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In Nice this year, we held a one-day meeting that brought together neuroscientists, experimental psychologists and clinical psychologists. Our purpose was to highlight a gap between neuroscience and practice in relation to talking treatments in psychiatry. The same gap seems to me to have become a major barrier to drug development: it is the absence of experimental steps to establish how treatments work in man. What instead has usually happened is that drugs well characterised in animals and test tubes are fast tracked into phase II clinical trials. Such trials use rating scales to assess ’efficacy’. What might be more rational would be to establish effects on more proximal measures of function that prove target engagement. The putatively mediating mechanisms could then provide insight in trials designed to study stages further down the causal chain of desired outcomes, the ultimate measure of which is restoration of the functions valued by the individual patient.
The same gap seems to have developed in psychotherapies. Leaving aside the folk psychology that underpinned traditional understanding of interpersonal difficulties, behaviour therapy was originally based on learning theory (behaviourism) and subsequently cognitive behaviour therapy (CBT) has incorporated cognitive science as a prelude to therapy innovation. However, proof of principle has had a lot in common with the phase II approach to drug trials. The emphasis is on symptom reduction in exactly the same way as for drug trials. Psychotherapy faces the additional challenge of how to choose a fair comparison intervention (and how to deal with demand characteristics that result from the lack of blinding).
In a similar way therefore, drug treatment and psychological treatment need a translational step informed by laboratory neuroscience to establish proof of concept. Such intermediate measures may allow more valid comparisons of different treatments but also enrichment for potential responders who may benefit particularly from a particular treatment. They may also provide the targets for understanding how drug and psychotherapy can be mutually amplified for patient benefit.
The Nice meeting created a great atmosphere and the participants illustrated the appeal and promise of psychological interventions, especially if access can be assisted by on line technology. But I think we showed that the translational step remains their challenge as it is for those of us interested by drug treatments. ECNP will in future provide a natural home for clinical psychologists who do translational neuroscience.
Guy Goodwin
ECNP President |
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