-behavioural therapy (CBT), interpersonal therapy (IPT), and psychodynamic therapy. These therapies focus on changing negative thought patterns, improving interpersonal relationships, and addressing underlying psychological conflicts. There are approximately 500 different kinds of talking therapies.
- Exercise: Regular physical activity is recommended as it has been shown to improve mood and alleviate symptoms of depression through the release of endorphins and the enhancement of overall physical health.
- Mindfulness and meditation: Practices like mindfulness-based stress reduction (MBSR) and mindfulness-based cognitive therapy (MBCT) help individuals focus on the present moment and become more aware of their thoughts and feelings without becoming overwhelmed by them.
- Light therapy: Primarily used for seasonal affective disorder (SAD), light therapy involves exposure to daylight or specific wavelengths of light, which can influence brain chemicals linked to mood and sleep.
- Art and music therapy: These therapies use the creative process of making art or music as a therapeutic tool to help people explore self-expression and, in turn, find new ways to gain personal insight and develop new coping skills.
- EMDR: Eye Movement Desensitisation and Reprocessing (EMDR) is a psychotherapeutic approach designed primarily to alleviate distress associated with traumatic memories. Developed by Francine Shapiro in 1987, EMDR therapy involves the patient recalling distressing experiences while simultaneously engaging in bilateral stimulation, typically through guided eye movements. This process is believed to facilitate the brain’s information processing system, allowing for the integration of traumatic memories into general memory networks, thus reducing their lingering emotional impact. EMDR is recognised as an effective treatment for trauma and PTSD by numerous mental health organisations, including the World Health Organisation (WHO).
- Yoga and Tai Chi: Both are forms of exercise that involve physical postures, breathing exercises, and meditation. They are known to reduce stress, improve physical and mental health, and enhance overall well-being.
- Social interventions: Social support and community engagement can be vital in alleviating symptoms of depression. This includes group therapy, support groups, and community activities.
- Occupational therapy: Helps individuals develop skills needed for day-to-day life, enhancing their ability to live independently and manage their symptoms in a productive manner.
- Nutritional counselling: Diet can significantly affect mood and mental health. Nutritional counselling aims to promote a balanced diet that supports mental health.
- Biofeedback: This technique teaches individuals to control bodily processes that are typically involuntary, such as heart rate, muscle tension, and blood pressure, with the aim of improving mental and physical health.
Some of the above are adjunctive ‘treatments’. Note carefully that in psychiatry ‘treatment’ has a broad meaning, especially in legal contexts. Not all in the above list will be recognised separate ‘treatments’ for depression.
Note that several therapies may treat different conditions. There can be expected to be variations on the therapies themselves in matching them. This table is not to be used to say “Ahahh.. so Personality Disorder therefore Art Therapy is good.” The matching of therapies to person and condition requires expert knowledge and application of expertise. There may be different subtypes of a therapy that may be chosen in the matching process. Therapy is like pills – not every therapy will work even with the best therapists doing the therapy.
The matching of treatment (chemical or non-chemical) or intervention is – unbeknownst to most – heavily dependent on accuracy of diagnosis. 30-odd years of experience in psychiatry has shown me that the majority of psychiatrists almost never match ‘evidence’ (from symptoms and signs) to diagnostic criteria and explain the detail of how they arrive at their diagnoses to patients. Misdiagnosis is rampant and unrecognised by the likes of the CQC or the GMC. Hence I’ve seen a pattern to throw patients on this or that chemical or into this or that therapy. Initial improvements usually follow from a combination of Hawthorne effects and Open Label Placebo effects (as explained by Prof Kaptchuk at Harvard). Then things do not work usually after 3 to 4 months.
| Therapy | Description | Applicable Disorders |
|---|---|---|
| Art and Music Therapy | Uses creative expression as a therapeutic tool to facilitate expression and reduce stress. | Depression, Anxiety, Personality Disorders |
| Assertive Community Treatment (ACT) | Provides comprehensive, community-based psychiatric treatment, rehabilitation, and support. | Schizophrenia, Severe Bipolar Disorder |
| Biofeedback | Teaches control over involuntary physiological processes to improve mental and physical health. | Anxiety, Stress-Related Disorders |
| Cognitive Behavioural Therapy (CBT) | Focuses on changing negative thoughts and behaviours, teaches coping strategies. | Depression, Anxiety, Bipolar Disorder, OCD, PTSD |
| Cognitive Remediation | Enhances cognitive function through targeted exercises, improving daily functioning. | Schizophrenia, Bipolar Disorder |
| Dialectical Behaviour Therapy (DBT) | Emphasises mindfulness and emotional regulation, effective for managing intense emotions. | Borderline Personality Disorder, Eating Disorders |
| EMDR | Eye Movement Desensitisation and Reprocessing is A psychotherapeutic approach designed to alleviate distress associated with traumatic memories through guided eye movements. | PTSD, Anxiety, Other Trauma-Related Disorders |
| Excercise | Regular physical activity that improves mental health by reducing symptoms of depression, enhancing mood, and increasing the release of endorphins. Exercise is also associated with better overall cognitive function and stress reduction. Exercise programmes have been proved scientifically to treat some kinds of depression and benefit other mental disorders. | Depression, Anxiety, Stress-related Disorders, PTSD |
| Family Therapy | Involves family members to improve dynamics and support, enhancing communication. | Personality Disorders, Eating Disorders, Depression |
| Group Therapy | Facilitates therapeutic sessions in a group setting, promoting shared experiences and mutual support. | Depression, Anxiety, Personality Disorders |
| Interpersonal Therapy (IPT) | Addresses interpersonal issues, improving communication, and solving relationship problems. | Depression, Eating Disorders |
| Interpersonal and Social Rhythm Therapy (IPSRT) | Stabilises daily rhythms and routines to improve mood regulation and reduce relapse. | Bipolar Disorder |
| Light Therapy | Uses exposure to daylight or specific wavelengths of light to treat mood disorders. | Seasonal Affective Disorder, Non-seasonal Depression |
| Mindfulness-Based Cognitive Therapy (MBCT) | Combines mindfulness techniques with cognitive therapy to prevent relapse. | Depression, Anxiety, Bipolar Disorder |
| Mentalisation-Based Treatment (MBT) | Improves the patient’s ability to recognise and understand mental states in oneself and others. | Borderline Personality Disorder, Eating Disorders |
| Nutritional Counselling | Focuses on improving diet to support mental health and overall well-being. | Eating Disorders, Depression, Anxiety |
| Psychoeducation | Provides information about disorders to patients and families, promoting understanding. | Bipolar Disorder, Schizophrenia, Depression |
| Psychodynamic Psychotherapy | Explores underlying unconscious conflicts influencing behaviour, based on psychoanalytic principles. | Personality Disorders, Depression, Anxiety |
| Schema Therapy | Targets and modifies deep-rooted patterns and themes in thoughts and behaviours. | Personality Disorders, Chronic Depression |
| Social Skills Training | Teaches essential interpersonal skills and social appropriateness. | Schizophrenia, Autism Spectrum Disorders |
| Supportive Psychotherapy | Provides emotional support and reinforcement, helping individuals cope with their condition. | Depression, Schizophrenia, Generalised Anxiety |
| Vocational Rehabilitation | Helps individuals gain or regain the ability to work, focusing on practical vocational skills. | Schizophrenia, Severe Mental Disorders |
| Yoga, Tai Chi and Complementary therapies | These practices involve physical postures, breathing exercises, and mindful movements to enhance physical and mental health. They help reduce stress, improve mood, and increase overall well-being. They have not be proved by robust scientific research as treatments for mental disorders. | May assist with Anxiety, Depression, Stress-related Disorders |
Troubling Scenarios
Sidebar 1: From a real anonymised case (the worst among several) – patient in individual therapy for over 15 years. Eventually came to NHS expert psychiatry team. Investigated and found to have developed dementia probably over the previous 10 years (an usually and you might think luckily slow burn – but wait). Total cost of therapy £500,000! Yes there are some rich people who are milked. Therapy was obviously useless for the most part, except to fill someone’s bank account.
Sidebar 2: Highly educated barrister suffered major physical trama 4 years previously after falling off a mountain. He suffered with serious anxiety and could not function in his usual role. Serious loss of earnings. Wife divorced him. Saw an expert professor of psychology (now deceased), who had him in ‘therapy’ for the previous 2 years. No progress. Eventually came to psychiatry. Through my clinical inputs we discovered major losses of frontal lobe function – underpinned by missing frontal lobes on MRI (no joke).
Sidebar 3: Patient in individual therapy once per week for 6 years in the NHS – it doesn’t matter for what. When I saw her in my ward she was chronic and seemingly not better off for all the therapy. I asked her what did she learn from her therapy. She’s drawing blanks. Nothing of substance; things like “We spoke about my life.” Over the next 3 weeks I realised there was clinical impairment of intellectual functions. I then had to ‘wrestle’ with a psychologist to do her cognitive assessment. On completion her IQ was 60 with major deficits in memory and abstract thinking. Therapy was useless.
These three real-life sidebars highlight critical issues in the field of psychiatry related to the importance of accurate diagnosis and appropriate therapy. In the first case, a patient received extensive but ultimately ineffective therapy due to an undiagnosed condition of dementia, which developed over a decade, resulting in substantial financial cost and misdirected treatment efforts. The second scenario illustrates a similar oversight, where a barrister experienced a significant decline in cognitive function due to frontal lobe damage from a physical trauma, which was initially overlooked despite ongoing psychological therapy. In the third case, a patient underwent years of therapy without noticeable improvement, revealing underlying intellectual impairments only identified through later cognitive assessment. These cases underscore the necessity for thorough medical evaluations, including cognitive and neurological assessments, prior to and during psychological treatments to ensure that therapy is both appropriate and effective, addressing the underlying biological foundations of mental health symptoms.
Diagnosis
Diagnosis is not simply a medical model thing. Psychiatric medications are tested via various phases of trial using diagnoses among real people. The same principles apply when we think about therapies. Like with medications matching the patient’s condition to the wrong therapy or to an inappropriate therapy can have serious consquences as shown the examples above.
Accurate diagnosis and appropriate therapy matching are indeed central to the efficacy of psychiatric treatment. Here’s an overview of these critical aspects:
Diagnostic accuracy
The precision of a psychiatric diagnosis hinges on thorough clinical evaluation, which includes detailed patient history, symptom assessment, and often, psychological testing. The DSM-5 and ICD-11 provide structured diagnostic criteria, which are essential tools used by clinicians to ensure consistency and accuracy. However, the complexity of psychiatric symptoms, which can overlap across various disorders, often complicates the diagnostic process. Moreover, the subjective nature of symptom reporting by patients and the interpretation of these symptoms by different clinicians can lead to variability in diagnoses.
Matching condition and therapy
Once a diagnosis is established, selecting an appropriate treatment plan is the next critical step. This involves considering the specific characteristics of the disorder along with the individual’s unique needs, preferences, and overall health. Treatment selection is often guided by evidence-based practices; however, it also requires clinical judgment to tailor these recommendations to individual circumstances. For instance, psychotherapeutic techniques such as CBT are generally effective for disorders like depression and anxiety, but the approach may need to be adapted or combined with other therapies based on the patient’s response to initial treatment and personal circumstances.
Integration of treatment modalities
Integrating various treatment modalities can enhance therapeutic outcomes. For example, combining psychotherapy with social interventions or lifestyle changes (like exercise and diet) can often provide more comprehensive benefits than a single approach. Moreover, monitoring and adjusting the treatment plan based on ongoing assessment of the patient’s progress is essential for achieving optimal outcomes.
Challenges and advancements
The field continually faces challenges such as the stigmatisation of mental health issues, discrepancies in patient access to care, and the need for personalised treatment strategies. Advances in technology and research, however, are facilitating improvements in diagnostic tools (like neuroimaging and genomics) and the development of more effective, personalised treatment plans.
Overall, the practice of psychiatry necessitates a dynamic and meticulous approach to both diagnosis and treatment, emphasising the need for ongoing education, research, and clinical acumen to handle the complexities of mental health disorders.
Summary
It doesn’t really matter if it is ‘private’ or NHS. Of prime importance are:
- Robust diagnosis.
- Ruling out of biological factors.
- Matching of treatment/intervention to chemical or therapist(s).
- Expertise and care of the ‘therapist’, if non-chemical.
