Psychotherapy for depression is underused and meds are overused

April 21, 2015

By Allen Frances, MD

In response to The Guardian article, Mindfulness as effective as pills for treating recurrent depression-study



This recent study found that Mindfulness/CBT is as effective as antidepressant pills for treating patients with recurrent depression presenting to general practitioners. Especially striking was the fact that the psychotherapy was delivered in groups and thus was particularly cost-effective.

The findings add to an already abundant literature showing that psychotherapy works as well as medications for mild to moderate depression and is cheaper and has more enduring effects. Despite the evidence, antidepressant medications continue to be massively over-utilized while psychotherapy continues to be under-utilized.

Part of the misallocation of resources results from convenience. It is much easier and quicker for a GP to give the patient a pill than to find him someone trained in delivering psychotherapy—especially if a friendly drug salesman has provided ‘free samples’ and there is no trained therapist in the neighborhood.

Part of the excessive medication use comes from the great power of placebo effect. It is over 50% in people with mild depression or in the worried well. Once you feel better, you have no way of knowing that the active ingredient in the pill probably had little to do with your response. The benefit, if any, is small and uncertain while the harms and risks are real and definite.

Most of the over-use of medication results from the successful Pharma propaganda campaign with the misleading message that all mental disorders are due to “chemical imbalance” and require a pill solution. Pharma has spent tens of billions of dollars marketing drugs. There is no marketing budget for psychotherapy, and slick marketing has trumped evidence based medicine.

But there is also flip side of the story. Medications are indeed essential, sometimes lifesaving, for severe depressions. It is a terrible paradox that we massively over-medicate those who don’t need medication, while neglecting those who desperately do. Only one third of those with severe depression have had treatment for it in the prior year. Medication is very helpful for the very few who need it, useless or harmful when given to the very many who don’t. We need to get our priorities straight—helping patients, not furthering Pharma’s profit machine.

Dr. Frances is professor emeritus of psychiatry and former chair at Duke University.