The case for CBT over antidepressants

To the Editor: In her book review,1 Wilhelm fails to comment on the central theme of Paul Biegler's The ethical treatment of depression: autonomy through psychotherapy.2 Biegler argues that clinicians have a moral duty to promote psychological therapies (including cognitive behaviour therapy) to individuals with uncomplicated depression, over and above antidepressant medications (ADMs). He reasons that patient autonomy and empowerment — surely central concerns for every physician — are most likely achieved with talking therapies, rather than drug treatment.

Wilhelm does not adequately critique Biegler's concern that “… doctors [are] failing on a vast scale to uphold their ethical obligations to patients with [uncomplicated] depression”.2 Instead, Wilhelm's review focuses on other issues, such as how “… Biegler does not sufficiently discriminate between different types of depression”. Biegler does state from the outset that his analysis is restricted to uncomplicated types of mild, moderate or severe depression. However, this is clearly outlined in a reference note rather than being discussed in the text.2

Wilhelm is also concerned that Biegler understates the therapeutic role of ADMs in complicated depression. However, Biegler is careful to note, for example, that doctors need to be aware that melancholic depression (to which Wilhelm refers) may be resistant to psychological therapies.2 Further, he refers to work concerning the role of stressors in the genesis of melancholic depression, so Wilhelm is incorrect to state that this is not acknowledged in the book.

Although therapy for complicated types of depression is of concern to Wilhelm, it is not the subject of the book. Nor does complicated depression account for the millions of ADMs consumed in Australia annually. Biegler's ethical analysis was motivated by this phenomenon.