Spot the problem in this scenario. Richard* is stressed. While he’s a high-flyer (a Rhodes Scholar no less), he’s under the pump at work and has just moved his family across nations. The job is taking more than it’s giving back. He’s in a dark place – very down, unmotivated, ill-humoured and lacking energy – so oblivion seems enticing. Worryingly, he also has a family history of depression.
Richard visits his family doctor who refers him to a psychiatrist. So far, this is unremarkable – as depression management goes.
With relief, Richard enters the psychiatrist’s plush rooms, sighs, and prepares to unburden himself and submit to wise counsel. But he’s in for a surprise. Within minutes he’s told he has depression, needs medication, and will likely do so for life. He leaves with sample pack of antidepressants in hand, and troubles still firmly packed in kit bag.
If you’re like me, you see the problem quickly. Richard, and around 70% of the people who share his diagnosis, can implicate a psychosocial stressor in the genesis of his depression. But his doctor has failed to identify and address it, even though stressor-focused treatments are available.
Evidence-based psychotherapy, in particular cognitive behaviour therapy (CBT), is as effective as medication in the common, lesser grades of depression. You read that correctly – CBT is as good as drugs at relieving the lowered mood, hopelessness, fatigue, guilt, and poor concentration that figure in the depressive diagnostic checklist.
And not only does psychotherapy reduce psychic distress, it also tackles stressors. In addition, CBT tutors healthy scepticism about the negative perceptions that pepper the depressive psychological landscape. Such ideas cause undue pessimism and arise, almost always, from biased information processing. Challenging negative thoughts is a critical element in the therapeutic success of CBT.
Incredibly, doctors who fail to unearth and address stressful life events, or guide a stance of scepticism to negative thinking, do nothing untoward. While recent guidelines laudably embrace a broader role for psychotherapy, depression initiative beyondblue still cites a publication that concludes, because drugs and psychotherapy are equally effective, really, either will do fine. As the authors of that paper state, it’s “not so much what you do but that you keep doing it”.
But is it really all right to just give people antidepressants? Does a doctor have a duty to do more, and provide psychotherapy?
For any other illness…
Try this thought experiment. You have abdominal pain and visit your doctor, who diagnoses gallstones and recommends an operation. You become increasingly anxious, agitated, and ultimately morose at the prospect of surgery. But the doctor has a pill for that – take an antidepressant and your fears will fall away so that you can bravely front up to surgery.
This scenario is laughable, of course. A doctor would never recommend antidepressants to foster acceptance of an unpalatable circumstance. Rather, the physician would explore your fears, determine what aspects of surgery concern you, and offer information about the pre- and post-operative processes.
In essence, the doctor would provide you with information that is material to your decision about surgery, enabling you to cope with your new circumstance and to work out which course is best. And in doing so your doctor conforms to an entrenched moral duty – to promote patient autonomy, that is, the ability to self-determine based on information that is critical to interests.
But, despite respect for autonomy being embedded squarely in the moral firmament of informed consent, it seems alien to many physicians that information, not just about treatment but that results from it could also be material.
Richard will, in all likelihood, believe it material to understand which stressor caused his depression, how best to address it, and how to simultaneously deal with his relentless negative thinking. To glean this, he needs psychotherapy, not just information about it.
And doctors know this. They already promote autonomy through a range of treatment regimes. Specialists in drug and alcohol rehabilitation supply crucial facts about limiting substance use, nutrition consultants advise overweight patients to diet and exercise, hypertension specialists provide strategies for reducing salt intake, and so on.
In each case, a treatment is recommended not just because it’s effective, but because it provides information material to crucial life choices.
And this is precisely why evidence-based psychotherapy ought to be provided to people with depression. Drugs may treat symptoms but they do nothing to help people navigate depression, appraise and manage stressors, or critique the validity of their negative thoughts. A prescription for antidepressants might fulfil a physician’s clinical duty of care on current guidelines, but drugs alone fall short in the moral domain.
What Richard did
Richard opted for the DIY solution. Luckily for him, he had a formidable analytical arsenal at his disposal, and his critical faculties had not been fatally routed. He rounded on his job as a noxious influence in his life and bravely resigned, to the amazement of his boss. The depression lifted, sans medication, in less than a month.
Recently, the black dog scratched at his door again. This time he was prepared, and confidently asked his new boss to cut back his workload a little. Most people are not endowed with such self-possession. What people with depression need are doctors prepared to pay more than lip service to autonomy and to provide psychotherapy in those common grades where evidence supports its use.
*Not his real name