Treating depression is an intriguing process. Dr. Friedman discusses how his medication choices in the past were akin to a coin toss: no one option was more or less effective than another. Added to that is the fact, as seen In my own work as a psychologist, that depression is a disorder that can wane simply with time.
Living with the beast of depression can be painful, even if it subsides over time. It is key to identify treatments that shorten the length and breadth of associated distress. Effective medications can be experienced as setting up a trap door: one still falls, one still experiences a variation in affect, but one no longer falls as far.
Talk therapies can be as equatable in effectiveness as SSRI medication. One seminal study found that the best predictor of treatment outcome wasn’t therapeutic approach. Rather, it was rapport. There is potency to a safe environment where emotions can be expressed and challenges explored with someone trusted.
Studies in the past have shown that talk therapies, including Cognitive Behavioral Therapy and Interpersonal Therapy, are as effective as medication in successfully treating depression. The advantage of talk therapies is that they can remain effective even when the treatment has been discontinued because the client now has tools to use moving forward. My thoughts around why medication can remain the first level of defense for general practitioners and others is that medication is consistent. In contrast, although manualized, CBT and IPT are modified in practice by therapists. If rapport is the mechanism of action for talk therapy, we must make sure that is developed in the therapy room.
Dr. Friedman discusses how Dr. Mayberg’s study looked at activity levels in the anterior insula, one area where emotional self-awareness and cognitive control occur. People with low activity in the anterior insula prior to treatment responded better to CBT than to an SSRI, Lexapro, and vice versa. This is a potential marker to guide treatment choice. Dr. Friedman discusses how certain co-morbidities including trauma should influence treatment choice.
While it may not make sense to do a brain assessment before deciding on a treatment for depression, it is a valuable exercise to continue fine-tuning treatment approaches for best fit. To me, a diagnosis is for the purpose of treatment planning. Mental health labels still carry stigma in our society; we want to maximize their utility by understanding the best course of action for the presenting problems.