Psychotherapy: a paradox.

An editorial appeared in the September 27, 2012, issue of Nature entitled “Therapy Deficit: Studies to Enhance Psychological Treatments Are Scandalously Under-Supported” (1). Out of character for a leading basic science journal, it argued for the active consideration of psychotherapy for treatment and research, and it emphasized the funding disparities between psychotherapy and medication. The editorial did not describe the psychotherapy paradox. While psychotherapy is fading from consciousness and practice in some developed countries, it is being enthusiastically embraced in developing countries hurt by HIV, natural disasters, wars, or political strife. For example, World Vision, one of the largest international philanthropies, funded two clinical trials of interpersonal psychotherapy for the treatment of depression in Uganda, a country devastated by HIV and civil war. The treatment’s positive results in reducing depression and sustaining the effects were widely disseminated (2–4). Another clinical trial was completed in Goa, India, using the initial phase of interpersonal psychotherapy to treat depression in primary care (5), and the results were the subject of a recent editorial that questioned whether psychiatrists were needed (6). Verdeli and I (7) responded strongly that psychiatrists were critical for overall quality control, patient evaluation, diagnosis, and program supervision. In fact, most of these global programs are led by psychiatrists. Canada has awarded two $1 million grants to a psychiatrist. The first grant is to train health workers in Ethiopia in administering interpersonal psychotherapy. The treatment is embedded in health care delivered by psychiatrists, family practitioners, and nurses and will reach 15,000 patients (P. Ravitz, personal communication, 2012; https://www.mshfoundation.ca/page.aspx? pid51822). The second grant is to scale up a treatment for depression that includes brief psychotherapy used in a stepped-care model within the primary care network of Partners in Health in Haiti. In Brazil, physicians, nurses, and other health and mental health professionals are being trained in psychotherapy for women and children who have been sexually abused (M. Mello, personal communication, 2012). A clinical trial of cognitive-behavioral therapy (CBT) by community health workers for depressed pregnant mothers was carried out in rural Pakistan (8). The study found a reduction in mothers’ symptoms at 6 months in the CBT group, and these results were sustained at 1 year. It also found a positive impact on health, including greater use of contraception. Birth spacing has been an important factor in reducing infantmorbidity. A randomized controlled clinical trial of CBT for patients with repeated primary care consultations for medically unexplained symptoms in general medical clinics in Sri Lanka found that CBT was feasible and effective in reducing symptoms of distress and number of visits (9). In 2008, the World Health Organization (WHO) launched the Mental Health Gap Action Program, which addresses the lack of care in resource-poor countries for people suffering from mental disorders (10). WHO noted that improvement in mental health care did not require expensive technologies, and the organization issued guidelines for managing care in nonspecialized health settings. Psychotherapy was strongly featured, and 11 psychotherapies were included in the WHO