Coming of Age on Zoloft (23 page)

Cumulatively, Dan refers to the changes he’s gone through in therapy as the development of “self-awareness.” Depression distorts, he said, and therapy has been of ser-vice by helping him get in touch with reality in a way that medication alone couldn’t do. “Therapy plays a huge role in this self-awareness thing,” he said. “I should give my therapist a lot of credit. It took someone with a completely neutral view of the situation to help me figure this stuff out.”

AS I’M SURE
you can tell by now, I am a big believer in therapy. I think that it offers a unique set of benefits that often make it a wise addition to medication, and that there are some problems for which it’s an appropriate response on its own. Therapy teaches self-understanding and self-mastery in ways that medications do not. It makes people feel better about themselves and more in control of their lives in a global sense, while also diminishing specific symptoms. These benefits come at no physical risk. And unlike the effects of a pill, they last forever—actually deepening and strengthening as they’re reinforced by life and time.

It’s worrisome, then, to watch therapy’s decline relative to anti---depressants. Though evidence and anecdote suggest that the two work well together, Americans have become demonstrably more likely to reach for the medication and skip the therapy completely. A recent large-scale study reported that among anti-depressant users in the U.S., the number also receiving therapy fell almost 40 percent from 1996 to 2005. A third of people taking anti-depressants were getting therapy in the mid-1990s; a decade later, only 20 percent were.
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Even though many experts recommend that antidepressants be used as a second-line treatment, to be tried only after psychotherapy is attempted and has failed, this sequencing is rarely carried out in practice. SSRIs are increasingly likely to be the sole remedy for an emotional problem.
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There are several factors at work besides consumers’ wishes that encourage the increased use of medication as a first-line (and often stand-alone) treatment. One of those factors is health insurance. While patients sometimes state a preference for psychotherapy instead of or in addition to medications, weekly therapy sessions are undeniably expensive—and in recent decades, most health insurance companies have grown increasingly reluctant to cover their cost. Where benefits do exist, patient copayments for therapy sessions tend to be higher, sometimes much higher, than copayments for medication ser-vices, and the number of visits allowed per year is often restricted.
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Coverage for SSRIs, by contrast, is usually unlimited.

These changes are a legacy of “managed care,” the insurance model that became prevalent in the United States in the 1980s. Managed care is a cost-control strategy premised on the idea that the insurance company will pay for the least-expensive effective treatment for a given illness. In addition to a decreased willingness to pay for psychotherapy, managed care has been associated with a push to have general practitioners, rather than specialists, act as gatekeepers for care and provide more ser-vices themselves. These days, the majority of prescriptions for antidepressants are written not by psychiatrists but by general practitioners, who do not provide therapy or even a semblance of it. Managed care has pushed psychiatrists away from providing talk therapy, too, by reimbursing them at much higher rates for prescribing medication.
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Timothy Dugan, a child and adolescent psychiatrist at Harvard’s Cambridge Hospital, told me that insurance will pay him more for a twenty-minute “med check,” where he adjusts a patient’s medications and writes a fresh prescription, than it will for a fifty-minute hour of psychotherapy. He did a little back-of-the-envelope calculating and estimated that, at least as an MD who can do either, he can earn $450 in an hour (by doing three med checks), or $125 for giving an hour of therapy.

For psychiatrists, these financial incentives are understandably hard to resist. Many have shifted the emphasis of their practices away from therapy and toward medication; thanks to shorter and less-frequent appointments, psychiatrists who once managed fifty or sixty patients at once may now handle client loads of more than a thousand.
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While psychiatrists used to provide psychotherapy along with medication, now prescriptions come from the doctor, and talk therapy, if it’s wanted, from a different practitioner altogether. The situation leaves psychiatrists less able to monitor their patients’ progress, because they see their patients less frequently and talk to them less extensively. It has also contributed to a shift in which psychotherapy, because it’s generally no longer provided by medical doctors, has come to seem increasingly less like a medical ser-vice. The issue isn’t quality—nonpsychiatrists can be excellent psychotherapists. But pushing therapy to the periphery of medicine strengthens the rationale for insurance companies not to fully cover it. Talk therapy joins the ranks of other “nice but not necessary” ser-vices, like acupuncture or massage, that can seem vaguely alternative and that consumers often expect to have to pay for themselves, while medical care for emotional problems becomes increasingly synonymous with pharmaceuticals.

Another factor that elevates medication and marginalizes talk therapy has to do with the way scientific research is funded. Academic careers in science and medicine are built on original, published research. Research is funded by grants, and grants are made by granting institutions; even researchers employed by universities are expected to finance their work with money from outside. (Indeed, it’s a proven ability to nab funding that helps make academic job candidates in the sciences attractive to potential employers in the first place.) In psychiatry, the vast majority of grant money comes from pharmaceutical companies—which, unsurprisingly, are interested in funding work that highlights the clinical benefits of potential new products, not the merits of un-patentable talk treatments. “If you have a research career, by and large it’s funded by drug companies’ drug trials,” Timothy Dugan explained to me. The upshot is clear: most of the research that’s done in psychiatry is done on medications, and most of the people who’ve become influential in the field are people who are personally and professionally invested in the promise of psychopharmaceuticals, not talk.

The shift away from talk therapy is both reflected and perpetuated in psychiatrists’ medical education. I spoke to a young psychiatrist in New York City who told me that she feels lucky to be able to practice the way she wants—she provides talk therapy to most of her patients, in addition to medication—because there are enough people in the city who are willing and able to pay a premium for these ser-vices. She said she is disappointed that psychiatry has moved away from therapy. She thinks this happened because insurance has made therapy less lucrative; because psychiatry has been trying to legitimize itself as a “real” medical specialty, which means prescribing pills—the ethos is “We’re real doctors, we don’t do that touchy-feely thing anymore,” she told me; and, she suspects, because prescribing drugs is less demanding. “It’s much easier to write a prescription and hand it to someone than it is to really sit there and focus on them for 45 minutes,” she said. Psychiatry has been deemphasizing therapy for so long, she continued, that the type of person who is drawn to the specialty is changing too; the field no longer necessarily attracts people who want to work closely and deeply with their patients’ inner lives. “I think there are some people who are just uncomfortable being a therapist,” she said. “And a lot of residency programs don’t provide so much training. You’re not trained to be a therapist, and you don’t feel good in the role of a therapist, because that takes time too.”

THE DECLINE IN
access to therapy is a shame. The data support therapy as an effective treatment option, and they support the power of therapy when combined with medications. Therapy doesn’t carry the risk of side effects. It helps people whom anti-depressants don’t help. And some patients prefer it to taking drugs. A number of the people I interviewed lent credence to the
Consumer Reports
survey’s contention that for many people, therapy can be a profoundly positive and lastingly helpful experience. I want to end with a few of their comments.

Isabel, age twenty-seven, of New York, took antidepressants all through high school and college, before quitting them just a couple of years ago. She’d had therapy on and off earlier in her life, but often at her parents’ insistence; because she often didn’t want to be there, she said, she didn’t get much from the experience. Isabel looked for a therapist on her own in her early twenties, when she was in a graduate program for fine arts and feeling unhappy about school and unsure of her direction. She described to me how good it felt to find somebody she clicked with.

One therapist that I had when I was in high school was helpful up to a point, and then she just wanted to talk about my relationship with my father a lot. And I was like, “I don’t want to talk about that. I don’t think that’s really very relevant.” But she was very pushy, and it felt like it was her agenda rather than my agenda.

Then I saw one when I first got to New York, and I
loved
her so much. She was great because she was really focused on the events of my actual life. We talked about underlying things, but she was the first one who felt like I was capable of changing things in my life which would then make me feel better. That was very helpful.

I was like, “I don’t like painting grad school, it feels silly.” And she said, “Maybe you would like to do something like advertising.” And I was like, “No one has ever said anything like that to me before.” She said maybe part of the reason you don’t want to leave school is because your mother likes art and wants to be an artist, and I was like, “Yeah, I see
that
connection.”

Therapy can also help the sizable portion of people who don’t get substantial relief from antidepressants. (One major study concluded that around 30 percent of people who try antidepressants ultimately find them ineffective; critics contend that the real figure might be much higher.
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) Now twenty-five and living on the East Coast, Elizabeth was the child of diplomats, and grew up all over the world. Elizabeth got depressed in middle school, and the embassy psychiatrist prescribed antidepressants to her when she was fifteen. She has taken them ever since, sometimes switching brands or dosages, looking for a stronger effect, but she’s never felt that medications gave her more than minor benefits. Elizabeth started doing therapy for the first time after she finished college, and she said that it’s helped her to a view on her situation that feels more accurate than the idea of simply having a chemical imbalance. In therapy she started to look at the role she’d played in her family, where she weathered conflict by “trying to be really good all the time, and never hurt anybody else’s feelings,” patterns she now believes had a lot to do with the problems that emerged when she was a teenager. Therapy helped her understand how her behavior developed over time and how it has contributed to the way she feels, and that understanding has brought her a new kind of relief.

I eventually have started to come around to the realization that my reaction to my situation when I was a kid didn’t occur because there was something wrong with me. It was because I was actually reacting like a normal person. I actually had plenty of things to be angry about, and there were plenty of good reasons why I repressed it.

Honestly I was never sure whether the antidepressants were working. Partly because I didn’t know what “working” would entail. And it’s only more recently when I’ve been in therapy and have been working on dealing with my anger that I’ve started to feel a lot better. And have actually sort of started to understand what that might mean.

Dana, from Boulder, began going to therapy around age ten, when her parents were divorcing. She started taking Prozac when she was fifteen, and continued both talk therapy and medication through the end of high school. Now thirty-one, she is finishing up a doctoral program in psychology—so moved was she by her experiences in therapy as a teenager that she decided to become a therapist herself. Dana told me that when she looks back on her high school years, it’s hard to separate the influence of the two approaches. But when she thinks about it, she believes that for her, the therapy was the more essential experience. “If I had not had treatment for depression (therapy and/or medication), I am sure my life would have been different,” she explained in an e-mail. “I’m inclined to attribute the majority of the helpful influence to my therapy, which has been introspective, relational, supportive, reassuring, challenging, enriching, and really valuable to me.” In our conversation, she summed it up like this:

I think that, in theory, I could have made it through my adolescence without antidepressants, and found myself in much the same place I am now. I could not have made it through my adolescence without psychotherapy. I can’t imagine just having said to my parents, “I feel depressed, and sometimes I want to kill myself,” and having them take me to a shrink who sat with me for twenty minutes, and gave me pills, and sent me on my way. I just can’t even conceive of that experience.

Nathan, also thirty-one, lives in Kentucky. He told me that his life was finally beginning to feel calm and stable after major turbulence throughout his twenties. In college, Nathan developed problems with substance abuse and drinking, to the extent that he was expelled from school. He moved to a major city, where he continued drinking heavily and using cocaine. He got into legal trouble and did lots of what in therapy-speak is called “acting out”: he got into fights, had screaming matches with his girlfriend, and once drunkenly slammed a door and severed a part his own finger. In college, he began to experience manic episodes, and they continued afterwards. He tried various antipsychotics, including Seroquel and Risperdal, and had terribly mixed experiences with them; they helped somewhat but also caused “horrible physical and cognitive side effects.” Through it all, Nathan wanted to find someone he could talk to. “I could find plenty of prescribing doctors, but to find anybody who would talk to me was impossible,” he said. He saw one psychiatrist he hated so much he didn’t want to return, and he stopped taking his medication. “I didn’t like this doctor,” he said. “I felt like he spent more time telling me about his own children and his words of wisdom for them than about me; he didn’t really want to find out too much about me. And that’s one reason why I quit taking those drugs, was that I never wanted to go back to see him to refill the prescriptions.”