There has been a lot of hand wringing recently over the lack of innovation in medication development for mental disorders and the reduced investments from the pharmaceutical industry in the development of psychiatric medications. This may be an era of angst for medication development, but simultaneously there has been a quiet flowering of innovative behavioral treatments. From cognitive therapy developed to reduce repeat suicide attempts,1 to family-based therapy for those with anorexia nervosa,2 structured behavioral interventions have been shown to be effective in randomized controlled trials.
A new report by Wilhelm and colleagues, just published in the August 2012 issue of the Archives of General Psychiatry, makes a good case for a behavioral intervention for Tourette syndrome (TS). TS, one of the most neurological of the neuropsychiatric syndromes, might be an unlikely target for a behavioral intervention. Vocal and motor tics appear involuntary and stereotyped, and typically are not considered targets for behavioral training approaches, which are critical components of cognitive behavior therapy. Medications, especially antipsychotics, have been used to control tics, but their side-effects and chronic use in young children have been a source of concern. And for many children, tics are difficult to control with medication. Although new research suggests that deep brain stimulation may by an effective and well tolerated method for controlling tics, the treatment is not widely available. 3
An initial report in children described Comprehensive Behavioral Intervention for Tics (CBIT), a therapy based on habit reversal training. The essence of CBIT is tic-awareness and competing-response training. Tic-awareness training teaches a child how to self-monitor for early signs that a tic is about to occur. Competing-response training teaches a voluntary behavior designed to be physically incompatible with the impending tic, thereby disrupting the cycle and decreasing the tic. Piacentini and colleagues reported more than 50 percent of children experienced significant improvement with CBIT, compared to less than 20 percent who improved following a control treatment. 4
For many children, with or without treatment, tics fade during adolescence. But for a significant percentage, tics persist into adulthood and may cause substantial morbidity. A variety of medications have been used for adults with TS, but as with children, the results are frequently inadequate and side effects are troublesome. This new report shows that CBIT has promise in adults as well as children. Following 122 adults receiving eight sessions over a 10- week period, 38 percent showed significant improvement relative to 6 percent receiving a control treatment. Improvement was sustained at 3- and 6- months after the end of the study.
CBIT appears to be a new option for people with certain subtypes of the syndrome. It joins the ranks of behavioral treatments that work for depression, obsessive compulsive disorder, and certain phobias. For those accustomed to randomized, double-blind, placebo-controlled medication trials, the behavior therapy trials may look less rigorous. However, contemporary psychotherapy trials, such as the CBIT trial, are designed to increase our confidence in the results. For example, these trials measure the delivery of the psychotherapy to ensure that it is implemented as intended. Also, to ensure that evaluation of participants’ outcomes is unbiased, they employ the use of independent, objective clinical evaluators who are not aware of which treatment a given participant receives. Behavioral treatments can be demanding, and for patients with the most severe forms of mental illness, engagement in behavior therapy alone may not be feasible. But these concerns about behavioral approaches are balanced out by the relatively low level of side-effects associated with these treatments and the low rate of relapse following the completion of treatment.
As the success of behavioral interventions becomes more widespread, we will need to address an “inconvenient truth.” For medications, we have a well-developed pathway for regulating use. A prescription for an antidepressant medication yields the same treatment, no matter who prescribes it. By contrast, we don’t have the same regulatory process for behavioral treatments. There is no federal agency that oversees the quality or effective dose of psychotherapy. And there is no easy way to assure that the behavioral intervention provided in practice is the same as the behavioral intervention tested in a research study. With the increasing evidence of the value of behavioral interventions, is this the time to develop a rigorous process for qualifying their use and ensuring their uniform dissemination?
1 Brown GK, Ten Have T, Henriques GR, Xie SX, Hollander JE, Beck AT. Cognitive therapy for the prevention of suicide attempts: a randomized controlled trial . JAMA. 2005 Aug 3;294(5):563-70. PubMed PMID: 16077050.
2 Lock J, Couturier J, Agras WS. Comparison of long-term outcomes in adolescents with anorexia nervosa treated with family therapy . J Am Acad Child Adolesc Psychiatry. 2006 Jun;45(6):666-72. PubMed PMID: 16721316.
3 Cannon E, Silburn P, Coyne T, O'Maley K, Crawford JD, Sachdev PS. Deep Brain Stimulation of Anteromedial Globus Pallidus Interna for Severe Tourette’s Syndrome . Am J Psychiatry. 2012 Aug 1;169(8):860-6. PubMed PMID: 22772329.
4 Piacentini J, Woods DW, Scahill L, Wilhelm S, Peterson AL, Chang S, Ginsburg GS, Deckersbach T, Dziura J, Levi-Pearl S, Walkup JT. Behavior therapy for children with Tourette disorder: a randomized controlled trial . JAMA. 2010 May 19;303(19):1929-37. PubMed PMID: 20483969; PubMed Central PMCID: PMC2993317.