The Editorial Demise of Psychotherapy and Psychosomatics Is Bad News For Us All

Today there is a substantial body of evidence that antidepressants worsen the long-term course of depression, a conclusion that deserves to be known by a global population and derives, in large part, from papers published in Psychotherapy and Psychosomatics. It was in 1994 that the editor-in-chief of Psychotherapy and Psychosomatics, Giovanni Fava, raised this concern, and for the next thirty years his journal provided a home for research and essays that collectively provided a sobering narrative about the clinical realities of long-term antidepressant use: the risk of developing chronic depression, difficulties withdrawing from the drugs, and persistent sexual dysfunction.

This was the clinical reality that Psychotherapy and Psychosomatics made known, a reality that was missing from mainstream psychiatric journals. Under Fava’s leadership, the journal also published articles related to long-term hazards with antipsychotics (such as drug-induced dopamine supersensitivity), the corruption of psychiatric practices by guild and pharmaceutical influences, and how meta-analyses of industry-funded trials, which are the foundation for the claim that antidepressants and other psychiatric drugs are effective, can lead to harmful clinical practices.

As Fava wrote in a 2022 editorial, when he stepped down as editor-in-chief:

After stepping down, Fava remained involved in the journal as “honorary” editor. The journal continued to be in good hands, and thus one of the few journals that was receptive to research findings that belied the narrative of therapeutic progress that the psychiatric guild and pharmaceutical companies have been promoting for decades.

However, in December, Karger, which is the Swiss-based company that publishes Psychotherapy and Psychosomatics, fired one of the two editors-in-chief, Jenny Guidi, informing her that it was “it was time for the journal to take a new direction.” That, in turn, led to a mass resignation at the journal: Fava is gone, so too Guidi’s co-editor in chief, Fiametta Cosci, most of the editorial board, and the journal’s statistical consultants. The two editors-in-chief were replaced by a Karger employee, Sam Bose, who was named the “managing editor.”

In short, the editorial leadership that made Psychotherapy and Psychosomatics such an important journal for more than three decades is now gone, which has profound implications for the future of the “evidence base” for psychiatric treatments that will appear in the scientific literature. Researchers whose findings counter the conventional wisdom—and thus counter vested financial and guild interests—regularly find it difficult to place their articles with a psychiatric journal, and now that difficulty will only grow more pronounced if the new editors of Psychotherapy and Psychosomatics take it in a “new direction.”

Indeed, the last issue that was edited while Guidi and Cosci were at the helm featured an article written by Mark Horowitz and James Davies, whose writings have often been featured on Mad in America. Their article was titled “Hidden Costs: The Clinical and Research Pitfalls of Mistaking Antidepressant Withdrawal for Relapse.” If Psychotherapy and Psychosomatics takes a new direction, this is the type of article that may not be able to find its way into the medical literature, or at least not into a journal with a high “impact factor.”

“Under previous editors, Psychotherapy and Psychosomatics became one of the world’s most respected mental health journals, known for its incisive, world-leading critical research that pushed boundaries and improved practice,” Davies said. “Karger’s decision to replace the editorial leadership without consultation is extraordinary, abruptly ending decades of success and accumulated expertise. This is a profound loss for both the research community and the public. Psychotherapy and Psychosomatics has long remained independent of the financial and ideological biases that pervade psychiatric research, creating an ethical space where scientific integrity—not external interests—determines what gets published. Its loss is a loss for us all.”

A Journal of Transformative Importance

This is a loss that will be felt deeply at Mad in America. Our science team has regularly reported on articles that have been published in Psychotherapy and Psychosomatics. Indeed, a search of Mad in America turns up 102 references to this journal. Fava’s work and his journal were also a critical source for my book Anatomy of an Epidemic: Magic Bullets, Psychiatric Drugs and the Astonishing Rise of Mental Illness.

In Anatomy of an Epidemic, I was focused on this question: How do psychiatric drugs impact the long-term outcomes of major psychiatric disorders? Does their long-term use promote lasting recovery and thus provide a long-term benefit, or do they, for some reason, worsen the long-term course of major disorders?

At that time, the conventional narrative—at least as told to the public—was that researchers had discovered that major psychiatric disorders were caused by chemical imbalances in the brain, and that psychiatric drugs fixed those chemical imbalances in the brain, like insulin for diabetes. This was a narrative that told of a great medical advance, and it had fueled a great expansion in the diagnosis of mental disorders and the prescribing of psychiatric drugs, both in the United States and abroad.

However, I knew from my research for my first book, Mad in America, which was published in 2002, that the chemical imbalance story, while being actively told to the public, was belied by the science. Moreover, in that book, I had investigated the long-term merits of antipsychotics, and I had dug up a line of research in the scientific literature, dating back to the 1950s, that told of how antipsychotics worsened the long-term course of schizophrenia and other psychotic disorders. These drugs lowered long-term recovery rates, and increased the likelihood that a person would remain chronically ill.

That, in fact, was a story of science that could be fleshed out by following NIMH-funded research, starting with the introduction of antipsychotics into asylum medicine in 1955 and continuing until the present day. American psychiatry, of course, was telling itself and the public a different narrative about these drugs, but the NIMH studies provided pieces of evidence that fit together like a puzzle, telling of that bottom-line impact of antipsychotics.

As I turned my attention to the long-term impact of antidepressants while researching Anatomy of An Epidemic, I knew that the low-serotonin hypothesis hadn’t panned out. I also knew that the short-term efficacy of antidepressants, an evidence base that came from industry-funded trials, was of a dubious sort, the drug-placebo difference so small that it was clinically irrelevant. However, my focus was on their long-term effects, and so I began my inquiry in the same way I had with the antipsychotics: what were outcomes for depressed patients prior to the arrival of antidepressants?

Studies of patients hospitalized for depression in the first half of the 20^th century, both in the U.S. and Europe, told of a spectrum of outcomes, which led to the conclusion that depression, for the most part, was an episodic disorder. Recovery rates at the end of one year would be around 85%, and studies that followed first-episode cohorts for a longer period of time reported that about 50% of the patients would have but a single episode, another 30% might have an episode every three or four years, and only about 20% would suffer from episodes more frequently than that.

This led experts in mood in disorders in the U.S., including leaders at the NIMH, to report in the 1960s and 1970s that depression was an episodic disorder, and that most people would recover regardless of any treatment. Most depressive episodes, explained Dean Schuyler, head of the depression section at the NIMH, “will run their course and terminate with virtually complete recovery without specific intervention.”

However, in the 1970s and 1980s, studies in the U.S. and abroad began to tell of how patients treated with antidepressants were frequently relapsing when they stopped taking these drugs. However, rather than see this relapse as possibly related to antidepressant use, leading academic psychiatrists in the U.S. saw it as reason to reconsider the “natural” course of depression. Perhaps their previous understanding that it was an episodic disorder was mistaken.

A 1985 panel of experts convened by the NIMH put it this way: “Improved approaches to the description and classification of [mood] disorders and new epidemiological studies [have] demonstrated the recurrent and chronic nature of these illnesses, and the extent to which they represent a continual source of distress and dysfunction for affected individuals.”

An NIMH study conducted at this time, which compared the antidepressant imipramine to two forms of psychotherapy and placebo, told of this poor outcome. At the end of 18 months, the stay-well rate for the imipramine was only 19%, which was far worse than outcomes for depressed patients in the pre-antidepressant era.

Enter Giovanni Fava into this narrative.

An Italian psychiatrist from Bologna, Fava became editor-in-chief of Psychotherapy and Psychosomatics in 1992. He had years of clinical experience working in an “affective disorders program” that involved treating patients “who were referred to us for difficulties in their management.” With his clinical experience uppermost in his mind, he wrote an editorial in 1994 arguing that it was time to consider whether antidepressants were increasing the chronicity of the long-term course of depression.

“Within the field of psychopharmacology, practitioners have been cautious, if not fearful, of opening a debate on whether the treatment is more damaging [than helpful],” he wrote. “I wonder if the time has come for debating and initiating research into the likelihood that psychotropic drugs actually worsen, at least in some cases, the progression of the illness which they are supposed to treat.”

He noted too the reluctance of the field to consider this possibility. “It is indeed rare to see such issues debated: is this because of some ‘censorship’ operated by medical journals, meeting organizers, and certain pharmaceutical manufacturers?”

Fava was now like the little boy who whispered that the king has no clothes.

Indeed, his editorial drew an immediate rebuke from Donald Klein, a prominent psychiatrist at Columbia University known for his work on pharmacological treatments for mood disorders. Klein, writing in Psychiatric News, urged that this discussion be shut down. “The industry is not interested [in this question], the NIMH is not interested, and the FDA is not interested,” he wrote. “Nobody is interested.”

Still, Fava persisted. Ross Baldessarini, one of the most prominent figures in American psychiatry, known in particular for his psychopharmacology research, wrote in 1995 that this question required “open-minded and serious clinical and research consideration,” and and in the years that followed, Fava fleshed out his argument. He cited several clinicians who earlier had told of how antidepressants were causing a “chronification” of the disease. He also pointed to a five-year study by a Dutch physician in the 1970s who found that exposure to antidepressants had increased the frequency of episodes. As for why antidepressants might have this long-term effect, Fava turned to research conducted by two Canadian investigators, Guy Chouinard and Barry Jones, who had concluded in the 1980s that antipsychotics induced a dopamine supersensitivity that made patients more biologically vulnerable to psychosis, and that long-term use of these drugs could lead to persistent, severe psychosis in a significant percentage of patients.

Like antipsychotics, Fava noted, antidepressants perturbed neurotransmitter systems in the brain, which led to compensatory “processes that oppose the initial acute effects of the drugs . . . when drug treatment ends, these processes may operate unopposed, resulting in appearance of withdrawal symptoms and increased vulnerability to relapse.” The longer one stayed on antidepressants, he wrote, the “higher the likelihood of relapse” following drug withdrawal. Yet, even those who stayed on antidepressants were relapsing with great frequency, which led Fava to suggest that the drugs could cause “irreversible modifications” and “sensitize” the brain to depression.

In papers published in 1995 and 1999, Fava summed up the problem in this way: “Antidepressant drugs in depression might be beneficial in the short term, but worsen the progression of the disease in the long term, by increasing the biochemical vulnerability to depression . . .  Use of antidepressant drugs may propel the illness to a more malignant and treatment unresponsive course.”

With Fava repeatedly beating the drum, he kept the issue alive in psychiatric research circles. In 1998, three physicians from the University of Louisville School of Medicine, in a letter to the Journal of Clinical Psychiatry, wrote that “it is possible that antidepressant agents modify the hardwiring of neuronal synapses [which] not only render antidepressants ineffective but also induce a resident, refractory depressive state.” Baldessarini also weighed in again, publishing an article in Psychotherapy and Psychosomatics, urging the field to investigate this possibility.

In 2011, Fava’s effort came to a notable conclusion. He published yet another article telling of how antidepressants “may propel the illness to a malignant and treatment-unresponsive course,” and then, that same year, a U.S. expert in mood disorders, Rif El-Mallakh, who had written an article in 1999 that supported Fava’s concerns, published a paper titled: “Tardive Dysphoria: The Role of Long-term Antidepressant Use in Inducing Chronic Depression.”

Moreover, El-Mallakh picked up on a larger theme that Fava had been harping on for decades: this drug-induced worsening might be common to other classes of psychiatric drugs, as all such drugs induced this “oppositional tolerance.”

El-Mallakh wrote: “Continued drug treatment may induce processes that are the opposite of what the medication originally produced.” This may “cause a worsening of the illness, continue for a period of time after discontinuation of the medication, and may not be reversible.”

At that moment, the narrative that had been promoted to the public, of antidepressants and other psychiatric drugs fixing chemical imbalances in the brain, had been completely flipped. Fava had told of psychiatric drugs that induced abnormalities in brain chemistry and worsened long-term outcomes, at least in the case of antidepressants, with a U.S. expert in mood disorders naming this effect drug-induced “tardive dysphoria.”

Today, there are a number of studies that can be cited that confirm that antidepressants have this negative long-term effect. While such studies have been published in various journals, several of the most important were published in Psychotherapy and Psychosomatics. To wit:

• In 2005, researchers in the Netherlands who followed 172 patients for two years after their depression had gone into remission reported that the relapse rate was 60% for those who stayed on antidepressants versus 26% for those who didn’t take an antidepressant. The high relapse rate for the patients who took antidepressants, the investigators concluded, was consistent with the idea that “continued antidepressant treatment may oppose the initial acute effects of [the] antidepressant . . . neurobiological mechanism(s) may be involved in increasing vulnerability to relapse.”
• In 2010, Ed Pigott and colleagues published their first review of the STAR*D findings, telling of how, at the end of the one year, only 108 of the 4041 patients who had entered the study had remitted during the acute phase of the study and then stayed well and in the trial to its one-year end. This was a documented stay-well rate of 3%. All of the others who had entered the trial had either never remitted, remitted and then relapsed, or had dropped out. This long-term outcome stood in dramatic contrast to outcomes in the pre-antidepressant era, when 85% recovery rates were reported, and also in dramatic contrast to a NIMH study of “unmedicated depression” in the early 2000s that similarly reported an 85% recovery rate at the end of one year.
• In 2017, a study of 3,294 people who were diagnosed with depression and followed for nine years revealed that those who took antidepressants had more severe symptoms at the end of nine years than those who didn’t take such medication. The difference in outcomes could not be explained by any difference in initial severity of depression.
• In 2018, a study of 521 depressed patients in Switzerland, who were followed from when they were 20 years old until they were 50 years old, found that taking an antidepressant at some point during that period was associated with worse outcomes at the end of the study, even when controlling for initial symptoms and other factors.

In addition to articles telling of antidepressants’ long-term effects, under Fava’s leadership Psychotherapy and Psychosomatics regularly published articles related to antidepressant withdrawal symptoms and conflicts of interest in psychiatry and medicine. In 2002, the journal published an analysis of the risk of suicide with SSRIs that contributed to the FDA’s decision to place a Black Box warning on these drugs. In 2006, it published perhaps the first report of patients suffering from post-SSRI-sexual-dysfunction (PSSD.) In 2015 it published the first systematic review of the literature on antidepressant withdrawal symptoms, telling of how the symptoms could be severe and did not necessarily wane after a few weeks.

In sum, the record that exists in the scientific literature telling of the long-term impact of antidepressants would be notably different today if it had not been for Fava’s writings and the many articles published in Psychotherapy and Psychosomatics. This was a journal that provided a counter-narrative to the narrative in mainstream psychiatric journals that told of the effectiveness of antidepressants and other psychiatric drugs, and rarely focused on their harms, including their long-term effects.

Fava Looks Back: The Rise and Fall of Psychotherapy and Psychosomatics

When Fava took over the editorial helm of Psychotherapy and Psychosomatics in 1992, he wanted it to be a journal that would be relevant to clinical practice, with articles often arising from clinical observations. This focus stood in contrast to an evidence base that arises from RCTs that compare symptom reduction in treated patients to a placebo group.

“Something that I realized very soon is that in the 1990s, the number of investigators who had familiarity with the clinical process was limited,” Fava said. “You can find people who publish about clinical methods, who give lectures, who teach, but these people wouldn’t know how to treat a patient in practice . . .  I always had a busy clinical practice so I could see what was going on in the real world. All the research aspects that I’ve been dealing with in my career as an investigator, the source came from clinical practice. The ideas and hypotheses were rooted in my clinical practice. If you don’t have that, you end up doing studies that may be elegant and may be rigorous, but they really have no relevance to what the clinicians do.”

The editorial Fava wrote in 1994, questioning whether antidepressants could worsen the long-term course of depression, arose from what he had observed in his patients. “I  observed a number of phenomena which were intriguing. Withdrawal syndromes were part of this phenomena, but there were also other clinical aspects, such as loss of clinical effect and so on. So I decided to write an editorial where I didn’t have any firm conclusion, but I was raising doubts about certain issues.”

In most journals, Fava noted, raising such issues was “forbidden.” But the publisher of Psychotherapy and Psychosomatics at that time, Thomas Karger, gave him a free hand in running the journal. “What was present in those days was something that is one of the most important ingredients of scientific research, and that is intellectual freedom, which many researchers do not have. They have lost it because of industry ties and so on,” Fava said.

Indeed, after Fava published a paper in 2006 by Sheldon Krimsky and Lisa Cosgrove, which told of the financial ties that the DSM-IV panel members had to pharmaceutical companies, Karger—after seeing the Washington Post report on the Krimsky article—wrote a simple note to his editor-in-chief: “I’m proud to be your publisher.”

With Thomas Karger his publisher, Fava had support for continuing his investigations on the long-term impact of antidepressants. Articles published in Psychotherapy and Psychosomatics told of withdrawal symptoms and how they could persist even after patients stopped taking the drugs, of suicide risks with the drugs, and how in longer-term studies, the drugs lost their “clinical effect” in a significant percentage of patients. Guy Chouinard was a member of his editorial board, and so Fava had his knowledge and experience to count on when he proposed that antidepressants could induce an “oppositional tolerance” that caused long-term worsening.

“Over the years, we collected a number of clinical investigators who were very independent and who had ideas that were important but didn’t find room in mainstream journals. We continued to do that until we reached an impact factor that was above the American Journal of Psychiatry,” Fava said. “That was really a paradox because the American Journal of Psychiatry is extremely powerful in terms of investments and so on. And we were this small group of people doing that.”

Psychotherapy and Psychosomatics also ran articles that raised questions about the merits of psychotherapy. The spirit of independent thought, and freedom to publish findings and clinical observations that could upset conventional beliefs, remained present throughout Fava’s three decades as editor-in-chief.

In terms of its pharmacology reports, the journal presented findings that stood in direct contrast to the “evidence base” that arose from RCTs, conducted mostly by industry in its short-term trials, and meta-analyses of RCTs. While such meta-analyses are regularly cited by leaders in psychiatry as proof that their treatments are “evidence-based” and effective, Psychotherapy and Psychosomatics, with its evidence rooted in clinical observations and research on clinical phenomena, published essays that argued meta-analyses were not a source of good clinical practice.

“Randomized controlled trials are a very important part of clinical science, but we should not forget that the results of randomized controlled trials apply to the average patient and they may not apply to all clinical cases,” Fava said.

Real-world patients, he added, may experience a spectrum of outcomes. For instance, there may be a positive change in one group, no change in a second group, and worsening in a third group.

“So what is the problem with meta-analyses?” Fava asked. “You just talk about the average. And particularly the third subgroup [that worsens], you don’t want to hear about it. In a way, evidence-based medicine has degraded clinical practice. What I mean is that with this idea, you have guidelines that apply to everyone, whereas it is the clinical judgement of the clinician who has to interpret those guidelines. But clinical judgement means independence, it means not following orders, not following guidelines.”

The demise of Psychotherapy and Psychosomatics, Fava said, was rooted in the retirement of Thomas Karger. The new corporate publishers were much more focused on “money.”

Psychotherapy and Psychosomatics operated under a “subscription model,” its revenues coming from subscribers, rather than advertisements, Fava noted. Libraries were a principal source of subscription revenues, but several decades ago libraries started to resist paying this expense. As a result, many publishers began turning to an “open access” model. However, this is a model that in many ways is antithetical to independent science and research arising from clinical experience, particularly since independent-minded investigators may lack grants that can pay “open access” costs.

“It creates a financial threshold for reporting certain things. It’s like if we go to a restaurant, we bring our own food, we go to the kitchen, we cook the food, we bring it to our table, we eat it, and we pay the bill. That’s open access,” Fava said.

Fava stepped down in 2022, after some “frictions” developed with the new corporate publishers. Two associate editors at the journal, Jenny Guidi and Fiametta Cosci, took over, with Fava remaining involved as an “honorary editor” to provide advice and help resolve controversial issues.

“But there was [now] a big difference, in that we no longer had a publisher who was proud of what we were doing,” Fava said. “We had a publisher who was concerned about other matters and didn’t care about the impact factor [our journal had]. In general, publishers now want to have a say in the editorial line of a journal.”

The publishers of Psychotherapy and Psychosomatics want to move to an open access model, he said. There were “problems” that arose between the publisher and the two chief editors, and in December Guidi was fired and Cosci resigned. The current managing editor, Sam Bose, is a company employee who has a background in “open access” publishing.

“He has no competence in the field,” Fava said. “And what they are looking for is someone who will follow directions.”

While Bose and a new editorial board have yet to put their stamp on the journal, Fava doesn’t think it will continue to be a home for research that challenges conventional wisdom.

It is, Fava concluded, a story of the “progressive loss of intellectual freedom.”

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Editor’s note: On March 26, MIA Radio will air a podcast interview with Giovanni Fava.

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MIA Reports are supported by a grant from Open Excellence, and by donations from MIA readers. To donate, visit: https://www.madinamerica.com/donate/