Does It Make Sense to Treat Depression with Drugs?

Depression is rooted in overwhelming emotional pain. Talk therapy is 
a successful, commonsense antidote, but pushing pills pays more.

By Bruce E. Levine, AlterNet
Posted on August 15, 2008, Printed on August 15, 2008

Both research and experience have long informed mental health 
professionals of a strong link between depression and relationship 
dissatisfaction. So why is psychiatry losing that awareness? One 
major reason is the disappearance in psychiatry of psychotherapy 
(talk therapy), in which it becomes obvious just how important our 
significant relationships are to our mental health. According to the 
August 2008 Archives of General Psychiatry article "National Trends 
in Psychotherapy by Office-Based Psychiatrists," the percentage of 
patient visits to a psychiatrist involving any psychotherapy fell to 
28.9 percent in 2004-2005 (from 44.4 percent in 1996-1997), and the 
percentage of psychiatrists using psychotherapy with all their 
patients dropped to only 11 percent in 2004-2005.

Psychiatry has increasingly replaced psychotherapy with something 
called "medication management," which largely consists of symptom 
assessment and prescription updates. Medication management typically 
takes 10 or 15 minutes and is scheduled every two to three months.

When doctors only offer medical management sessions every couple of 
months, they can neglect to ask about a patient's marriage; and even 
if they do ask about it, they are likely to accept at face value a 
stoic patient's reply that "my marriage is fine." A competent 
psychotherapist knows that patients, initially, often avoid 
acknowledging an abusive or neglectful relationship, the pain of 
which may be too overwhelming; and that it can take a great deal of 
time and repeated gentle questioning to discover important truths.

In quality psychotherapy, a mental health professional takes the time 
necessary to create trust, which is required to effectively explore a 
patient's relationship life. Miserable significant relationships or 
the absence of any significant relationships are common sources of 
depression. And major antidotes to depression are genuine 
friendships, satisfying intimacy and supportive community.

The Interactional Nature of Depression (1999), edited by 
psychologists Thomas Joiner and James Coyne, documents with hundreds 
of studies the interpersonal nature of depression -- and its 
interactional vicious cycle. In one study, the best single predictor 
of depression relapse was found to be the response to a single item: 
"How critical is your spouse of you?"

In another study of unhappily married women who were diagnosed with 
depression, 70 percent of them believed that their marital discord 
preceded their depression, and 60 percent believed that their unhappy 
marriage was the primary cause of their depression.

Depression is fueled by overwhelming emotional pain, and an unhappy 
significant relationship is one common source of such pain. Other 
common sources of pain that can fuel depression include workplace 
alienation, poor physical health and financial difficulties. People 
use a wide variety of "compulsions" (actions one feels that are not 
freely chosen) to shut down overwhelming pain or to distract from it. 
Depression is one of those compulsions (others include substance 
abuse, overeating and gambling).

In a vicious cycle, the pain of an unhappy marriage can fuel a wife's 
or husband's depression; then that depressed wife's or husband's 
negativity can result in their spouse's negative reactions; these 
negative reactions can make the marriage even unhappier; and the pain 
of that increasingly unhappy marriage can serve as additional fuel 
for depression.

Social isolation and loneliness can also fuel depression. Sociologist 
Robert Putnam, in Bowling Alone (2000), reports, "Low levels of 
social support directly predict depression, even controlling for 
other risk factors." Putnam adds that "countless studies document the 
link between society and psyche: People who have close friends and 
confidants, friendly neighbors and supportive co-workers are less 
likely to experience sadness, loneliness, low self-esteem and 
problems with eating and sleeping."

Why has medication management replaced psychotherapy for 
psychiatrists? The simple answer is money.

Insurance companies favor medication management because the cost of a 
medication management session is approximately half the cost of a 
psychotherapy session, and medication management sessions are 
routinely scheduled once every two to three months rather than 
weekly, as is psychotherapy.

Drug companies -- exposed in recent Congressional investigations as 
being corrupting forces in psychiatry -- also favor medication 
management, the focus of which is primarily drugs. Psychiatrists 
themselves can make far more money with medication management than 
with psychotherapy. While psychiatrists bill about half as much for a 
medication management session as they do for a psychotherapy hour, 
they can conduct a minimum of four medication management sessions for 
every one psychotherapy session. Moreover, many psychiatrists do 
five- or ten-minute medication management sessions, so they can 
complete five or six of these sessions in the same hour that it would 
take to do a psychotherapy therapy session (including preparation and 
note writing). Psychotherapy also requires far more emotional 
involvement than medication management, making it psychologically 
difficult for a psychotherapist to work as many patient hours as a 
medication manager. The bottom line is that psychiatrists who offer 
only medication management routinely make nearly triple the income as 
do psychiatrists who provide mostly psychotherapy.

Psychotherapy is effective for some depressed people, as it can help 
them extricate from abusive relationships and gain knowledge of how 
to form caring relationships, but psychotherapy is no panacea. There 
are incompetent and mediocre psychotherapists, and even the best 
psychotherapist will tell you that they are not always successful, as 
sometimes they can only help patients gain awareness of the sources 
of their depression but are unable to help them effect necessary 

While psychotherapy may not help all depressed people, the loss of 
psychiatrists practicing psychotherapy means the loss of basic common 
sense in psychiatry about depression. To the extent that the general 
public trusts psychiatry pundits, both depressed and nondepressed 
people will lose awareness that overwhelming emotional pain is the 
fuel of depression -- and that relationship dissatisfaction is a 
major source of such pain. If we lose that awareness, we lose a piece 
of our humanity.

This article originally appeared on the Huffington Post.

Bruce E. Levine, Ph.D., is a clinical psychologist and author of 
Surviving America's Depression Epidemic: How to Find Morale, Energy, 
and Community in a World Gone Crazy (Chelsea Green, 2007).