Depression’s rising costs require a human solution

Justin Thomas

• Last Updated: June 14. 2009 8:04PM UAE / June 14. 2009 4:04PM GMT

The headline “‘Dream’ hospitals unveiled” began a mouth-watering description of the state-of-the-art facilities and equipment envisioned for the new Al Mafraq and Al Ain hospitals.

Other headlines heralded strategic partnerships with leading German and American health care service providers. It is all undoubtedly great news, but one very important area of health care is not particularly improved by state-of-the-art equipment, facilities or overseas partners. I am talking of course about psychotherapy.

While many people would still dismiss psychological problems as insignificant and denigrate those experiencing them as the “worried well”, the empirical research data tell a very different story. A landmark study commissioned by the World Bank in the mid-1990s suggests that by 2020 the global burden of depression will be second only to heart disease, and among women, where rates of depression are traditionally higher, depression is estimated to become the number one burden of disease. This strange term “burden of disease” essentially relates to the economic or financial implications of a particular illness.

Dr Jan Scott at the Institute of Psychiatry in London suggests that the annual health care cost of treating depression in the UK’s National Health Service eclipses that spent on the treatment of hypertension and diabetes combined. Similarly five of the top 10 burdens of disease listed by the World Health Organisation are related to a psychological disorder. The rising prevalence, and the massive financial implications, of depression and other psychological disorders have directed significant research interest towards identifying the most effective treatments, with a renewed emphasis on cost, as well as clinical effectiveness.

One of the most significant findings to emerge from this search for clinical and cost effective treatments for depression is that some talk-based psychotherapies perform at least as well as drugs, often even outperforming them in terms of symptom remediation. An additional factor that contributes to the costliness of depression is its chronic relapse rates: 80 per cent of patients will experience repeated episodes and on average experience four major episodes with a duration of 20 weeks each. So, as important as it is to remediate the symptoms of depression, it is arguably more important to try and prevent relapses. This is where psychotherapy comes into its own.
One particular psychotherapy, known as cognitive behavioural therapy (CBT), performs at least as well as antidepressant drugs, but more importantly, it has consistently been found to reduce the rate of relapse in depressive illnesses. In light of such findings several nations have adopted clinical guidelines for the treatment of depression that cite CBT as a treatment of choice. There are numerous reasons for this: number one, CBT works. Additionally, it is popular with patients, as there is no fear of side effects, adverse drug reactions or addiction. From a cost effectiveness standpoint, the chances of the client relapsing are reduced: less episodes equals less cost, and similarly, compared to many other forms of psychotherapy CBT is mercifully short – fewer sessions also equals lower costs. But what exactly are the active ingredients in this treatment of choice for depression?

In essence CBT assumes that distorted thinking patterns lie at the heart of depression. The goal of the CBT therapist is to work together with the client to identify and replace these distorted patterns of thinking with patterns more conducive to optimum emotional functioning. Numerous techniques are used to achieve this, from carefully questioning the validity or usefulness of certain beliefs and assumptions, to developing coping skills, employing imaginal techniques and experimenting with alternative behavioural responses. Whatever techniques are employed there is always an emphasis on collaboration and learning. This typically means that by the end of treatment the client will have mastered enough CBT skills to be able to leverage them against the slings and arrows of outrageous fortune. This is arguably the secret sauce of CBT, as it empowers the client to act as his own therapist going forward.

In a little over 40 years CBT has grown to become one of the foremost psychotherapies in the western world. It has applications across a broad array of health problems, from depression, anxiety and psychosis to bulimia and obesity. The evidence supporting its effectiveness in the treatment of depression is particularly compelling. However, the implementation of CBT, like all talk-based therapies, hinges on being able to communicate in the language of the client. Furthermore being culturally in tune with clients is especially important.

While a broken leg is a broken leg in any language, broken hearts take on particularly subtle linguistic and cultural meanings. If effective evidence-based psychotherapy is going to be widely available for UAE citizens, it will require state-of-the-art, home-grown human beings, who are culturally and linguistically able to deliver it.

Justin Thomas is a psychologist and assistant professor working within the department of Natural Science and Public Health at Zayed University in Abu Dhabi