The Ethical Treatment of Depression
Dr Paul Biegler
By Dr Paul Biegler
In Australia, as in most other Western countries, medication dominates the treatment of depression. The under use of evidence-based psychotherapy is an ethical indictment of contemporary depression management. Depression will affect one in six Australians over their lifetime and around 80 per cent of those who see a general practitioner will receive an antidepressant. In this country, more than 12 million prescriptions for antidepressants are written annually at a cost of over a quarter of a billion dollars. Yet, Cognitive Behaviour Therapy (CBT), a form of psychotherapy, achieves equivalent symptom improvement in most grades of depression, but is grossly under-represented in treatment statistics.
This imbalance exists despite the fact CBT offers something a drug alone cannot – insight. CBT requires people to understand depression is, in most cases, a response to especially stressful circumstances. In addition, CBT tutors people that a depressed mood biases information processing in a way that fosters unrealistic pessimism. As a result, depressed people treated with CBT are better equipped to deal with causal stressors, and to “de-bias” pessimistic judgments so that they accurately reflect reality. By contrast, antidepressants lift mood independent of any requirement for insight into the nature and significance of the depressed response.
This is a critical difference between the two treatments, and one that is cause for serious ethical concern. In the language of moral philosophy, the self-knowledge engendered by CBT promotes personal autonomy. Autonomy is the capacity to self-determine, to make decisions that best reflect one’s values, and to retain control during adversity. The medical profession already recognises the value of autonomy – doctors assiduously promote it each time they apprise patients of treatment options during the informed consent process.
In consequence, it is puzzling that many physicians seem content to provide depressed people only with medication, denying them the material understanding of causal stressors and decision-making biases, and the concomitant promotion of autonomy. This aberration becomes more intelligible on learning that psychotherapy remains only an optional treatment on Australian and international depression management guidelines. As they stand, the guidelines fail to acknowledge that self-knowledge empowers people with depression to make more autonomous life choices. Psychotherapy has a moral value that transcends its clinical effect. It is time this trait was given its due, and for evidence-based psychotherapy to become a treatment benchmark for all with depression.
Paul Biegler is the author of The Ethical Treatment of Depression: Autonomy through Psychotherapy published by The MIT Press. He is Australian Research Council Postdoctoral Fellow in the Centre for Human Bioethics, School of Philosophical, Historical and International Studies, Monash University.