Therapy in a new light

April 27, 2004|By Daniel L. Buccino

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.

Because of 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 - which calls for increased monitoring of patients for suicidal thoughts and other serious side effects, such as 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 free of side effects, contributed to not-inconsequential sexual side effects in patients. Imagine recovering enough from depression to be interested in sex again only to discover that you were unable to fully function sexually.

These new medications often require a commitment to long-term maintenance treatment.

We also 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 co-payments 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 antidepressant advisory was prompted in part by reanalysis of pharmaceutical industry data that revealed that the medications were not as safe as they were touted to be and that they also were not as effective, especially in children. The FDA has had access to heretofore proprietary and confidential data that revealed that antidepressants are not always terribly effective (over 65 percent 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 a 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.

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.

Though some patients can benefit from more long-term, 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.

We know that therapy works efficiently and durably, and is comparatively inexpensive in the short term and even more so over the long term, when lifetime maintenance medications and physician visits are considered.

And although everybody with depression is at some risk for suicide, psychotherapy does not cause weight gain or sexual dysfunction.

Daniel L. Buccino, co-founder and co-director of the Baltimore Psychotherapy Institute, is on the clinical faculties of the Johns Hopkins University School of Medicine and the University of Maryland School of Social Work.

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