Psychopharmacology Plus Psychotherapy for Depression Treatment

To the Editor: I read the report of Unützer and his colleagues (1) in the March 2003 issue with great interest. In the national debate about insurance coverage for psychiatric treatment, this study of the amount patients are willing to pay for depression treatment is timely and provocative. With many factions weighing in on the matter, these authors must be commended for seeking the input of patients. Ultimately, it is the patients who suffer the agonies of depression. Their willingness to pay for treatment is therefore of prime importance.

However, I would like to note a significant methodological concern. In the first sentence of the report, the authors state quite accurately that "Antidepressant medications and psychotherapy can substantially reduce or completely eliminate the symptoms of depression." A study by Thase and associates (2) is but one example of research that supports the validity of a dual approach to treatment. Indeed, Scott and colleagues (3) have reported that cognitive therapy is more effective than pharmacotherapy in preventing relapse in depression.

Unfortunately, Unützer and his colleagues chose to focus solely on pharmacotherapy. In light of the validated importance of psychotherapy, they were in effect asking, "How much would you be willing to pay for substandard care?" The findings of their study would have been much more useful if they had explored the attitudes of patients toward the minimal standard of care.

The use of symptomatic patients in the study somewhat further undermines the health economic implications of the findings. A story about a famous Viennese otolaryngologist comes to mind. He was summoned to the home of a duke to remove an obstruction from the throat of the duke's young son. After he saved the boy's life, the duke asked him what the fee would be. The surgeon, known for his sharp wit, replied that he would be satisfied with half of what the duke was prepared to pay while his son was choking to death. People in agony clearly have a much different perspective on the cost of treatment than those who do not yet see a need for treatment.

Despite these limitations, Unützer and his colleagues have explored an underexamined area that has great bearing on current health policy. Recovery from depression not only demands scientifically based care, it also requires the commitment of the patient to make sacrifices for his or her health. This study begins the important process of examining how much our patients are willing to pay to get better.

Dr. Mark is a clinical researcher and member of the trauma department of Meir Hospital in Kfar Saba, Israel.