Pills or Talk Therapy? If You're Confused, No Wonder
June 8, 2004
by Benedict Carey
Moody teenagers who visit therapists for help often wonder how useful all that talk about feelings and emotions really is. Now, many doctors are asking the same thing.
Last week, researchers presented findings from a large government-financed study showing that depressed teenagers were much more likely to improve by taking Prozac than by undergoing a standardized form of talk treatment, cognitive behavior therapy.
For parents desperately trying to help a depressed teenager, the study may appear to make their choices even more confusing. Already worried by Food and Drug Administration warnings that antidepressants can be dangerous for a small number of children and adolescents, parents now face the news that the best alternative, talk therapy, may be a waste of time.
Yet experts say the results of the study are more complicated, and less discouraging, than they might seem at first glance. The study, to be published this year, offers some reassurance that the drugs are probably helping. At the same time, it makes clear that psychotherapy does have a place. Although statistically, therapy alone was no better than a placebo, it did lift depression in 43 percent of the teenagers studied, compared with 35 percent given dummy pills. Almost three-quarters of the adolescents who combined talk and drug treatments improved significantly, and the psychotherapy appeared to reduce the risk of suicide.
"It was very close to a significant effect," said Dr. Michael E. Thase, a professor of psychiatry at the University of Pittsburgh, "and the added effect the therapy had confirms for me that it's showing some benefit."
Dr. Thase said good psychotherapies sometimes did not work in big studies. Large-scale investigations, by focusing on group averages, can also hide individual differences. Some people thrive in therapy, others do not. Therapists' skills vary widely. And people sometimes fare better with a form of psychotherapy other than the one being tested.
Previous research has suggested that other techniques can help soothe teenage depression, and several forms of talk therapy have not been tested at all.
Dr. Martin E. P. Seligman, a professor of psychology at the University of Pennsylvania who has worked with troubled adolescents, wrote in an e-mail message that the findings on cognitive therapy would have to be verified in further studies, "particularly so, because prevention of depression using C.B.T. procedures works well among adolescents at risk for depression." C.B.T. stands for cognitive behavior therapy.
He also said in the e-mail that some teenagers picked up the techniques so well that they became "emotional acrobats."
The government study, led by Dr. John S. March, a professor of psychiatry at Duke, found that Prozac had about the same effects on depression in 378 teenagers as it did in adults. After 12 weeks, 61 percent of those taking the drug reported feeling significantly better, the researchers reported.
"This provides what I would consider definite, clear-cut evidence for the effectiveness of medication in a segment of the pediatric population for which very little evidence existed, and supports what many psychiatrists have been doing in practice," said Dr. Jeffrey A. Lieberman, a professor of psychiatry and pharmacology at the University of North Carolina.
The drug effects were strong enough to prompt some rethinking about standard treatments, said Dr. Harold S. Koplewicz, director of the Child Study Center of New York University. At many clinics, depressed teenagers routinely receive some form of counseling before being prescribed drugs.
"This study truly makes us rethink what the first line of attack should be, and I believe we have to share the results with parents before a teenager starts treatment," Dr. Koplewicz said.
Psychiatrists and pediatricians emphasized the importance of regular visits for children on antidepressants, to monitor reactions. The researchers reported five suicide attempts among adolescents in the study who were given Prozac and one attempt among those given placebos. Citing suicide risk, the Food and Drug Administration cautioned doctors and families in March to pay close attention to children and adults on antidepressants, especially in the first weeks of therapy or when dosages are changed. Adolescents who become hyperactive, suddenly agitated or who act strangely out of character may be reacting badly to the drugs, experts say.
The benefit of talk therapy has been much clearer in studies of adults. Researchers find that roughly 60 percent of depressed adults feel significantly better after completing a form of focused talk therapy like cognitive therapy, the type used in the study, or interpersonal therapy, another form that is often used in comparison trials.
In interpersonal therapy, people work to mend the specific personal problems like a dispute, a loss or a betrayal that led them to fall into despair. The therapy may last 10 to 20 weeks or longer and usually stays focused on managing specific relationships. Cognitive therapy typically involves 8 to 12 hour long sessions in which people learn to dispute and defuse self-degrading thoughts - "I am an awful parent," and "I'm a failure as a student" - that feed on themselves and cause people to sink into depression. These methods are the only two that researchers have standardized well enough to study systematically, and they have generally worked as well as medication in people 21 and older.
"Almost all such adult studies show similar positive results for both cognitive therapy and drugs over placebo," Dr. Seligman said.
Experts say there are several possible reasons why cognitive therapy might fail teenage patients. The approach tends to work best for people with mild to moderate forms of depression. Those with more stubborn conditions often do better with a combination of drugs and talk therapy.
The success of the techniques is highly dependent on the therapist's skill. And working with a standardized manual, as many researchers do, can limit a psychologist's flexibility in dealing with teenagers' individual problems.
"You can't do cognitive therapy from a manual any more than you can to surgery from a manual," said Dr. Aaron T. Beck, a professor of psychiatry at the University of Pennsylvania and the director of the Beck Institute for Cognitive Therapy.
Depending on the teenager, Dr. Beck said, the therapist might bring family members into sessions.
"Adults are mature enough to learn most of what they need to know at the office,'' he said. "But with teenagers you really have to look at the family environment."
Often, too, teenage depression is tied to trouble in relationships like a breakup with a boyfriend or a falling out with a good friend, crises best handled directly, with interpersonal therapy. Several studies show that interpersonal techniques can relieve depression in teenagers, said Dr. David A. Brent, a psychiatrist at the University of Pittsburgh.
"I think we need to look at a variety of approaches before deciding" talk therapies are ineffective, Dr. Brent said.
The underlying problem in reaching a troubled teenager is clear to just about any parent of one. Adolescence is a fog, a kind of high fever. Emotion swamps reason; rumination undermines introspection. It is not an ideal time, many psychiatrists acknowledge, to perform therapy that requires the detached moment-to-moment self-awareness crucial to cognitive therapy.
"This component of the therapy, watching and monitoring your own feelings and thoughts, is notoriously difficult for some teenagers," said Dr. David Shaffer, a professor of psychiatry and pediatrics at Columbia. "The development of these skills happens during adolescence, and it happens irregularly and quite late in many kids."
There is a huge difference, cognitive therapists say, between a high school junior who is emotionally scarred by mediocre SAT scores and one who can feel the same devastation but manage to say, after some work with a therapist, "Well, I had a bad day."
Another problems is that talk therapies typically involve extensive take-home work like keeping diaries, and teenagers already have plenty of homework.
"They're usually referred to treatment by their parents or teacher and simply not motivated to do the therapy," said Dr. Mark A. Reinecke, the chief of the psychology division at Northwestern University and a co-author of the government-financed adolescent study. "And it's very clear from studies that you're not going to do well if you're not motivated."
Whether they favor talk therapy or drugs, doctors and psychologists who treat teenagers every day welcome any debate or public discussion about adolescent depression. Child and adolescent psychiatrists are overbooked. Psychologists who specialize in teenage depression are in short supply, and at least half of teenagers with symptoms get no treatment at all, many studies show.
"I think, over all, some good can come out of this discussion if it convinces more and more doctors to get kids into treatment," said Dr. Marvin H. Lipkowitz, chairman of psychiatry at the Maimonides Medical Center in Brooklyn, N.Y. "And I think it calls attention to the need for psychotherapy. For if you're going to treat a child with medication, you do better when combined with therapy. The bottom line is, you need to be meeting and talking with the child on a regular basis."