Depression and Drugs
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
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
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
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
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).