ALLAN ABBASS, M.D.
DAVID M. GARDNER, Pharm. D.
Dalhousie University
Department of Psychiatry
Am Fam Physician. 2004 May 1;69(9):2071-2, 2074.
Psychotherapy and Medication Options for
Depression
TO THE EDITOR: Recent studies have shown an increase in the number of
prescriptions for medications to treat depression and a decrease in the use of
psychotherapy for depression.1 This trend suggests that brief psychotherapies are
unavailable or underused, despite the established efficacy and patient preference for
brief psychotherapies.2
The mainstream brief psychotherapies for depression include cognitive-behavior
therapy, interpersonal therapy, and short-term dynamic psychotherapies. The
availability of these treatments is variable. In the private sector, these therapies can
cost more than $100 an hour. In the public sector, these therapies are available at no
charge, but usually require longer waiting periods for access. The access to
antidepressants is more obvious and reliable but not necessarily less expensive (see
accompanying table&on page 2072).
Comparison of Pharmacotherapy and Psychotherapy for
Treatment of Depression
Parameter
Antidepressant
Brief psychotherapy
Usual recommended
treatment duration
6 to 12 months
16 hourly sessions over 4
months
Cost*
216 to $1,485 per 9
months
$320 to $1,600 per
treatment course
Pretreatment preference2
++
+++
Attrition†
++
+
Response rates3
+++
+++
Response in severe
depression4
+++
++
Remission rate2,3
++ to ++++
++ to +++
Relapse rates on cessation2,5
++
+
Adverse effects
+++
+
Access/convenience
++++
++‡
Key: + = 0 to 25 percent effect; ++ = 25 to 50 percent effect; +++ = 50 to 75 percent effect;
++++ = at least a 75 percent effect.
*-Cost range for antidepressant treatment is based on the purchase prices (including a $9
monthly dispensing fee) of the least expensive selective serotonin reuptake inhibitor (SSRI)
at minimum dosage (fluoxetine [Prozac], 10 mg per day) to the most expensive SSRI at
maximum dosage (citalopram [Celexa], 60 mg per day). Cost range of brief psychotherapy is
based on publicly provided therapy to private psychologist-provided therapy.
†-Early treatment withdrawal from ongoing therapy (attrition) was used to measure treatment
acceptability.
‡-Access to psychotherapy may be higher than we have indicated, especially in urban
settings. However, caregivers, because of system problems, often censor this option without
fully exploring it with their patients.
Information from references 2 through 5.
For most patients with depression of mild to moderate severity, psychotherapy and
antidepressants appear equally effective.3 In severe cases, antidepressants may
provide greater symptomatic relief.4 Psychotherapy is preferred by patients, and
treatment tolerance and acceptance appears better.2,3 Comparative studies,5 which
have included only older antidepressants (e.g., tricyclic antidepressants, monoamine
oxidase inhibitors), have demonstrated lower dropout rates with brief
psychotherapies (22.2 percent) than with pharmacotherapies (37.1 percent). The fact
that dropout rates with the use of newer antidepressant agents remain high with only
a modest advantage over older antidepressant agents implies that this advantage for
psychotherapies persists. This greater acceptance may be partly related to adverse
effects, which are a common reason for prematurely terminating therapy with
antidepressant drugs. Adverse effects, at least in terms of somatic side effects, do
not appear to be a factor with psychotherapy. Some studies5 also have shown an
enduring effect with psychotherapy that reduces the risk of relapse and recurrence
after treatment has been terminated (20 percent versus 50 percent relapse at two
years for psychotherapy and pharmacotherapy, respectively). Even though the
literature is unclear, combinations of psychotherapy and antidepressant medications
may have an added effect in certain patients5 and may be less costly to the health
care system than pharmacotherapy alone.6
Given the equal efficacy and patient preference for psychotherapies, we are
compelled to examine why the rates of psychotherapy use have decreased while the
prescribing of antidepressant medications has increased. The expensive and
effective marketing of pharmaceutical companies has made a generation of
physicians well versed in the prescription of antidepressants. Is it possible that
physicians are not aware, because of "marketing" deficits, of the effectiveness,
acceptability, and preferences for psychotherapies? Is there an education bias in
medical schools and residency programs that fails to emphasize these options? Or,
is it because physicians cannot access psychotherapies even if that is what their
patients would prefer? It is vital that we answer these questions, in the service of
our patients with depression.
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