This post from the British Psychological Society just popped up in my feed reader:
A line was crossed in 2005 as anti-depressant medication became the most widely prescribed class of drug in the USA. …
“It is unclear why the shift toward pharmacologic and away from psychological treatment is occurring,” the researchers said, “although limited access to evidence-based psychological treatments certainly plays some role.”
Kathryn McHugh and her colleagues identified 34 relevant peer-reviewed studies up to August 2011 involving 90,483 people, in which the participants were asked to indicate a straight preference between psychotherapy or drugs. Half the studies involved patients awaiting treatment, the others involved participants who were asked to indicate their preference if they were diagnosed with a psychiatric disorder. The researchers had hoped to study preferences among patients with a diverse range of diagnoses but they were restricted by the available literature – 65 per cent studies pertained to depression with the remainder mostly involving anxiety disorders.
Overall, 75 per cent of participants stated a preference for psychotherapy over drugs. Stated differently, participants were three times as likely to state that they preferred psychological treatment rather than medication. The preference for therapy remained but was slightly lower (69 per cent) when focusing just on treatment-seeking patients, and when focusing only on studies that looked at depression (70 per cent). Desire for psychotherapy was stronger in studies that involved more women or younger participants.
The author’s noted that, given the evidence showing comparable efficacy for psychotherapy and medication in treating most forms of anxiety and depression, there is strong empirical support for greater use of talk-therapy.
UPDATE: Ross shared this APA post on the cost-effectiveness of talk-therapy:
A quick fix?
The behavioral health management companies that now dominate the field have a good reason to prefer medication to psychotherapy: They don’t have to pay for patients’ pills.
Managed-care companies typically “carve out” the mental health portion of patients’ medical care, assigning that responsibility to specialized behavioral health companies. These companies, however, cover only the cost of providing patients with access to mental health providers and facilities. Responsibility for paying prescription drug costs lies with the original managed-care companies. Since behavioral health companies must squeeze psychotherapy costs out of tight budgets, says Pomerantz, it’s not surprising that they favor general practitioners over psychotherapists and psychopharmacological solutions over psychotherapeutic ones. By doing so, he explains, they shift costs back to the managed-care companies themselves.
Even more importantly, says Pomerantz, behavioral health carve-outs typically have a short-term perspective when they consider their bottom lines. While medication gets doled out over long stretches of time, psychotherapy is typically provided in short but intensive periods. Because health plans’ budgets focus on expenses in a given year, medication has an obvious short-term advantage no matter what the eventual long-term cost.
Although conditions such as schizophrenia and manic depression clearly warrant medication, he adds, behavioral health companies are pushing patients toward medication even when psychotherapy or a combination of psychotherapy and medication would be best for them.
“In a recent survey, almost 90 percent of patients who visit psychiatrists are taking psychotropic medications,” says C. Henry Engleka, assistant executive director for marketing in APA’s Practice Directorate. “Instead of medication being used as an adjunct to psychotherapy, the opposite is generally true in most managed-care practices now.”
That’s too bad, says Pomerantz, because over the long run psychotherapy is often more effective, and thus cheaper, for many conditions. Although psychotherapy requires more of an upfront investment, he explains, it pays off by getting the job done and preventing relapses. By contrast, patients on medication often relapse once their medication stops and may require a lifetime of expensive pills. In a column in Drug Benefit Trends, Pomerantz cites several studies from the ever-increasing literature on this topic to prove his point:
In a randomized, controlled trial, researchers assigned 75 outpatients with recurrent major depression to three groups: acute and maintenance treatment with antidepressants, acute and maintenance cognitive therapy and acute antidepressants followed by maintenance cognitive therapy. Cognitive therapy proved as effective as medication in both the acute and maintenance phases, with a trend favoring cognitive therapy’s long-term efficacy (British Journal of Psychiatry, 1997, Vol. 171, p. 328-334).
In another study, researchers randomly assigned 40 patients who had been successfully treated with medication for recurrent major depression to two groups: clinical management or cognitive-behavioral therapy. Over 20 weeks, antidepressants were tapered off and then discontinued in both groups. Two years later, only 25 percent of the patients who received cognitive-behavioral therapy had relapsed compared with 80 percent of the other group [Archives of General Psychiatry, 1998, Vol. 55(9), p. 816-820].
In a meta-analysis of studies published between 1974 and 1994, researchers compared controlled trials of cognitive-behavioral therapy and pharmacological treatment for patients with panic disorder. While both treatments worked in the short run, the results were more positive and longer lasting for cognitive-behavioral therapy (Clinical Psychology Review,1995, Vol. 15, p. 819-844).
There are plenty of other studies with similar results, says psychologist Steven D. Hollon, PhD, of Vanderbilt University, citing the work of psychologists like David H. Barlow, PhD, on panic disorders and G. Terence Wilson, PhD, on bulimia. Hollon’s own research on depression has also found that people who receive focused psychotherapy stay better longer than people who just receive medication.
If the insurance industry would only listen to this research, says Hollon, the implications could be far-reaching.
“Just do the math,” he says, noting that pharmacotherapists may keep depressed patients on expensive antidepressants for the rest of their lives. “If you can get with four months of psychotherapy the same benefits you get from a year and a half to two years of continuous medication, you begin to break even after about a year’s time even though it’s more expensive upfront to provide psychotherapy. If the benefits extend over a half decade or decade, your savings really start piling up. But managed-care folks don’t think that way.”
Abstract: This paper raises the question about whether the data on the medications we call antidepressants justify the label of antidepressant. The authors argue that a true antidepressant should be clearly superior to placebo, should offer a risk/benefit balance that exceeds that of alternative treatments, should not increase suicidality, should not increase anxiety and agitation, should not interfere with sexual functioning, and should not increase depression chronicity. Unfortunately, these medications appear to fall short on all of these dimensions. Many of the “side effects” of these medications have larger effect sizes than the antidepressant effect size. To call these medications antidepressants may make sense from a marketing standpoint but may be misleading from a scientific perspective. Consumers deserve a label that more accurately reflects the data on the largest effects and helps them understand the range of effects from these medications. In other words, it may make just as much sense to call these medications antiaphrodisiacs as antidepressants because the negative effects on libido and sexual functioning are so common. It can be argued that a misleading label may interfere with our commitment to informed consent. Therefore, it may be time to stop calling these medications antidepressants.
From the conclusion:
If we do not call these medications antidepressants, what are some alternative labels that may better fit the existing data? The effect sizes for many of the “side effects” are larger than the antidepressant effect sizes. Using labels like antiaphrodisiac medications, agitation enhancers, insomnia inducers, suicidality inducers, mania stimulators, or gas busters obviously would not offer the same marketing appeal. Though tongue in cheek, we consider these possible labels to be more accurate than the commonly used label of “antidepressant.” It could be argued that the outcomes with the largest effect sizes should be offered as the primary label for a medication.
These guys are pretty sarcastic. And, their sarcasm is unlikely to be a conversation starter, but I suspect that there is more of this backlash to come.
It brings to mind a comment from a recent episode of On Being[emphasis mine]:
…individuals are hopelessly biased, they cannot perceive the truth by themselves.
Science is not just an individual activity. We expect our scientists, we exhort them, to be as objective as they can and a good scientist tries to do so very earnestly, but still fails. So therefore, there must be a social process that causes science to work to be a truth-discovering process.
This thing about scientific truth-discovery being a social process puts it’s finger on something very important. It’s one of the things that so frustrating about hearing people tout evidence-based policies.
Consider the arguments for naloxone distribution. I’ve honestly got no quarrel with it, I just believe that it’s a woefully inadequate response. Of course it’s true that it’s an evidence based policy. I’m sure it saves lives. My problem is that advocates draw a straight line from this truth to universal implementation, AND anyone who balks is anti-science. The problem is that these advocates don’t ask what else we know to be true. For example, treatment also reduces overdose deaths. We fail to discuss what else improves this measure (overdose deaths), we also fail to discuss what other measures are important. If we have that conversation, then we can discuss why it sh0uld or shouldn’t jump to the top of the list without accusing others of being anti-science.
This social aspect of truth-discovery is too often too exclusive. Of course, we can not and should not give equal standing to every goofball with a pet theory, but the points in the antidepressant paper above and the recent GSK scandal demonstrate that the current custodians of evidence are all too capable of leading us into policies based on something other than truth while scolding anyone who questions their evidence.
UPDATE: Just to clarify two things.
First, we’re not anti-medication, but we do believe that their benefits are overstated, the adverse effects are understated, that other methods are just as effective or more effective (And, provide additional benefits.) and that they too often constitutes risk management rather than real treatment.
Second, I see naloxone as first aid. I have no interest in interfering with access to first aid of any kind to anyone with any kind of physical crisis. However, first aid should be FIRSTaid (Not last aid or only aid.), and meaningful treatment for the real problem should follow. I tend to bristle because these calls for naloxone programs never seem to include calls for access to treatment of adequate quality, intensity and duration following the overdose.
The mainstreaming of medication has bred confusion about what’s normal. In some sectors, we’ve grown so vigilant about the possibility of having a mental disorder that this vigilance becomes counterproductive, a source of anxiety in itself. Every negative emotion becomes a potential sign or symptom. I think people, particularly adults, should use medication if they wish, but I am concerned about the changing goalposts of what’s considered pathological. It’s nice to know that medication is available, but it’s also important not to lose sight of the comfort that can come from talking openly with each other, realizing that not every instance of feeling sad, or overwhelmed, or disappointed, or anxious, is a sign of something medically wrong.
With youth, I feel that a conservative approach to medication is best.
Partly that’s because of the way that getting a mental-health diagnosis can intersect with the adolescent search for self. Being diagnosed and using medication confers an identity, that of someone with a mental disorder. To an adolescent who is preoccupied with constructing an identity anyway, and looking for clues to who she is, that can be a big deal. Some adolescents feel that having a diagnostic label is clarifying and that it helps them. But others wrestle with it. They ruminate about what it means to be sick. They take that identity deep inside, and sometimes magnify it way out of proportion. A diagnosis event can have lasting, rippling consequences, and I think adults should be very cautious and careful before they impose a diagnostic label, or let a young person self-impose such a label, on what may be ordinary developmental struggles.
More thoughts on the use of antidepressants with kids. Here, she’s commenting on a piece in The Atlantic that discussed her book.
I think one thing that piece illustrated nicely is the potential difference between starting antidepressants as an adult and starting them young.
Kelly was saying, ‘Look, antidepressants help people; they helped me; they’re this wonderful thing, and I don’t understand why you people are trying to shoot holes in them.’ Kelly has a story that was similar to that of a lot of adults who start antidepressants: she was in therapy for years; therapy was helpful but notthat helpful; she went into crisis and finally overcame whatever inner resistance she had about trying antidepressants, and they were great — she wished she’d tried them sooner.
I very much respect that story, and many others have one like it. Part of what I’m on about in the book is that for people who start medication as teens, or even younger, the story is different. For them, using medication is often not their choice or not their idea. They don’t have the experience of trying other remedies for years and then reaching a point where they say, ‘You know what, these things aren’t working, this problem isn’t going away, and I’m going to take it seriously now and try something new.’ They haven’t necessarily had a chance to sort out what’s the turmoil of growing up and what might be deeper or longer lasting. Sometimes it’s very obvious that an adolescent is dealing with a real mental problem that goes way outside the realm of teen angst. But in other cases it isn’t always so clear. So for some of the people who start young, the narrative ends up not being one like Maura Kelly’s, of, ‘I had a problem, and then I used my own agency to find a solution, and it was wonderful.’ It’s more like, ‘Someone thought I had a problem, and this thing was given to me, and maybe it helped me or maybe it didn’t, sometimes it’s hard to tell, and if I stayed on it for years then I’ll never be quite sure, either what was the matter in the first place, or how I would have developed if I hadn’t taken this drug.’ It’s a singular experience, but it’s becoming more and more a hallmark of our time. That’s what I was trying to capture in the book.
One trend I find interesting is this. There was a time when anecdotes were used to attack antidepressants. The reaction of researchers and other advocates was that evidence should guide practice. Now, as the evidence has softened, we see many of these advocates using anecdotes to make their case. I’m not one to dismiss experiential knowledge, so this is just an observation.
Many people struggling with alcohol dependence who could benefit from medication are not receiving it, according to an expert who spoke at the recent American Psychiatric Association Annual Meeting.
“Antidepressant prescribing is 100 to 200 times as great as prescriptions for medications approved to treat alcohol dependence, despite the fact that the prevalence of disorders for which antidepressants are prescribed—major and minor depression and anxiety disorders—is only two to three times that of alcohol dependence,” says Henry Kranzler, MD, Professor of Psychiatry at the Treatment Research Center at the University of Pennsylvania and the Philadelphia VA Medical Center.
There’s plenty of room for debate about whether high antidepressant prescribing rates represent money well spent or good medicine, but I’ve covered that before. (See below)
He expresses some enthusiasm about Topamax and then touts a new drug coming from Denmark:
Lundbeck, a Danish pharmaceutical company, has submitted an application for approval by the European Medicines Agency of the medication nalmefene to be used on an as-needed basis to reduce heavy drinking, according to Dr. Kranzler. “This is a novel approach and could have an impact on treatment throughout the European Union and possibly the U.S.,” he adds.
Danish pharmaceutical company H. Lundbeck A/S yesterday unveiled clinical data on its potential blockbuster drug nalmefene at the 2012 European Congress of Psychiatry clinical in Prague. While Lundbeck and its Finnish partner Biotie Therapeutics Corp. from Turku underline an impressive 66% reduction in total alcohol consumption, a closer look at placebo data is disconcerting. In three placebo-controlled Phase III studies, the drug with the trade name Selincro was given to heavy drinkers who also were given medical advice about their drinking habits. Selincro aims at eliminating the brain’s pleasure response to drinking. After six months, numbers of heavy drinking days (total alcohol consumption) in the first study dropped from 19 to 7 (84g to 30g) in the drug arm, and from 20 to 10 (85g to 43g) in the placebo arm. The numbers of the second study were less convincing and – even worse – in the third study the drug arm barely outperformed the placebo. Nevertheless Biotie-CEO Timo Veromaa thinks that “Selincro has the potential to transform the way alcohol dependence is managed by both patients and physicians.”
I believe that medications may play a helpful role in the future, but I’m underwhelmed by the current stable of drugs and troubled that so much energy gets put into promoting expensive drugs of dubious value.
This is an exciting time in the treatment of alcoholism, because the field of medication treatment for alcohol dependence is expanding into the arena of personalized medicine, he says.
I’d love to see helpful drugs come along and I think a lot of these docs and researchers have good motives, but they have one tool (the prescription pad) and they seem to consistently oversell it.
* The ASAM event disclosure lists that Dr. Kranzler and/or his projects have recieved money from Alkermes, Roche, Pfizer, Lundbeck, Lilly, Eli Lilly, Janssen, Schering Plough, GlaxoSmithKline, Abbott and Johnson & Johnson. ProPublica does not list him at all. Possible explanations are here.
A research group at the University of Michigan and Indiana University concluded that physicians were 1.52 times more likely to prescribe antidepressants to Caucasians than to Hispanics for the same major depressive disorders.
The researchers also found that whites were more likely to be prescribed newer, more expensive antidepressants, which also happen to be considered the “first line” prescription for the disorders.
It would be interesting to look at differences in the course of their depression.