to the editor: The article1 in the April 1, 2003 issue of American Family Physician by Rodriguez and colleagues provides a practical outline of the approach to sports-related eye injuries. I found Table 3, which discussed the treatment of selected eye injuries, to be particularly useful. I would like to expand on the use of emergent lateral canthotomy in cases of blunt trauma. In these cases, if the globe is proptotic and tense, the physician should suspect a retrobulbar hematoma.2,3 Failure to recognize this condition can lead to optic nerve ischemia and resultant vision loss.

Orbital pressure can be relieved with a lateral canthotomy. To perform this procedure, a small amount of local anesthetic is injected in the region of the lateral canthal tendon. A straight hemostat is placed in the region between upper and lower lids, thereby causing a crush injury to the lateral canthus. Using scissors (e.g., Straight Stevens), a cut is made across the hemostatic line to the level of the lateral orbital rim. Further orbital decompression is facilitated by performing cantholysis through blunt dissection. The clinical usefulness of this procedure was made evident to me while on duty in the emergency department. A 20-year-old man was evaluated after a blunt force injury to his left eye. His globe was proptotic and tense, and he had only light perception. The lateral canthotomy procedure was performed, and his vision was restored to 20/40. Knowledge of this procedure is a must for physicians, especially those in remote areas where access to ophthalmology is not readily available. The emergent lateral canthotomy can be a potentially sight-saving procedure.

MARK D. BENTON, D.O.
Department of Family Practice
Naval Hospital Pensacola
Pensacola, FL 32512-0003

REFERENCES

1. Rodriguez JO, Lavina AM, Agarwal A. Prevention and treatment of common eye injuries in sports. Am Fam Physician 2003;67:1481-8.

2. Ellis E 3d, Scott K. Assessment of patients with facial fractures. In: Rutkauskas JS, Redding SW, Mulliken RA. Oral-facial emergencies. Emergency medicine clinics of North America 2000;18:411-48.

3. Vassallo S, Hartstein M, Howard D, Stetz J. Trau-matic retrobulbar hemorrhage: emergent decompression by lateral canthotomy and cantholysis. J Emerg Med 2002;22:251-6.

The opinions and assertions contained herein are the private views of the author and are not to be construed as official or as reflecting the views of the U.S. Navy Medical Department or the U.S. Navy Service at large.

editor's note: Obviously, the procedure described should only be tried by those with appropriate surgical experience, or in times of emergency when no other resources are available.

to the editor: Recent studies have shown an increase in the number of prescriptions for medications to treat depression and a decrease in the use of psychotherapy for depression.1 This trend suggests that brief psychotherapies are unavailable or underused, despite the established efficacy and patient preference for brief psychotherapies.2

The mainstream brief psychotherapies for depression include cognitive-behavior therapy, interpersonal therapy, and short-term dynamic psychotherapies. The availability of these treatments is variable. In the private sector, these therapies can cost more than $100 an hour. In the public sector, these therapies are available at no charge, but usually require longer waiting periods for access. The access to antidepressants is more obvious and reliable but not necessarily less expensive (see accompanying table&on page 2072).

Comparison of Pharmacotherapy and Psychotherapy for Treatment of Depression Parameter Antidepressant Brief psychotherapy Usual recommended treatment duration 6 to 12 months 16 hourly sessions over 4 months Cost* 216 to $1,485 per 9 months $320 to $1,600 per treatment course Pretreatment preference2 ++ +++ Attrition† ++ + Response rates3 +++ +++ Response in severe depression4 +++ ++ Remission rate2,3 ++ to ++++ ++ to +++ Relapse rates on cessation2,5 ++ + Adverse effects +++ + Access/convenience ++++ ++‡ Key: + = 0 to 25 percent effect; ++ = 25 to 50 percent effect; +++ = 50 to 75 percent effect; ++++ = at least a 75 percent effect. *-Cost range for antidepressant treatment is based on the purchase prices (including a $9 monthly dispensing fee) of the least expensive selective serotonin reuptake inhibitor (SSRI) at minimum dosage (fluoxetine [Prozac], 10 mg per day) to the most expensive SSRI at maximum dosage (citalopram [Celexa], 60 mg per day). Cost range of brief psychotherapy is based on publicly provided therapy to private psychologist-provided therapy. †-Early treatment withdrawal from ongoing therapy (attrition) was used to measure treatment acceptability. ‡-Access to psychotherapy may be higher than we have indicated, especially in urban settings. However, caregivers, because of system problems, often censor this option without fully exploring it with their patients. Information from references 2 through 5.

For most patients with depression of mild to moderate severity, psychotherapy and antidepressants appear equally effective.3 In severe cases, antidepressants may provide greater symptomatic relief.4 Psychotherapy is preferred by patients, and treatment tolerance and acceptance appears better.2,3 Comparative studies,5 which have included only older antidepressants (e.g., tricyclic antidepressants, monoamine oxidase inhibitors), have demonstrated lower dropout rates with brief psychotherapies (22.2 percent) than with pharmacotherapies (37.1 percent). The fact that dropout rates with the use of newer antidepressant agents remain high with only a modest advantage over older antidepressant agents implies that this advantage for psychotherapies persists. This greater acceptance may be partly related to adverse effects, which are a common reason for prematurely terminating therapy with antidepressant drugs. Adverse effects, at least in terms of somatic side effects, do not appear to be a factor with psychotherapy. Some studies5 also have shown an enduring effect with psychotherapy that reduces the risk of relapse and recurrence after treatment has been terminated (20 percent versus 50 percent relapse at two years for psychotherapy and pharmacotherapy, respectively). Even though the literature is unclear, combinations of psychotherapy and antidepressant medications may have an added effect in certain patients5 and may be less costly to the health care system than pharmacotherapy alone.6

Given the equal efficacy and patient preference for psychotherapies, we are compelled to examine why the rates of psychotherapy use have decreased while the prescribing of antidepressant medications has increased. The expensive and effective marketing of pharmaceutical companies has made a generation of physicians well versed in the prescription of antidepressants. Is it possible that physicians are not aware, because of "marketing" deficits, of the effectiveness, acceptability, and preferences for psychotherapies? Is there an education bias in medical schools and residency programs that fails to emphasize these options? Or, is it because physicians cannot access psychotherapies even if that is what their patients would prefer? It is vital that we answer these questions, in the service of our patients with depression.

ALLAN ABBASS, M.D.
DAVID M. GARDNER, Pharm. D.
Dalhousie University
Department of Psychiatry

QE II HSC, AJLB Suite 9215
5909 Veterans Memorial Lane
Halifax, Nova Scotia, Canada B3H 2E2

REFERENCES

1. Tanielian TL, Marcus SC, Suarez AP, Pincus HA. Datapoints: Trends in psychiatric practice, 1988-1998: II. Caseload and treatment characteristics. Psychiatr Serv 2001;52:880.

2. Chilvers C, Dewey M, Fielding K, Gretton V, Miller P, Palmer B, et al. Antidepressant drugs and generic counselling for treatment of major depression in primary care: randomised trial with patient preference arms. BMJ 2001;322:772-5.

3. Casacalenda N, Perry JC, Looper K. Remission in major depressive disorder: a comparison of pharmacotherapy, psychotherapy, and control conditions. Am J Psychiatry 2002;159:1354-60.

4. Elkin I, Gibbons RD, Shea MT, Sotsky SM, Watkins JT, Pilkonis PA, et al. Initial severity and differential treatment outcome in the National Institute of Mental Health Treatment of Depression Collaborative Research Program. J Consult Clin Psychol 1995; 63:841-7.

5. Canadian Psychiatric Association, Canadian Network for Mood and Anxiety Treatments (CANMAT). Clinical guidelines for the treatment of depressive disorders. Can J Psychiatry 2001;46 (suppl 1):5S-90S.

6. Burnand Y, Andreoli A, Kolatte E, Venturini A, Rosset N. Psychodynamic psychotherapy and clomipramine in the treatment of major depression. Psychiatr Serv 2002;53:585-90.