Antidepressants and Therapy, a Strange Alliance

With Psychopharmacology So Popular, Do We Still Need Therapy?

Scott Miller

There was a time when therapists, and much of our larger culture, saw depression and other human troubles as complex conditions of mind and heart, influenced by many subtle inner and outer forces. But in the last decade, a vast intellectual and emotional sea change has taken place. We now inhabit a culture where many people hold the view that their emotional pain is "biochemical" and can be cured by simply taking a pill.

Emotional suffering, according to this new view, is a genetic glitch, successfully treatable by drugs. Depression is no longer thought to be shaped by such diverse forces as a sedentary, lonely or impoverished life; the loss of love, health or community; "learned helplessness" or feelings of powerlessness arising from unsatisfying work or an abusive relationship. Its resolution no longer requires anyone to get meaningful support from others, to establish a collaborative relationship with a good psychotherapist, to draw on community resources, or for communities to address conditions that breed depression. No, depression is now publicly defined as a purely biological illness, treatable---thank heaven---by the miracle antidepressants.

These miraculous drugs, the story goes, are effective with 75 to 85 percent of the people who take them. In this prevailing cultural script, therapy, like an old character actor, is sometimes ignored altogether, and never given more than a minor supporting role. Only one solution, apparently, is needed, and only one is offered: the passive consumption of a pill.

These views have taken on the luster of scientific truths. But they are not truths. They are myths. They have not been confirmed by the latest discoveries of neuroscience, nor are they supported by outcome research. They seem true because they have been repeated and reinforced by mass-market advertising intended to make taking antidepressants seem as normal and pervasive as swallowing aspirin.

The message is seductive and it works: if these drugs were books, they would be runaway bestsellers. While most mental health professionals would acknowledge that the explanation given to clients is a gross oversimplification of actual brain functioning, few reject the biochemical model altogether. Fewer still question the effectiveness of the drugs, and virtually no one challenges the idea that combining medication with therapy is the best of all treatment options.

The first and perhaps most pervasive myth about SSRIs and other newer antidepressants is that their effectiveness is a matter of scientific record, conclusively demonstrated in strict, controlled, double-blind, placebo studies---the gold standard in medical research.

But because of the shrinking of federal grants and the privatization of research funding that began in the Reagan years, pharmaceutical companies now pay for the majority of clinical trials of drugs. The AHCPR metareview, for example, noted that out of 315 published clinical trials of 29 antidepressant drugs, every study that identified a sponsor had been funded by a drug company. The ubiquity of drug company funding may also help account for the dearth of research comparing the effectiveness of therapy and medication: why would drug companies fund research that might prove a competing product (such as therapy) was equally or more effective?

Wouldn't the best of all possible worlds be one in which medications were combined with therapy, giving clients enough stability to make use of therapy and creating a sort of double-whammy treatment effect? The idea that both together must be better than either one alone for treating depression has become the newest orthodoxy among many professional groups. In fact, this sensible-sounding "compromise" solution actually promotes the use of medications, by implicitly suggesting that virtually anybody who enters therapy for any reason could usefully take them.

Our exaggerated sense of the efficacy of psychiatric drugs may also be colored by the fact that drug companies are under no obligation to publish the results of failed clinical trials. Thomas J. Moore, a health policy analyst at George Washington University, for example, recently found, in a search of FDA files, the results of two identical trials of the antidepressant Serzone. The one showing a marginally positive result was published, but Moore found no indication that the other trial, showing no measurable drug effect, was ever published.

In our own practices, we never suggest medication as the treatment of first resort. Instead, we begin therapy on the assumption that if we follow the client's lead, ask about the client's own theory of how change takes place and strengthen the therapeutic bond, we will enhance therapeutic outcomes of all kinds---with and without medication. When clients believe that medication will help and are "in the driver's seat" in making an informed choice, we have found that SSRIs can be helpful at times.

At the core of this approach is our faith that change occurs naturally and almost universally: the human organism, shaped by millennia of evolution and survival, tends to heal and to find a way, even out of the heart of darkness. When we hang on to this belief in our hearts, we level the playing field and can compete with the noisy medical ideologies promoted by profit-making drug companies and championed by factions within our own professions.

This blog is excerpted from “Exposing the Mythmakers."Read the full article here. >>

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Topic: Psychopharmacology

Tags: add | antidepressants | depression | drugs | ED | emotion | emotional pain | HEAL | loss | mental health | mental health profession | mental health professional | mental health professionals | neuroscience | practices | prozac | psychotherapist | science | serotonin | SSRI | ssris | success | TED | therapist | therapists | therapy | treating depression

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3 Comments

Sunday, February 15, 2015 2:13:49 AM | posted by Jay
I do appreciate professionals questioning the current trends, especially in terms of over reliance on meds in scenarios where therapy could lead to the required healing- and more likely a lasting one. However, I do think this article is light in terms of speaking to recurrent severe major depressive episodes (potentially also mixed in with anxiety... Not to mention bipolar and other conditions)... Where a client has tried everything "right" to try and get well and yet is still dangerously unwell, what else is available at present to try than medication? Especially in a society that rarely supports people in the ways that may enable recovery just with therapy (extended time off work, support to afford housing and food - and to not lose everything a person has, additional assistance in navigating and managing all of the demands and details of life that can become impossible during such times of illness). I do see part of the point being made - that questionably effective Pharma is being relied upon to band aid some systemic issues in our society. However, until there are huge changes in the way society regards mental health issues and is willing to participate in the funding of genuine and effective mental health treatment, what else can professionals offer clients who are struggling and have already exhausted all of their capacity to manage their symptoms, despite consistent committed and ongoing therapy?

Saturday, February 14, 2015 7:06:05 PM | posted by David Allen M.D.
This article contains the hidden assumption that all cases of depression are alike in some respect, and glosses over the difference primarily between dysthymia, which does not respond to antidepressants well at all but almost always requires psychotherapy, and true major depressive disorder, for which in its severe melancholic form psychotherapy is completely useless.

The drug companies have been glossing over this difference for decades, with both researchers and subjects alike being given financial incentives for exaggerating their symptoms.

While there is some overlap in symptoms so it may be difficult at first to tell the difference, the primary differences are usually fairly clear: differences in the pervasiveness and persistence of vegetative symptoms and the difference in functioning between a depressive episode and the patient's baseline.

It's also true that drugs and therapy target different aspects of all depressive disorders. Asking which is better is like asking what is better for heart disease, digoxin or blood pressure control.

Mental health professionals who don't know these things need to go back to school.

Saturday, February 14, 2015 6:28:14 PM | posted by Betsy Brach
Perhaps the intent of this article is to be provocative. It certainly provoked a strong reaction from me. I agree that some people see medication as a magic bullet and shy away from doing the hard internal work. And that some elements of our culture and the media support that. I also agree that medication shouldn't be the knee-jerk first action. However the use of medication as the first line or only treatment is not nearly as pervasive as the authors purport it to be. I don't see that in the clients who come to see me, or in the practice of many of my colleagues who offer psychotherapy and can prescribe. Many people are hesitant to take meds, worried about becoming dependent on the meds in order to feel okay. My strongest reaction to the article comes from my experience in being with clients who really work in therapy and feel a sense of failure if they end up resorting to using medication to augment the process. There are so many ways of healing available, and I believe the approach needs to be individualized to each client without bringing in the bias that medication is the last resort. SSRI's are only one piece of a large armamentarium (there are other drug classes too). Using them early can sometimes prevent a person from sinking into a deeper depression that is even harder to recover from and leaves it's own trauma. Medications can augment psychotherapy and allow for deeper work. This article feels out of balance.