Treating Mental Illness

We tend to divide treatments for mental illness into “psychological” approaches and “biological” ones; the former typically involve “talk therapy” and the latter medication. But this either-or way of thinking obscures the fact that talk therapy affects the brain and is no less biological than pills.

Numerous findings over the last two decades demonstrate how talk therapy alters the brain. Disabling conditions like clinical depression and anxiety can be treated effectively by understanding distorted patterns of thought, becoming aware of emotional conflicts that have not been conscious, or practicing new behaviors. Talk therapy is a potent treatment for serious mental disorders and not simply for the “worried well,” as it is sometimes characterized.

These conditions can also be treated with medication, either alone or in combination with talk therapy. Whereas the effects of medication tend to go away once the medication is stopped, the benefits of talk therapy can be enduring because of the significant changes that take place not only in the “mind” but in the “brain,” too. This is a real-life example of what the Nobel laureate Eric Kandel has discovered: learning affects the ways in which the brain forms new connections.

Why does this matter? It is important that the public know that talk therapy is an important tool in the healing process precisely because of its powerful effects on the brain. Medication, which is lifesaving for many, tends to be overprescribed. Rather than being introduced as part of a comprehensive treatment that includes psychotherapy, it is often used in its place. We should be aware of the cultural trends that devalue psychotherapy and the listening healer and the unintended consequences that may ensue.

LARRY S. SANDBERG

New York, May 20, 2013

The writer is a psychoanalyst, a clinical associate professor of psychiatry at Weill Cornell Medical College and the co-author of “Psychotherapy and Medication: The Challenge of Integration.”

Readers React

It is good to see talk therapy get a fair hearing in the lay press as a “biological treatment.” Those of us who have used both talk therapy and medication in practice have known about the evidence, both clinical and experimental, and have been informing our patients accordingly for a long time. That it has not gotten enough traction in our society, and that there has not been more confirming research, bear witness to the enormous power of the insurance industry (which does not pay psychiatrists enough to do psychotherapy or conjoined treatment) and the pharmaceutical industry (which has a vested interest accentuating the benefits of medication).

While psychoanalytic psychotherapy is more useful to patients in the long run, it is harder to get the most out of this treatment in the beginning because of the physical symptoms of their depression/anxiety, which are more rapidly addressed with medication. I usually put it bluntly — that it is hard to get much from talking when you are not sleeping and feel physically as if you have been run over by a steamroller.

Most patients cannot afford true conjoined treatment. And I refuse to see patients for only the 8 to 15 minutes allotted by their insurance for a “medication visit.” So we do the best we can with longer visits with less frequency, even though the reimbursement for this is quite poor.

The brain is a wonderful organ. It heals. And it can be helped to heal.

DAVID GORENBERG

West Tisbury, Mass., May 23, 2013

The writer is a psychiatrist in private practice and a former clinical associate professor of psychiatry at the University of Pennsylvania.

Dr. Sandberg makes an excellent case for multi-modality therapy of mental illness — chemical and interpersonal. But until we determine that this approach is part of the right of all Americans to quality health care, most people will not have the financial wherewithal to acquire the benefits of talk therapy, nor will most insurers cover what can be a protracted and expensive alternative to a pill.

To be brief, who is going to pay for this?

LEONARD A. ZWELLING

Bellaire, Tex., May 22, 2013

The writer is an oncologist.