Tuesday, April 2, 2013

The Bias Towards Drugs in Treating Depressed Older Patients

I recently read an article on "How to adapt cognitive-behavioral therapy for older adults" that came to me in Current Psychiatry, a "throw-away" journal (one that comes to professionals free of charge and without subscription, typically containing non-peer-reviewed articles and often replete with advertising). The article itself was excellent, but the opening paragraph was revealing in terms of the problematic way psychiatric treatment is typically framed nowadays:
Some older patients with depression, anxiety, or insomnia may be reluctant to turn to pharmacotherapy and may prefer psychotherapeutic techniques. Evidence has established cognitive-behavioral therapy (CBT) as an effective intervention for several psychiatric disorders and CBT should be considered when treating geriatric patients. (emphasis added by me)
Perhaps as the spouse of a college English teacher I'm overly fussy about language, but to my eye this paragraph gives drugs the position of privilege in treating elderly patients with the common symptoms of depression, anxiety, or insomnia, and relegates psychological interventions like CBT to "be considered" if drugs are rejected. Readers wouldn't guess that the National Institute for Health and Clinical Excellence (NICE) guideline on treating depression in adults recommends various applications of CBT as the first intervention for subthreshold depressive symptoms or mild to moderate depression. Drugs only come in later (except for more severe depression)!

Outcome studies suggest that CBT is at least as effective as medication for mild to moderate depression. Given that medication side effects can be especially problematic in an elderly population, why the bias against psychosocial interventions? I see four main reasons:
  1. From non-stop pharmaceutical marketing to physicians and the public, we associate drugs with images of butterflies, sunshine, smiling faces, and other seductive visions. The multi-billion dollar marketing campaign synergizes with our wish for quick and easy fixes to our problems.
  2. Ageism, as reflected in aphorisms like "you can't teach an old dog new tricks," promotes the belief that elderly folks are too set in their ways to change by psychological means. Empirical studies show this isn't true.
  3. Non-mental health clinicians may worry that they aren't adequately skilled at providing CBT or other psychosocial interventions like my primary care colleague years ago who said, in unintended verse: "I know what to do when they're dying/But not what to do when they're crying."
  4. For harried primary care physicians (the likeliest group to see elderly patients with mild depression) writing a prescription takes much less time than initiating a psychosocial intervention.
Lack of skill and the crunch of time are serious impediments. But they're not insoluble. CBT has been adapted to self-guided formats. Non-mental health clinicians and aides have been trained in basic CBT approaches. And CBT has been delivered by telephonic means.

The degree to which we favor drugs over psychosocial treatments ultimately reflects a form of bias. That's why I discuss it in a blog about ethics!

(For an example of how our national tilt towards mechanistic thinking about human process affects another age group, see yesterday's New York Times article reporting that 11% of school aged children have been given a diagnosis of ADHD. Stimulants represent a nine billion dollar blockbuster business.)

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