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The mental health care labyrinth

For people suffering from depression, misinformation abounds. Drugs work — or do they? Talk therapy is the answer — or is it?

Parsing through the contradictions not only shows how treatment is far from being one-size-fits-all, but also reflects changes in the field of mental heath care and an increasing disparity between psychiatry and psychology.

A recent analysis released by the American Medical Association revealed that for patients with less severe depression, antidepressant medications are just as effective as using a pill placebo. The study looked at the effects of only two kinds of drugs: Paxil, a selective serotonin reuptake inhibitor or S.S.R.I., and imipramine, an older, generic drug in the category known as tricyclics. Prozac and Lexapro have similar effects as Paxil.

For those with severe depression, the drugs provided substantial relief. But most people with moderate or mild depression improved just with talk therapy and a placebo pill. Robert J. DeRubeis, a co-author of the AMA study and a professor of psychology at the University of Pennsylvania, says that the placebo effect works “pretty well” for these patients in the short run.

Such a public inquiry into the usefulness of antidepressants caused an uproar in the mental health world. Richard A. Friedman, a professor of psychiatry at Weill Cornell Medical College, wrote in a New York Times article that the study “contradicted literally hundreds of well-designed trials, not to mention considerable clinical experience.”

Critics of the findings say that it could dissuade patients from seeking drug therapy. Achieving remission for patients with depression can also involve multiple attempts at finding the right drug. According to a survey published in January in The Archives of General Psychiatry, only half of the Americans suffering from major depression are already getting treated, and a mere 20 percent are getting the necessary care outlined by the American Psychiatric Association.

These percentages plunge even lower when looking at specific populations such as African Americans and Mexican Americans, who are among the least likely to receive adequate care. When factoring in aspects like economic feasibility or social stigma, it’s clear that access and awareness are crucial when it comes to mental health treatment.

Psychiatrist Daniel Carlat, the author of “Unhinged: The Trouble with Psychiatry,” thinks the current model of psychiatry has become flawed, privileging medication at the expense of other treatments. “Both meds and therapy are crucial,” Carlat writes on his blog. “The ultimate mental health practitioners, in my view, should be equally skilled at both psychopharmacology and psychotherapy.”

An increase in antidepressant usage can be attributed to a rise in the availability of medications, as well as decreased insurance coverage of psychotherapy. The amount of psychiatrists who proffered talk therapy at all of their patient visits dwindled from 19 percent in 1997 to 11 percent in 2005.

Before starting patients with less severe depression on medication, DeRubeis suggests that doctors could recommend self-help books like “Mind Over Mood” or “Feeling Good,” proven alternative treatments like exercise or a better diet, or cognitive behavioral psychotherapy.

“Depression is a very serious problem, and the largest problem is that it is under-diagnosed and under-treated,” says DeRubeis. “We need to be sure that people who need treatment are getting treatment. But we also need to emphasize that it is not helpful to think of depression in simplistic terms, as a problem that must be addressed with medications.”

Instead of pointing the blame at overmedication, perhaps the focus should be on getting the most effective treatment for those in need. Or perhaps these recent findings just serve to clarify what is already known: that there is no singular solution to treating depression.

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