Psychotherapy for Depression

YOUR FIRST & BEST TREATMENT CHOICE

John M. Grohol, Psy.D.
June 20, 1995, last updated on June 26, 1998

     This article was written in response to a number of shorter articles from the most recent issue of the American Psychologist (June, 1995, Volume 50, Number 6). These articles were written in response to a prior article in this same journal, which made the same case for psychotherapy as being the treatment of choice for depression, but in gentler terms. I think the time for gentler terms is past and that individuals should be fully informed as to their treatment options, especially with regards to what has been conclusively shown to work for depression. Many individuals often turn to psychotropic medications for immediate relief of emotional problems. I don't believe the research backs up such a solution, as you will see below. Following the extensive quotes from the journal, I have also outlined the major points of these articles.

     Some items I feel need to be clarified here. First, depression as talked about throughout this article refers only to Major Depressive Disorder (look at the criteria for a Major Depressive Episode here also). This does not include depression as a result of the loss of a loved one, due to medical causes, or Bipolar Disorder (manic-depression). "Medical causes" does not mean, however, that the depression is caused by some sort of "chemical imbalance." There is no such proven fact, only a theory, just like the half-dozen or so psychological and other medical theories for the cause of depression. Second, the studies discussed below do not yet predict individual responses to the specific treatments mentioned. In other words, just because it works for most people still does not mean it will work for you. It is more likely to work for you, but no scientific study, either in psychology or medicine on this topic, yet are specific to an individual's own situation, environment, genetics, etc. Keep this in mind.

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The preponderance of the available scientific evidence shows that psychological interventions, particularly cognitive-behavioral therapies (CBTs), are generally as effective or more effective than medications in the treatment of depression, even if severe, for both vegetative and social adjustment symptoms, especially when patient-rate measures and long-term follow-up are considered (Antonuccio, 1995).

[You] may [also] want to consider the meta-analysis by a Yale psychiatrist (Wexler & Cicchetti, 1992) who reviewed seven well-controlled outcome studies of 513 individuals and concluded that combined treatment offers no advantage over treatment with psychotherapy alone and only modest advantage over treatment with pharmacotherapy alone. When dropout rate is considered with treatment success rates, pharmacotherapy alone is substantially worse than psychotherapy alone or the combined treatment. The review concluded that in a hypothetical cohort of 100 patients with major depression, 29 would recover if given pharmacotherapy alone, 47 would recover if given psychotherapy alone, and 47 would recover if given combined treatment. On the other hand, negative outcome (i.e., dropout or poor response) can be expected in 52 pharmacotherapy patients, 30 psychotherapy patients, and 34 combined patients. This meta-analysis suggests that psychotherapy alone should usually be the initial treatment for depression rather than exposing patients to unnecessary costs and side effects of combined treatment (Antonuccio, 1995).

The empirical data are quite clear [with regards to the most effective treatment for depression]. Meta-analyses carried out by a number of investigators come to the same conclusion (e.g., Antonuccio et al., 1994; Wexler & Cicchetti, 1992). Psychotherapy alone is more effective than medication; combined psychotherapy with medication is no more effective than psychotherapy alone, but the relapse rate is higher among depressives treated with combined treatment than with just psychotherapy (Karon & Teixeira, 1995).48

Moreover, a consistent finding across studies is a higher dropout rate among those receiving medication, either because of side effects or because the medication has not helped. These patients are treatment failures but are not included as treatment failures in the data for their studies (Karon & Teixeira, 1995).

The APA work group (Munoz et al., 1994) mentioned but did not emphasize the fact that the double-blind clinical trial for psychiatric medication has been shown to be a sham: As Seymour Fisher and Roger Greenberg (1993) among others, have shown, the double-blind placebo controlled study is not blind. Side effects are so obvious that more than 80% of the patients know whether they are on active medication or placebo, patients are equally accurate about other patients on the ward, and nurses and other personnel are privy as well. In some studies the only people who claim to be blind are the prescribing physicians, and in other studies the prescribing physicians admit being as aware of the patients' condition as everyone else (Karon & Teixeira, 1995).

The Munoz et al. article details the important meta-analysis by Greenberg, Bornstein, Greenberg, and Fisher (1992) covering 22 controlled studies (N=2,230), which calls into serious question the perceived efficacy of tricyclic antidepressant medications, which are shown only to be more effective than inert placebo and only on clinician-rated measures, not patient-rated measures. If patients cannot tell that they are better off in a controlled study, one must question the conventional wisdom about the efficacy of antidepressant drugs. The newer selective serotonin reuptake inhibitors (SSRIs, such as Prozac, Paxil, and Zoloft) do not appear to fare much better (Antonuccio, 1995).

With active placebos, so that the patients and psychiatrists are not easily informed, the empirical data show that medication effect sizes are hard to distinguish from the placebo. Also not mentioned is that most antidepressant medications habituate, and the patients' symptoms return. Most patients believe they would feel even worse if they were not taking their medication (Karon & Teixeira, 1995).

[People] do not even know the rigorous data about medication. Everyone knows that it often takes years to provide evidence of safety and effectiveness and be approved by the Food and Drug Administration (FDA). But what is not known is that although these studies often have large number of participants, patients may have been given the medication for only short periods of time -- much shorter periods of time than in clinical practice. Prozac, for example, has been advertised as having been administered to either 11,000 or 6,000 patients in preapproval clinical trials. But in all the controlled preapproval trials there were only a total of 286 patients on Prozac, and the controlled trials lasted only six weeks (Breggin & Breggin, 1994). In all the preapproval data submitted, 86% of the patients received Prozac for less than three months. Only 63 patients out of thousands had taken the drug for two years or more -- the way it is used in clinical practice (Karon & Teixeira, 1995).

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So what does all this mean? I believe you should be aware of the following points... Keep in mind, however, that these points are made in general and do not necessarily pertain to your specific situation or depression. Some individuals, for instance, have tried many different forms of psychotherapy and have found little relief. Obviously their preferred modality of treatment will include some form of antidepressant medication. These are only general guidelines that should be discussed with your treatment providers; never make such important treatment decisions without first consulting them.

• Psychotherapy is the preferred treatment of choice for depression, regardless of the depression's severity or symptoms. Multiple meta-analyses have come to this conclusion, so it is not a conclusion based on just one lone case study or the like.

• Combined treatment of psychotherapy and medication should be your second choice, when choosing effective treatment options for depression. This is likely the most commonly-used treatment for depression today and there is absolutely nothing wrong with it. Never go against professional advice given with regards to your treatment, unless you have first discussed it with your treatment providers. Especially with depression, it is better to play it safe, than be sorry.

• Medication alone should be your last choice and only used as a last resort. Although you will likely gain some short-term relief of the most outward symptoms of your depression, studies have shown that medications don't work very well in the long-term.

• Always consult your physician or psychiatrist before beginning or stopping any medications. This article is not meant as advice to your specific situation, but as overall education.

• Opponents of the above who claim to cite "placebo control" studies as the gold standard of research are arguing from ignorance. There is no such gold standard in place in the social sciences and "placebo control, double-blind studies," as illustrated above, is often a hoax. Don't fall for it; be an educated consumer and patient.

• When opponents do cite "placebo controlled" studies, check to see if they know whether the outcome was determined by clinician-rated measures or patient-rated measures (or both). Obviously, it's nice if clinicians find significant changes in their patients' behaviors. However, it is vitally more important to you, as a person who may be suffering, to want treatment where you will feel better. Typical clinician-ratings used in psychiatric studies is the Hamilton rating scale, which is simply the clinician's subjective determination of your feelings. Look for studies that instead utilize patient-ratings, such as the Beck Depression Inventory or third-party reports (e.g.- family members).

• People who are taking psychotropic medications should better inform themselves as to the negative and adverse side effects of those medications. Ask your physician about these, or consult the insert for the medication (which you can also request from your doctor if you do not already have one). Also, drug handbooks found in many larger bookstores in the medical section might come in handy, as will the PDR. You might also benefit from a more thorough understanding of how political and un-scientific the drug approval process is in the United States by reading Breggin & Breggin's book, Talking back to Prozac (1994). I don't usually like Breggin or the positions he takes, but I found this to be a fascinating account of the FDA workings and the actual numbers used in the Prozac trials, obtained through the Freedom of Information Act. They scared me and they should scare you too.

     As Consumer Reports noted in their two articles, Pushing Drugs (Feb., 1992) and Miracle Drugs (March, 1992), physicians are actively marketed to by drug companies, given free gifts and vacations. That "professional" you think you're paying to receive the best and most thorough treatment available may be in the pocket of a pharmaceutical company; I have met many doctors who are. So don't be too surprised that when a new antidepressant medication is marketed (such as Serzone) that you suddenly see a whole host of psychiatrists prescribing it, not based upon the medical research, but because it's new.

     Wouldn't you rather have your treatment based upon long-standing and well-accepted research in the scientific community, that has been tested time and time again? Or something that was tested on perhaps no more than 60 other people in the entire country?? As an informed consumer, I imagine the answer becomes clear. Many psychiatrists are beholden to the pharmaceutical companies for their livelihood. You don't have to be for your treatment.

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Last reviewed:
  On 15 Sep 2002
  By John M. Grohol, Psy.D.