Thursday, 5 September 2013

Most mental health patients prefer psychotherapy over drugs

A line was crossed in 2005 as anti-depressant medication became the most widely prescribed class of drug in the USA. Here in England, the use of anti-depressants has risen to its highest ever level with 50 million prescriptions written last year. And yet a new meta-analysis finds that, given the choice, the vast majority of patients would prefer to receive psychotherapy over drugs.

"It is unclear why the shift toward pharmacologic and away from psychological treatment is occurring," the researchers said, "although limited access to evidence-based psychological treatments certainly plays some role."

Kathryn McHugh and her colleagues identified 34 relevant peer-reviewed studies up to August 2011 involving 90,483 people, in which the participants were asked to indicate a straight preference between psychotherapy or drugs. Half the studies involved patients awaiting treatment, the others involved participants who were asked to indicate their preference if they were diagnosed with a psychiatric disorder. The researchers had hoped to study preferences among patients with a diverse range of diagnoses but they were restricted by the available literature - 65 per cent studies pertained to depression with the remainder mostly involving anxiety disorders.

Overall, 75 per cent of participants stated a preference for psychotherapy over drugs. Stated differently, participants were three times as likely to state that they preferred psychological treatment rather than medication. The preference for therapy remained but was slightly lower (69 per cent) when focusing just on treatment-seeking patients, and when focusing only on studies that looked at depression (70 per cent). Desire for psychotherapy was stronger in studies that involved more women or younger participants.

Given the evidence showing comparable efficacy for psychotherapy and medication in treating most forms of anxiety and depression, the researchers said their data "support empirically based practice decisions in favour of greater rates of selection of psychological treatment for these disorders."

This new study provides further justification for the UK's Improving Access to Psychological Therapies (IAPT) programme that started a nationwide roll-out in 2008. However, if most people prefer therapy but drug prescriptions are still rising, this raises the question of how effective the IAPT project has been. Coincidentally another recent paper concluded that that IAPT has failed to curb the long-term rise in antidepressant prescriptions in England.

Unfortunately, the current research by McHugh et al has several problems that limit its impact. This includes the fact it was unable to look in detail at preferences for combination therapy (drugs plus psychotherapy), nor factors such as illness severity or urgency. Above all, the nature of the study means it can't tell us anything about why most people prefer psychotherapy over drugs, although likely explanations include fear of health risks and stigma.


McHugh RK, Whitton SW, Peckham AD, Welge JA, and Otto MW (2013). Patient preference for psychological vs pharmacologic treatment of psychiatric disorders: a meta-analytic review. The Journal of Clinical Psychiatry, 74 (6), 595-602 PMID: 23842011

Post written by Christian Jarrett (@psych_writer) for the BPS Research Digest.


Martin Johnson said...

In the US, the massive marketing of psycho-pharmacology directly to the public played a major role in the explosion of drug sales. There is no equivalent marketing of psychotherapy. As to access to evidence based treatment,(and in the US) psychology has not helped itself by publicizing internal political rifts between academic and professional psychologists while claiming, incorrectly, that cognitive-behavioral psychotherapy is the only evidence based treatment.

utter nutter said...

The notion that pharmacological treatments for major psychological distress are scientific and evidence based is questionable to say the least. Ben Goldacre's analysis of how drug trials are manipulated just scratches the surface in many ways. American psychiatry getting into bed with pharmaceutical companies to counter the threat of to their profession by emerging psychotherapies was the start of this but 'mentally ill' people have consistently been subjected to harmful, often torturous medical treatments that claimed to be scientific for over a century. I recommend as a valuable source of information.

The search for evidence based psychotherapy is likely to be fruitless, not least because it's based on a medical model of being able to give doses of therapeutic interventions. No two therapists will ever be the same and no two clients will ever be the same. Effective psychotherapy is always tailored to the unique abilities, needs and preferences of both client and therapist. That's probably why studies of the effectiveness of different therapy modalities indicate that around 80% of their effect is down to the quality of the relationship between client and therapist.

Anonymous said...

I'm not a psychologist or psychiatrist and have never bee a mental health patient. But it seems to me that both approaches have to be used. It's pretty clear that mental states can affect the physiology of the brain and body. If just thinking about sex gets your sexually aroused, then it stands to reason that other types of mental events can have their own effects, some of them deleterious, on the brain. So why couldn't you reverse, or at least ameliorate, those deleterious effects by fostering other types of mental events through psychotherapy? It seems to me that if you just use drugs, you're eliminating or reducing the effects of mental trauma without addressing the underlying issue. On the other hand, using drugs can jump-start and complement the psychotherapuetic process.

Anonymous said...

The Cambridge Textbook of effective diagnosis and treatment of psychiatric illness (Tyrer and Silk) makes the point that patient acceptance improves the effectiveness of treatment. So where more than one kind of treatment is available and reliable evidence says both are effective then a good clinician will choose with patient preference in mind.

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