Psychotherapy vs. Medications: The Verdict Is In

The profession of psychology is under heavy scrutiny with revelations that officials in the American Psychological Association (APA) colluded with the Department of Defense, tailoring its established ethics policies so that they comported with DOD preferences after the 9/11 attacks. Although those senior officials have resigned or retired in the wake of the scandal, the entire affair has the potential to tarnish the reputation of the thousands of licensed clinical psychologists working in the field who provide ethically responsible mental health services.

It would be a shame if the clients who stand to benefit from these services turned away from the psychological interventions that have the potential to help them. Psychotherapy is known to be an effective treatment for a wide range of psychological disorders. Yet, even before news of the APA scandal hit the press, the average person seeking help has tended to seek psychiatric drugs rather than psychotherapy. Antidepressants and antianxiety medications are among the leading prescription drugs not only in the U.S. but around the world.

We think nothing of getting a prescription filled for one of these psychotropic medications that we may obtain, without much consultation, from a medical professional. However, you should be concerned that these drugs may not only fail to treat your psychological symptoms but can have a host of adverse side effects.

In a critique of psychiatry’s reliance on pharmacological interventions, Professor of Clinical Psychiatry at Weill Cornell Medical College Richard Friedman, writes that “American psychiatry is facing a quandary: Despite a vast investment in basic neuroscience research and its rich intellectual promise, we have little to show for it on the treatment front.” Echoing the concern that we are an overmedicated world when it comes to psychological disorders, he notes that even the newer and supposedly better new drugs are no more effective than the old ones. Almost all (95%) of the federal dollars spent on mental health research go to drugs, not psychotherapy, in clinical trials.

Indeed, if you turn on the television for an ordinary half hour of news, you’ll be assaulted not only by ads for heartburn, psoriasis, and erectile dysfunction, but for the medications aimed at treating depression, bipolar disorder, and anxiety. The only reason there aren’t more ads for schizophrenia, I suppose, is that the disorder is far more rare and therefore not “worth it” for advertisers to promote. It sounds, from these ads, that these medications are the key to picking up or lowering your mood as needed and resolving that irksome anxiety you can’t seem to shake off. As long as you don’t pay attention to the many side effects the advertisers are required to list, you may be ready to follow the advertiser’s advice and “ask your doctor.”

Unfortunately, these ads are working too well. Friedman cites an investigation by Kathryn McHugh and colleagues, of the well-respected McLean Hospital showing that the vast majority of people seeking treatment for depression and anxiety disorders prefer pharmacological to psychological interventions by a ratio of 3 to 1.

As McHugh and colleagues note: “The past 10 years have seen a substantial increase in the prescription of antidepressant medications, which surpassed all others as the most commonly prescribed class of medication in the US in 2005. There is also evidence of a concurrent decrease in patients receiving psychological treatment. However, the available data on patient preference, efficacy, and cost-efficacy for depression and anxiety do not support this trend, and imply that many patients are not engaged in their preferred psychological treatment” (p. 7).

Psychologists in all but three states in the U.S. (Illinois, Louisiana, and New Mexico) are not allowed to prescribe medications, so it’s not even an option for people outside these states to receive psychotropic medications directly from their therapist, assuming the therapist isn’t a psychiatrist. However, the evidence cited by McHugh agrees with the majority of studies on therapy effectiveness showing the advantages of skipping the drugs altogether.

Why, then, do people prefer drugs to therapy? We can get some clues from a recent study published by Cincinnati VA psychologist Jeremiah Schumm and colleagues (2015) on the preferences of veterans for treatment of Post-Traumatic Stress Disorder (PTSD). The U.S. Department of Veterans Affairs has made treatment of PTSD a priority, for obvious reasons.

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The evidence-based guidelines for PTSD treatment include offering Cognitive Processing Therapy (CPT) and Prolonged Exposure (PE) therapy. Medications (such as benzodiazepines) are not recommended because “there are no demonstrated benefits of these medications in treating PTSD. These medications have possible harmful side effects including the risk for addiction, overdose in combination with alcohol, and interference with benefits of some psychotherapies” (p. 78).

Yet, when Schumm offered a choice of CPT or PE treatments to veterans either with our without medications, the veterans showed a similar bias as patients in general with only 30% preferring psychotherapy alone. Schumm and his colleagues conclude that the best service psychologists can offer their clients is educational information about their treatment options. In fact, the majority of veterans in this study reported high levels of satisfaction with an orientation group provided before therapy to inform them about the options available to them.

You, then, deserve this right to receive a proper orientation for yourself or your loved ones when you’re seeking mental health interventions. Don’t be satisfied when your provider sends over a prescription to your pharmacy without explaining all the options available to you. Use the Internet search skills that led you to Psychology Today to explore the free online services provided through the National Institute of Mental Health, APA, and your state (or country’s) psychological association. It may be up to your provider to prescribe your treatment but it’s up to you to explore the ones that have the greatest evidence-based effectiveness.

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Copyright Susan Krauss Whitbourne 2015.