12 March 2004

More drugs, fewer couches used to treat depression

More Americans are seeking help for depression than did so a decade ago, but they're popping more pills and spending less time on the couch, a new study says.

More Americans are seeking help for depression than did so a decade ago, but they're popping more pills and spending less time on the couch, a new study says.

Researchers found the number of people who received outpatient treatment for mood trouble jumped from 1.7 million in 1987 to 6.3 million in 1997. During that time, the share of those taking antidepressant drugs more than doubled, while the share of those receiving psychotherapy fell by more than 10 percent.

Experts say those trends reflect the confluence of several factors: an increased awareness of depression as a curable disease, along with a gradual shedding of the stigmas associated with it; drug companies' aggressive promotion of new antidepressants, such as Prozac and Zoloft; and a general effort by health insurers to encourage patients to see primary care doctors instead of more expensive specialists.

Overall, the study is "a welcome development" that "strongly suggests that there are relatively fewer people in the United States who have depression who are not getting treated," says lead author Dr. Mark Olfson. However, what the increased reliance on medication over psychotherapy means "remains unclear."

The findings appear in the Journal of the American Medical Association.

Antidepressant use doubled
Estimates for the percentage of American adults who suffer a bout of major depression each year vary widely, from 5 percent to nearly twice that figure.

Olfson, of Columbia University and the New York State Psychiatric Institute, and his colleagues reviewed patient records from 1987 and 1997, covering a total of more than 67 000 people. They found the rate of outpatient treatment for depression rose from 0.73 per 100 people to 2.33 per 100 people.

Antidepressant use doubled during the period, from 37 percent to nearly 75 percent of patients, but the share of those who sought psychotherapy fell, from 71 percent to 60 percent. In absolute terms, though, the number of patients receiving psychotherapy rose across the decade.

Echoing that trend, the number of annual office visits per patient for depression fell from nearly 13 percent in 1987 to 8.7 percent in 1997. Olfson says that may reflect the fact that patients who receive prescriptions for antidepressants often don't need to come to the office for a refill.

The proportion of patients who saw physicians, including psychiatrists, for their depression rose from about 69 percent in 1987 to more than 87 percent in 1997, the researchers say. Although the study didn't address the issue, Olfson says earlier evidence shows that half or more of the doctors who prescribe mood drugs are primary care physicians, not specialists.

Health plans or other third parties paid for 39 percent of depression visits in 1987, a figure that climbed to 55 percent in 1997.

Dr. Kerry Sulkowicz, a New York City psychoanalyst and an officer of the American Psychoanalytic Association, says the latest findings are decidedly mixed.

Psychotherapy undervalued
While he says it's good news that more Americans feel comfortable seeking help for depression, Sulkowicz considers it a "tragedy" when insurers discourage people from undergoing prolonged psychotherapy. The cost of two sessions with a therapist can easily outstrip that of a month's supply of mood drugs, he says.

"Medication alone for many people is not the answer," Sulkowicz says. "It can be extremely helpful, but the combination [of drugs and psychotherapy] tends to be more effective than medication alone."

Roughly 23 percent of patients received both antidepressants and psychotherapy in 1987, compared with about 45 percent in 1997, the latest study shows.

Dr. Douglas Jacobs, a Harvard psychiatrist who started the National Depression Screening Day to raise awareness of the disease, says the new research shows that effort has helped.

"It doesn't show that, still, over 60 percent of people who suffer from depression aren't getting treated," Jacobs adds.

Nor, he says, do the findings suggest patients are better served by medication, as opposed to psychotherapy.

"One size doesn't fit all. For some patients, medication is effective. For others, psychotherapy is effective. And for the majority of patients, a combination is the most effective," he says.

For more information on depression, contact the Mental Health Information Centre (021) 938 9229 or the Depression and Anxiety Support Group is 0800 11 8392.

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