Am Fam Physician. 2004;69(9):2071-2074
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).
| 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 | ++++ | ++‡ |
For most patients with depression of mild to moderate severity, psychotherapy and anti-depressants 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 anti-depressants (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 anti-depressant 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.