BBC News

When taking pills can be better than talking

By Professor Richard Gray
University of East Anglia

image captionAntidepressants 'can save lives'

Talking therapies are often cited as the best way of helping people with mental health problems.

But Richard Gray, a professor of nursing research, says sometimes pills are the answer.

Sitting in a village hall with 50 other people listening to a Powerpoint presentation about coping with stress is probably not what you have in mind when you think about receiving a talking treatment.

But this is the reality for many patients on the NHS's Improving Access to Psychological Therapies (IAPT) programme.

Depression and anxiety may affect up to one in four of us at some point in our lives and is a major reason why people are on long term sick leave or are unemployed.

Psychological treatments (such as CBT - cognitive behavioural therapy) and antidepressant medication are very effective in treating these illnesses.

But when given a choice most choose a talking therapy over medication.

Why people prefer psychological treatments is unclear but might be because of the negative media stories and stigma associated with taking pills for a mental illness.

'Voting with their feet'

Accessing talking treatments has, for many years, been restricted by the very limited number of qualified therapists that can provide the therapy.

The IAPT programme, launched in 2007, sought to address this; making talking treatments available to the many, not just the few.

The investment of £170m to make talking treatments widely available was aimed at enabling large numbers of economically inactive patients get back to work.

But the end of first year, evaluation suggests that patients on IAPT received, on average, just three sessions of treatment; well below the 16-20 sessions recommended by the National Institute for Health and Clinical Excellence (NICE) to be effective against depression and anxiety.

Large numbers of patients are seemingly voting with their feet and walking away early. Does this reflect the quality of therapy or the way it is being offered (back to our of 50 patients in the village hall)?

Improving access to talking treatments is a major campaigning issue for major mental health charities.

And it was striking that the majority of the media coverage surrounding the launch of the recent government mental health strategy also seemed to focus on the single issues of improving access to psychological treatments.

Is it time to question our seeming obsession with talking treatments?

'Troubling and dangerous'

Although it feels like heresy to suggest this I want to stand up for the very important role medication can play in the treatment of mental illness.

Antidepressants are very effective in treating moderate to severe depression, quickly alleviating distressing and disabling symptoms in about seven out of 10 patients.

Yes, pills can have side effects but so does CBT.

There are many patients that I have worked with who feel passionately that antidepressants have literally saved their lives.

Unlike talking treatments, prescribing a medication guarantees patients will get the full "dose" of treatment.

When it comes to severe mental illnesses such as schizophrenia and bipolar disorder I think it is even more important to stand up for medication which, I believe, should be viewed as the foundation for effective treatment.

I have been quite taken aback recently to hear a number of experienced psychiatric colleagues promoting psychological therapies as the preferred treatment choice for patients with these illnesses.

This is a troubling and dangerous consequence of our talking treatment obsession.

CBT can be helpful against schizophrenia and bipolar depression (but not mania), but requires patients to be taking medication first.

Both psychological therapies and medication have a role to play in helping people move on with their lives and recover from mental illness.

There are, I think, real challenges facing those implementing IAPT in guaranteeing that patients get the quality of talking treatments they require; surely not mass CBT in the village hall.

Taking medication means that patients get a treatment that has been shown to be effective in treating their symptoms.

Is it time to think about Improving Access to Pharmacological Therapies?

Professor Gray is a co-author of a book on CBT for psychosis from which he receives royalties. He has also received fees and honoraria for providing consultancy and giving lectures on behalf of Jannsen Cilag, Eli Lilly, AstraZeneca, BMS and Otsuka Pharmaceuticals.