Talk Is As Good As a Pill

By John Leo

Many psychotherapists, perhaps most, believe that 1) talk therapy certainly works, but 2) no one will ever be able to prove it. Studies designed to demonstrate the effectiveness of psychotherapies have often bogged down in procedural squabbles and in doubts that anything remotely scientific can rise from such a subjective field. But now therapists have a study to cheer about: a six-year, $10 million effort concluding that talk therapy can be just as good as drug therapy in treating depression. Exultant scientists at the National Institute of Mental Health, which funded the project, hail it as a "landmark," and Psychiatrist Jerome Frank calls it the "standard against which all other psychotherapy research will be assessed." Says Herbert Pardes, former director of NIMH: "It is unique in terms of size and the elegance of its construction."

Some 240 patients and 28 therapists are involved in the ongoing project at three sites: the University of Pittsburgh; the University of Oklahoma in Oklahoma City; and George Washington University in Washington. The study compares the effectiveness of two forms of brief psychotherapy with treatment by a standard antidepressant drug, imipramine. The drug got quicker results, but the talk therapies caught up after three months. By the end of the 16-week test period, all three treatments had eliminated serious symptoms of depression in more than half the patients.

So far, only a six-page summary of initial findings has been released. Describing the interim results last week at the American Psychiatric Association's annual meeting in Washington, the coordinator of the project at NIMH, Irene Elkin, said there is no evidence that drug treatment is any more effective than cognitive behavior therapy or interpersonal psychotherapy. Those therapies were chosen because they are commonly used for depression and can be readily taught to therapists from official manuals. Says Morris Parloff, a retired psychologist who helped frame the study: "We picked them because they are brief and very definable, from different approaches, and both have been tested and found effective."

Unlike Freudian treatment, which is psychodynamic and concerned with the genesis of unconscious conflict, the two talk therapies are straight-from-the- shoulder approaches dealing with the patient's current problems. Cognitive behavior therapy, the creation of Psychiatrist Aaron Beck, assumes that depression is the result of disordered patterns of thinking and tries to get patients to drop unrealistically negative views. Interpersonal psychotherapy, developed by the New Haven-Boston Collaborative Depression Project, attempts to reassure patients and improve their relationships.

All three treatments worked well with less disturbed patients. But among the severely depressed (44% of the sample), cognitive behavior therapy proved less effective than drug or interpersonal therapy. Researchers are inclined to doubt that the difference is significant. The general finding that the two different talk therapies are about equally effective strengthens the hand of those who believe that since most therapies get about the same results, the hotly debated differences among talk treatments are basically irrelevant.

The announcement of the findings comes at a time when drug treatments are on the rise and psychotherapists are under heavy pressure from health- insurance programs to find quick and cheap treatments that work. Though the art and experience of the therapist may be crucial to a cure, these are factors that hardly lend themselves to scientific analysis, which is one reason that the NIMH study chose talk therapies that can be packaged and dispensed relatively easily. The 18 therapists who conducted the two talk therapies were certified in those treatments after two years of training.

The study included a control group of patients who received placebos instead of imipramine, along with verbal support and encouragement by psychiatrists. % In this group, 29% of patients lost their serious symptoms, although they had no treatment. Many depressions wax and wane or clear up on their own, and the sheer act of deciding to enter a therapy program may sometimes be more beneficial than the therapy itself. The way to catch any such brief psychological boost is in follow-up studies. The NIMH project is testing patients after six, twelve and 18 months, with the end of the tests due by December. Three-quarters of these results are already in, but Elkin has not looked at them yet. She says she has her hands full just examining the treatment data.