Comparing Psychotherapy and Pharmacotherapy

To the Editor: The review by Dr. Klein concerning psychotherapy and pharmacotherapy for the treatment of some conditions elegantly showed that studies comparing cognitive behavior therapy and pharmacotherapy for severe depression have not demonstrated that cognitive behavior therapy equals or surpasses drug treatment. The reader might then infer that this conclusion does not apply to nonsevere depression, especially since the APA practice guideline on this topic (1) supports the use of psychotherapy as acceptable treatment for nonsevere depression. However, if one agrees with Dr. Klein, as I do, that a pill placebo control is necessary for comparing psychotherapy and drug therapy in order to determine that the sample includes subjects who were responsive to drug treatment, then the conclusion that Dr Klein drew for severe depression should apply to nonsevere depression: viz, there are insufficient data to conclude that psychotherapy equals or surpasses drug treatment.

The methodological difficulties of robustly testing this question indicate that we need large multisite studies to ensure expert pharmacotherapy and psychotherapy. Considering the enormous use of psychotherapy, it seems odd that in the 21st century we still lack good evidence for its efficacy for the many mental disorders for which we have substantial, pivotal evidence for the efficacy of drug treatment. I cannot imagine that the proponents of psychotherapy would object to such studies. We cannot depend on drug companies to fund such studies (although that would be nice), so that leaves it up to the National Institute of Mental Health. Perhaps we need a Food and Drug Administration (FDA) counterpart for psychotherapy. Doesn’t the public deserve to know that psychotherapy is safe and effective and how it compares to drug treatment?