Two weeks ago we saw reports of a new study purporting to show that anti-depressants were of little use for most people suffering from mild to moderate Depression. Dr. Richard Friedman wrote a rebuttal for the New York Times which he explained some of the reasons the study was inaccurate:
Before You Quit Antidepressants ...
Last week, The Journal of the American Medical Association published a study questioning the effectiveness of antidepressant drugs. The drugs are useful in cases of severe depression, it said. But for most patients, those with mild to moderate cases, the most commonly used antidepressants are generally no better than a placebo.
For the millions of people who take these drugs, and the doctors who prescribe them, this provocative claim had to be confusing, if not alarming. It contradicted literally hundreds of well-designed trials, not to mention considerable clinical experience, showing antidepressants to be effective for a wide array of depressed patients.
But on close inspection, the new study does not stand up to that mountain of earlier evidence. To understand why, it helps to look at the way it was conducted.
The study is a so-called meta-analysis — not a fresh clinical trial, but a combined analysis of previous studies. A common reason for doing this kind of analysis is to discover potential drug effects that might have been missed in smaller studies. By aggregating the data from many studies, researchers gain the statistical power to detect broad patterns that may not have been evident before.
You should read his report to understand how limited the JAMA study was in its usefulness. My interest is in discussing the treatment of Depression that is not studied or measured by Academic Psychiatrists.
During the 1950s and 60s, Psychiatry was dominated by Psychoanalysis. Patients with mild to moderate Depression were usually treated with Psychoanalysis or Psychodynamic Psychotherapy, with variable results. There was a very good reason for the therapy approach at the time: the field of biological Psychiatry was in its infancy and our drug armamentarium was essentially non-existent. The first antidepressants, developed in the 1950s were the MAOIs (monoamine oxidase inhibitor), drugs with dangerous side effects difficult to tolerate and take safely. In the 1060s the Tricyclic antidepressants came into widespread use. These drugs were easier to tolerate but were still quite dangerous, with narrow safety margins, and were typically prescribed only by Psychiatrists who specialized in Pharmacotherapy. As such, the use of TCAs and MAOIs were restricted to those patients for whom the benefits clearly outweighed the risks; mild to moderate Depression of the non-life threatening variety were still addressed primarily by Psychotherapy.
The approval of Prozac in 1988 changed the entire field. Prozac, and the other SSRIs were far safer (almost impossible to use for a successful suicide attempt) and far easier to tolerate. With such a safety profile there was little reason to withhold such medications from patients who suffered from even mild Depression; to most people there was no downside. However, there has always been something missing in the reports on the efficacy of anti-depressants. Such medications are always given in the context of a relationship of the patient to the Doctor. Such therapeutic relationships have been recognized since antiquity as beneficial to the sufferer. Since Freud's day we have learned a great deal about the relationship and its impact on the people involved. Psychodynamic Psychotherapy is that treatment which mobilizes the unconscious aspects of the relationship in order to help the patient resolve previously poorly resolved conflicts. Such treatments are effective, though not for everyone, and offer long lasting benefits. [HT: NS]
Psychodynamic psychotherapy brings lasting benefits, new study finds
Psychodynamic psychotherapy is effective for a wide range of mental health symptoms, including depression, anxiety, panic and stress-related physical ailments, and the benefits of the therapy grow after treatment has ended, according to new research published by the American Psychological Association.
Psychodynamic therapy focuses on the psychological roots of emotional suffering. Its hallmarks are self-reflection and self-examination, and the use of the relationship between therapist and patient as a window into problematic relationship patterns in the patient's life. Its goal is not only to alleviate the most obvious symptoms but to help people lead healthier lives.
"The American public has been told that only newer, symptom-focused treatments like cognitive behavior therapy or medication have scientific support," said study author Jonathan Shedler, PhD, of the University of Colorado Denver School of Medicine. "The actual scientific evidence shows that psychodynamic therapy is highly effective. The benefits are at least as large as those of other psychotherapies, and they last."
There are several reasons that there exists so much less empirical evidence for the efficacy of the Psychodynamic Psychotherapies. There exists no way for a large corporation to make money off of the dispensing of such treatment and therefore little incentive to actually perform the studies. Psychodynamic Psychotherapy also typically takes a longer time that Medication and the short term treatments (like CBT) to show its effects (though there is evidence that the benefits are deeper and longer lasting.) Insurers have lots of incentives to discourage long term treatments, even when such treatments are more definitive than the short term approaches. in addition, learning to do Psychodynamic Psychotherapy is difficult and takes significant training. Not everyone is well suited to do the work and not every therapist is a good fit for every patient. All of these points conspire to incentivize medication treatment for everything ranging from unhappiness to full bore depression and leaves unaddressed the question: Is there any downside to our current Medication-centric approach to unhappiness and Depression? There are different answers for patients who are moderately to severely Depressed and those who are mildly Depressed or merely unhappy.
Most Psychiatrists, even the Psychopharmacologists if they are candid, will admit that the patients with Depression who do best are those who receive a combination of Psychotherapy and Medication. Patients in therapy are most likely to take their Rx consistently, a necessity for a good result, and are most likely to take their Rx for a long enough time to treat the current episode. The best way to minimize the risks of relapse has always been recognized as determining the triggers of the episode and the cascade of psychological events which cause unhappiness to spiral into Depression.
For those who use anti-depressants as a way to numb their unhappiness and allow themselves to remain in unhappy conditions, when such drugs do their partial work, it can interfere with the person's' ability or interest in actually resolving the causes of their unhappiness. The lost opportunity costs of the SSRIs can be considerable.
Not everyone can benefit from Psychodynamic Psychotherapy; not every Therapist-Patient pair is workable; not every unhappy or Depressed person should enter Psychodynamic Psychotherapy. However, we do know, and are adding to our knowledge on a daily basis, that human beings are social and cannot exist outside of relationships (even if the depth and intensity of those relationships is unconscious.) To put it into more Psychobiological terms, the human brain exists in a web of relationships with other human brains, all with multiple feedbacks affecting their functioning. Imagining we can tamper with the chemistry of our brains without regard to the interrelationships involved is an oversimplification that ultimately leads to unnecessary suffering.
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