The first issue of Ethical Human Psychology and Psychiatry (EHPP) for 2011 covers a wide range of topics highlighting the journal's mission of publishing peer-reviewed manuscripts dealing with ethics and challenging aspects in psychology and psychiatry. The contents include manuscripts from Canada, Mexico, Japan, and the United States, reflective of the international coverage of EHPP.
During 2010, there was some reprieve from the global financial crisis. However, many countries, including the United States and across Europe, have extremely high unemployment rates, and financial insecurity continues as a major backdrop in the lives of many citizens across the globe. Under these circumstances, increasing stress has consequences for the mental health of societies. There is sufficient evidence to indicate that, although wealth may not prevent problems in social and emotional well-being, it is clear that financial insecurity and socioeconomic deprivation are associated with increased mental health problems (Marmot, 2010).
Under deteriorating socioeconomic circumstances, an increased rate of depression in the population could be seen as a consequential outcome. Treatments for depression primarily rely on the use of medication, particularly selective serotonin reuptake inhibitor (SSRI) drugs, to alleviate perceived symptoms and, hopefully, remission from the depressive state. However, treatments under the bio-psychiatric model place no emphasis at all on the social and environmental circumstances contributing to an individual's mental state. In ongoing attempts to validate the science, massive investment is made by drug companies and government agencies to prove effectiveness of drug-based treatments for depression.
The lead article by H. Edmund Pigott provides a critical analysis of the $35 million sequenced treatment alternatives to relieve depression (STAR*D). STAR*D was a National Institute of Mental Health (NIMH)-initiated research study spanning 7 years, with additional follow-up studies continuing today. The study was conducted to "determine the effectiveness of different treatments for people with major depression who have not responded to initial treatment with an antidepressant" (NIMH, 2010, para. 1). STAR*D is the largest and longest study ever conducted to evaluate depression treatment (NIMH, 2010).
Pigott's analysis identifies problems with the reporting and conduct of the study and challenges the roles of the American Journal of Psychiatry and the NIMH, promoting what he has identified as biased reporting of STAR*D's results. One clear challenge detailed by Pigott is the overall prodrug bias underpinning the study.
In reviewing the available NIMH information on STAR*D, the editor of EHPP notes that in Level 2 of the study, "Participants could also switch to, or add on, cognitive psychotherapy" (NIMH, 2006). The findings reported in relation to cognitive therapy (CT) found "Participants received up to 16 sessions of CT over 12 weeks. About 25 percent of those who switched to CT alone, and about 23 percent of those who added it, became symptomfree. The rates were not significantly different from those who were in medication-only treatment pathways in Level 2, suggesting that CT was generally as effective as medication as a second step in treating depression" (NIMH, 2007, para. 4). In designing the study, one unclear variable is why all Level 1 participants were given the antidepressant citalopram (Celexa) for 12-14 weeks, and why CT was not offered as a potential alternative in Level 1 treatment.
There also appears to be confusion in the terminology used by NIMH in relation to CT. In 2006, they referred to cognitive psychotherapy, yet in the findings of the study, they report the use of cognitive therapy. It appears both the definition and limitation of CT to only one form suggests a failure to investigate adequately alternatives to drug therapies in treating depression.
Other alternative interventions, such as improved diet and exercise, which have had support in research in the treatment of depression, do not even rate a mention in the overall approach taken in STAR*D (Barbour, Edenfield, & Blumenthal, 2007; Blumenthal et al. …