In today’s Opinion pages of the New York Times, Judith Warner presents one of the smartest articulations of the problems facing mental health in the popular press that I have ever read. Its timeliness is based on recently released findings out of the University of Pennsylvania published in the Journal of American Medical Association that medication for depression on average doesn’t work better than placebos. Warner explains that it’s not that these medications aren’t powerful, but rather that usually what they are targeting is not that severe. In other words, if you are trying to treat a set of people most of whom are only a little depressed, you are unlikely to see much of an effect because the difference between a little depressed and not depressed is not much. Most people who receive medications are sad, troubled, the “worried well,” but not severely depressed. When you exclude these folks form analyses, you get a group composed of those who are severely depressed, and you see bigger effects of medication. Warner sums up the problem nicely:
And here the truer story about mental health care in America begins to unfold. The trouble is not that the drugs don’t work; it’s that the care is not very good.
Most medication is prescribed by general practitioners (“GP’s”), who do not have expertise in mental health. Without being able to tell the difference between a severe diagnosis and normative sadness or acute, situationally-based depression, it’s not too surprising that GP’s overprescribe. Combined with the ties between famous psychiatrists and drug companies (e.g., the 2009 case of a prominent Harvard psychiatrist taking a lot of money from big pharma over years to plug such meds), this sets up a perfect recipe for providing meds to many many many people who probably could do just as well finding other solutions for their problems.
Warner then touches on psychotherapy, which, it turns out, is cited as a more common treatment for depression than medication, according to another study in the Archives of General Psychiatry. So most depressed people avoid meds, making the previous problem moot… great! Well, Warner then properly turns to the recent damning study in Psychological Science in the Public Interest, which showed that most psychologists do not use empirically supported treatments despite the replication of their effectiveness and the dissemination of their methods through associations like the American Psychological Association. Warner:
This is the big picture of mental health care in America: not perfectly healthy people popping pills for no reason, but people with real illnesses lacking access to care; facing barriers like ignorance, stigma and high prices; or findings care that is ineffective.
For those of us who are trained in the US system and interested in global mental health, I can’t think of anything more important than developing a critique of our own failures. Let’s not globalize American medication or our rejection of empirically supported treatments.