Reflections
Ethics Mental health Pharmacology
Volume 198 - Issue 9

The case for CBT over antidepressants

Author:  Kay A Wilhelm

Med J Aust 2013; 198 (9): 507. || doi: 10.5694/mja12.11268
Published online: 20 May 2013
THIS BOOK is by a doctor with an abiding interest in the philosophy of medicine. Paul Biegler is an Australian Research Council Postdoctoral Fellow at the Centre for Human Bioethics, Monash University, and a recipient of the 2011 Australian Museum Eureka Prize for Research in Ethics.The book describes the therapeutic use of antidepressant medication (ADM) versus cognitive behaviour therapy (CBT), and concludes that it is unethical ...
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The ethical treatment of depression: autonomy through psychotherapy.
Paul Biegler. Cambridge, Mass: The MIT Press, 2011 (213 pp, $45.95). ISBN 9780262015493.

THIS BOOK is by a doctor with an abiding interest in the philosophy of medicine. Paul Biegler is an Australian Research Council Postdoctoral Fellow at the Centre for Human Bioethics, Monash University, and a recipient of the 2011 Australian Museum Eureka Prize for Research in Ethics.

The book describes the therapeutic use of antidepressant medication (ADM) versus cognitive behaviour therapy (CBT), and concludes that it is unethical to provide the former as a first option to all patients suffering from depression. This is based on the author’s view that ADMs do not promote autonomy nor change vulnerability, whereas CBT enhances resilience and changes cognitive vulnerability to depression.

However, Biegler does not sufficiently discriminate between different types of depression. He acknowledges that some types may require ADMs to allow patients to process information, but underplays this point. In these cases — such as melancholic and psychotic depression, some medical illnesses and, arguably, depression related to serious personality disorders — ADMs can improve cognition and judgement to enable sufferers to make informed choices, while ongoing ADMs and psychotherapy may be necessary to decrease vulnerability and promote autonomy. And although Biegler talks about precipitating stressors, he doesn’t acknowledge the place that environmental stressors can play in melancholic depression, often a point of confusion.

The case is meticulously built up through progressive chapters. It is a thought-provoking book, but not one to skim through or dip into. It is recommended for people with a serious interest in the area. It addresses important issues and is timely as the costs of providing CBT have become less of an issue with the advent of excellent self-help books and internet programs, and greater access to clinicians providing CBT. It will be of interest to general practitioners, psychiatrists, psychologists and people involved in health economics and health planning, albeit with the aforementioned caveats in mind.

Author

  • Kay A Wilhelm1
  • 1. St Vincent’s Hospital, Sydney, NSW
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