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Depression Rising, but Psychotherapy Declines

Gap Between Drug Treatment and Talk Therapy Widens

By Salynn Boyles
WebMD Health News

Reviewed by Laura J. Martin, MD

Dec. 6, 2010 -- More Americans than ever are receiving treatment for depression, but the number getting psychotherapy with or without drugs continues to decline, a national survey finds.

Depression treatment rates increased dramatically during the 1990s with the introduction of the selective serotonin reuptake inhibitor (SSRI) antidepressants Paxil, Prozac, and Zoloft.

Other SSRIs, including Celexa, Lexapro, and Luvox soon followed, as did newer classes of antidepressants represented by drugs like Cymbalta, Effexor, and Wellbutrin.

Despite all the new drug choices, the use of antidepressants increased only modestly during the last decade -- from about 74% of patients treated in 1998 to 75% in 2007, the survey revealed.

But there was a dramatic decline in the number of treated patients who received psychotherapy.

In 1998, almost 54% of patients being treated for depression had some form of psychotherapy, compared to 43% in 2007.

Columbia University psychiatry professor Mark Olfson, MD, MPH, who was a co-author of the survey, says the decline in psychotherapy was disproportionately high among medically underserved populations including Hispanics and the poor.

"While it is good news that depression treatment seems to be more accessible, the decline in psychotherapy raises the possibility that many patients aren't receiving optimal care," Olfson tells WebMD.

Depression Treatment Trends

Overall, the number of Americans who received outpatient treatment for depression increased from about 6.5 million to 8.7 million between 1998 and 2007.

After adjusting for inflation, there was an increase in public expenditures for outpatient depression treatment, with the biggest rise seen for older Americans receiving Medicare.

Medicare costs for depression treatment were estimated to be roughly $2.2 billion in 2007, compared to around half a billion dollars in 1998 -- a more than 300% increase.

It was during this period that Medicare's Part D program, which subsidizes the cost of prescription drugs, went into effect.

Among the other trends between 1998 and 2007:

  • Among teens treated for depression, antidepressant use decreased from 60% to 52%, possibly reflecting concerns about suicide risk with the drugs. But psychotherapy also declined from 75% to around 66% during the period, and combination treatment with drugs and psychotherapy dropped from 46% to 35%.
  • The decline in psychotherapy was seen in whites, African-Americans, and Hispanics, but was greatest in Hispanics. During the period, the percentage of treated Hispanics getting psychotherapy fell from 60% to 43%.
  • The psychotherapy decline was seen for all educational levels except one -- people with advanced degrees. Among those treated for depression with more than four years of college, psychotherapy use increased from 45% to 55%. Antidepressant use also increased in this group, as did the use of antidepressants with psychotherapy.

'Decline in Psychotherapy Shortsighted'

Although the survey did not address the reasons for the decline in psychotherapy usage, it is clear that economic factors have played a major role.

Antidepressants are typically covered by private health insurance, while psychotherapy, if it is covered at all, is often limited.

Santa Barbara, Calif., psychologist Lisa Firestone, PhD, calls the decline in psychotherapy a worrisome trend that is shortsighted.

"Drug treatment may seem cheaper, but antidepressants that don't work can end up costing much more than effective psychotherapy," she says. "Poorly treated depression is a major cause of ER visits and sick days taken."

She points to research suggesting that for certain subgroups of patients, including those with a history of child abuse or other childhood traumas, psychotherapy is much more effective than drugs.

Firestone is the director of research and education at the Glendon Association in Santa Barbara.

"Certainly there is a role for both drugs and psychotherapy, and the combination of the two, in the treatment of depression," she says. "The fact that we are seeing a major decline in psychotherapy is of great concern to me."

SOURCES: Marcus, S.C. Archives of General Psychiatry, December 2010; vol 67: pp 1265-1273.Mark Olfson, MD, MPH, Center for Health Equity Research and Promotion, Philadelphia Veterans Affairs Medical Center.Lisa Firestone, PhD, clinical psychologist and director of research and education, Glendon Association, Santa Barbara, Calif.News release, JAMA/Archives, Dec. 6, 2010.

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