There are hundreds of studies that show that pharmacotherapy is used to treat depression in adult and geriatric populations. There are far fewer studies that test the efficacy of psychotherapies and even fewer studies that focus on combined treatment for older patients. This discrepancy is largely a consequence of industry support of research in the former and the dependence on NIMH funding in the latter two. The sober lesson we have learned from STAR*D is that there are no pharmacological treatments that work for everyone.
STAR*D (Sequenced Treatment Alternatives to Relieve Depression) was a massive set of studies, conducted under grants from NIMH, in which they attempted to replicate real world treatment of depression. In the real world, depression often--if not usually--coexists with another disorder, such as anxiety. In most studies, the subjects have uncomplicated depression. That makes it easier to interpret the results, but raises questions about applicability of the results to the real world. In most studies, the subjects were given one medication and evaluated for depression after a set period. In the real world, if the patient isn't responding to treatment, the treatment is changed.
In STAR*D, the subjects were more heterogeneous and they were given sequenced treatment. Hence, the treatment was more applicable to the real world. The results, which Miller summarizes in one sentence above, are, I think, consistent with what all of us practitioners know. Treatment effects are significant, but there is no
predictability in response to treatment. Not everyone gets better easily.
In the real world, psychotherapy is often added to medication management. In STAR*D, there were a number of studies of psychotherapy. Here is one report of adding cognitive therapy to the mix. NIMH summarizes the results as follows:
Switching to or adding cognitive therapy (CT) after a first unsuccessful attempt at treating depression with an antidepressant medication is generally as effective as switching to or adding another medication, but remission may take longer to achieve.I believe also, that either this study or another study had evidence that showed that the subjects, when given a choice of medication change or psychotherapy, often opt for medication change. There are two reasons for this. First, taking medication is easier and less anxiety-provoking than going once a week for psychotherapy. Second, all of the television ads for drugs give the impression that they are the way to go. Yet several types of psychotherapy, most notably cognitive therapy and interpersonal therapy, have very good track records.
All of this is equally true with the elderly. Miller argues that psychotherapy is particularly important for the elderly:
Every depression is expressed in an interpersonal context and thus its effects in the patient cause ripples that sometimes damage relationships that need to be addressed for potential repair work. The goals of combination treatment in late life are to:
- Be able to restore a state of homeostasis or balance by lessening the severity of the depression (and any comorbid anxiety).
- Maximize the coping ability of the patient.
- Foster a more positive outlook of remaining strengths and opportunities.
- Solicit external supports to foster not only a sense of being "backed up" but also a sense of having valued and purposeful integration into a social network.
Working with the elderly is different from other types of psychotherapy, because there is more emphasis on coping with problems in the real world. Therapists often worry that elderly clients will be too rigid to benefit from therapy. However, that rigidity is often outweighed by a strength not possessed by younger clients. Elderly persons have been through a lifetime of problems and usually have a well-developed repertoire of coping skills. The trick in therapy is to identify them and encourage the client to use them again.
So, the answer to the question, medication, psychotherapy, or both? is "It depends." It's frustrating that mental health professionals have not been able to identify who will profit from what kind of treatment. It's still very much a trial-and-error process, despite a significant amount of science in both medicine and psychology. By combining psychotherapy and medication, we can often bring out the best of both treatments. Miller illustrates this by paraphrasing Kay Redfield Jamison (An Unquiet Mind): "Lithium diminishes my depression, but psychotherapy heals."