In Practice

A practicing doctor's views on psychiatry and contemporary culture.

Culture Watch: Psychotherapy—or Mental Health Care—for All?

Does the press favor psychotherapy over medication?

imageHow do we view mental illness and mental health care? I’m thinking of issues that are contentious here and now: diagnosis, prescribing, and psychotherapy. From time to time in this blog, I will try to gauge the cultural climate by examining the depiction of psychiatry in the media, with special attention to the treatment of disputed disorders, like depression, attention deficits, and social anxiety.

Exhibit one is an article titled “Psychotherapy for All: An Experiment.” It appeared under a banner headline, over a five-column photograph, atop this week’s science section of the New York Times—the most prominent exposure for a mental health report in recent memory. The piece described a trial conducted in outpatient medical clinics in Goa, India, of intensive outreach and treatment for common psychiatric disorders. The reporter emphasized the use of lay psychotherapists, high school and college graduates trained to apply variants of cognitive therapy and more generally to spend time with and listen to patients with mood disorders.

The word antidepressant appears in the article three times, first in the eleventh paragraph, as part of a generalization about treatments useful for anxiety and depression. In the twenty-fourth paragraph, readers learn that depressed patients in the study are offered a range of interventions, including antidepressants. “Antidepressant” appears a final time in paragraph thirty-five, when it emerges that a patient in counseling (“’I feel better when I tell my problems to somebody else,’ she said”) is also taking medication.

Why is medication so minor an add-on in a story about wider access to mental health care? Do the experimenters perhaps downplay the role of antidepressants? This question interested me because I thought I had read of work in Goa by the main investigator, Dr. Dr. Vikram PatelVikram Patel, a psychiatrist at the London School of Hygiene and Tropical Medicine.

Sure enough, in my files I found a report by Dr. Patel, published in the Lancet in 2003, about the efficacy and cost-effectiveness of interventions for common mental disorders in Goa. Dr. Patel and his team had provided psychotherapy, Prozac (fluoxetine), or a placebo to outpatients in hospital clinics. Patients who had high scores on a general screening instrument for mental distress were assigned to an intervention. About half of the patients were predominantly depressed, with the rest experiencing a combination of depression and anxiety, but the research was not looking at precise diagnosis.

Generally, the patients—most were uneducated women—reported that their symptoms diminished over time, whatever the intervention. In this experiment, the psychotherapy conferred no apparent benefit over placebo at any point, whether at two months, six months, or one year. The Prozac did better than the placebo at two months, but then the difference faded, in part because patients who felt better stopped taking the antidepressant.

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The most notable outcome concerned medical expenses. By the end of a year, the Prozac group was costing less a month to treat (for all disorders), while the placebo and psychotherapy groups were costing more. The financial differences for patients and their families were especially dramatic, in terms of time lost from work, time traveling for consultations, and so forth. While the other groups’ costs went down between 32% and 37%, the families whose ill member was on Prozac saw a 60% monthly savings at the one-year mark. Patel concluded, “Thus, an affordable antidepressant, such as fluoxetine in India, is the preferred treatment for common mental disorders in general health-care settings in developing countries, because it produces a quick recovery from illness and leads to savings in costs.”

So, what appeared in the Times story—via the headline and the bulk of the reporting—to be a psychotherapy trial was a comprehensive mental health intervention conducted by a psychiatrist who had found striking benefits for antidepressants in the treatment of common mood disorders. I don’t know why the Times ran the article as it did, under that “Psychotherapy for All” banner. My impression is that in the press, now is psychotherapy’s moment. We—and here I include myself—like the idea of human interaction, in this case modestly trained people speaking with their compatriots. In contrast, medication is mercantile, mundane, and suspect. But wouldn’t full reporting have said that this experiment on 2000 patients had already been piloted on 450 subjects—and that, in that case, it was the Prozac that made the difference?

Peter D. Kramer is a psychiatrist and author. His books include Against Depression and Listening to Prozac.

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