To Treat Depression, Just Give 'Em what They Want

The following was originally posted to Thought Broadcast.

A doctor’s chief task is to determine the cause of a patient’s suffering and to develop a course of treatment. In psychiatry, the task is no different: examine the patient, determine a diagnosis, and initiate treatment. However, “treatment” comes in many forms, and what works for one patient may not work for another. A good psychiatrist tries to figure out which approach is ideal for the patient in his office, rather than reflexively reaching for the prescription pad and the latest drug option.

How to determine what’s the best course of action for a patient? Recent research suggests one potentially foolproof way: Ask him.

A paper in this month’s Psychotherapy and Psychosomatics by Mergl and colleagues shows that patient preference (that is, whether the patient prefers medications or psychotherapy) predicts how effective a treatment will be. In their study, patients who expressed a preference for medications at the beginning of treatment had a better response to Zoloft than to group therapy, while patients who preferred therapy showed the exact opposite response.

In an even larger study published in 2009 by James Kocsis and colleagues at Weill-Cornell in New York (comparing nefazodone, an antidepressant, with a cognitive therapy approach called CBASP), a similar result was obtained: patients with chronic major depression who entered the study expressing a preference for drug treatment had higher remission rates when receiving medication than when receiving psychotherapy.

The numbers were quite shocking:

Patients who preferred medication:

Treatment received

Remission rate

Avg. depression score (HAM-D) at end of study (high score = more depressed)

Meds

45.5%

11.6

Therapy

22.2%

21.0

Patients who preferred therapy:

Treatment received

Remission rate

Avg. depression score (HAM-D) at end of study

Meds

7.7%

18.3

Therapy

50.0%

12.1

(original HAM-D scores were approximately 26-27 for all patients, constituting major depression, and patients in this study had been depressed for over two years)

Thus, if a depressed patient wanted therapy but got medications instead, their chances of “remitting” (ie, having a fully therapeutic response to nefazodone) were less than 1 in 12. But if they did get therapy, those chances improved to 1 in 2. Interestingly, patients who preferred therapy and got combination treatment (meds and therapy) actually did worse than with therapy alone (remission rate was only 38.9%), leading the authors to conclude that “few patients who stated a preference for psychotherapy benefited much from the addition of medication.”

It’s not surprising, at first glance, that people who “get what they want” do better. After all, a depressed patient who insists on taking meds probably won’t get much better if he’s dragged into psychotherapy against his will, and the patient who believes that a weekly session with a therapist is exactly what she needs, will probably have some resistance to just getting a pill.

But then again, isn’t depression supposed to be a hard-wired biological illness? Shouldn’t a medication have a more profound effect, regardless of whether the patient “wants” it or not?

Apparently not. The fact that people responded to the treatment they preferred means one of two things. There may be two different types of depression, one that’s biological and one that’s more behavioral or “exogenous,” and people just happen to choose the appropriate treatment for their type due to some predisposition or innate tendency (self-knowledge?). Alternatively, the “biological” basis of depression is not all it’s cracked up to be.

One question raised by these results is, why don’t we listen more to our patients and give them what they say they want? If half the people who want therapy actually get better with therapy, doesn’t that make it hard to justify meds for this population? Conversely, when we talk about “treatment-resistant depression,” or “depression that doesn’t respond to antidepressants alone,” could it be that the people who don’t respond to pills are simply those who would rather engage in psychotherapy instead?

I believe the implications of these findings may be significant. For one thing, insurers are becoming less likely to pay for therapy, while they spend more and more money on antidepressant medications. These studies say that this is exactly what we don’t want to do for a large number of patients (and these patients are easy to identify—they’re the ones who tell us they don’t want meds!). Furthermore, trials of new antidepressant treatments should separate out the self-described “medication responders” and “therapy responders” and determine how each group responds. If the “therapy responders” routinely fail to respond to drugs, we need to seriously revamp our biological theories of depression. Its chemical basis may be something entirely different from how our current drugs are thought to work, or maybe depression isn’t “biological” at all in some people. This will also keep us from wasting money and resources on treatments that are less likely to work.

While it’s often risky to ask a patient what he or she wants (and to give it to them), depression may be just the opportunity to engage the patient in a way that respects their desires. These data show that the patient may know more than the doctor what “works” and what doesn’t, and maybe it’s time we pay closer attention.