We know that many heart patients (like me, for example), experience some degree of situational depression immediately following a cardiac event. When we seek help, that help is far more likely to come as a prescription for an antidepressant drug rather than a referral to a professional for talk therapy. In fact, talk therapy – either by itself or in combination with medication – is actually on the decline(1) while the rate of antidepressant use has increased by almost 400% in the past two decades.(2)
This is important, because we also know from 2015 research on depression published in the British Medical Journal (BMJ) that, for most people, there is no statistically significant difference in effectiveness between talk therapy and taking drugs.(3) When researchers tracked treatment outcomes for those suffering from depression, they found patients responded equally to either treatment. So why hasn’t the rate of talk therapy gone up by 400%, too?
The BMJ study’s lead author Dr. Halle Amick explained:
“We don’t think this finding is particularly surprising, because each treatment has its own evidence base that shows they’re effective in treating major depressive disorder.
“But this is one of the few studies to actually compare them head to head. And the finding is important because many doctors don’t have an understanding of cognitive behavioral therapy, and often don’t feel fully comfortable prescribing it.”
The take-away message from Dr. Amick: if a doctor doesn’t talk about psychotherapy as a treatment option, patients should be encouraged to ask about it.
This is not only a quality-of-life issue, but a depressed heart patient is unlikely to follow even the most basic of doctor’s orders like taking cardiac meds, quitting smoking, eating heart-healthy food or exercising.
Dr. Stephen Parker is an Alaska cardiac psychologist (and more importantly to me, a heart attack survivor himself). As he explains:
“As a psychotherapist, I have spent much of my work life talking with/listening to folks about their lives. I certainly believe that it can be useful and meaningful.
“As a heart patient, I have found that the cardiology industry emphasizes drugs over lifestyle, facts over feelings. It is a disturbing trend that more and more people are being treated with drugs alone.”
After being discharged from hospital, I expected to feel happy and grateful because I’d just survived a widowmaker heart attack. Instead, I felt exhausted, distressed, weepy, and unmotivated to even drag myself out of bed in the morning. I slept in my clothes. I no longer cared about basic personal hygiene like showering or washing my hair, and I no longer cared about how I looked or how I smelled. All I wanted to do was crawl back under the covers.
I tried very hard to paste on my best happy face around my family and friends, but eventually I found simply making conversation so utterly exhausting that it just seemed easier to make excuses and avoid others entirely. See also: The New Country Called Heart Disease.
I didn’t even know it at the time, but I was depressed. This type of mild to moderate depression can occur frequently after a health crisis like a heart attack, and is often known as “situational depression” or “stress response syndrome”. It’s also what mental health professionals call an adjustment disorder that can strike in the early weeks following a traumatic life event as we struggle to make sense of something that makes no sense.
The good news is that, unlike severe clinical depression, situational depression typically tends to run its course over about a six-month period, and can often eventually fade with or without treatment.
The best-studied form of talk therapy is called cognitive-behavioral therapy, which involves examining how our thoughts affect our emotions, and learning ways to change behaviour patterns that may be negatively affecting our mental wellbeing.
Before I was discharged from hospital after that heart attack, not one person in the CCU (the hospital’s intensive care unit for heart patients) had warned me of the reality of these mental health issues. Not one cardiologist, not one nurse, not one janitor had said even one word to me about what turns out to be a very common problem – a problem that cardiologist rarely mention to their patients. See also: When are Cardiologists Going to Start Talking about Depression?
Unfortunately, many heart specialists may not have the time or the expertise to address depression, according to cardiologist Dr. Sharonne Hayes, founder of the Mayo Women’s Heart Clinic:
“Cardiologists may not be comfortable with ‘touchy-feely’ stuff. They want to treat lipids and chest pain. And most are not trained to cope with mental health issues.”
Cardiologists aren’t the only physicians ignoring mental health issues.
My (now former) family doctor was clearly reluctant to refer me to a psychotherapist despite my repeated requests for this referral. She claimed that there was “a one-year waiting list” for such appointments. (Here in Canada, appointments with registered psychologists are only partially funded through employee extended health benefits programs, while appointments with psychiatrists are fully funded through our healthcare system).
After months of taking the antidepressant drugs my doctor had prescribed, and then trying different drugs, and then higher doses of drugs (with little if any relief), I persisted, asking her again in desperation for a referral for talk therapy.
It was obvious to me that she just did not want to do this. “I suppose you want a good one?” she muttered as she scanned a long list of local psychotherapists. She told me she’d have to send out a referral request to several on the list, just to find even one professional in this whole town who would be able to squeeze me in. Within two days, I came home from the grocery store one morning to find five phone messages from five local psychotherapists, each offering me an office appointment that same week. I picked the name of a therapist within walking distance of my home, and one day later, I was seated on her couch.
One. Day. Later.
So much for that one-year waiting list . . .
Most antidepressants are being prescribed by family physicians, not by trained mental health professionals. It turns out that fewer than half of people taking more than one kind of prescribed antidepressant drugs have actually seen a mental health professional during the past year, according to a Harvard Medical School National Health and Nutrition Examination Survey.(2)
Many of us are reluctant to seek out talk therapy. As the Canadian Mental Health Association explains:
“Some people worry about asking for help because there can be stigma around mental health problems. They may believe that asking for help means admitting that something is wrong. Some people worry about how others might see them.
“Asking for help means that you want to make changes or take steps towards your new health goals.
“We should celebrate the courage it takes to speak up and make changes. Getting help is part of recovery.”
And as Dr. Katherine C. Nordal wrote in her American Psychological Association online column(4):
“Psychotherapy doesn’t need a ‘black box’ warning. It doesn’t cause common side effects, such as weight gain, nausea, sexual dysfunction or sleep disturbance. It doesn’t stop working altogether when treatment ends.
“In fact, psychotherapy arms users with a new set of problem-solving skills they can apply whenever needed.”
“This can’t be surprising to anyone who has been watching trends over the last decade. Insurance companies prefer that patients receive medication, which they can control, over psychotherapy, which is harder to control.
“Every day, anyone who watches television or reads popular magazines encounters at least one and usually several ads for one or another of the heavily advertised antidepressants or atypical antipsychotics. Nowhere in any of those ads is it even suggested that the combination of psychotherapy and medication has been shown again and again to be superior to medications alone.
“I have heard physicians say that patients do not want to take the time for psychotherapy, that they prefer to take meds instead. Well, of course they do – because that is what they are being taught to do.
“There are no ads for psychotherapy. No public service announcements about the value of talking to another human being as a way to deal with depression or other emotional ills. The only advocates for the value of psychotherapy are psychotherapists – and our voice is way too muted to be heard over the din of the psycho-pharmacological messages.”
It’s important to keep in mind that most published research favouring the use of antidepressant drugs has been funded by the drug companies that manufacture those drugs.
But it’s also important to mention here that antidepressant drugs can be very effective in treating debilitating symptoms of severe depression for some people.
And Dr. Parker sums it up like this:
“Research suggests that drug therapy combined with talk therapy is more effective than drug therapy alone. Yet the trend is against this.
“What will it take to put the ‘heart’ back into medicine?”
M. Olfson et al, American Journal of Psychiatry, online August 4, 2010.
L. Pratt et al, “Antidepressant Use in Persons Aged 12 and Over: United States, 2005–2008,” NCHS Data Brief No. 76, October 2011.
Comparative Benefits and Harms of Second Generation Antidepressants and Cognitive Behavioral Therapies in Initial Treatment of Major Depressive Disorder: Systematic Review and Meta-analysis,”
K. Nordal, “Where Has All the Psychotherapy Gone?” American Psychologist Association: Perspectives on Practice, November 2010, Vol 41, No. 10, 17.
Q: Has your physician supported your requests for talk therapy referrals?
- Depressed? Who, Me? Myths and Facts about Depressiona after a Heart Attack
- 10 Non-Drug Ways to Treat Depression in Heart Patients
- When are Cardiologists Going to Start Talking about Depression?
- The New Country Called Heart Disease
- Depressing News about Depression and Women’s Heart Disease
- Does that Ache Signify Undiagnosed Depression?
- “I’m Not Depressed!” – And Other Ways We Deny the Stigma of Mental Illness After a Heart Attack