Category Archives: Clinical Interviewing

The Efficacy of Antidepressant Medications with Youth: Part II

After posting (last Thursday) our 1996 article on the efficacy of antidepressant medications for treating depression in youth, several people have asked if I have updated information. Well, yes, but because I’m old, even my updated research review is old. However, IMHO, it’s still VERY informative.

In 2008, the editor of the Journal of Contemporary Psychotherapy, invited Rita and I to publish an updated review on medication efficacy. Rita opted out, and so I recruited Duncan Campbell, a professor of psychology at the University of Montana, to join me.

Duncan and I discovered some parallels and some differences from our 1996 article. The parallels included the tendency for researchers to do whatever they could to demonstrate medication efficacy. That’s not surprising, because much of the antidepressant medication research is funded by pharmaceutical companies. Another parallel was the tendency for researchers to overstate or misstate or twist some of their conclusions in favor of antidepressants. Here’s the abstract:

Abstract

This article reviews existing research pertaining to antidepressant medications, psychotherapy, and their combined efficacy in the treatment of clinical depression in youth. Based on this review, we recommend that youth depression and its treatment can be readily understood from a social-psycho-bio model. We maintain that this model presents an alternative conceptualization to the dominant biopsychosocial model, which implies the primacy of biological contributors. Further, our review indicates that psychotherapy should be the frontline treatment for youth with depression and that little scientific evidence suggests that combined psychotherapy and medication treatment is more effective than psychotherapy alone. Due primarily to safety issues, selective serotonin reuptake inhibitors should be initiated only in conjunction with psychotherapy and/or supportive monitoring.

The main difference from our 1996 review was that in the late 1990s and early 2000s, there were several SSRI studies where SSRIs were reported as more efficacious than placebo. Overall, we found 6 of 10 reporting efficacy. An excerpt follows:

Our PsychInfo and PubMed database searches and cross- referencing strategies identified 10 published RCTs of SSRI efficacy. In total, these studies compared 1,223 SSRI treated patients to a similar number of placebo controls. Using the researchers’ own efficacy criteria, six studies returned significant results favoring SSRIs over placebo. These included 3 of 4 fluoxetine studies (Emslie et al. 1997, 2002; Simeon et al. 1990; The TADS Team 2004), 1 of 3 paroxetine studies (Berard et al. 2006; Emslie et al. 2006; Keller 2001), 1 of 1 sertraline study (Wagner et al. 2003), and 1 of 1 citalopram study (Wagner et al. 2004).

Despite these pharmaceutical-funded positive outcomes, medication-related side-effects were startling, and the methodological chicanery discouraging. Here’s an excerpt where we take a deep dive into the medication-related side effects and adverse events (N.B., the researchers should be lauded for their honest reporting of these numbers, but not for their “safe and effective” conclusions).

SSRI-related medication safety issues for young patients, in particular, deserve special scrutiny and articulation. For example, Emslie et al. (1997) published the first RCT to claim that fluoxetine is safe and efficacious for treating youth depression. Further inspection, however, uncovers not only methodological problems (such as the fact that psychiatrist ratings provided the sole outcome variable and the possibility that intent-to-treat analyses conferred an advantage for fluoxetine due to a 46% discontinuation rate in the placebo condition), but also, three (6.25%) fluoxetine patients developed manic symptoms, a finding that, when extrapolated, suggests the possibility of 6,250 mania conversions for every 100,000 treated youth.

Similarly, in the much-heralded Treatment of Adolescents with Depression Study (TADS), self-harming and suicidal adverse events occurred among 12% of fluoxetine treated youth and only 5% of Cognitive Behavioral Therapy (CBT) patients. Additionally, psychiatric adverse events were reported for 21% of fluoxetine patients and 1% of CBT patients (March et al. 2006; The TADS Team 2004, 2007). Keller et al. (2001), authors of the only positive paroxetine study, reported similar data regarding SSRI safety. In Keller et al.’s sample, 12% of paroxetine-treated adolescents experienced at least one adverse event, and 6% manifested increased suicidal ideation or behavior. Interestingly, in the TCA and placebo comparison groups, no participants evinced increased suicidality. Nonetheless, Keller et al. claimed paroxetine was safe and effective.

When it came to combination treatment, we found only two studies, one of which made a final recommendation that was nearly the opposite of their findings:

Other than TADS, only one other RCT has evaluated combination SSRI and psychotherapy treatment for youth with depression. Specifically, Melvin et al. (2006) directly compared sertraline, CBT, and their combination. They observed partial remission among 71% of CBT patients, 33% of sertraline patients, and 47% of patients receiving combined treatment. Consistent with previously reviewed research, Sertraline patients evidenced significantly more adverse events and side effects. Surprisingly and in contradiction with their own data, Melvin et al. recommended CBT and sertraline with equal strength.

As I summarize the content from our article, I’m aware that you might conclude that I’m completely against antidepressant medication use. That’s not the case. For me, the take-home points include, (a) SSRI antidepressants appear to be effective for some young people with depression, and (b) at the same time, as a general treatment, the risk of side effects, adverse effects, and minimal treatment effects make SSRIs a bad bet for uniformly positive outcomes, but that doesn’t mean there won’t be any positive outcomes. In the end, for my money—and for the safety of children and adolescents—I’d go with counseling/psychotherapy or exercise as primary treatments for depressive symptoms in youth, both of which have comparable outcomes to SSRIs, with much less risk.

And here’s a link to the whole article:

 

Antidepressant Medications for Treating Depression in Youth: A 25-Year Flashback

About 25-years ago Rita and I published an article titled, “Efficacy of antidepressant medication with depressed youth: what psychologists should know.” Although the article targeted psychologists and was published in the journal, Professional Psychology, the content was relevant to all mental health professionals as well as anyone who works closely with children.

Yesterday, when teaching my research class to a fantastic group of Master’s students in the Department of Counseling at UM, I had a moment of reminiscence. Not surprisingly, along with the reminiscence, came a resurgence of emotion and passion. I was sharing about how it’s possible to find an area of interest that hooks so much passion, that you might end up tracking down, literally everything ever published on that topic (as long as the topic is small enough!).

The motivation behind my interest in the efficacy of antidepressants with youth came about because of a confluence of factors. First, I was working with youth every day, many of whom were prescribed antidepressant medications. Second, I was in a sort of professional limbo—working in full-time private practice—but wishing to be in academia. Third, out of virtual nowhere, in 1994, Bob Deaton, a professor of social work at the University of Montana, asked Rita and I to do an all-day presentation for the Montana Chapter of the National Association of Social Workers. Bob’s offer was not to be refused, and I’ve been in Bob Deaton’s debt ever since. If you’re out there reading this, thanks again Bob, for your confidence and the opportunity.

To prep, Rita and I split up the content. One of my tasks was to dive into all things related to antidepressant medications. Before embarking on the journey into the literature, I expected there would be modest evidence supporting the efficacy of antidepressants in treating depression in youth.

My expectations were completely wrong. Much to my shock, I discovered that not only was there not much “out there,” but the prevailing research was riddled with methodological problems and, bottom line, there had NEVER been a published study indicating that antidepressants were more effective in treating depression in youth than placebo. I was gob smacked.

Just to give you a taste, here’s the abstract:

Pharmacologic treatments for mental or emotional disorders are becoming increasingly popular, especially in managed care environments. Consequently, psychologists must remain cognizant of medication efficacy concerning specific mental disorders. This article reviews all double-blind, placebo- controlled efficacy trials of tricyclic antidepressants (TCAs) with depressed youth that were published in 1985-1994. Also, all group-treatment studies of depressed youth using fluoxetine, a serotonin-specific reuptake inhibitor (SSRI), are summarized. Results indicate that neither TCAs nor SSRIs have demonstrated greater efficacy than placebo in alleviating depressive symptoms in children and adolescents, despite the use of research strategies designed to give antidepressants an advantage over placebo. The implications of these findings for research and practice are discussed.

Early in my research class this semester, an astute young woman asked about the “rule” she had heard about that you shouldn’t cite research that’s more than 10-years-old. It was a great question. I hope I responded rationally, but my apoplectic-ness may have showed in my complexion and words. In my view, we cannot and should not ignore past research. As Samuel Clemens once wrote, “History doesn’t repeat itself, it only rhymes.” If we don’t know the old stuff, we may miss out on the contemporary rhyming pattern. In our article, 25-years-old now, we also discussed some medication research reporting shenanigans (although we used more professional language. Here’s an excerpt of our discussion about drop-out rates.

Dropout rates. Side effects and adverse events can significantly affect medication study outcomes by causing participants to discontinue medication treatment. For example, in the IMI [imipramine] study with children ( Puig-Antich et  al.,  I987), 4 out of 20 (20%) of the medication group did not complete the study, whereas in the two DMI [desipramine] studies ( Boulos et al., l99 l; Kutcher et al., 1994 ), 6 out of 18 (33%) and 9 out of 30 (30%) medication participants dropped out because of side effects. For each of these studies, participants who dropped out of the treatment groups before completing the treatment protocol were eliminated from data analyses. The elimination of dropout participants from data analyses produced inappropriately inflated treatment-response rates. For example, although Puig-Antich et al. (1987) reported a treatment-response rate of 56% (9 of 16 participants), if all participants are included within the data analyses, the adjusted or intent-to-treat response rate is 45% (9/20). For the three studies that reported the number of medication protocol participants who dropped out of the study, the average reduction in response rate was 16.5%. Overall, intent­to-treat response rates ranged from less than 8% to 45% (see Table 2 for intent-to-treat response rates for all reviewed TCA studies).

What’s the value, you might wonder, of looking back 25-years at the methodology and outcomes related to tricyclic antidepressant medication use? You may disagree, but I think the rhyming pattern within antidepressant medication research for youth (and adults) remains. If you’re interested in expanding your historical knowledge about this rhyming, I’ve linked the article here.

Research can be boring; it can be opaque; it can be riddled with stats and numbers. Nevertheless, for me, research remains exciting, both as a source of amazing knowledge, but also as something to read with a critical eye.

The Art of Giving Feedback–Revised

[Note: This is an edited and updated version of a post I did a year or two ago.]

Giving and receiving feedback is a huge topic. In this blog post the focus is on giving and receiving feedback in classroom settings or in counseling/psychotherapy supervision. The following guidelines are far from perfect, but they offer ideas that instructors and students can use to structure the feedback giving and receiving process. Check them out, and feel free to improve on what’s here.

Before you do anything, remember that feedback can feel threatening. Hearing about how we sound and what we look like is pretty much a trigger for self-consciousness and vulnerability. Sometimes, when we look in the mirror, we don’t like what we see, and so obviously, when someone else holds up a mirror, the feedback we experience may be . . . uncomfortable. . . to say the least. To help everyone feel a bit safer, the following can be helpful:

  • Acknowledge that feedback is scary.
  • Emphasize that feedback is essential to counseling skill development.
  • Share the feedback process you’ll be using
  • Make recommendations and give examples of what kind of feedback is most useful.

Acknowledge that Feedback is Scary: You can talk about mirrors (see above), or about how unpleasant it is for most people to hear their own voices or see their own images, or tell a story of difficult and helpful feedback. I encourage you to find your own way to acknowledge that feedback triggers vulnerability.

Feedback is Essential: Encourage students to lean into their vulnerability and be open to feedback—but don’t pressure them. Explain: “The reason you’re in a counseling class is to improve your skills. Though hard to hear, constructive feedback is useful for skill development. Don’t think of it as criticism, but as an opportunity to learn from mistakes and improve your counseling skills.” What’s important is to norm the value of giving and getting feedback.

Share the Process You’ll be Using: Before starting a role play or in-class practice scenario, describe the guidelines you’ll be using for giving and receiving feedback (and then generate additional rules from students in the class). Here are some guidelines I’ve used:

  • Everyone who volunteers (or does a demonstration or is being observed) gets appreciation. Saying, “Thanks for volunteering” is essential. I like it when my classes establish a norm where whoever does the role-playing or volunteers gets a round of applause.
  • After being appreciated, the role-player starts the process with a self-evaluation. You might say something like, “After every role play or presentation, the first thing we’ll do is have the person or people who were role-playing share their own thoughts about what they did well and what they think they didn’t do so well.”
  • After the volunteer self-evaluates, they’re asked whether they’d like feedback from others. If they say no, then no feedback should be given. Occasionally students will feel so vulnerable about a performance that they don’t want feedback. We need to accept their preference for no feedback and also encourage them to solicit and accept feedback at some later point in time.

Giving Useful Feedback: It’s always good to start with the positive. Try to be very clear and specific about some things you especially liked. I usually take notes to help me with this; I’ll write down exactly what the role player said and put a + sign next to it so I can say something like, “I see in my notes that I put a + sign next to your very first paraphrase. You seemed to be tracking very well and you shared what you heard with your client in a way that felt nice.

Constructive or corrective feedback shouldn’t focus so much on what was done poorly, but emphasize what could be done to perform the skill even better. Constructive or corrective feedback might sound like this: “I noticed you asked several closed questions. Closed questions aren’t bad questions, but sometimes it’s easier to keep clients talking about important content if you replace your closed questions with open questions or with a paraphrase. Let’s try that. How could you change one of your closed questions to an open question or a paraphrase?” BTW: General and positive comments (e.g., “Good job!”) are pleasant and encouraging, but should be used in combination with more specific feedback; it’s important to know what was good about your job.

Constructive feedback should be specific, concrete, and focused on things that can be modified. For example, you can offer a positive or non-facilitative behavioral observation (e.g., “I noticed you leaned back and crossed your arms when the client started talking about sexuality.”). After making an observation, the feedback giver or the group can explore potential hypotheses (e.g., “Your client might interpret you leaning back and crossing your arms as judgmental”). The feedback giver can also offer an alternative (“Instead, you might want to lean forward and focus on some of your excellent nonverbal listening skills.”).

With constructive feedback you can take some of the evaluation out of the comment by just noticing or observing, rather than judging, “I noticed you said the word, ‘Gotcha’ several times.” You can also ask what else they might say instead, “To vary how you’re responding to your client, what might you say instead of ‘Gotcha’?”

General negative comments such as “That was poorly done.” should be avoided. To be constructive, provide feedback that’s specific, concrete, and holds out the potential for positive change. Feedback should never be uniformly negative. Everyone engages in counseling behaviors that are more or less facilitative. If you happen to be the type who easily sees what’s wrong and have trouble offering praise, impose the following rule on yourself: If you can’t offer positive feedback, don’t offer any at all. Another alternative is to consciously focus on using the sandwich feedback technique when appropriate (i.e., say something positive, say something constructive, then say another positive thing).

IMHO, significant constructive feedback is the responsibility of the instructor and should be given during a private, individual supervision session. The general rule: “Give positive feedback in public and constructive feedback in private” can be useful.

Finally, students should be reminded of the disappointing fact that no one performs perfectly, including the teacher or professor. Also, when you do demonstrations, be sure to model the process by doing a self-evaluation (including things you might have done better), and then asking students for observations and feedback.

A Free Psychotherapy.net Video Offering

I’m just writing you all on this beautiful fall afternoon in Montana to let you know about a FREE 20ish minute video titled, “Working Online with Suicidal Clients in the Age of COVID.” The video features Victor Yalom of Psychotherapy.net and me discussing issues related to suicide and distance counseling.

In honor of national Suicide Prevention Awareness Month, Psychotherapy.net is offering this video free (n.b., to access the video, you’ll need to enter your email address). Note: I used “n.b.” in my previous parenthetical comment to stick with the “Yalom” theme, because I learned to use n.b. (along with a plethora of new vocabulary words, like solipsistic, amnestic, servility, internecine, and sacrosanct), from reading Irvin Yalom’s group psychotherapy textbook.

Here’s the link: https://academy.psychotherapy.net/suicide-prevention-2021-jsf-signup

Victor and I also collaborated on a longer (7.5 hour) suicide assessment and treatment psychotherapy.net video that may be available through your university library subscription.

I hope you’re all as healthy and well as possible.

Happy Autumn,

JSF

Skills and Strategies for Conducting Excellent Clinical Interviews

As seen on a Sussex Directories Inc site

Hello.

This morning I had the honor of spending two hours with counselors from the Western Tidewater Community Services Board in beautiful Virginia. Unfortunately, I wasn’t in Virginia, but the magic of Zoom made the connection and collaboration possible.

The presentation focused on how to integrate assessment and relational factors into an initial clinical interviews. The powerpoints are here:

Before signing off, I want to emphasize how much I enjoyed the short and Zoom-based interactions I had with the Western Tidewater clinicians. They were focused, interested, and engaged. Being with them (over 120 people) increased my belief that there are good people in the world. Thanks!

The ACA Town Hall is Tomorrow

Rita and I get to be the guests for tomorrow’s online ACA Town Hall. The topic for the day is suicide, but more generally, the Town Hall, moderated by ACA President Dr. Kent Becker, is designed to be a community event for ACA members. The suicide discussion will be brief and there will be several other break-out groups in the Zoom format.

To participate, you’ll need to be a member of the American Counseling Association (ACA). As ACA members, you can attend for free, but you need to register in advance. Here’s the link: https://imis.counseling.org/store/events/registration.aspx?event=DOH2021SEP

My apologies for the late notice on this.

I hope everyone is well and thriving as much as possible.

John

Coping with Suicide Deaths

A recent smoky sunrise on the Stillwater River

As most of you know, I recently published an article in Psychotherapy Networker on my long-term experience of coping with the death of a client by suicide. In response to the article, I’ve gotten many supportive responses, some of which included additional published resources on coping with client death by suicide.

This blog post has two parts. First, I’m promoting the Networker article again to get it more widely shared as one resource for counselors and psychotherapists who have lost a client. Below, is an excerpt from the article. . . followed by a link. Please share with friends and colleagues as you see fit.

Second, at the end of this post I’m including additional resource articles that several people have shared with me over the past two weeks.

Here’s the excerpt . . .

The Prevention Myth

I’d worked with Ethan for about 20 sessions. Stocky, socially awkward, and intellectually gifted, he often avoided telling me much of anything, but his unhappiness was palpable. He didn’t fit in with classmates or connect with teachers. Ethan felt like a misfit at home and out of place at school. Nearly always, he experienced the grinding pain of being different, regardless of the context.

But aren’t we all different? Don’t we all suffer grinding pain, at least sometimes? What pushed Ethan to suicide when so many others, with equally difficult life situations and psychodynamics, stay alive?

One truth that reassures me now, and I wish I’d grasped back in the 1990s, is that empirical research generally affirms that suicide is unpredictable. This reality runs counter to much of what we hear from well-meaning suicide-prevention professionals. You may have heard the conventional wisdom: “Suicide is 100 percent preventable!” and, “If you educate yourself about risk factors and warning signs, and ask people directly about suicidal thoughts or plans, you can save lives.”

Although there’s some empirical evidence for these statements (i.e., sometimes suicide is preventable, and sometimes you can save lives), the general idea that knowledge of suicide risk, protective factors, and warning signs will equip clinicians to predict individual suicides is an illusion. In a 2017 large-scale meta-analysis covering 50 years of research on risk and protective factors, Joseph Franklin of Vanderbilt University and nine other prominent suicide researchers conducted an exhaustive analysis of 3,428 empirical studies. They found very little support for risk or protective factors as suicide predictors. In one of many of their sobering conclusions, they wrote, “It may be tempting to interpret some of the small differences across outcomes as having meaningful implications, . . . however, we note here that all risk factors were weak in magnitude and that any differences across outcomes . . . are not likely to be meaningful.”

Franklin and his collaborators were articulating the unpleasant conclusion that we have no good science-based tools for accurately predicting suicide. I hope this changes, but at the moment, I find comfort in the scientific validation of my personal experience. For years, I’ve held onto another suicide quotation for solace. In 1995, renowned suicidologist Robert Litman wrote, “When I am asked why one depressed and suicidal patient dies by suicide while nine other equally depressed and equally suicidal patients do not, I answer, ‘I don’t know.’”

Here’s the link to the full article: https://www.psychotherapynetworker.org/magazine/article/2565/the-myth-of-infallibility

Here are the additional resources people have shared with me:

Ellis, T. E., & Patel, A. B. (2012). Client suicide: what now?. Cognitive and Behavioral Practice19(2), 277-287.

Jorgensen, M. F., Bender, S., & McCutchen, A. (2021) “I’m haunted by it:” Experiences of licensed counselors who had a client die by suicide. Journal of Counselor Leadership and Advocacy. DOI: 10.1080/2326716X.2021.1916790

Knox, S., Burkard, A. W., Jackson, J. A., Schaack, A. M., & Hess, S. A. (2006). Therapists-in-training who experience a client suicide: Implications for supervision. Professional Psychology: Research and Practice, 37(5), 547-557.

Ting, L., Jacobson, J. M., & Sanders, S. (2008). Available supports and coping behaviors of mental health social workers following fatal and nonfatal client suicidal behavior. Social work, 53(3), 211-221.

As always, thanks for reading, and have a great day!

Montana Conference on Suicide Prevention — My Powerpoints

Good morning. I’m listening to Dr. David Jobes talk about innovations in approaching suicide assessment and treatment. I’m struck by the breadth and depth of his knowledge . . . and also discouraged by him acknowledging how difficult it is to change people’s mindsets regarding suicidality and its treatment. At this point we ALREADY have many effective psychosocial treatments, but disappointingly, the media and public knowledge still leans toward profiling hospitalization and the potential of medication (both of which show very mixed results).

I’ll stop with my rant here and post my ppts. Thanks for reading . . . and be sure to get the word out on innovations in suicide assessment and treatment (aka psychosocial treatments).

Tomorrow – Another Suicide Prevention Conference with Free CEUs

The second of two consecutive suicide prevention conferences with free CEUs is tomorrow! Just in case you didn’t know, this conference, the Montana Conference on Suicide Prevention, has two full hours of David Jobes–the creator of CAMS–in the afternoon. How often do you get to listen to Dr. Jobes for two hours, for free, and get CEUs? Not often, I suspect.

Here’s the conference link. Go to the bottom to find the registration button: https://www.montanacosp.org/

In related news, I just got an email from the Association for Humanistic Counseling about an upcoming all-day conference on Strengths-Based Suicide Assessment and Treatment (with me presenting!). The date is: 9.24.21. This one has a small fee for CEUs . . . but it’s cheaper if you become an AHC member. Here’s the registration link for that one: https://events.r20.constantcontact.com/register/eventReg?oeidk=a07eibjc7x5afb40bd4&oseq=&c=&ch=

Have a great evening and I hope to “see” you tomorrow at the Montana conference.

Mental Health Academy Suicide Summit PowerPoint Slides

Good morning! The 2021 MHA Suicide Summit has started (see below) and I’ll be up in less than an hour.

Sometimes I think the hardest part about doing workshops is writing the workshop blurb. My problem-and maybe it’s just my problem—is that the process of writing workshop blurbs nearly always impairs my judgment. I start out writing like a sensible and rational person, but eventually I decompensate into displaying delusions of grandeur. For the Mental Health Academy Suicide Summit, I completely lost touch with reality and claimed that I would,

  1. Describe strengths-based principles for suicide assessment and treatment
  2. Be able to implement three strengths-based assessment tools (and recognize the limits of risk and protective factor assessment)
  3. Identify suicide drivers (and goals) linked to seven common life dimensions
  4. Describe at least one wellness and mood management positive psychology strategy for patients and practitioners.

Of course, all of this is great, but, here’s the catch. I’m only presenting for 45 minutes!

If anyone out there can help me become more realistic, I would appreciate the input.

In the meantime, here are the ppts for the presentation today.

John