Discuss the relative values of drug treatments and ‘talking therapies’ for depression in the NHS, with reference to current health policies
Drug treatments and ‘talking therapies’ are available modes of treatment for depression within the NHS. Both interventions are of value and their appropriate implementation is guided by current health policies, specifically The National Institute for Health and Clinical Excellence (NICE) guidelines. For mild depression, drug therapy is not recommended and talking treatments such as Cognitive Behavioural Therapy (CBT) are seen to be more appropriate.
For more severe depression drugs are suitable, and selective serotonin reuptake inhibitors (SSRIs) are usually prescribed as they have the least side effects. However, a combination of a psychological treatment with medication maybe the most valuable course for people with moderate or severe depression (NICE, 2007). It may be suggested that a stepped care model to intervention is considered.
Depression is one of the leading causes of health problems in the UK. It is estimated that by 2020 major depression will be the second most common health problem in the world, behind heart disease (World Health Organisation). As such effective interventions for this condition are essential. Currently in the UK, the NHS offer drug treatments and ‘talking therapies’ for the treatment of depression. The effectiveness of these available interventions as modes of treatment for depression have been debated and as such this essay aims to explore the values of drug treatments and ‘talking therapies’ for depression in the NHS with reference to current health policies. Firstly it will concentrate on a description of depression before moving on to discuss the current policies for the treatment of depression and the value of drug and talking therapies.
There are two main types of depression; major depressive disorder and bipolar disorder. This essay will focus on major depressive disorder. Major depression is defined in terms of only depressive symptoms. To meet the DSM classification criteria individuals must have experienced five symptoms from a list of predefined symptoms over a two week period. These include low mood most of the day, a marked decline in interest or pleasure in activities, disrupted sleeping patterns, fatigue or loss of energy, altered eating habits, an inability to concentrate, feelings of worthlessness or hopelessness, suicide ideation or thoughts of death and irritability or agitation (Field, 2003).
According to current health policies, specifically The National Institute for Health and Clinical Excellence (NICE) guidelines, it is recommended that both drug treatment and talking therapies are available on the NHS (NICE, 2007).
In accordance with NICE guidelines, the treatment for depression varies depending on the level of depression experienced. It is suggested that, for mild depression, medication is not appropriate because the benefits are outweighed by the risk of side effects. In this instance short-term talking treatments such as Cognitive Behavioural Therapy (CBT) are seen to be more relevant. For more severe depression antidepressants are suitable, and selective serotonin reuptake inhibitors (SSRIs) are suggested because their side effects are usually better tolerated than those of other types of antidepressants. However, for people with moderate or severe depression a combination of a psychological treatment with medication maybe the most valuable course (NICE, 2007).
There are several drug therapies available that act in different ways and have various success rates (Gumnick and Nemeroff, 2000). Antidepressant drugs work on chemical messengers in the brain to alter mood. They try to lessen the symptoms of depression so that an individual may determine their actions proactively or feel able to engage in CBT. It commonly takes between two to four weeks before the medication takes effect. It is usually recommend that a person continues taking them for six months in order to avert a recurrence.
Antidepressants often cause unpleasant side effects, which are initially worse at the beginning of treatment. Of the various different types available, SSRIs are usually the favoured first choice because, although they have as many listed side effects, they are usually better tolerated. Others include tricyclic antidepressants and MAOIs (monoamine oxidase inhibitors). Tricyclic antidepressants (TCA) have been found to reduce symptoms in approximately 50-70% of individuals, yet it must be noted that placebo drugs have also been seen to reduce symptoms in 20 to 30% of people (Gumnick and Nemeroff, 2000). Withdrawal symptoms may be experienced when someone stops taking antidepressant drugs regardless of the type they are taking. This is particularly common if they have been taking them for a longer period of time. As such withdrawal from this medication is a slow process involving a reduction of the dose in stages over a period of weeks.
The ‘talking therapy’ of choice for depression as recommended by NICE is cognitive behavioural therapy (CBT). CBT is an evidence based collaborative therapy that challenges an individual’s thoughts and beliefs (Wells, 1997). The benefits of CBT in the NHS context are that it is a relatively short term treatment which approximates the length of the early phase of drug therapy (Kennedy, Lam, Nutt, and Thase, 2007). It is targeted to ease the core symptoms of depression and to provide the individual with the skills to manage their mood. The evidence suggests that the psychological interventions, particularly CBT, are at least as successful as medication in the treatment of depression, even if severe (Antonuccio, Danton, DeNelsky, 1995). Computerised CBT (CCBT) is now available, making this therapy more accessible, and it can be used alongside or instead of sessions with a therapist. It is not appropriate for someone with severe symptoms, and NICE recommend people are assessed before using one of the programmes (NICE, 2007).
It becomes clear that there are values associated with both drug interventions and ‘talking therapies’ in the treatment of depression. In particular, CBT provides an accessible mode of treatment which aims to equip the individual with strategies to challenge and cope with their low mood. This is done within a ‘safe’ context where the person is encouraged and supported and there are no known side effects (Knaus and Ellis, 2006). Depending on the severity of depression, some individuals may not be able to engage in CBT and in this scenario antidepressants have significant value as they enable the person to feel able to engage in therapy which challenges their thoughts and attitudes. As such both drug treatment and talking therapies have their place as effective treatment for depression. Perhaps a stepped cared model may be useful when thinking about the most applicable mode of treatment for depression.
The stepped care model presents a structure for managing the provision of services, and aids both practitioners and clients to identify and access the most effective interventions. The most effective and least intrusive intervention is initially offered. If a client does not benefit from that treatment or decides that it is not suitable for them, they should be offered a fitting intervention from the proceeding phase (Scogin, Hanson and Welsh, 2003). In this case the value of drug and talking interventions will be realised to provide the client with the most effective and suitable intervention.
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