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Rapid Responses: Rapid Responses published:
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study does not relate to reality
- anthony t frais (30 April 2005)
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The Tide is Turning
- Des Spence (1 May 2005)
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The economics of bibliotherapy
- Martin J Breach (5 May 2005)
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More realistic response strengthens the case
- Adam M Dierckx (20 May 2005)
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Small fees; medium fees and large fees
- susanne mccabe (21 May 2005)
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anthony t frais, author university of leeds
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The authors of the study seem blissfully unaware that cognitive behaviour therapy is quite useless in cases that present with profound depression. Cognitive behaviour therapy is only at its best when the patient has recovered from depression. It should be considered a prophylactic against relapse rather than an alternative to anti depressants. Have the authors also considered whether too many GPs are prescribing anti depressants inappropriately? Competing interests: None declared |
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Des Spence, GP Glasgow G20
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A change in practice is long overdue. I did as I was taught. I used a depression rating score and diagnosed depression. This often meant using my position of authority and knowledge to convince patients that they were indeed suffering from an illness called clinical depression. I used Prozac. To begin with treatment was suggested for 3 month, later this was extended to 6 months and eventually editorials suggested continuing treatment long term. I followed the evidence and expert advice and used SSRI to treat PMT, eating disorders, anxiety, post natal depression, panic disorder, OCD and even Social phobia. Life ,children, marriage and time changes your perspective. More importantly 8 years full time in the same general practice gave me a longitudinal perspective of mood issues that short, skewed and processed research could and will never elicit. We are at sea with uncontrollable emotional swells slowly lifting us up and down. Modern medicine deludes itself if we really think we fight these forces of nature. The medical nirvana of emotional flat lining is neither attainable or desirable. Medication helps in a very small and select group of patients with depression. The antidepressant and “everybody’s depressed” message was spun by a greedy pharmaceutical industry and a myopic medical profession. Stop the widespread use of antidepressants as they are eroding our well being and dismiss life as a simple spark of synaptic electricity . More talk therapies please. Time for society to invest and recognize the role of friends, family, faith ,music, art ,exercise and the maligned idea of community in managing mood. Making us happy is not in the gift of health care nor medication ,of that I am certain. Competing interests: None declared |
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Martin J Breach, GP principal Haydock WA11 0JN
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The authors have estimated the opportunity cost of the recent rise in antidepressant spending by valuing it in terms of cognitive therapy provided by a cognitive therapist. They estimate that, at an annual cost of £40,168, a clinical psychologist could treat six patients per day for 40 weeks per year. As such therapy would typically consist of a series of 6 sessions, a therapist therefore could treat some 200 patients per year. Many depressed patients can benefit enormously from bibliotherapy, learning to apply the principles of cognitive therapy from reading. A book I commonly recommend (Feeling Good, by David Burns) is available for less than £5.00. For £40,168 it would be possible to purchase over 8000 copies of this book; and for the total opportunity cost quoted (£310m)62 million copies could be purchased, more than sufficient for the entire population of the UK (whether depressed or not). It seems that there is a missed opportunity: for less than the cost of a month's prescription of the cheapest SSRI many patients would potentially obtain life-long benefit (which could obviously complement pharmacotherapy, or future consultations with a therapist if required). It is my view that all depressed patients should have access to suitable titles: this study suggests that provision of such books could be a much more efficient and economical use of resources than spending linked to higher levels of antidepressant prescribing. Competing interests: None declared |
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Adam M Dierckx, SpR in Psychotherapy Department of Psychotherapy, Warneford Hospital, Oxford, OX3 7JX
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Hollinghurst et al (Ref 1) provide a compelling argument for reducing antidepressant prescribing in favour of CBT provision for depressed patients. Though I am wholly in agreement with this recommendation I believe that they overstate their case to some degree and that this may make it easier for cynics to dismiss the case unreasonably. As a psychotherapist I hope to ensure this does not occur. First, they overestimate the number of patients that could be seen. It would take a relatively experienced therapist to deliver fully effective therapy in up to 6 sessions and such a therapist would have training and CPD commitments that would limit their clinical time. Secondly, such therapists would be likely to be more senior and paid accordingly. These points are pertinent given the inclusion of therapy by trainees in the analysis. Thirdly, this study does not take account of the better side effect profile of newer drugs. Thus, even with the same number of patients treated with drugs, more would switch to the newer medicines (with commensurate cost implications). For these reasons the cost differential is such that fewer patients could be treated by CBT than they conclude. However, this should not undermine their basic case that psychological therapy is not just desirable to patients but delivierable in an affordable way. Recent government documents (Ref 2) agree with this but seem not to change the myth at the 'front line' that psychotherapy is too expensive. Perhaps we do indeed require a "powerful body" (Ref 1) to advocate its use. Adam Dierckx SpR in Psychotherapy Ref 1 Hollinghurst S et al. Opportunity cost of antidepressant prescribing in England: analysis of routine data. BMJ 2005; 330: 999 Ref 2 Organising and Delivering Psychological Therapies Department of Health, Stationary Office, July 2004 Competing interests: None declared |
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susanne mccabe, retired cf5 6su
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BMJ and other publications could strengthen guidelines regarding 'declaration/conflicts of interest' by stating ceilings to describe 'small fees' and higher fees . This would make payments/interests even more transparent without compromising privacy. The amount considered by some may indeed be small but to others a significant incentive which may affect the weight given to decisions or be included in readers' judgements. (This is a commnent in general and not a response to this specific article.) Competing interests: None declared |
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