As regular readers know, your editor is a big fan of a type of psychotherapy called Cognitive Behavioral Therapy (CBT). Cognitive therapy is a modern non-drug therapy that teaches clients new ways of thinking and feeling. The basic concept is that it is our distorted thinking that creates psychological problems of anxiety, depression, panic, etc. The cognitive therapist combines teaching cognitive skills with behavioral techniques that allow the client to overcome their difficulties.

And much to his surprise, this week Forbes Magazine put CBT on their cover! The Forbes article about Cognitive Behavioral Therapy was very positive. They summarize 30 years of research, including studies that show that CBT works well for insomnia, hypochondria, anxiety, depression, bulimia, obsessive compulsive disorder, preventing suicide, and even matches surgery for low back pain. Here is a video demonstration of exposure treatment for an elevator phobia.

They also compare the effectiveness of CBT to antidepressant medication. Although both work, in the long run CBT is more cost effective, and leads to less relapse. In one study comparing Paxil to CBT, only 31% of the CBT group relapsed within one year of completing treatment, compared to 76% of the Paxil group! This is a very big difference. The skills that clients learn seem to have a lasting impact on preventing future depressions.

Even in terms of cost, CBT beats antidepressant medications, at least with the assumptions the Forbes editors made. After three months of treatment, they estimate the costs of cognitive therapy at $1200 and the costs of medication treatment with Effexor at $502, which includes one psychiatrist visit at $200, and $302 in drug costs. At one year, they estimate the costs of cognitive therapy at $2000, and drug treatment at $2009, which includes $800 for four psychiatrist visits at $200 each, and $1209 for the Effexor.

As much as I like the comparison, it is based on faulty assumptions. First of all, it’s not clear how many sessions of cognitive therapy they are estimating. The $2000 would pay for 20 sessions at $100, but only 13 at $150. It’s probably optimistic to believe that a good outcome would come out of only 13 sessions. And because the primary group of professionals who perform cognitive therapy are psychologists, who typically charge more than masters level therapists, $100 is probably too low.

So let’s fix the numbers. Let’s assume 25 sessions of cognitive therapy, at $150 per session, which comes out to $3750. That’s probably a fairer assumption.

Now let’s look at the other assumptions. Effexor is an expensive, non-generic anti-depressant, which costs $100 a month, or even more. But the generic version of Prozac, called fluoxetine, can cost as little as $10 a month. And four psychiatrist visits in a year is also too optimistic. In my experience, patients need every two week visits initially to get the medication adjusted, and after 6 or 8 weeks, can graduate to once a month, and after another 3 visits, can be seen every three months. Also, psychiatrists typically charge at least $300 for the initial evaluation, and less than $200 for the follow-up visits which tend to be shorter visits.

So by these assumptions, the psychiatrist visits would cost $1380 at least. This brings the total cost of one year of treatment with Effexor to $2589. Of course, if fluoxetine was substituted then the total costs would only come to $1500!

So drug treatment costs less than cognitive therapy, right? It either costs a lot less ($1500 compared to $3750) or somewhat less ($2589 compared to $3750).

But there is still a glitch in the assumptions. We are only looking at the first year costs. Remember the statistics mentioned above, that up to 76% of patients who stop taking antidepressants relapse back into depression. Those are pretty bad odds. If a patient stayed on Effexor for 5 more years, their total cost of treatment would skyrocket to $6756, assuming psychiatrist visits 4 times a year. Compared to this cognitive therapy looks good!

There is another, unmentioned advantage to cognitive therapy, which is incredibly important, and which too often is left out of this debate. Here’s the dirty little secret the drug companies don’t want you to know—most antidepressants ruin your sex life! With really just a few exceptions (Wellbutrin, and Emsam) almost all of the major antidepressants make it much harder to have an orgasm for both men and women, and for men may make it difficult or impossible to get or maintain an erection. Antidepressants should really be called anti-sex drugs! (Caveat: not everyone will have the sexual side effects, but most will.) Here is a good article about the sexual side effects of antidepressants.

And this leaves out all of the other side effects of antidepressants. Here’s a link to common side effects of antidepressant medication Dry mouth, dry eyes, blurred vision, nausea, insomnia, headaches, the list goes on and on. How do you place a value on the costs of side effects?

Cognitive therapy obviously has no sexual side effects, or any other side effects. So for this reason, and for the advantage in preventing relapse, I believe cognitive therapy should be the first choice therapy for those patients suffering depression, providing they can afford therapy or have good insurance coverage for therapy. If not, then having your regular doctor prescribe and monitor a generic antidepressant such as fluoxetine (Prozac), sertraline (Zoloft), or bupropion (Wellbutrin) is the best option, with the downside being that you will most likely need to take the medications long-term to avoid relapse, and that you will most likely have physical side effects. Thus it may be worth taking a loan from your credit card in the form of a cash advance, or simply using a credit card to pay for cognitive therapy. After all, that’s how most people pay for their next car, or flat screen television set.

So here’s the executive summary. Cognitive therapy works for a large variety of common psychological problems, and even a few physical problems. Although initially it costs a little more, the effects are longer lasting than medication treatment. And in the long run, it can end up saving money. Best of all, other than working a little bit on therapy homework, there are no side effects of therapy! Conclusion: If you are depressed, anxious, having insomnia, obsessive compulsive disorder, hypochondriasis, phobias, or relationship problems, your first move should be to find a psychologist who specializes in cognitive therapy. Borrow the money if you don’t have it, or put it onto your credit card, but don’t miss out on this effective treatment out of some false sense of economizing.

Copyright 2007 The Psychology Lounge/TPL Productions

The New York Times reported that Rebecca Riley, a four year old girl from near Boston, was found dead on the morning of December 13, a victim of an apparent overdose of the psychiatric drugs Seroquel, an antipsychotic drug; Depakote, a powerful anti-seizure medicine used for mood control, and Clonidine, a blood pressure drug often prescribed to calm children. Rebecca had been diagnosed at having bipolar disorder at the age of two! So some overzealous psychiatrist had diagnosed her as been manic depressive at age 2.

Now this is pretty crazy. A child at two is a work in progress, and if is virtually impossible to diagnose anything at that age. The only exceptions are the developmental disorders, such as autism. Probably Rebecca was a difficult child, prone to moodiness and maybe even tantrums. So her parents, with a willing psychiatrist, gave her mind-numbing drugs to calm her, rather than learning better parenting skills. From the article: “A relative of her mother, Carolyn Riley, 32, told the police that Rebecca seemed “sleepy and drugged” most days, according to the charging documents. One preschool teacher said that at about 2 p.m. every day the girl came to life, “as if the medication Rebecca was on was wearing off,” according to the documents.”

This is more than sad, it is pitiful. How many other, nondrug interventions were tried before using medication? Was there parenting training? Was there a home visit, to see how Rebecca and her parents were interacting? The article does not say, but I’m guessing that none of these things were done. There’s an old saying, “Give a young boy a hammer, and everything becomes a nail.” In much the same way, bringing a child to a psychiatrist means that they are likely to get drugs. That’s why the first stop for children, especially young children, should be to a child psychologist, a psychologist who specializes in treating children and their families.

It should also be noted that most psychiatric medications are not and have never been approved for use in young children. There are no studies of using these drugs on toddlers. Although it might be occasionally reasonable to use drugs meant for adults on older teenagers, who are at least biologically similar to adults, it is irresponsible at best to use these drugs with young children.

The problem is that giving kids drugs is too easy. From the New York Times article, “Paraphrasing H. L. Mencken, Dr. Carlson added, ‘Every serious problem has an easy solution that is usually wrong.’” Behavioral problems in children can be very serious, and the behavioral interventions take time and commitment. Learning good parenting techniques, such as the proper use of time-outs and other interventions, takes dedication and a competent psychologist’s help.

As with adults, medications should always be reserved for after all other interventions have failed. And with children, only medications that have been tested on children, and used for years should be tried. If psychiatrists want to prescribe these medications for children, let them first run the research trials required by the FDA to test safety and effectiveness. Let’s not kill anymore Rebecca Riley’s!

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Copyright 2007 The Psychology Lounge/TPL Productions