Psychotherapy Without Antidepressants Shows Best Results for Depression

New study finds psychotherapy alone to be the best first-line intervention option to mitigate the risk of suicide attempts and other serious psychiatric adverse events.

26
26072

Psychotherapy without antidepressants is the best treatment for depression, according to a new study. According to the researchers, psychotherapy alone beats antidepressants alone, but it also beats combination therapy (drugs plus therapy) for people with depression. Harvard researcher Nur Hani Zainal published this new analysis in Psychological Medicine.

“The present meta-analysis consistently found that psychotherapy monotherapy had stronger aggregate effects than combined treatment and ADM-only in decreasing the probability of suicide attempt, psychiatric ED visit, psychiatric hospitalization, and/or suicide death for MDD patients,” Zainal writes.

The finding contradicts conventional wisdom, which claims that combining antidepressants (ADMs) with psychotherapy is the most effective treatment for people with depression (MDD).

You've landed on a MIA journalism article that is funded by MIA supporters. To read the full article, sign up as a MIA Supporter. All active donors get full access to all MIA content, and free passes to all Mad in America events.

Current MIA supporters can log in below.(If you can't afford to support MIA in this way, email us at [email protected] and we will provide you with access to all donor-supported content.)

Donate

26 COMMENTS

  1. In response to this article, I would refer the MIA reader to the excellent book by Jeffrey Masson, “Against Therapy: The Myth of Emotional Healing.” Depression and the many other patterns of behavior and thinking arbitrarily categorized as sick, pathological, dysfunctional, and disturbed by the mental health industry cannot be “treated” in a literal sense unless they stem from demonstrable physical causes. Otherwise, we are operating in the realm of metaphor, not medicine or science.
    Without the bogus categories listed in the pseudo-scientific compendium of billing codes known as the DSM, what gives so-called mental health professionals the authority and legitimacy to diagnose emotionally distressed individuals and practice their widely disparate forms of therapy? Not to mention the power imbalance and humiliating labels inherent in the therapist-patient relationship.

    Report comment

    • While I agree that labels are in great part arbitrary and based on social norms, your description of therapy is rather simplistic.

      For one, many therapists don’t work from a medical model perspective, which means they don’t diagnose per se, or if they do for insurance purposes, they don’t base any treatment on labels. Second, power imbalances depend heavily on the approach. I’ve only worked with people collaboratively in every therapy experience I had. When a therapist wanted to claim to be a better expert in my life than I was, I simply fired them and found a better fit.

      I’m also not sure why you imply the existence of different therapy modalities is negative or takes credibility away from the profession. Do medical doctors use only one treatment or cure for all conditions or situations? Then why should other health professionals dealing with something much more complex use some standard procedure? Should they ignore individual differences and contexts?

      I don’t know how you define “treatment”, but if a person is so emotionally distressed that they can’t sleep, eat, take care of their kids, protect themselves from danger, or are wanting to commit suicide, I think any reasonable person understands they need and often badly want help. This certainly doesn’t only apply to those with clear physical causes.

      Report comment

      • To Blue:
        You have called my critique of the mental health industry “simplistic.” Let me point out certain elementary facts.
        Actually, the gist of this entire debate over the legitimacy of so-called psychotherapy IS quite simple and straightforward. Genuine science and medicine should be based on rigorous scientific methodology, which consists of careful, long-term experimentation, testing, and VERIFIABLE findings. If these criteria are ignored, distorted, or deliberately suppressed, we are not dealing with true science or medicine, but a set of hypotheses and groundless speculations, which are often colored by the particular theorist’s cultural, racist, and sexist prejudices (e.g. Jung’s notion that the “Aryan” and Jewish collective unconscious is fundamentally different; Freud’s half-baked theory of female “penis envy”; the widespread support among American psychiatrists for eugenics and sterilization in the first half of the twentieth century; and the Soviet psychiatric establishment’s diagnosis of political dissent as a form of schizophrenia, to cite just a few random examples that come to mind).
        Second, you claim that “many” therapists don’t employ the medical model in their practice. Can you be a little more specific: exactly how many? From what I have read (including the testimony of numerous contributors to this website), the predominant paradigm continues to be the debunked theory of a chemical imbalance or its latest unproven successor, faulty brain circuits. This pernicious paradigm provides the rationale for the pervasive drugging of underage children in order to adapt them to a stultifying educational system. Here, as elsewhere, fallacious premises can have disastrous emotional and physical consequences.
        Furthermore, you seem to complacently accept the fact that even when mental health professionals don’t diagnose their clients, they still use the sham categories of the DSM for insurance billing purposes. You may find this conduct unobjectionable, but to me it’s complicity in fraud and contributes to the perpetuation of what Thomas Szasz rightly calls “the science of lies.”
        Furthermore, you mistakenly conflate the medical profession with the mental health industry. The efficacy and advisability of genuine medical treatments can be determined by demonstrable criteria, as I pointed out above; apart from a relatively small number of neurological conditions such as dementia, none of the hundreds of supposed disorders listed in the DSM were discovered in laboratories, but were concocted by panels of would-be experts whose financial ties to pharmaceutical companies and ECT device manufacturers certainly give rise to legitimate concerns about their basic integrity and competence. Dr. Peter Gotzsche, among others, has shed light on this ethical problem in his many articles for the MIA readership.
        As for your claim that “any reasonable person” will recognize that people in severe emotional distress may badly need the assistance of a professional, I don’t believe that I, you, or anyone else should arrogate to himself the authority to determine what another individual may need in his or her life. If somebody does wish to reach out for help in a particular situation, the best option would be a non-judgmental, non-hierarchical support group of intelligent peers, not a self-styled “professional” working in a field rife with conflicts of interest, dubious constantly debunked hypotheses, and a long track record of emotional and physical harm inflicted upon its victims.

        Report comment

    • I forgot to address one point raised by Blue’s response to me: the matter of power imbalance in the therapist-patient relationship.
      Blue says that he/she is able to determine when this relationship oversteps its proper boundaries and becomes oppressive or otherwise objectionable. I commend him/her for this insight and strength of character.
      The unfortunate fact remains, however, that more often than not patients undergoing some type of treatment (whether it be talk therapy, administration of neurotoxins, ETC, or other modality) are unduly impressed and persuaded by the “credentials” of their supposed mental health professional, who may in fact have ties to a pharmaceutical company (take the notorious case of Dr. Joseph Lieberman of Harvard, who received millions of dollars from Johnson & Johnson to promote its products). The average person tends to defer to the authority of those garbed in white lab coats who have framed diplomas on their walls. This unquestioning obedience to authority is what leads millions of well-meaning parents, for example, to consent to the drugging of their children with harmful neurotoxins. I know of two such cases among my own acquaintances.
      So I will summarize my argument with the question I have repeatedly posed: If the DSM, which is reputed to be the authoritative guide to the diagnosis and treatment of hundreds of mental disorders, has no universally applicable, scientifically verifiable criteria for proving the superior efficacy of one or another of its ever-changing hypotheses, what can be the basis for the legitimacy of any of the modalities it advocates? I am old enough to remember a time when intensive Freudian psychoanalysis over a period of many years was considered the gold standard of talk therapy; then Primal Therapy became the rage during the 1970s and 1980s; now the latest fad seems to be CBT. In the absence of any scientifically valid criteria, I see no reason whatsoever why these or any other treatments deserve credence.

      Report comment

  2. Ugh. Talking to someone without the use of brain damaging chemicals is better than talking to someone while on such chemicals or just using the chemicals. And this is measured on the scales used by the guilds that created the labels in the first place.

    How about universal basic income as a treatment for every psych label ever? Or perhaps using all the money spent on psych interventions to stock food banks and provide real medical care?

    Report comment

    • I think that you’re spot on but putting an entire industry under the gun is bound to get nuclear level blowback. There’s too much money at stake in the pharmaceutical industry, the entire workforce of mostly pink collar track do gooders, the benefit managers and the rest of the insurance industry. Then those in academia who are selling graduate education training the counselors, and social workers who are working without there being any actual resources for those people without hope. Nurse case managers acting as gatekeepers and selling the psychiatric miracle of medical intervention have jobs that are also in jeopardy. There’s an entire cottage industry created by the stress of income disparity for the social construct of poverty. Once the stressors of hunger, homelessness, lack of medical care, or parenting without resources can be mitigated with UBI, daily living becomes less of a struggle, and the emotional responses are far less extreme and debilitating, and money is freed up for brain research into the very real mental disorders that affect a small percentage of the population. Then the focus can be treatment and care. The profitable industry built around societal blaming of the individual for their unique despair over the disadvantages of poverty and offering no helpful resources to change that circumstance is an idiotic job creation scam.

      Report comment

  3. The free blurb offered to non-paying readers is misleading even in light of the study abstract. The study results indicated benefit of therapy alone over antidepressants and combined modalities only in children and teens, whereas adults were found to benefit most from combined therapy. Let’s not get sloppy and unscientific here ok?

    Report comment

    • Hi Matt, thanks for your thoughtful questions.

      I would encourage you to read our entire article. This is a quote from Zainal’s piece: “On average, psychotherapies, especially those that integrate cognitive-behavioral and related theories, appear to be the best first-line intervention option to mitigate the risk of suicide attempts and other serious psychiatric adverse events in depressed youth and adult populations.” Again, the researcher says: psychotherapies are the best first-line option in youth AND adult populations.

      In my article about Zainal’s piece, I do mention that a secondary subgroup analysis found that the harms of antidepressants were much more severe in youth. However, I believe that it is best when reporting on research to focus on the primary analysis first, then the sensitivity analyses, and finally the secondary outcomes from multiple subgroup analyses, which are the most prone to bias. I don’t disagree with Zainal’s conclusion (antidepressants shouldn’t be used in kids). Just explaining why I covered the study in this format.

      Report comment

      • You must have linked the wrong article then, because what I read was
        “Subgroup analysis revealed that the average treatment effect of lower suicide attempts and other serious psychiatric adverse events in psychotherapy-only over combined treatment was statistically significant in youths but not in adults” and “Plausibly, psychotherapy should be prioritized for high-risk youths and combined treatment for high-risk adults with MDD.”

        Report comment

        • Hi Alanna, thanks for your questions. As I mention above in my response to Matt, I did indeed report on that secondary subgroup analysis, among others. As you note, that particular secondary analysis found that for adults, the difference between combined therapy and therapy alone was not statistically significant (although in terms of raw numbers, therapy alone was still better, and indeed the odds ratio was actually LARGER in adults [1.95] than in youth [1.86]). Thus, even in the subgroup analysis, and even going by statistical significance alone, there is no reason to add antidepressants to therapy when therapy alone is just as good in terms of outcomes. Why add antidepressants, taking the risk of worse outcomes, when it certainly adds no benefit?

          From the study: “Subgroup analysis revealed that the average treatment effect of lower suicide attempts and other serious psychiatric adverse events in psychotherapy-only over combined treatment was statistically significant in youths (OR 1.86 [1.07–3.23]) but not in adults (OR 1.95 [0.52–7.35]”

          Report comment

  4. But how many therapists does one need to go through before getting bonafide assistance? I’m not insinuating drugs are better but I’m witnessing my partner’s struggle with MDD and have sat in on, and eavesdropped on others (my partner is aware), zoom therapy appointments and am confused by the lack of involvement exhibited by the therapists. No hard questions. No prying questions. What are you reading? What are watching? What are you getting out of that? How are your family members? I could go on.
    Being a neurotypical, I might not understand what a therapist “does.” I’m willing to concede that I don’t know what to expect from a psychotherapist. But I was expecting a positive, prying cheerleader that would also hold my partner’s feet to the fire on some occasions. I could be wrong. Instead, I listen to my partner repeat to the therapist the same jargon they tell him and they can’t see thru that? Sometimes I’d like to scream, can’t you see thru this BS? Can’t you hear him repeat your words verbatim? Just because he says these things, does he mean them? Ask him! Ask him what he’s done to substantiate what he says!
    And then the pregnant pauses. Those make me furious. The conversation wanes (because they’re not asking questions!) and so my partner will just start saying anything to fill the void. Which typically is more BS because he’s uncomfortable with the silence. I get it, that’s on him, but what’s up with the pregnant pauses?? Is that part of the therapy? To make the patient squirm until they blurt out anything? Fine, but follow it up with questions. Please!
    In all fairness my partner does a TON of self work. But it seems the older he gets, the harder it’s become to manage 🙁
    Everything I read extols the benefits of psychotherapy but I’m just not seeing it. It seems like at the end of the day, you’re on your own, and must figure it out yourself. Hence, the self work. And there’s nothing inherently wrong with that. As excruciating as it can be at times, he’s capable of doing the self work; my heart goes out to those who aren’t.
    Anti-anxiety meds have helped over the years when anxiety was at the fore. But for the past several years depression has overruled. Antidepressants have not worked.
    Perhaps it’s a money thing as far as psychotherapy goes. For example, could it be the more you can pay, the better treatment you get?

    Report comment

  5. This could be misleading!! I am not sure what one sets out to achieve with misinformation. This could put people’s lives at risk, instead of helping them. Both Psychotherapy and Medication are needed in most cases of depression. Medications moreso if depression is severe, persistent, or getting worse.

    What factors could lead to Depression. I will just mention a few:
    1. Biological- Ones genetics, family history. A chemical inbalance. For persistent, severe cases. You can psychotherapy all you want. Nothing to little, changes.
    2 . Psychological – personality traits, self esteem, trauma or abuse, Stressful life events like divorce, loss of loved one, financial issues, etc. Talking helps, some need meds if Depression persists.
    3. Environmental- exposure to violence, chronic stress, neglect, socioeconomic disadvantaged etc
    4.Health conditions- especially Chronic ones like-Chronic pain, Hormonal fluctuations, Thyroid disorders.
    5.Substance Abuse, which can also exacerbate mental health issues.
    6. Social- loneliness, no social support, difficult personal relationships.
    7. Work- High stress work environments, job insecurity, excess of workload, harassment, work conflicts. The right Medications tailored to the person’s needs is mostly the way to go.

    Report comment

    • You are sharing the “general consensus” that we’ve all been taught to believe. I suggest you read some of these stories from real people who totally believed what you say and had not so great or horrible experiences.

      I’m puzzled also hoe “the right medications” are going to help with anything but #1. And of course, research has never really shown “chemical imbalances” to be real, measurable things. So you actually make a great argument that medication is at best a very small part of any treatment approach, yet you seem to be arguing it’s the whole thing.

      Report comment

  6. The talking professionals will destroy vulnerable individuals just as surely as the psychiatrists will and they often use the psychiatrists in their games. As a survivor of what is apparently standard treatment for middle America along with the predictable yet almost unstoppable and nearly inescapable downward spiral that accompanies and follows such so called treatment…

    The whole industry is dangerous and ridiculous. At best a talking professional might be honest about your situation and maybe even able to provide some pointers on how to improve your situation. Probably not. Delusions obfuscation jargon mystification….

    These are what the helping industry needs to survive.

    Report comment

  7. Many people here are arguing personal opinion over Imperial data. the empirical data says that psychotherapy for depression is quite affective in most cases, 85%success rate compares very well with most medical treatments. But like with any powerful treatment, some people won’t improve and a small number might even get worse. In any profession, there are some who are not good at it.

    Report comment

    • Affective it certainly is. Several years of being talked out of my perspectives and insights and being lied to, verbally abused, and having experienced coercive “therapeutic” methods have left me angry and outraged.

      Report comment

    • Actually, “imperial” strikes me as a fitting metaphor for the grandiose pretenses of the entire mental health industry, which fancies itself the supreme arbiter of what constitutes normal, proper thought, emotion, and behavior. Its unwarranted claim to authority, however, is based on a foundation of duplicity, greed, and lust for power (see Thomas Szasz’ “Psychiatry: The Science of Lies”). This sordid enterprise (not profession) willingly cooperates with any oppressive regime, be it neoliberal corporate fascism, Nazism, or Soviet communism.

      Report comment

    • Well look I’m with Dr Kingsley ok, what should be a last resort has become a first response, I’m of the school of thought that it’s better to work out trauma and abuse through talk therapy, cbt especially I’ve found effective.

      Coming up in a world where it feels like so many things can be treated with a pill, illnesses a lot (physical and mental) can be cured or tamed with a pill. So it reinforces the toxic idea in youts minds that there’s a chemical out there to set you straight. And tge shadow of drug addiction that is.

      Disclaimer, I’m not a psychologist, I’m actually an accountant and a drug user in a past life, and a lot of time to think and analyze.

      Report comment

  8. I live with multiple diagnosed mental health conditions, I am a two-time suicide attempt survivor, I’ve been on various psychiatric medications, experienced talk therapy, I have experienced two in-patient psychiatric hospitalizations, PHP, IOP, recently became a caregiver for a younger sibling experiencing serve symptoms with their mental health, and I’m currently pursuing my master’s degree in Social Work. Over the years, in my experience, resources and finances, or the lack thereof, have directly impacted my ability to seek and maintain quality mental health care. Now that I am experiencing this from a family caregiver perspective, I still find this to be true. I have gotten into mental health and suicide advocacy work over the last few years. I couldn’t access the entire article. However, I did read all of the comments. I found each perspective shared insightful, thought-provoking, and informative in some way.

    Report comment

  9. It’s almost comical how psy-professionals keep trying to prove that “psychotherapy” is better than psychiatric drugs when in reality it’s just the other side of the same dirty coin; its talky-talk spiel is just as gimmicky as psychiatry’s drugs.

    Report comment

LEAVE A REPLY