The Baltimore Psychotherapy Institute
By Daniel L. Buccino
17 April 2004
Copyright Ó 2004 DLBuccino
I spend most of my week working in the public mental health system where I see firsthand how helpful our newer antidepressant and antipsychotic medications are. Thanks to these medications, combined with various rehabilitation, case management, and psychotherapy services, more patients are able to enjoy a far more robust quality of life outside of hospitals than ever before.
Psychotropic medication has been lifesaving to countless patients and will continue to be prescribed despite the Food and Drug Administration’s March 22 advisory on antidepressants and continued reports that the FDA is withholding data on links between the medications and youth suicide.
Yet the FDA advisory calling for increased monitoring of patients for suicidal thoughts and other serious side effects like agitation, insomnia, irritability, impulsivity, and mania actually underscores the place and power of psychotherapy in the treatment of most emotional and behavioral disturbances. Talk therapy works – and in many cases as well or better than medications at lower cost, with fewer side effects, and more lasting benefits.
Even before the FDA’s warning, we knew that many of the newer antidepressants, initially touted to be side effect-free, contributed to not inconsequential sexual side effects in patients. Imagine recovering enough from a depression to be interested in sex again only to discover that the sexual apparatus, as it were, was not fully functional. These new medications also often require a commitment to long term maintenance treatment.
We know that some of the newer antipsychotic medications are associated with significant weight gain and diabetes.
All of these new psychotropic medications filled with extraordinary promise are also extraordinarily expensive. Many insurance companies restrict access to these medications through high copayments and restrictive lists of approved drugs. There are always risks associated with any treatment, and with the FDA advisory and high costs, now is the time to rediscover other reliable treatments.
The FDA antidepressant advisory was prompted in part by reanalysis of pharmaceutical industry data which revealed that the medications were not as safe as they were touted to be, and that they were also not as effective, especially in children. The FDA has had access to heretofore proprietary and confidential data which revealed that antidepressants are not always terribly effective (over 65% of some unpublished studies failed to support drug efficacy) and that even in instances where they appeared efficacious, they weren’t always convincingly effective in relation to placebo.
Other data reveal that medications are most likely to be effective when prescribed by physicians who are best able to establish collaborative, hopeful treatment relationships with their patients. Since treatment relationship, the creation of hope, and a plan for the future is central to the psychopharmacologist’s amplification of the expectation of change in patients, we see that as central to the psychotherapist’s project as well.
Research confirms repeatedly that psychotherapy is a safe and effective treatment for many psychiatric disorders and problems of living and is currently being extended with promise into the treatment of major mood disorders and psychosis.
Despite the Woody Allen mythology, therapy generally does not take forever or cost a fortune. Even in the public mental health system most patients are seen less than twelve times a year. Most patients are able to make deep and lasting changes in psychotherapy fairly quickly and the average treatment episode remains at about six sessions.
Though some patients can benefit from longer term, more intensive treatment, the evidence suggests that early change in therapy predicts later change. Conversely true, if change is not happening early in treatment, it is not very likely to happen much later in treatment either. Another therapist or treatment model may then be indicated.
Despite some sectarian squabbles, the psychotherapy business is really the “change” business since change is the outcome most patients desire.
We know convincingly that therapy works, it works efficiently and durably, it is comparatively inexpensive in the short term, and especially over the long term when lifetime maintenance medications and physician visits are considered. Although everybody with depression is at some risk for suicide, psychotherapy does not cause weight gain or sexual dysfunction.
As patients and physicians reconsider their options in the wake of the FDA advisory, it is time to admit that psychotherapy remains a first-line treatment.
Daniel L. Buccino is Co-Founder and Co-Director of the Baltimore Psychotherapy Institute and is on the clinical faculties of the Johns Hopkins University School of Medicine and the University of Maryland School of Social Work.