| When Are
Antidepressants Better Than Psychotherapy?
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By: Michael G. Conner, Psy.D, Clinical &
Medical Psychologist
Exactly when is taking an antidepressant better than psychotherapy? These questions are important when you consider that antidepressants are prescribed inappropriately or unnecessarily to millions of Americans and many psychotherapy techniques are as trendy as MTV and less therapeutic. Unfortunately, the answer to the question of "Which is better?" will depend on who you ask. But deciding what to believe is ultimately up to you. If you are facing this question for yourself, then the consequences will be yours. This means you need to understand the controversy over the facts and the fiction. The treatment recommendations patients will get from professionals are shaped long before a patient is even seen. For practical purposes, the relevant factors include economics, research findings and recommended treatment guidelines. There are also emerging issues which are forcing professionals to examine their assumptions and philosophy of treating mental, emotional and behavioral problems. For more information on various antidepressants see the following internet resource: www.RxList.Com Summary
The standards for treating mental, emotional and behavioral problems with drugs, counseling or psychotherapy cannot be separated from the economics of this country and the sources of funding that train professionals and fund research. While there is a need for competent psychotherapists and counselors, the opportunities to practice competently are shrinking as result of managed care limitations and the elimination of services. Managed mental health companies spend up to 40% of money available for treatment on administration and an additional 30% of your money can go to profit. That is the reason why psychotherapy services have been cut back and even eliminated over the past five years. Research studies that describe when, how and why antidepressants should be used have been presented exceptionally well by the medical research and pharmaceutical industries. In sharp contrast, research on the use of counseling and psychotherapy has not been well focused nor has it been funded nearly as well. Alternative approaches including naturopathic and orthomolecular treatments for depression have not been pursued aggressively by the pharmaceutical industry primarily because these industries can't have exclusive manufacturing and distribution rights. Pharmaceutical companies can't patent and own the rights to substance found in nature. Managed Mental Health Care has had a tremendous impact on the practice of counseling and psychotherapy over the past five years. Access to counseling and psychotherapy services, your right to choose your treatment professional, the duration of treatment and the type of problems covered by health insurance have been drastically reduced or eliminated by managed health companies that are reaping record huge profits. From an economic perspective, the pharmaceutical and managed mental health care industry as well as many medical practitioners, support antidepressant medications as the first line of treatment for depression. Medications are relatively inexpensive in the short run. Psychotherapy is relatively expensive in the short run. The long term benefits and impact of these approaches are the subject of a growing clinical and economic debate. Assuming all things are equal (and that is a big assumption) companies looking for short term profits tend to authorize the use of antidepressants and limit the use of counseling and psychotherapy. In Europe and Canada the practice of medicine is not nearly as profit oriented, nor is medicine so strongly influenced by investors and the stock market. These countries have had a long standing interest in the use of natural substances rather than artificially created pharmaceutical drugs. While there is not a great deal of research in the U.S. on this subject, there is a great deal of experience and research in other countries on the use and benefits of naturopathic substances. American pharmaceutical companies and the U.S. government are only now beginning to show an interest. Most of this interest is due to tremendous public interest in natural substances and the amount of money the public is now spending on alternative treatment approaches. There has been a significant amount of research in the United States on the benefits and problems associated with antidepressant medications. Nearly all this research is funded or indirectly supported by pharmaceutical companies and their investors. In addition, these industries indirectly support medical training and have a strong influence on public opinion, medical practice and the publication of research. Research has focused a great deal on pharmaceutical drug interventions and very little on the outcomes from counseling and psychotherapy. There has been a growing focus in the past few years on the process and long term benefits of counseling and psychotherapy. What little research has been conducted in the past has indicated that psychotherapy is helpful, can provide a lasting benefit and has economic advantages. No definite answers have surfaced. New research is reporting that psychotherapy is effective and valued by the public. While managed mental health care is restricting and limiting counseling and psychotherapy services, researchers are also reporting that the managed mental health care industry has not interpreted previous research correctly and is providing less psychotherapy than suggested by research findings. Original research that demonstrates the effectiveness and potential of antidepressant medication is being re-examined. For instance, patients selected for studies on the effectiveness of antidepressant medications are in many cases distinctly different from the people who are ultimately prescribed these medications. As many as 1000 subjects with a diagnosis of depression may be screened to find 15 people with uncomplicated depression who are also suitable for a research study. While we may know something about the benefits of an antidepressant for people with simple depression, the benefits of antidepressant medication for complicated depression has not been adequately studied and is merely assumed. A ground breaking re-analysis of past research on antidepressants found that 75% of the improvement is not caused by the medication. Up to 50% of the total improvement associated with an antidepressant can be attributed to what is called an active placebo effect. This means that the unintended psychological and physical side-effects are being misinterpreted by patients as improvement or that the drug is actively working. Up to 25% of patients' improvement is actually the result of changes that are caused by the passage of time. This includes changes in the patients environment and the tendency for people to recover and adapt over time. Finally, up to 25% of the improvement is actually the intended effect of the antidepressant. Antidepressant medications can be an effective and beneficial. How effective and who it will be effective with has not been determined. Numerous guidelines have been proposed and recommended on the use of antidepressants and psychotherapy. These guidelines are the products of committees and task forces that reach a consensus in light of research and clinical practice. For the most part these conclusions reflect the practices and research histories of the professions represented. In general,
Antidepressant treatment guidelines consist of recommendations which when applied to a population will provide some improvement to a percentage of those people. Whatever improvement is noted, there is also a significant percentage of the population treated with antidepressants who demonstrate no improvement and may even get worse. Treatment of mental, emotional and behavioral problems using counseling and psychotherapy began long before antidepressant medications were discovered. Until recently, counseling and psychotherapy has been a cottage industry of individual practitioners guided by professional ethics and professional standards of care. Treatment is increasingly influenced and directed by managed mental health companies. As a result, the standards of practice that were formerly relied on are no longer guiding the practices of counseling and psychotherapy. A complete recovery from depression that can be attributed to an antidepressant medication is the exception, and not the rule. The side effects of antidepressant medications can produce significant psychological and medical problems. Antidepressant medications will most likely be helpful when treating people with "pure" and "uncomplicated" depression. Antidepressant medications are less likely to be effective when depression is associated with psychological and social problems or other medical problems which directly cause depression. Antidepressant medications will generally reduce some symptoms of depression but may cause other symptoms and lead to other psychological and emotional problems. The use of antidepressant medication is controversial and a questionable practice with children since the impacts of these drugs have not been adequately studied on children. One important problem surfaces when a patient agrees to a trial on antidepressants. There is no way to predict whether or not a person will benefit from taking a particular antidepressant medication. Trial and error is often necessary. Some patients may find it necessary to undergo several trials of antidepressants and endure unpleasant side effects until a useful medication is found. The use of antidepressants to treat mental, emotional and behavioral problems should be avoided unless such treatment (a) is medically necessary, (b) there is no other acceptable alternative, and (c) the side-effects and the risk of taking (or not taking) medications are fully understood.
Counseling and therapy can be
helpful for most situations involving psychological, emotional,
relationship, parenting, family and employment problems. You will get more
out of therapy if you are informed, educate yourself and take an active
(rather than passive) role in finding and selecting your counselor or
psychotherapist.
The risk associated with competent
counseling or psychotherapy is usually minimal, but can vary depending on
the problem or situation. The biggest challenge in undergoing
psychotherapy is what can be called "dosage." Most problems require
a minimum of 3 to 6 months of counseling or psychotherapy to produce a
lasting benefit. Very few problems or conditions require more than 1 year.
People may continue therapy or counseling for personal growth,
relapse prevention and for support.
In the past year, the use and benefits of antidepressants and psychotherapy have been questioned by scientists, researchers and practitioners. Opinions and conclusions have emerged.
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