Psychotherapy Has an Enduring Effect on Depression—in Contrast to Depression Pills

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A network meta-analysis published last month in World Psychiatry showed that psychotherapy has an enduring effect on depression—in contrast to depression pills.

This is an important meta-analysis. The authors included 81 randomised trials, with 13,722 participants. Sustained response was defined as responding to the acute treatment and subsequently having no depressive relapse through the maintenance phase (range 24-104 weeks). The authors extracted the data reported at the time point closest to 12 months. Psychotherapy, and the combination of psychotherapy and depression pills, were better than depression pills alone, and better than “standard treatment,” with risk differences ranging from 12 to 16 percentage points.

closeup photo of two people's hands; one holding a pill bottle and one making a questioning gesture

Unfortunately, the authors, several of whom are psychiatrists, draw a number of highly misleading conclusions. They seem to be trying to defend the indefensible prevailing belief among psychiatrists that depression pills are good for people. As an example, they imply that a combination of pills and psychotherapy has merit, despite their finding that pills do not add anything to the effect of psychotherapy. Moreover, pills expose the patients to serious harms that can be fatal, which they do not mention.

There are many reasons why we would expect psychotherapy to be considerably better than depression pills in the long run.

First, this is what other meta-analyses have shown.

Second, depression pills do not have any clinically relevant effect on depression. The difference between the pills and placebo is about 2 points on the 52-point Hamilton Depression Rating Scale, but the minimal clinically relevant effect on this scale is 5-6 points (7-8 points in more conservative analyses, and in a graph in the original article). This means that neither clinicians nor patients can tell the difference between the improvement on pills versus placebo.

In the Discussion section, the authors write that their “findings suggest that adding pharmacotherapies does not interfere with the enduring effects of psychotherapies. The combination therapies followed by discretionary treatment were as effective as the corresponding psychotherapies (OR=1.08, 95% CI: 0.74-1.56).”

It is misleading to say that adding pills (an ineffective treatment) did not impede the enduring effect of psychotherapy. The authors reveal their bias by saying that the combination was “as effective” as psychotherapy. They should have said that adding a pill was ineffective!

Third, depression pills change brain functions and bring the patient to an unknown territory where the patient has not been before. This is problematic because you cannot go from a chemically induced new condition back to normal unless you taper off the drugs, and even then, it will not always be possible, as you might have developed irreversible brain damage. In contrast, the aim of psychological treatments is to change a brain that is not functioning well back towards a more normal state.

Already the Introduction contains an inexcusable blunder. The authors write that, for patients in remission, it is well documented that continuing pharmacotherapies can reduce the depressive relapse rate in the maintenance phase. This has not been “well documented.” It has been known for many years that the so-called maintenance studies, which they cite, are fatally flawed because many of the patients switched to placebo suffer from withdrawal effects, which can last for months or even years.

Many patients in the “placebo” group, which is actually a drug-withdrawn group, will develop an abstinence depression. In a study where patients who had been in remission for 4-24 months had their maintenance therapy changed to placebo for 5-8 days at a time unknown to the patients and clinicians, the three most common withdrawal symptoms were worsened mood, irritability, and agitation, and 25 of 122 patients on sertraline or paroxetine fulfilled the authors’ criteria for depression. In contrast, not a single patient of 122 would be expected to become depressed during 5-8 random days after psychotherapy.

The authors mention in the Results section that, “In terms of all-cause discontinuation, all the treatments appeared more acceptable than pill placebo.”

This is not correct for depression pills, and it illustrates that their network meta-analysis, which was based on published trial reports, was biased in favour of pills. One of the authors is psychiatrist Andrea Cipriani, who was first author on a totally flawed network meta-analysis that compared different depression pills. I called my criticism of this paper, “Rewarding the companies that cheated the most in antidepressant trials.”

Other researchers showed, based on the trials Cipriani et al. had included, that the effect size of depression pills was higher in published trials compared with unpublished trials (p<0.0001). They also demonstrated that the drug withdrawal design is flawed (the effect size was larger in trials with a “placebo run-in” than in trials without (p=0.05). Finally, they showed that the outcome data reported by Cipriani et al. differed from the clinical study reports in 12 (63%) of 19 trials.

When my research group studied all-cause discontinuation, we did not use a single published trial report, but only clinical study reports we had obtained from the European and UK medical agencies. It was huge work to study drop-outs in the placebo-controlled trials. We included 71 clinical study reports, which had information on 73 trials and 18,426 patients. We found that 12% more patients dropped out while on drug than while on placebo (p<0.00001).

This is a terribly important result. The psychiatrists’ view is that depression pills do more good than harm, but the patients’ view is the opposite. The patients preferred placebo even though some of them were harmed by cold turkey effects. That means that the drugs are even worse than found in the trials.

Because we had access to detailed data, we could include patients in our analyses that the investigators had excluded, e.g. because some measurements had not been made. Our result is unique and reliable, in contrast to previous reviews using mostly published data. For example, a previous large review of 40 trials (6391 patients) reported that dropouts were the same (relative risk 0.99) when paroxetine was compared with placebo.

The Discussion section also reveals the authors’ bias towards drug therapy. They write that, “Rare but critical events such as suicidality, and more common yet subtle downsides such as withdrawal symptoms from antidepressants should be more systematically measured and reported to appropriately inform our treatment choices.”

No more data are needed to “appropriately inform our treatment choices.” The simple, but for psychiatrists, uncomfortable truth is that depression pills should not be used for anyone. Depression pills double the risk of suicide in children, adolescents, and adults, whereas psychotherapy halves future suicide attempts in people admitted after a suicide attempt. The authors should have concluded that patients with depression should be treated with psychotherapy and not with pills.

Under Conclusions, the authors write: “Initiating the treatment of a major depressive episode with combination therapies or psychotherapies alone may lead to 12-16% increments in rates of sustained response at one year, relative to protocolized pharmacotherapies or standard treatment in primary or secondary care.”

This statement is also misleading. The authors should have said that it does not help the patients to add a depression pill to psychotherapy but exposes them to unnecessary harm, which can be fatal, and involves many other effects, e.g. sexual disturbances in half of those treated, which can become permanent and persist after the drug has been stopped.

The authors also conclude that, “Combining psychotherapies with pharmacotherapies has an edge in terms of sustained response but has risks of side effects and potential withdrawal symptoms. Such combinations may be reserved for those who value faster relief or who may be deemed difficult to treat.”

This is pure nonsense and wishful thinking, which is in direct contradiction of the most reliable evidence we have. First, the combination does not have any “edge in terms of sustained response.” Second, pills that have no relevant clinical effect cannot provide “faster relief” than if the patients do not get them. Third, they cannot be useful for those who are “deemed difficult to treat.” And why should patients who are already suffering the most be subjected to even more suffering? The authors are paying lip service to a failed psychiatric paradigm, while they suggest to their colleagues to harm their patients.

On one of the first pages in my most recent book about psychiatry, I warn the patients: “If you have a mental health issue, don’t see a psychiatrist. It is too dangerous and might turn out to be the biggest error you made in your entire life.” The current network meta-analysis provides support to my warning.

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Mad in America hosts blogs by a diverse group of writers. These posts are designed to serve as a public forum for a discussion—broadly speaking—of psychiatry and its treatments. The opinions expressed are the writers’ own.

18 COMMENTS

  1. When people are sad, they just need someone to listen to them and respect their needs. They don’t need pills. They don’t need alcohol. They don’t need ect or other elaborate letter initialed initiated therapies. People need gentle guidance so they can figure out why they are sad. Sometimes, it is really just a physical issue, so psychiatric pills can really mess that up. There are as many reasons to for a person to be sad as there are people on Earth. Discovering why you are sad can be a learning experience and the answer as to how to stop the sadness could be life-changing. Psychiatric pills and other psychologically based therapies just short-circuit the path to truth. And, what they don’t tell you is that after the drugs and the gas-lighting therapies, etc. you are left with working to try to put back all the pieces of who and what you are so you can be healed and restored. Psychiatry, etc. doesn’t heal you. It nearly destroys you. Thank you.

    • How on this earth did we ever reach the point where anyone can walk into a psychiatrist’s or primary care doctor’s office, complain about nothing more than feeling a little down, and come away with a prescription for a powerful brain-altering drug that not only doesn’t really work but likely will do harm? Where the doctor (who has no idea what the drug actually does) likely won’t monitor your response to the drug, and likely will dismiss your complaints of ill effects, and likely will give you wrong advice when you want to get off it? Was it all money that brought us to this point?

  2. A great read!

    I fully agree with all of it.

    I feel an interesting inquiry would be to ask “why” popping a pill is so sexy. If we do not explore why that may be the case then we miss out on vital learnings about humans that we may need to know.
    I will have a pub quiz guess here and now that it taps into a spiritual yearning for magical thinking to be a “go to” treatment choice. A human need for “the miracle”. Humans have been looking for that since the discovery of body paints. A shamanistic or holy treatment by waving a wand. It is why humans were complicit in exalting the merchants of psychiatry. A binary codependency. But it may spring up in the new paradigm. Maybe in a wish for a super magical new kind of psychotherapy. On the one hand the new paradigm could go with the innate flow of that almost ancestral human need for the simple quick fix, perhaps by bringing in more spirituality, to feed the “miracle yearning”, but the new paradigm must be aware of doing so intentionally and not get swept up in the same priestly fervour psychiatry did.

    I suppose though the human does not just have a need to believe in miracle cures but can rely on other healings, slower more plodding healings that take years. Often such therapy relationships are about mutually grieving the limits of magical thinking. And that mutual shared recognition becomes a kind of “love”. Whose peace passeth all understanding.

    • I think it helps people to avoid dealing with real but semi-conscious conflicts that are really at the root of feeling hopeless about life in many cases. Certainly was true for me! It’s a lot of work to re-think one’s view of life and one’s habitual behavior. It’s easier to blame it on the brain and take the pill. At least in the short run. Especially if someone in authority is doing the hard sell on it. I did not WANT to get therapy – I NEEDED to, but it took two other people dragging me kicking and screaming to get it started. Very glad I did.

      Of course, a lot of “therapists” these days don’t do what I consider therapy. Many seem to use a forced and very shallow form of “cognitive behavioral therapy” and aren’t interested in childhood trauma or internal conflicts. I was very fortunate in getting a good one on the first shot, but it still wasn’t any fun, and I felt like quitting partway through. A pill would have been a LOT easier, but of course would never have been a tenth as beneficial in the long run.

  3. Peter, I appreciate your no nonsense, no bullshit, no mincing words, blogs.
    A few reading your blogs will definitely make a difference in their or others lives.

    Will some people be forever sad? Will some have bad lives? Of course, but NOT because they stayed away from psychiatry.

    Psychiatry and much of their minnions could care less about people’s quality of life, it is about saving their own skin and income.

    Psychiatry itself sees the mess they make each and every day, yet why would they then continue doing what doesn’t work?
    Why would they heap more suffering on those who suffer and then blame it on their “mental illness”?

    And it is why it is super important to get the loud voices out there. Warnings born from wisdom and knowledge. I do not know the solution to each and every person’s woes, I DO KNOW, it’s not psychiatry.

    Psychiatry is in the business for itself.

    • I agree with yoy, sam plover about psychiatry. It is NOT the answer. Psychiatry obscures all truth with the drugs, the therapies, the many treatments, etc. It is all “FAKE!” Today is Thanksgiving. If you can not afford therapy or the drugs or for whatever reason, can not have exposure to therapy or drugs, etc. be thankful. And, if any celebrity wants to call themselves some psych diagnosis or launch some mental health platform, who cares. I think the one thing that being away from “psych world” has taught me is that each one of us is on our unique journey through life. And, yes, we, as humans do need each other to stay healthy, etc. each one of us must confront our little demons “alone”. Even when we ask another for assistance, we must rely on that “inner voice” to see if it rings true for us. Psychiatry, with its drugs and therapies, steers us away from reliance on that “inner voice.” The New Age lies to us and tells us to rely on that “inner voice” and then takes it away from us in their little gaslighting dance. There are many who say that “inner voice” comes from God and is our connection to Him. I tend to agree. When you begin to rely on that “inner voice” you find yourself no longer a zombie, no longer sleep-walking through life. Then you realize what is important is what you think, not some psychiatrist, therapist, celebrity, mass media person, governmental official, etc. And you become like the poet says, “master of your own ship.” And you crave seafood, too. Thank you.

  4. Thank you all. Please all keep working and writing to tear down the beast of psychiatry.

    I can’t risk therapy to help me deal with mental torture because of my story, ironically involving criminal violations of the mental health code. Plus I don’t have the resources to look for a therapist I could relate to.

    Meanwhile a pop star/actress announced plans to further confuse:

    https://www.usnews.com/news/health-news/articles/2021-11-23/singer-selena-gomez-to-launch-mental-health-platform

    Selena Gomez: “I went to one of the best mental hospitals in America, McLean Hospital, and I discussed that after years of going through a lot of different things, I realized that I was bipolar,” Gomez said. “And so when I got to know more information, it actually helps me. It doesn’t scare me once I know it.”

    Bi polar is an awful thing to call a person, especially one’s self.

    Sounds like the result of a magician sawing a woman in half.

    • Glad to see you spreading some consciousness about these so-called “role model” celebrities who allow their unresolved confusion to be exploited by the psych industry, becoming mascots for mystification and self-effacement. Demi Lovato is another one, and the list goes on. Let’s hope Britney doesn’t get pulled into this — hopefully after what she’s experienced she realizes that psychiatry is a tool of physical and mental control, and nothing more.

      The psychiatrized need to send a message to these people that they don’t represent us and their self-indulgent corporate sponsored publicity campaigns on behalf of psychiatry and big pharm are counterproductive.

  5. “On one of the first pages in my most recent book about psychiatry, I warn the patients: “If you have a mental health issue, don’t see a psychiatrist. It is too dangerous and might turn out to be the biggest error you made in your entire life.” The current network meta-analysis provides support to my warning.” Peter C. Gøtzsche, MD

    Excellent! Thanks!

    I doubt my library has your books, but I’ll check.

    Why not write an open public letter to Selena Gomez about what she should realize about psychiatry, that she may NOT have been told at McLean, read about or realize, as she launches her media platform about mental health?

  6. Privately, many people want to be a brain in a jar. Its like people want to be the docile fed up elephant in the room. When the world is too much people slope off to hide under a quilt in their bed specifically to be a brain in a jar wrapped in a feathery cocoon. And people take a pill to stop their bodies jangling intolerably with anxiety. They cosh their bodies all sedate. They become disembodied. They want the bliss of the quiet jar. It is a liddable womb metaphor. A glass womb for storing and protecting the distressed psyche so it feels no more abject misery. Pills offer to do that magician’s trick. They tip a person’s brain into a bottle. People all sit at computers to become zoned out lit up brains in jars. They meditate to become cloudy brains in jars. They take street drugs to fall on floors and be brain in jar existers. No animal does this. No animal does not have a brain be its whole body. I imagine you cannot squash an animal in a jar without sustaining claw marks. The human is unable to belong to its long suffering body. But the body that used to be part of the human brain can no longer feed the brain what it needs, the cold press of veg patch soil, the snow crystal spiking through a hole in the shoe, a billow of sun warmth on the nape of the neck, a breeze whickering the jacket. The nervous system is like an enormous wig. Its tendrils weave right to the tips of the toes. The whole person is raw delicate supersensitive brain. The whole person cannot be squashed in a jar without there being no life whatsoever. The body needs to work in concert with the environment, not just for the brain but for the good of the environment or the environment becomes its own kind of brain in a jar, separated from its children, its nerves, its peripheries…..Us.

  7. Just to add to my phones comment..
    if you are looking for the delayed onset strobe hallucination it is very ephemeral to try to spot. You almost have to relax your eyes until you feel your vision semi-glaze over. Or it is also like trying to spot floaters inside the gel of your eyes. Being as the hallucination is emanating from your brain’s vision don’t so much try to see the flashing chequer or grid or mosaic on the wall as if it is really on the wall or you will miss it through staring too hard. It is more like the soft dapples of light that a sunlit bowl of water reflects on a ceiling, those almost smoky watery lights. Flickering at a stunning rate. Try to look for it like you look to see smoke in a room yet knowing it is sort of inside your eyes. It is as if you are wearing glasses with mottles of pale yellow light. It is not so much that you want to see the yellow splots but more the shadowy flicker going whop whop whop whop whop really fast. Perhaps try to see it after using the phone for maybe two or three hours all week. But even if you dont see visuals, and no they are not migrane effects, the main point is the fatigue and hyper see saw that occurs many hours later… that is the concern.
    A phone is now doing the job “a person” in your community used to do.
    A person used to be our smartphone.
    Just like a psych pill solution used to be “a person” in your community.

    A person used to do everything our phones do and be our comfort and shoulder to cry on.

  8. Thank you, Peter, for your warranted righteous indignation, and honest truth telling. It’s so very much needed.

    Although I will say – at least in the US, and based upon my personal experience – most psychologists, social workers, and other DSM “bible” billers do seem to function as tentacles of, and “partners” with, the psychiatrists.

  9. seems pretty clear that the entire industry does almost nothing to help and causes much harm – over inflated claims on all sides are a constant. We don’t need psychotherapy but for more of our needs to be met by working to create cultures of wellbeing where real mutually supportive relationships have more a chance of being made.

    • Good way of putting it.

      A major flaw in this “psychotherapy vs. drugs” debate is the idea that it has to be one or the other, also that “psychotherapy” is a constant, when in fact it varies from one “professional” to the next. One person’s psychotherapy is another’s poison.

      Another flaw is assuming that a true solution exists or can exist under the existing political/economic apparatus. This runs counter to the narrative of experts having everything under control, and all socio-political issues being medical ones.

      • Actually, there really is no debate. You can not have one without the other no matter what they claim. And they each feed on each other like parasites on a dying animal. And, yes, unless you say no to them, they will kill you and not look back with any remorse. It is us who must be careful not to look back or we will be turned to stone. And then who wins. As they say, the devil is in the details. Thank you.

  10. Regarding comments I have often seen in my venturing.

    The word FAKE sometimes comes up.

    Yeah like climate change is FAKE and acidification of the ocean is FAKE and methane meltdown in Siberia is FAKE and people who expire from cytokine storms in Covid in Intensive Care are FAKE and deforestation is FAKE and acid rain is FAKE and sea level rise is FAKE and extinction of polar bears is FAKE and extinction of White Rhinos is FAKE and the decimation of the world’s honey bees is FAKE and the melting of the polar ice caps is FAKE and like everyone who used to say they felt traumatized were horrifically deemed to be coming up with FAKE symptoms and how women who were battered and raped were told their experience was FAKE.

    Anyones experience of their own genuine illness is not FAKE.

    One illness translated in twenty different countries will be given twenty different names. None of those twenty names are THE SAME for each of those countries. And each individual may choose for THEMSELVES what they prefer to call their own illness. There is NO justification for calling something like global warming FAKE anymore. And there is NO justification for ever implying that other people’s choice of what to call their own experience of their own illness is FAKE. An indiginous tribal person will have a totally different name and understanding of what a mental illness is, from say someone in Greece or Botswanna or Alaska or Nepal.
    FAKE is a juvenile word in my opinion. It is lazy. It is a word that does not permit any scientific openness to doubt.

    Not everything that comes out of psychiatry has no credibility. Altzheimers is REAL. Post partum hormone psychosis storms are REAL. LSD brain disruption to the point of lasting psychosis is REAL. Anorexia nervosa is REAL. Catatonic statue psychosis is REAL. Amnesiac fugue is REAL. I KNOW my schizophrenia is a REAL illness. If I call it any other name it is still a REAL illness. So it does not matter which name I call it or get bullied into rebranding it, it is still my same REAL illness. I do not care one jot that the exact cause has not been definitely found. Those who live with chronic pain of unknown cause do not get told their pain is FAKE.

    Lets all play a game of saying my schizophrenia is trauma but it is such a whopper of a trauma I cannot get my head around the idea it is trauma (kind of patronizing to assume greater knowledge of me than I do, kind of a bit like how experts used to muffle the actually traumatized by patronizingly telling them they were not traumatized, ie flip sides of the same “its just FAKE coin”)…I digress…lets say I am so biffed by trauma I cannot tie my shoe laces and I hear voices all day and it makes me feel ill enough to die, and lets say it is just trauma…but lets say I DO NOT WANT to call it trauma, since in my traumatized state I can barely bare to eat. Lets say I WANT to call what I have schizophrenia and I get really upset and ill and crucified when someone tells me its trauma.
    I ask this now…Is it not disrespectful to the traumatized who think they are schizophrenic to muscle in on their brokenness and try to fix them in an experts way, in ANOTHER persons way, just because the other person thinks their way is the best way?
    If it is their traumatized choice to cheerfully keeping calling their illness schizophrenia is it not honouring and respecting the deep depth of their shatterment to LEAVE THEM ALONE to happily call their illness what the heck they feel like calling it? Is that not what trauma focused care IS for, allowing the traumatized to lead the way in their own choices? Even if that choice does not agree with anyone else? Even if that choice they make is to see their illness as coming from a martian’s diamond tipped umbrella? If it makes the traumatized happy to call themselves autistic or bipolar or schizophrenic then who is ANY other expert to pontificate on what is “for their own good”. The ideology of “for their own good” comes from the wish to control. That in itself is behind most traumas.

    This “my way is the best way” is how psychiatry used to be about trauma. It was condescending and patronizing to do so then. Being condescending and patronizing is when ANY person tells another human being that their illness and their preferred understanding of their illness and their name of their illness and their preferred choice of treatment and their preferred treatment ideology, be it religious or spiritual or medical or therapeutic or social or political or shamanistic or herbal or nutritional or psychiatric or psychological or musical or gender or mystical or ANY other preferred treatment is FAKE.

    As a word the word FAKE is best left to the mink coats of the pettiness of Parisian catwalks. As a word it is all accusation and no solution and no reconciliation and no future vision. It is intrinsically invasive.

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