A recent review of the evidence by the American College of Physicians (ACP) determined that cognitive behavioral therapy and antidepressants had similar levels of effectiveness for the treatment of depression. In a critical commentary for the Journal of Mental Health, however, Michael Sugarman from Wayne State University challenges these findings. Pointing to differences in research settings and clinical practice, Sugarman asserts that “these head-to-head comparisons are heavily biased in the direction of psychiatric care.”
“Antidepressant therapy is only as effective as psychotherapy if patients can meet with a clinician on a regular basis, and as the recommendations note there are a number of adverse effects associated with antidepressants that can be avoided with psychotherapy,” Sugarman added in an interview with MIA.
The acceptance of the equivalency of these treatments is based on the assumption that the administration of antidepressants in clinical trials is consistent with real-world care. Sugarman argues that in order to extract as much data as possible, clinical trials actually provide a great deal of attention and care to participants. On average, a participant receiving an antidepressant in a trial will receive ten visits over a twelve week trial, and Sugarman argues that “this careful monitoring is actually a mechanism of improvement for patients with depression.”
Speaking with MIA, Sugarman explains how the divergence in care from trials to clinical practice can bias the research literature towards antidepressants:
“Providing these opportunities for interaction with study personnel and clinicians, visiting a medical environment, and discussing their symptoms and improvements all have beneficial effects, and contain many of the same core components of psychotherapy. This bears out in research too; in trials that contain more follow-up visits, patients in both antidepressant and placebo groups show greater clinical improvement over the course of the trial. Additionally, as readers of Mad In America likely know, the difference between antidepressants and placebos are small (only about 2 points on the Hamilton Rating Scale for Depression), and about 80% of the improvements in clinical trials are also seen in patients in the placebo group, likely due to many of the aforementioned factors.”
“The problem in translating these trials into clinical practice is that these components are rarely recognized as part of the mechanism by which patients show improvement. Rather, the medication is prioritized at the primary aspect of the treatment, and the relationship between clinician and patient and the provision of supportive attention are sacrificed. A lot of this may be due to the heavy caseload that physicians have, and they often do not have the time available to meet with patients on a regular basis like in the clinical trials. However, I view this as a violation of an appropriate translation from research to the clinic: Patients in clinical trials receive the joint benefit of the medication plus intense clinical monitoring, whereas patients in the real world often receive just the medication.”
“In contrast, psychotherapy research more closely mirrors what patients are likely to encounter in the real world. Patients are provided with one hour of therapy per week in an appropriate clinical setting and are able to develop a strong relationship with their clinician.”
The therapeutic setting combined with care and attention from a clinician contribute to the placebo components of treatment. “For patients,” he explains, “interacting with physicians and study personnel can be rich opportunities for social interactions and developing relationships, contrasting the isolation and relative lack of activity that can often accompany depression.” Sugarman also notes that although the ACP recommendations explicitly mention CBT as an equally effective treatment to antidepressants, other forms of psychotherapy are also useful. However, if a client has a particular preference for a specific type of therapy, they might receive a greater benefit if they can receive that intervention.
The commentary is available open-access from the Journal of Mental Health.
Read it in full here →
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Michael A. Sugarman (2016): Are antidepressants and psychotherapy equally effective in treating depression? A critical commentary, Journal of Mental Health, DOI: 10.3109/09638237.2016.1139071 (Full Text)
It’s bizarre how therapy is treated as if it were a pill. What I mean is that the comparisons assume that therapy is some reliable, consistent thing, always the same… where the skill and training of the therapist doesn’t matter and is not mentioned, where the weekly frequency of the treatment doesn’t matter… where the setting of the sessions doesn’t matter… etc. As if therapy sessions were being produced off an assembly line just like Zyprexa and Seroquel.
That ain’t how human relationships work baby. The frequency of the interaction, the skill of the therapist, the fit between therapist and client; these all powerfully interact to affect efficacy and outcome.
They should compare 2-3x a week psychotherapy over a long time period with long-term use of antidepressants, i.e. for 1 year or more. That would probably blow antidepressants out of the water. In fact the Tavistock already did one study of this kind, in which long-term psychoanalytic psychotherapy was far superior to treatment as usual including antidepressants. Here it is:
http://tavistockandportman.uk/about-us/research/current-research-projects/adult-depression-study-tads
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Good luck getting funding or psychodyanmic therapists interested in conducting the research.
A 14% depression recovery rate vs a 4% recovery rate isn’t that great considering the extreme cost difference. Also considering natural recovery rates of depressive symptoms this isn’t glowing for any kind of treatment. I know they were other benchmark outcomes that psychotherapy outperformed Treatment as Usual, but this is the big outcome and it doesn’t impress me. Follow-ups are more impressive, but time not in treatment is also good for depression in turns out.
The Fonagy study was therapy + Treatment as Usual (not including short term therapies) vs Treatment as Usual. They did not exclude medication use. Actually, the Long Term Psychoanalytic Therapy group had 21% of of folks on medication vs the control group who had 37% of participants on meds.
I didn’t do a thorough read of the whole article, but I didn’t see any documentation of negative effects or individual worsening. I wish these longterm studies, especially of analytic therapies, would include data of the people who did not get better or got worse.
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Nathan, don’t cherrypick.
You forgot this part, “44% of the patients who were given 18 months of weekly psychoanalytic psychotherapy no longer have major depressive disorder when followed up two years after therapy had ended; for those receiving the NHS treatments currently provided the figure was only 10%.”
That is impressive.
The 14 vs 4% figure is for having no depressive symptoms whatsoever. That’s rare; even many “normal” people have a low-level of depressive symptoms some of the time.
And quite a bit of psychotherapy research is going on outside of the USA in Finland, Germany, Italy, and England. You should check out research by Paul Knekt and Falk Leichsenring on long-term psychotherapy outcomes, the other Tavistock studies, Anthony Bateman/Fonagy’s other work on intensive psychotherapy for borderline and psychotic states, CBT for psychosis in Northern England, Open Dialogue initiatives in London run by Russell Razzaque… there’s a lot of good stuff out there if one knows where to look. Some people are having good luck with this research; try to be a little more positive…
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Interestingly, BPD, the therapies that WORK, the ones we grow out of and don’t need anymore are the ones very few can access. Effective, humane treatment is simply not accessible to most people. What is accessible is ineffective, long term addictive treatment, inhumane treatment, abusive treatment, and that which makes people worse or leads to iatrogenic damages such as chronic pain related problems, resulting trauma, and worsening depression.
Yes, we can change this. 1) Show we can live just fine without inhumane treatment. 2) Those who are caregivers refuse to use force in their practice 3) Define ourselves as who we are, not as diagnoses, and care for ourselves in a way that we choose. 4) Help and encourage those to do likewise, through legal advocacy, encouragement, and setting decent examples ourselves. 5) Continue to pass our stories along, so that our words will not die with us, but live on, and carry our message to the world that still suffers. Lest we not forget that we were once slaves. 6) Next year, Freedom.
I borrowed a bit of that from my own memories of the Passover Seder.
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I’m going to agree completely with BPD Transformation, and Julie Greene MFA. It helps ME to read your thoughts and words here. We ARE PART of an online community, and we help provide the support that we and others need.
As just one more example, – here in my own small town, which has been ravaged by the lies of the pseudo-science drug racket of psychiatry & “the “community mental health center” SCAM, – I have worked to develop a PERSONAL, and also a BUSINESS and PROFESSIONAL relationship with the local “Director” of the “Agency”. My friend has been the victim of an iatrogenic pharmacological disorder. After speaking with BOTH of these people, I was able to facilitate a 3-way meeting in a local coffee shop. With my help, my friend was able to speak HER TRUTH to HIS “power”, and the Director heard, and SAW for himself, how she is being HARMED by the quack shrink who has been grossly over-“medicating” her. Maybe the quacker will listen to her BOSS, and hopefully begin to reduce the chronic over-dosage, and resulting damage. My friend does SUFFER, DAILY, with both severe akathesia, and tardive dyskinesia. And, neither the Quack Docs, -OR- the nurses, will listen.
MAYBE they will listen, now. And, it isn’t really “therapy” that my friend and I share. But, I know each of our lives is better when we can get together regularly and chat over a coffee. She really does help me, too. ( Her actual “therapist” is simply awful! ) Thank-you for being on MY team, TOO, Julie, & BPD!…….~B.
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I haven’t been particularly impressed with Leichsenring’s work. Lots of issues in analysis and reporting, and making claims that data do not suggest. I’m not against psychotherapy or psychotherapy research, but I think we are naive to give it a pass not reporting on negative effects. The research just becomes the same as drug research, showing statistical effects for indicators that may not be all that meaningful and documenting or downplaying risk. We forget that the drug paradigm came after half a century of psychotherapy-based mental health care that did not have all that successful of a history.
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NOT documenting or downplaying risk.
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I’d like to comment, “Nathan” – first, I’m sure you’re aware that the great FRAUD, Siggy Freud, has been 100% deconstructed, and invalidated. He did way more harm than good. And, I’m not as familiar academically with the names you’ve named, as you seem to be, so that’s not where my comments are aimed….
Therapy is very “therapist-determined”. The success or failure has as much to do with client-therapist rapport, as which TYPE of therapy is offered. Where client & therapist just don’t “mesh”, it won’t matter the *type* of therapy offered.
And, a good “fit”, a good rapport, will produce good results from most any type of therapy. But, sadly, almost NONE of all this can be adequately reduced to anything that can statistic-alized, so to speak!…. So, about the best “Research” that can be done, will be some type or degree of psycho-babble, and gobbledygook…. And, I’ve found, that for me, helping others can be as much therapeutic as anything I’ve ever gotten from any therapist. And, psychiatrists are notoriously BAD at ‘RAPPORT…. I’ve never had a *GOOD* *ONE*….
Thanks!
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Nathan, while these statistics are interesting we should be careful not to reify psychotherapy too much. Each psychotherapist, relationship between therapist and client, setting for psychotherapy, length/frequency of psychotherapy is different… psychotherapy is a human-to-human relationship, and human relationships vary in an infinite number of ways and degrees.
Still, the simplistic concrete data we have in Leichsenring, Knekt, Duncan, Gottdiener, and other meta-analyses of psychotherapy, suggest that long-term human relationships usually are helpful, which is both obvious and better supported than the (mostly lacking) data on long term use of drugs.
I recommend you to check out The Heart and Soul of Change by Duncan if you haven’t. It’s pretty convincing in showing that 75-80% of people feel and function better with, rather than without, long-term psychotherapy. This effect size is pretty consistent across different types of therapies and lengths of therapies, increasing in accord with longer/more frequent treatment, as one would expect.
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First of all the pharmaceutical industry convinced the world that psychiatric drugs are the best available solution today for every mental health problem. Then, psychiatrists started cooperating with therapists.
This way they eliminated their potential competitors, and they took advantage of the benefits of therapy to cover the inefficiency of psychiatric drugs, since both are used at the same time.
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Me? I have been, apparently, permanently & totally STIGMATIZED, for life, so my
credibility is null & void. But my anecdotal evidence remains. I’ve had years of both good and bad “psychotherapy”, and years of mostly bad Rx drugs. The anti-depressants, the SSRI’s,
were a waste of time and money. At worst, they evoked the general topic of suicide in my passing thoughts. ( It was the tricyclic antidepressant “elavil”, combined with the major tranq/anti psychotic Trilafon, that drove me to the brink of actual suicide, but that was 30 years ago, now….)….
So, what’s my assessment of the “pills vs. talk” debate?
I’d rather have good therapy, from any good therapist, than have any psych drugs at all.
And if I had to have drugs with my therapy, I’d only want the placebos. They work the best.”
(c)2016, Tom Clancy, Jr., *NON-fiction
What a freakin’ JOKE this latest “study” truly is…..
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Wait! Look at what is assumed to be true here, but in fact, might not be. When I was a kid, depression, whether you might have thought of it as “just sad,” or, “to the point of thinking of suicide daily,” was never considered a disease. No matter how bad it was, and how much a person suffered, it still was not a disease. It was seen as something a person endured. By all means, we all hoped that the person would feel better. I recall speaking to others my age and telling them I was concerned. Did I desire to do hocus pocus to “fix” what I did not see as disorder? No! Nor did anyone, at that time. Human suffering is part of life. We are doing a person who suffers a disservice by calling suffering “illness” in the media, in mental health offices, and in our social circles. This only alienates the person, pressuring that person, now desigated sicko, to “get well soon.” If I feel depressed the last thing I am going to do is anything close to “Ask your doctor.” Why? I’m not sick! To me, this is common sense. God forbid, a doctor visit is far more expensive than cracking a few jokes and shaking up the ole brain cells.
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I clearly recall in the late 1980’s – early 1990’s, having discussions with my “therapist” at the local “community mental health center”, and the distinction between “endogenous”, and “exogenous” depression. Supposedly, the “endogenous” depression was caused by some mysterious inner voodoo, while the “exogenous” depression was supposedly caused by external factors & forces. But, funny, I don’t recall hearing such talk the last decade or 2…. Could we REALLY have been so naive, or were we bamboozled by the bull-O-ney….????…. I still say ALL so-called “mental illnesses” are almost as real as presents from Santa Claus….. And a shrink with a Rx-script is the Grinch gonna fix the light that won’t light on yur Christmas tree….but he’s gotta take it back to his workshop to fix it….. The human carnage that the pseudo-science LIES of psychiatry have wrought, should be seen as the genocide which they are….. What’s worse, is that however well-intentioned the whole “community mental health center” idea may have been, the REALITY is destruction of the very community cohesion which COULD HAVE been so much more helpful in the first place….without all the lies and drugs….. If psychiatry is such a valid “science”, then WHY has nobody ever done any follow-up studies, to assess long-term effectiveness….????…. To me, that omission alone disproves the claims of the quack shrinks….
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Do they mean real depression or just coming up positive for it on one of those questionnaires written by the pharmaceutical companies ?
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Well, I don’t about depression and analysis, but I know analytic therapy has the worst record of treatments for neuroses, none of the psychotherapies being as effective as no treatment- and I believe Hans Eysenck’s 1952 observations have been repeatedly verified over the decades..
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This is not true, “neuroses” – meaning less severe emotional problems in general – benefit significantly from therapy on average… see how 80% of people are better off with therapy than without in Barry Duncan’s book The Heart and Soul of Change… see the metaanalyses of psychotherapy effectiveness in Paul Knekt, Falk Leichsenring, and Jonathan Shedler’s work. Time to forgot about this outdated research from Eynsenck.
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Actually neuroses were decanonized in the last DSM, they were renamed personality disorders and no longer officially exist, right (it would seem that you would be the expert on this)?
Time to forget about all research into the “efficacy” of competing “treatments.”
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That’s funny, with each DSM, these diagnoses get a makeover faster than our various tech giants such as Microsoft come out with newfangled versions. Soon enough, patients will wake up each morning only to find a note by their beds, “Congratulations. You diagnosis was successfully updated to the latest version.”
Do we need to unhook, unplug, skip out on appointments, tune out, stop complying, and at least start questioning what we are told or getting a second opinion now and then? Or, how about this, ya’lls: When the time comes to die decades too young from everything psychiatry does or did, and St. Peter, while standing at the gate, does his role call, kindly do the following: When he calls out, “NEXT!” just don’t show up. And I’ll see you tomorrow instead. Love, Julie and Puzzle.
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LOL, just LOL, like >rotflmfao < ….must be Julie the MFA, and Puzzle the Pooch, right!?….
Thank-you for the happy laugh!
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No, neuroses were less serious problems like phobias, obsessions, compulsions, and the personality conflicts of people who experienced oedipal conflict (in the Freudian language) rather than pre-oedipal problems i.e. splitting and serious structural deficits of self-comforting capacity. Really, neuroses could stand for more mild experiences of depression, anxiety, conflict, etc. They are not the same as what is commonly meant by personality disorders; personality disorders are several degrees of magnitude more severe in the eyes of most psychiatrists who still think that way.
When I say personality disorders do not exist I mean that they are not discrete nor valid. But a continuum or spectrum of experience ranging from psychosis, through states of splitting and structural deficit of self-comforting ability (often labeled personality disorders), into less serious states of minor anxiety/depression, does exist… these emotional problems are real, they just aren’t illnesses.
I do not think this research is worthless, but it’s certainly too concretized and reified.
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I absolutely DO mostly agree with you, “BPD”, but there’s a minor point or 2 that I must comment on. I can’t give ANY real credibility or validity to ANYTHING “Freudian”. He was at best a short, mis-guided dead end. He was a cocaine addict, and wrote a book about cocaine, singing its’ praises. His “primal horde” theory was total hogwash. (If it *was*true*, none of us would be here – we’d have killed ourselves off eons ago….) His whole “oedipus/electra” nonsense was another wrong-headed fantasy, based on Greek mythology.
All those European and Jewish intellectuals loved that stuff.
But it’s bunk, and been totally debunked, and “deconstructed”, meaning it has been dissected and studied in great detail. NONE of it holds up in the light of current knowledge. And, our common understanding of the brain and CNS was much simpler back in Freud’s time. We didn’t have the understanding we do today. For a personal example, yeah, I *DID* wanna kill my Dad (but not REALLY!), when I was a teenage boy/man, but not so I could have sex with my Mother! No, rather, I “hated” him because sometimes when he got drunk, he beat the crap out of me, and he was pretty mean to me most of the time. He abused me verbally, mentally, psychologically, yes, and THAT is why I wanted to “kill” him. Not that I was homicidal, – NO!, again, it was more accurate to say “revenge fantasies”. THAT is what Sicko Siggy Freud twisted into his “Oedipus Complex” nonsense. Same with that “Electra” nonsense. Many of Feuds’ early female patients, um, I mean VICTIMS, were just that – they’d been molested, abused, or even raped, and it was the TRAUMA resulting from those crimes, that Freudio twisted into “hysteria”…. Much of what you *THINK* you “know” about Freud is garbage. Lies. Misunderstandings. Propaganda. And, yes, much of it is a Patriarcal /misogynistic / misanthropic delusion. Your thoughts….?________
I DO want to see more rigorous oversight and scrutiny of the research, so you know I’m on YOUR side here!….
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Ugh, Shedler’s manifesto. It was not research. It was a rallying cry tucked into a poorly defined systemic review of not very well designed studies…
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Don’t be afraid to agree with something Nathan! Rather than find the one little hole you can pick in whatever is said…
Shedler’s writing is pretty interesting IMO. CBT is a lot less well evidenced than is commonly thought.
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No, no no no no. We “need” treatment just as much as a diabetic “needs” insulin.
However, the goal of “diabetes management” is “self-management.” Most doctors and other caregivers are happy and proud when a diabetic patient decides to take things into his/her own hands and quit smoking, join a gym, eat healthy, or take up yoga. Doctors are happy to see patients taking initiative to lower sugar on their own, and reduce the frequency of lab checks and ER visits.
Not so for the mental patient. Should a mental patient decide to try fish oil, he/she is “self-medicating,” possibly engaging in “risk-taking behavior” since he didn’t consult his doctor. He is no longer considered a competent decision-maker.
When I decided to take up running as a possible way to take better pride in my body and help myself see food as fuel instead of fearing it as my enemy that would make me fat, and found that I was making immense progress, I was immediately knocked down by my “therapist.” I know now she depended on keeping me weak and needy. She insisted that I was “self-harming” by “overexercising.” To make her extra furious, I went out and ran my first 5k. That was December 19, 2010. My therpist was so, so mad. She insisted I go to the psych ER on the 1st of January, for a broken tooth. That was a rather long and costly ordeal, I must say, in the name of “therapy.”
PS: I don’t run that fast, but in my heart, I won that race. The next one’s gonna be a 10k. Just for her…Naw, in spite of her. For you all’s.
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I hear a placebo is good for anything that ails you.
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Frank, Puzzle is not fooled by placebo bones. A photo of a bone tastes like photo paper and ink to her.
Somehow, there’s a bit more wisdom in the above statement than I bargained for. Maybe Puzzle should have told me that some 30 years ago. “Puzzle, why didn’t you wake me up sooner! Drat! How long have I been asleep!”
Bradford, other patients kept telling me that 20 therapists wasn’t enough. The 21st would come along, they said, and that one would be the right one.
The Right One? The very best therapist for you is you. Guaranteed. Why? You are the #1 expert on YOU. Hmm…So my guess is that none of us will have a lengthy commute.
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I hear you, Julie Greene! Loud and clear! My BEST “therapists” have been my best friends. And, some of my WORST ENEMIES have had Masters Degrees, and PhD’s, and even MD degrees. But the most dangerous one, I mean the MOST DANGEROUS ONES, were the quack shrink pseudo-science drug racket “psychiatrists” They LITERALLY KILLED some of my friends, and darn near killed me, too….
The LIES of psychiatry have done, and continue to do, far more harm than good. And, sadly, it’s the same, if not worse, than it was 20, 30, 40 years ago…. Back then, you were generally at least in high school before they got their hooks, and claws, and DRUGS in you…. Nowadays, they’re hooking elementary school kids on *SPEED*, aka “Ritalin / Adderal”. And, yes, some of these sickos are seriously discussing “diagnosing” and *DRUGGING* *FETUSES*…. God, I wish I was making this stuff up….. *SOME* psychiatrists are as bad as any Nazi Death Camp doctor, etc. ( Yes, there are a few good ones, but they are too little, too late…. If it were within my power, I would force ALL shrinks to renounce their evil ways, and repent. Um, at the risk of sounding like some loony-tunes Bible-thumper….!) The general, mass-media-brainwashed public just doesn’t get the message….
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