November of the Soul by George Howe Colt

Author:George Howe Colt
Language: eng
Format: epub
Publisher: Scribner

The ascendancy of the SSRIs has tipped the scales in the long, bitter turf war between biologically oriented and psychodynamically oriented therapists. These days, few clinicians would suggest that psychotherapy alone, without medication to address the underlying illness, is enough to prevent profoundly suicidal individuals from killing themselves. Yet many would maintain that medication alone is enough to deal with depressed and possibly suicidal individuals. Indeed, in most so-called therapy, the only contact the doctor may have with a patient following an initial assessment and prescription are brief follow-up visits to discuss side effects and to ascertain whether the dosage needs adjustment—a procedure quicker and, in many cases, no more personal, than an automobile’s three-thousand-mile oil change. Discussions of treatment issues in the literature revolve around medication, monitoring, and compliance; psychotherapy, if mentioned at all, is usually described only as an aid in encouraging adherence to the pharmaceutical schedule.

The recent controversy over SSRIs and suicidal behavior suggests, however, that while psychopharmacology has changed the way we treat suicidal people, it may not, by itself, be enough. Despite their extraordinary success, medications have proved to be something of a red herring in the treatment of suicidal patients. They may relieve the symptoms of psychiatric illness, but they do little to alleviate the stresses—family problems, loss, trauma—that may have triggered or exacerbated the illness. And, says psychiatrist John Maltsberger, “While they are no doubt important in preventing a great many suicides, they do not necessarily alter the underlying vulnerability to suicide.” Indeed, the excitement over antidepressants has obscured the fact that depressed and suicidal patients are best served by a combination of medication and psychotherapy. When a recent NIMH study of 439 depressed teenagers concluded that Prozac was far more effective than talk therapy in treating depression, it was hailed as a triumph of medication over psychotherapy; all but ignored was the finding that the most effective treatment of all was Prozac and talk therapy. Numerous other studies have demonstrated better outcomes in depressed, bipolar, or schizophrenic patients who receive both medication and psychotherapy rather than drugs alone. Yet most insurance companies cover the costs of brief medication visits but not of more than a few sessions of psychotherapy, which is often dismissed as expensive, complicated, time-consuming, and even irrelevant. “Medicine alone is not sufficient for treatment of suicidality,” concluded a comprehensive report on suicide by the Academy of Sciences in 2001. “. . . Psychotherapy provides a necessary therapeutic relationship that reduces the risk of suicide.”

What kind of psychotherapy? Because the field is itself fragmented by turf battles, there is little agreement on how to treat any mental illness. A person suffering from depression may be treated with yoga, Reiki, massage, hypnosis, sleep-deprivation therapy, homeopathy, magnets, Saint-John’s-wort, Qigong, acupuncture, or any of the more than 250 types of psychotherapy practiced today. (Of them, only psychoanalysis is agreed to be inappropriate for suicidal patients: “Most are too anxious, too depressed, or just not well enough put together to stand it,” says Herbert Hendin, himself a psychoanalyst.

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