Psychiatric care, not meds, fall short
By Judith Warner
"Startling results," promised the CNN teasers, building anticipation for a segment on this week's big mental health news: a study led by researchers at the University of Pennsylvania indicating that the antidepressants Paxil and imipramine work no better than placebos ("than sugar pills," said CNN) for people with mild to moderate depression.
It sounded true. After all, any number of experts have argued that antidepressants — and selective serotonin reuptake inhibitors like Paxil in particular — are overhyped and oversold. And after years of hearing about shady practices within the pharmaceutical industry, and of psychiatrists who enrich themselves by helping the industry market its drugs, we are primed to believe stories of psychiatric trickery. Yet in all the excitement about "startling" news and "sugar pills," a more nuanced, truer story about mental health care in America was all but lost.
That story begins to take shape when you consider what the new study actually said: Antidepressants do work for very severely depressed people, as well as for those whose mild depression is chronic. However, the researchers found, the pills don't work for people who aren't really depressed — people with short-term, minor depression whose problems tend to get better on their own. It's often been observed, merely participating in a drug trial (with its conversation, education and emphasis on self-care) can be anti-depressant enough. None of this comes as news to people who have been prescribing or studying antidepressants over the past 20 years.
And, contrary to popular belief, there's no evidence that most psychiatrists regularly prescribe pills straight off to people who can get better by reading about depression, exercising or doing nothing.
That people have come to believe otherwise may be in part because most patients with depression are treated by general practitioners, not psychiatrists. Studies have shown that these primary care doctors don't strenuously enough screen their patients for depression before prescribing drugs, or closely monitor their care afterward.
Inadequate treatment by nonspecialists is only a piece of the problem. In fact, most Americans with depression, rather than being overmedicated, are undertreated or not treated at all. This might have been big news this week too, had anyone noticed another academic study, a survey of nearly 16,000 people published this month in The Archives of General Psychiatry, which looked more broadly at the picture of depression in America. The survey found that those who did get care were given psychotherapy more often than drugs. That finding might give heart to those who would prefer to see more alternatives to psychiatric drugs — if it weren't for the fact that so much psychotherapy is so bad.
"Those kinds of things are not being sorted out in this country because there's no system. Nobody's asking these questions," said Robert J. DeRubeis, a professor of psychology at the University of Pennsylvania.
With health care reform almost certainly on the horizon, perhaps now we can hope they will start asking.