There are two basic approaches to treating depression and anxiety – medication and “talk” therapy.
Where you turn for help will, to a large extent, determine what kind of treatment you receive. If you consult your family physician or your insurance company, most often you will receive medication. If you consult a psychologist, most often, you will at least start out with talk therapy. Most providers tend to see the kind of treatment that they provide as “primary” and the other treatment as a supplement or compliment to this primary treatment.
At this point, most people wonder, “But which is better?” The available research indicates that, in general, a combination of both approaches together works best for most people. However, this statistic is based on averages of large groups of people – you are an individual and your particular circumstances may indicate that another approach is preferable. Because each approach has advantages and disadvantages, little more information may help you think about what you want to try first. The good news about medication is that in general, it tends to provide some relief a little more quickly than talk therapy. The bad news is that over half of those who begin drug therapy, end up trying at least two different drugs – and ten percent try five or more – before finding one or a combination of them, that is both effective and have side effects that they can tolerate. A second consideration is that people who rely only on medication don’t get as much relief as those doing either talk therapy or the combination of therapies after 3-4 months of treatment. There are other concerns about medications that I will mention later.
The good news about talk therapy is that those willing to work at it over thirteen or more sessions get more relief than those only taking drugs. In fact, those taking only drugs often find they are a little less effective after 3-4 months. Those who use a combination of talk and drugs had the best outcomes of all – with 80% experiencing significant relief – but only slightly less than talk alone at 78%. The bad news about talk therapy is that it is time consuming and insurance companies don’t reimburse for talk therapy as well as they do for other illnesses. This is a social and political issue that is referred to as “parity” in the professional and legal literature.
Like many psychologists, I usually talk with my patients about medication and it’s potential to be helpful to them. For many people who seek my help, medication is unnecessary, but available if they choose. Many people choose a psychologist because they would prefer to achieve success without drugs. For those whose depression and/or anxiety is long term and/or severe, I usually recommend that they include medication as part of their treatment and provide a referral to one of the very capable psychiatrists that I know. For those with less severe depression and anxiety who want to include drugs as a part of their treatment, I often suggest that they first consult their family physician. This allows them to work with someone whom they know and who is familiar with their medical history. Often, it is a little less expensive and most internists and family physicians do a good job with these people.
The decision to use medication should not be taken lightly. While the new (since about 1987) class of antidepressants called SSRI’s have provided better relief than the older tricyclics and MAO inhibitors and with a much lower side effect profile, they still do have side effects. Adverse sexual side effects (loss of interest and ability) and weight gain are the most commonly reported side effects. It should come as no surprise that the package inserts that identify the adverse sexual side effects at less than 15% are based on studies sponsored by the drug companies. In 2004, Consumer Reports found rates about three times higher – 41% to 53% depending on which drug. This finding is similar to the only published comparative study, which was done at the University of Virginia and published in the Journal of Clinical Psychiatry. Furthermore, about 20% of people reported weight gain, 15% to 20% said that the drugs made them feel drowsy or disoriented and 34% of those who discontinued drugs, said that they did so because they found the side effects intolerable. So, while drugs can be helpful – and in fact have been a lifesaver to some people – they are not without problems. The decision about their role in therapy is often a personal one, best decided by the patient.
When research is conducted to see what accounts for improvement in psychotherapy, there are two factors that account for more positive change than any others: the quality of the relationship between the therapist and the patient and the length of time in treatment. I see a lot of outcome research – often trying to see if a particular protocol is better in treating a particular illness than another – and invariably the quality of the therapeutic relationship is the most important factor in improvement. This is most dramatically and convincingly demonstrated in several “mega-analyses” where large groups of outcome studies are combined and subjected to sophisticated statistical analysis. The quality of “fit” between therapist and patient trumps every other factor and all other factors combined! It is for this reason that in my brochure, I encourage people to “choose their psychologist carefully. Choose one who you feel comfortable with and who you feel works hard to understand you on your terms, not theirs. Being understood is different from being agreed with.” If you think that therapy could be helpful to you, please call and I would be happy to consult with you about the decision.