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By Ami Albernaz
In response to a National Institute of Mental Health-sponsored
study that found Prozac to be more effective than cognitive behavioral
therapy (CBT) in depressed adolescents, some New England psychologists
are warning against reading too much into the findings.
The study, which involved 439 teenagers ages 12 to 17 who were
moderately to severely depressed, found that those who took Prozac
alone fared better than those in talk therapy, with 61 percent and
43 percent showing improvement, respectively. The cases in which
medication and CBT were used in combination yielded the highest
rate of success, proving effective 71 percent of the time. Of those
teenagers assigned to a placebo condition, 35 percent showed improvement,
although the difference in success rates between those who went
through CBT alone and those in the placebo group was not statistically
significant.
While the findings might cast antidepressants in a more positive
light, following speculation of a suicide link in a small number
of cases, some psychologists say that not too much should be inferred
from one study and that other studies have shown talk therapy to
be effective in adolescents.
"Invalid conclusions are often drawn in the media from single and
limited studies," says Michael Goldberg, Ph.D., president of the
Massachusetts Psychological Association and director of Child and
Family Psychological Services in Norwood, Mass. "One cannot conclude
that medication is better than CBT from this study alone."
Goldberg adds that because the study did not find a significant
effect of CBT above a placebo condition - which had been found in
several previous studies - the integrity of the CBT provided or
the research methodology needs to be considered.
"Given the complete body of research about the effectiveness of
CBT in preventing depression in at risk teenagers, treating depression
in adults and adolescents, usually as or more effectively than medication,
the generalizability of this study to CBT conducted by others must
be questioned," he says.
Other psychologists concur with Goldberg in that when evaluating
medication and cognitive behavioral therapy, the whole body of research
- not one study alone - must be considered.
"I'm skeptical. There's a tendency of the media to focus on the
findings of one study, and make a lot out of them," says Peter Rees,
Ed.D., a Trenton, Maine psychologist who works with adolescents.
Rees adds that he is concerned that such focus might result in inaccurate
information being spread and refers to the attention given to a
possible link between antidepressants and suicide. "It might actually
be more a case of misdiagnosis. Maybe depression was diagnosed when
it was really bipolar disorder and the diagnosis pushed it into
a crisis state."
While the benefits of talk therapies such as CBT and interpersonal
therapy have been clearer in studies of adults, psychologists say
such therapies can offer real benefits for teenagers in forming
new social relationships and coping with the thorny issues of negotiating
autonomy with parents.
"This cannot be accomplished through medication alone," says Virginia
Shiller, Ph.D., chairperson of the Connecticut Psychological Association's
Children and Youth Committee. "If you simply medicate and there
are underlying issues, then you're not resolving them. There are
so many issues that come up in adolescence and [therapy] is a prime
opportunity to help them develop better peer skills and develop
in healthy ways."
Some psychologists worry that study findings that seem to favor
medication over talk therapy might encourage managed care providers
to endorse medication in an effort to cut costs. Goldberg says he
worries that it will become increasingly difficult for people to
use health insurance for talk therapy, even though many other studies
have shown it to be effective. (He cites findings published last
year that CBT costs one-third less than drug therapy). He fears
this could lead to a two-tiered mental health system in which those
clients who can afford to pay privately will receive psychotherapy
and those who are less well-off will be treated primarily with drugs.
Shiller says she fears a situation in which insurance panels stipulate
that in order for a patient to be in therapy, he or she will also
have to be on medication. Such a requirement, she adds, could also
be threatening for patients who are reluctant to take psychotropic
drugs. "People can have a tremendous resistance to taking medication,"
she says. "To be told at the outset that you can take this drug
can be off-putting."
Shiller is among the many psychologists who believe that medication
has its place, and that medication and therapy can work well in
concert. She also believes that patients might be best served by
having the elements of their treatment decided upon in one place
- raising the issue of prescribing privileges for psychologists.
"Medications are now much more a part of the treatment of many
patients, and it can be a problem when treatment is split between
different providers," she says. "If we're going to provide patients
with optimal integration, I think psychologists with training should
be able to prescribe. It's in patients' interest to have one provider."
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