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2009-11-25 07:58:00
VIEWPOINT
Dr Jennifer Wild
Senior lecturer at the Institute of Psychiatry
Despite a large increase in cognitive behaviour therapy (CBT) doctors are still pushing drugs at patients, according to Dr Jennifer Wild, a senior lecturer at the Institute of Psychiatry.
In this week's Scrubbing Up, she argues that GPs need to understand that psychological therapies like CBT work and should choose to offer them.
People with depression often get better when they change the way they think.
Since therapy is more likely to achieve this with longer-lasting results than drugs, doctors need to stop pushing pills and start pushing treatments that work.
Depressed people feel low, worthless, and often suicidal. They need treatment.
Six million people suffer from depression and anxiety in the UK, and surveys show that most do not want to take drugs.
They want a treatment with long-lasting results.
'Distorted thinking'
This treatment is cognitive behavioural therapy (CBT).
CBT is based on a well-supported theory of how depression starts and what keeps it going: distorted thinking patterns.
Change people's thoughts and recovery occurs.
Professor Robert DeRubeis at the University of Pennsylvania and his team have shown that when depressed people in treatment significantly changed their thoughts, they got better.
GPs should improve how they assess depression, and they must bear in mind that longer lasting recovery from this debilitating disorder results from a change in thinking style
But the picture is confusing.
Depressed people also recover with placebo, particularly if they have mild or moderate depression.
Drugs get results, but they are not long-lasting, and have side effects.
Professor Peter Tyrer, a psychiatrist and editor of the British Journal of Psychiatry, agrees with me that while old antidepressants knocked you out and made you feel sleepy, new ones have unpleasant side effects such as insomnia, agitation, vomiting and nausea.
'Assessing depression'
What should doctors do?
GPs should improve how they assess depression, and they must bear in mind that longer lasting recovery from this debilitating disorder results from a change in thinking style.
It makes sense to offer treatments that address this.
The UK government introduced the Improving Access to Psychological Therapies (IAPT) initiative, which is expanding the availability of psychological treatments for people with depression and anxiety
Since 2006, GPs have been offered incentives to properly assess depression using screening questionnaires.
However, a recent study in the BMJ showed they would prefer to rely on their clinical judgment, which tends not to agree well with the questionnaires.
Even when GPs do rely on screening instruments to assess depression, they still offer 80% of depressed patients drugs and 20% therapy.
Thankfully, in 2008, the UK government introduced the Improving Access to Psychological Therapies (IAPT) initiative, which is expanding the availability of psychological treatments for people with depression and anxiety.
Better therapies
This initiative is based on scientific evidence which shows psychological therapies like CBT work - and have longer lasting results than drugs.
Professor David Clark, national clinical adviser for IAPT, tells me that 115 out of England's 154 primary care trusts now have an IAPT service.
He says this will undoubtedly ensure that patients have a real alternative to medication.
But GPs need to be aware of the programme.
Professor Tyrer thinks that unfortunately, GPs are likely to say that IAPT is not universal so they have no choice but to give antidepressants.
Why are drugs being pushed?
Aggressive marketing has expanded the use of drugs for mental health problems, and antidepressants are now also marketed for anxiety with little evidence to suggest they help.
The teaching medical students receive also leaves them with an incomplete picture.
Alex Roels, medical student at King's College, London says that most medical students see antidepressants as the treatment of choice for depression.
Best practice guidelines state that drugs can be offered with a therapy like CBT for moderate to severe depression, but should not be offered for mild cases.
Since relapse is common for people who have already been depressed, the guidelines state they too should be offered a treatment like CBT because this reduces relapse more than drugs can.
Despite this, rates of prescribing antidepressant drugs have been increasing.
'Fewer chronic prescriptions'
However, with IAPT there is room for change since a larger workforce is now available to deliver the recommended psychological treatments.
So we should see fewer people getting drugs for depression in the first place, which should reduce the number of chronic prescriptions.
But this will only happen if GPs get on board with the reality that psychological therapies like CBT work and choose to offer them.
That choice would save money by reducing the incidence of relapse and the cost of chronic long-term drug use.
It would also deliver what patients say they want: therapy rather than drugs.
Have you been given drugs when you really wanted psychological therapy? Or do you feel that your GP got it right and has really helped you?
Provocative thoughts from experts in the worlds of health and medicine