Placebo Effect, Part 2

Not so fast, just how severe is the depression?

Maybe the placebo effect is not enough but can antidepressants actually beat it? Generally, in basic studies of adults, antidepressants are more effective than placebos. However, those who do not trust antidepressants are quick to say that the margin of effectiveness between the two is not enough to outweigh the side effect risks of the actual medicine. Some go so far as to say that a significant portion of antidepressants effectiveness outside of clinical trials can be attributed to placebo effect. This claim is supported by the risk of relapse after initial signs of remission during antidepressant treatment. The argument is essentially that patients feel better due to a placebo effect when first given antidepressants but that this improvement cannot last long term and therefore, the antidepressants are not better than a placebo. Personally, I do not think my research has supported that claim however. In a previous post,  I discussed a study that indicated that patients whose monoamines were more abundant (the main biological effect that antidepressants induce) were less likely to have recurring symptoms of depression after initial remission. Also, I have found a new study that indicates that the more severe the depression, the more the antidepressants outshine placebos. This study does mention that the difference in success between antidepressants and placebos can be almost nonexistent in more mild or moderate cases of depression.

While I have detailed a variety of alternative treatments for depression, the two options that are considered genuinely substantial are psychotherapy and antidepressants. This fact combined with the prevalence of depression as a condition means that psychiatry and psychology are fighting against a formidable foe with limited resources. Severe depression especially can result in death. Furthermore, these deaths tend to be suicides which can have a profound effect on the loved ones of the deceased, resulting in the propagation of depression in even more people. Depression has a certain stigma to it because it is easier to blame on personal weakness than more straightforward biological malfunctions, however, the condition must be seriously addressed. If severe depression really is treated more successfully by antidepressant medications than mild to moderate depression, the treatment of depression can only be improved by that fact and having an effective way to help the severely depressed is indispensable.

You have to have confidence in your placebo or it's unlikely to succeed.

Another thing that is relevant about the placebo effect in depression treatment: while the concept that a placebo effect in the treatment of depression can lead to later recurrence due to inadequate treatment may be a valid complaint, it is my opinion that patients should not let fear of placebo effects reduce their confidence in their medicine. It is unfortunate if a placebo effect that cannot be sustained long term causes the helpful effects of a medication to cease, however, the fact remains that the placebo effect is not likely to be harmful. In the event that one medication no longer works, it can either be determined that the patient might find more long term success with a different antidepressant or perhaps it can even be considered that the severity of that patient's depression is not high enough for the medication to have more than a possibly temporary placebo effect. So long as there are no intolerable side effects, even a placebo-effect induced improvement is better than no improvement at all. In addition, there is another way to improve the long term success of a drug depression treatment and that is by adding psychotherapy to the treatment plan.

Moran, Mark. "Does Placebo Effect Mask True Efficacy of Antidepressants?" Psychiatric News. 2 July 2010. Web. 25 Apr. 2012. <http://pnhw.psychiatryonline.org/content/45/13/17.2.full>.

Sipkoff, Martin. "Antidepressants Work Best For the Severely Depressed." Managed Care Magazine Online. Web. 25 Apr. 2012. <http://www.managedcaremag.com/archives/1003/1003.medmgmt_antidep.html>.

Nauert, Rick. "Placebo Effect Among Antidepressants | Psych Central News." Psych Central.com. Web. 25 Apr. 2012. <http://psychcentral.com/news/2007/08/15/placebo-effect-among-antidepressants/1131.html>.

Placebo Effect, Part 1

In double blind clinical trials, patients are split up into two groups. In the case of an antidepressant trial, some of the patients are given the antidepressant and some are given a sugar pill (called a placebo) but no one, including the doctors, knows who got which treatment. As mentioned in previous posts, this is how the effectiveness of antidepressants is usually measured: the effects on the patients taking the real antidepressants are compared to the effects experienced by those taking the sugar pill. The placebo effect (the amount to which the sugar pill is described as effective) in antidepressant trials has been known to range between 15 percent and 70 percent response rates. It also seems that over the time, as antidepressant trials have been performed, the placebo effects documented in the more recent trials are higher.





The placebo effect is a powerful though not well understood phenomena of medicine and of life. To what extent can the power of positive thinking and expectation produce medical results? The basis of the placebo effect seems to be that if a patient expects to be affected by a medicine or treatment in a specific way, they are more likely to perceive that effects. In a way, this is similar to the concept of confirmation bias in psychology: if a person has an opinion, they will be more likely to notice evidence that supports that opinion. However, the placebo effect in a condition like depression that is significantly subjective in some aspects cannot be underestimated. The extent to which psychology can affect illness, especially mental illness, is still mysterious due to the limited knowledge of the causes of depression and other mental illnesses. Why have the placebo effect statistics in antidepressant trials increased over time? It is possible that as the drugs became less new and more commonly prescribed, public opinion of their usefulness increased thus increasing the placebo effect.

In this way, the placebo effect seems like a very good thing. If belief in a medicine alone is enough to produce improvement in depression symptoms, why bother with risky complex medications at all? The reason why sugar pills are not just prescribed in everyday life rather than antidepressants is as follows. The placebo effect is reliant on the patient's belief that they are taking an effective medicine, so obviously if a doctor were to prescribe sugar pills to a patient to attempt to induce a helpful placebo effect, the ethical and practical issues may be tricky. It seems inherent that a doctor should not simply lie to a patient. As the person taking the pill, the patient needs to know what the pill he is taking contains for medical safety reasons and because it is his right. In a clinical trial, the situation is more controlled and the participants know that they might be receiving a placebo so the concealment is acceptable. In fact, as the main goal of the doctors has shifted from treating one patient's depression successfully to measuring how successful a certain drug is typically, the difference in objective makes the concealment more than just acceptable but also necessary. In the end, the placebo effect is used in clinical trials to determine the worth of the other medicine tested. To treat serious conditions like major depression, it is ideal to produce more improvement than the placebos can provide on their own even in the best case scenario. In studies, medicines are compared to placebos and the extent to which the success of the medicine exceeds the success of the placebo is measured. This measurement is extremely important. If the effect of an antidepressant is indistinguishable from a placebo pill then the medicine is no more helpful than a sugar pill while the antidepressant is more dangerous than a placebo due to the side effects of the former.

Or maybe my grasp on what is considered ethical in medicine nowadays isn't so on point?

Are antidepressants actually more successful than placebos? Survey says, hear more about the implications of the placebo effect on the efficacy of antidepressants in my next blog post.

"MedicineNet.com." Medterms. 14 Mar. 2004. Web. 24 Apr. 2012. <http://www.medterms.com/script/main/art.asp?articlekey=31481>.

 Kirsch, Irving. "Challenging Received Wisdom: Antidepressants and the Placebo Effect." McGill Journal of Medicine. Web. 24 Apr. 2012. <http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2582668/>.

"Confirmation Bias." ScienceDaily. ScienceDaily. Web. 24 Apr. 2012. <http://www.sciencedaily.com/articles/c/confirmation_bias.htm>.

Lakoff, Andrew. "The Right Patients for the Drug: Managing the Placebo Effect in Antidepressant Trials." BioSocieties. Web. 25 Apr. 2012. <http://www.palgrave-journals.com/biosoc/journal/v2/n1/full/biosoc20075a.html>.

Hope After All?

Antidepressants can cause dangerous suicidal thoughts in people of all ages. The FDA requires labels and brochures distributed with the drugs to warn about all of the possible side effects. The question is: is warning the public enough or should more drastic measures be taken?

In the case of adults, I think that personal choice should be allowed. An adult with a prescription from a doctor should not be kept from taking antidepressants, despite the risks. However, I do not think the same is true for children. In children, the prescription of certain antidepressants should be discouraged, if not outlawed. The difference is that in children the odds of positive effects from tricyclic antidepressants are slim to none, making the risk of administering these drugs to children a foolish one to take. In doing more research, I found that while tricyclic antidepressants do not usually help children, fluoxetine (the SSRI usually known as Prozac) has been showed to be effective, especially when combined with cognitive behavioral therapy. This indicates that since the original FDA study claiming the effects of SSRIs was "clinically insignificant" in children the matter has been further researched in a way that may have encouraged doctors to prescribe the pills to children.

It is fortunate that the SSRIs were studied further as the need for an effective treatment in severely depressed children is great. It seems that the atypical antidepressant bupropion (often marketed as Wellbutrin) has also shown positive effects in children. It is interesting to consider why there is such a difference in effectiveness in children and adults. Most likely, the mechanism of depression on the brain is different in children than in adults due to the process of brain development.

In the end, I think that the question of personal choice versus social responsibility comes down to effectiveness. If there is a chance that the doctor-prescribed medication may help the patient, the patient should have the right to take that chance.

"Open Trial of Bupropion SR in Adolescent Major Depression." 25 Aug. 2004. Web. 20 Apr. 2012. <http://onlinelibrary.wiley.com/doi/10.1111/j.1744-6171.2003.00123.x/abstract>.

 "The Treatment for Adolescents With Depression Study (TADS): Long-term Effectiveness and Safety Outcomes." Archives of General Psychiatry, Oct. 2007. Web. 19 Apr. 2012. <focus.psychiatryonline.org/data/Journals/FOCUS/1833/foc00108000063.pdf>.

Think About the Children

 You are worried about seeing him spend his early years in doing nothing.  What!  Is it nothing to be happy?  Nothing to skip, play, and run around all day long?  Never in his life will he be so busy again.  ~Jean-Jacques Rousseau, Emile, 1762

They don't work? Why do we prescribe them?

One special subgroup of the depressed population consists of depressed children. As mentioned in my previous post, children (which we can consider anyone up to the age of 18) are depressed in large numbers. However, on the other hand, according to Peter Breggin's book Medication Madness: A Psychiatrist Exposes the Dangers of Mood-Altering Medication, antidepressants are currently considered by the FDA as no more effective than placebos in depressed children. In fact, Breggin claims that due to the risks of side effects, including increased suicidal tendencies, antidepressants are not helpful to children but are actually consistently harmful to them if there is any effect. So how do the depressed children get help? Some families have opted out of medicating their kids with antidepressants, favoring instead child psychologists. However, despite what Breggin seems to consider a decisive verdict of ineffectiveness for antidepressants in children, they are still commonly prescribed. I have mentioned highly sought after child psychiatrists who charge between hundreds and thousands of dollars for an initial assessment. The rest of this blog post will be an attempt to understand why this medicine continues to be prescribed to a vulnerable social group if it is known to be useless or harmful.

In 2004, the FDA applied a black box warning to antidepressants that states that they can increase "the risk of suicidal thinking and behavior in pediatric patients." By doing this, the FDA drew attention to a serious side effect and directly mentioned the group they considered the most at risk. It is definite that harmful antidepressant side effects have been documented in children. However, these risks also exist to a lesser extent in adults but, unless lethal or intolerable side effects are certain or overwhelmingly likely, I do not think the prescription of antidepressants should stop due to those side effect risks. There's still a chance that an adult individual will find an antidepressant that can help them with manageable or negligible side effects. Does this possibility for improvement not exist for children?

After examining the FDA-sponsored study, it seems that Dr. Irving Kirsch concluded that, in children, as compared to placebo, the effects of tricyclic antidepressants were statistically insignificant and that while SSRIs were statistically significant, they were not "clinically significant." The FDA has spoken. Who disagrees? I am not sure. I can find a variety of studies concluding that tricyclics are worthless for children and while most studies say more information needs to be ascertained about SSRIs for children, they admit that SSRIs are minimally effective, if at all. Even the drug company GlaxoSmithKline sent out warnings about prescribing paroxetine to children due to the suicide risks in 2003, before the FDA put out the black box warning.

Overall, it seems that science does not support the effectiveness of antidepressants in children. The fact remains that there are children, even small children, taking these drugs. SSRIs are considered by many in the medical profession as the safest antidepressant to prescribe to children despite the apparent lack of therapeutic reward that accompanies the drugs serious side effects. Why are children taking these medications? Perhaps, there is evidence of effectiveness that I have not been able to find. Perhaps, their lack of effectiveness is not widely known or agreed upon among the doctors actually making prescriptions. Perhaps, science cannot yet give us a full evaluation of the positive effects these drugs can potentially have, effects that could be observed in practice. Perhaps, doctors suppose that some cases of depression in children are severe enough to risk side effects to attempt to achieve even a slight improvement. I fear I do not have the resources to decisively explain why children are still prescribed antidepressants. In the end, the FDA did not create a ban, it simply issued a warning. If doctors continue to prescribe these pills to children, they do so at their own risk. Unfortunately, they also do it at the risk of the patient and his loved ones, who often rely primarily on the advice of their doctor. Should we allow parents and their children to collaborate with their doctors and make up their own minds or should the prescription of antidepressants to children be limited by law? This important juncture between social responsibility and personal choice in psychiatry will be discussed further in my next blog post.  

"Efficacy and Safety of Antidepressants for Children and Adolescents." BMJ Group. Web. 18 Apr. 2012. <http://www.bmj.com/content/328/7444/879.full>.

"Dr. Irving Kirsch and Dr. David Antonuccio on the Efficacy of Antidepressants with Children." Web. 18 Apr. 2012. <http://www.ahrp.org/risks/SSRI0204/KirschAntonuccio.php>.

Papanikolaou, K., C. Richardson, A. Pehlivanidis, and Z. Daifoti-Papadopoulou. "Efficacy of Antidepressants in Child and Adolescent Depression: A Meta-analytic Study." National Center for Biotechnology Information. U.S. National Library of Medicine, 3 Aug. 2005. Web. 18 Apr. 2012. <http://www.ncbi.nlm.nih.gov/pubmed/16075184>.

Tsapakis, EM, F. Soldani, L. Tondo, and RJ Baldessarini. "Efficacy of Antidepressants in Juvenile Depression: Meta-analysis." National Center for Biotechnology Information. U.S. National Library of Medicine, July 2008. Web. 18 Apr. 2012. <http://www.ncbi.nlm.nih.gov/pubmed/18700212>.

Hazell, P., D. O'Connell, D. Heathcote, J. Robertson, and D. Henry. "Efficacy of Tricyclic Drugs in Treating Child and Adolescent Depression: A Meta-analysis." BMJ Group, 8 Apr. 1995. Web. 18 Apr. 2012. <http://www.bmj.com/content/310/6984/897.short>.

"A Black-Box Warning for Antidepressants in Children?" The New England Journal of Medicine. 14 Oct. 2004. Web. 18 Apr. 2012. <http://www.nejm.org/doi/full/10.1056/nejmp048279>.

Let's Make This More Concrete

As a BASIS student, I cannot escape the fact that I am a junkie for numbers, just like my peers. For that reason, though I cannot stress enough that statistics cannot reflect the individual's experience with depression and antidepressants, I'd like to share some statistics anyway.

According to one site, "over 15 million people in the United States [are] suffering from depression." Furthermore, this is an epidemic condition that affects children as well as adults. Another site claims that "pre-schoolers are the fastest-growing market for antidepressants. At least four percent of preschoolers -- over a million -- are clinically depressed." The risk for depression increases in women, the elderly and people with pre-existing health conditions.

Why does there seem to be such a tendency in psychiatry to prescribe antidepressants often and to not let them go away? The answer is simple: depression isn't going anywhere. According to UpliftProgram.com, "depression will be the second largest killer after heart disease by 2020 -- and studies show depression is a contributory factor to fatal coronary disease." That's right. It will be a killer. Depression is often viewed by society as more within the control of the patient but we cannot allow lives to be lost while we blame people for being sad. This condition needs to be taken seriously. It does produce negative health effects including a weakened immune system. The prevalence of severe depression is no secret. According to indepression.com, "2 out of every 3 people who commit suicide already talk about it to friends or family."

Antidepressants can cause side effects increasing suicide attempts but they can also help those who are drowning in suicidal thoughts come up for air. It may seem like a risky paradox. It may seem like psychiatrists should be more cautious about who they prescribe these pills to but there can be no question that some people genuinely need the prescription. In fact, based on the statistics I have found, "80% of depressed people are not currently having any treatment." So while I cannot claim that these drugs are perfect, I think I can make the argument that they are better than nothing. "Antidepressants work for 35 to 45% of the depressed population" and no, that is not enough but like I've said before, the numbers mean little to the individual. Our treatment methods are inadequate. I came into this project skeptical of antidepressants and as the conclusion of the third trimester of school draws nearer, I find that overall, depression is not being treated effectively, whether drugs are administered or not.

Teen Depression Graph. Digital image. Web. 13 Apr. 2012. <http://www.at-risk.org/blog/wp-content/uploads/teens-with-mde.jpg>.


"Depression Statistics." Web. 13 Apr. 2012. <http://www.indepression.com/depression-statistics.html>.

"Depression Fact Sheet: Depression Statistics and Depression Causes." Depression Solutions with the Uplift Program: Depression Self Help, Relationship Help, Depression and Anxiety Resources, Treatment and Information. Web. 13 Apr. 2012. <http://www.upliftprogram.com/depression_stats.html>.


"Depression Statistics." Depression Statistics. Web. 13 Apr. 2012. <http://www.depressionstatistics.org/>.

The Importance of Cohesive Care

As I have previously discussed, it is likely that the combination of drugs and therapy is ideal. So where can a patient go to get both? Not many places. Psychiatrists and other medical doctors can prescribe medication. Psychologists and counselors are trained in talk therapy. Rarely do psychiatrists provide both services. This may seem like basic specialization, dividing tasks by education. At the very least, it's a new trend. A few decades ago, your psychiatrist would be your psychotherapist. What changed and why does it matter?

What happened?
1. Psychology developed in legitimacy and importance as an academic study over time and thus, more psychologists entered the market. They go through less school than psychiatrists, a fact that is especially important to the next point.

2. Prescribing drugs without performing psychotherapy became financially beneficial to psychiatrists. A psychiatrist is usually burdened with the debt of medical school. They often cannot afford to spend 45 minutes per client if they want to make good money and work reasonable hours. Also, certain insurance factors make it possible to charge more for a fifteen minute appointment to prescribe drugs that a longer appointment that includes therapy.

So what do we do now? Typically, if a family doctor or a psychiatrist prescribes a psychiatric drug, they will also refer the patient to some kind of psychotherapist. It is completely up to the patient whether they want to go and since the disconnect between the two professions, less people being treated for depression go through therapy. The first meeting with a psychiatrist includes a family history and gathering of information about the patient that lasts 45 minutes. The following meetings tend to be fifteen minute checkups in which the psychiatrist focuses on checking for any side effects to the drug and determining it's level of success. This alone can be very expensive. It seems that some patients have decided that to add a therapist on top of a psychiatrist is an unacceptable expense.

What does this have to do with the effectiveness of antidepressants? I have already discussed that antidepressants can be effective. I have discussed that they are usually better in conjunction with therapy, so the fact that less depressed patients are receiving therapy is not good. I have also mentioned that in rare cases the medications can have extremely serious side effects. Antidepressants, in many ways, are considered one of the less risky psychiatric drugs but this does not mean that the patients taking them do not need serious attention. Depression can not only be a destructive disease due to it's relation to a lack of motivation in life, but also because the side effects of the medication used to treat it can be serious. As it stands, according to an article written for The New York Times, psychiatrists not only spend little to no time in therapy with their patients, they also reach diagnoses ten times more quickly than they often would have in previous decades. Perhaps, part of this can be considered prompted an increase in psychiatric knowledge overall, but it is undeniable (and the psychiatrist interviewed even admits) that a psychiatrist is more likely to make a quick diagnosis because it is financially prudent to do so. This new method of psychiatry and psychology at the very least causes a disconnect between the person with insight into the mind of the patient and the person filling out the prescriptions. Is it not possible that ideal care would make the psychological insight a prerequisite for the prescription? Apparently some people think so! Not everyone has given up on the idea of combined psychiatry and psychotherapy. There still are options if you want one mental health professional in your life but at an astronomical cost. According to the New York Times, "top child psychiatrists charge $2000 or more for initial evaluations," including talk therapy.

This trend of separation, so motivated by the cold realities of economics, seems unstoppable. The kind of combined treatment that might both allow drugs more thorough monitoring in patients and ensure the constructive support of therapy is not in reach for the average citizen. However, mental health is a serious issue and depression is a common condition. It is not unreasonable to hope that society will begin to realize that it is in their best interest that therapy be brought back into the picture whether they have to pay extra or not. I believe the most effective way to take an antidepressant for major depression is as part of a cohesive and well-monitored treatment plan and part of that success relies on the expertise and attentiveness of both a psychiatrist and a psychologist.

"Psychiatrist, Psychologist, Counselor, Therapist: What's the Difference?" Lotus Group. Web. 12 Apr. 2012. <http://www.lotusgroup.biz/psychiatrist-psychologist-counselor-therapist-whats-the-difference

Harris, Gardiner. "Talk Doesn’t Pay, So Psychiatry Turns Instead to Drug Therapy." The New York Times, 5 Mar. 2011. Web. 12 Apr. 2012. <http://www.nytimes.com/2011/03/06/health/policy/06doctors.html?pagewanted=all>.

Grohol, John M. "Psychiatry Doesn't Do Psychotherapy Anymore." Psych Central.com. Web. 12 Apr. 2012. <http://psychcentral.com/blog/archives/2011/03/06/psychiatry-doesnt-do-psychotherapy-anymore/>.

Shapiro, Linda A. "DRUG THERAPY PAYS. TALK THERAPY COSTS and Is Often Being Tossed." Wellsphere. 20 Mar. 2011. Web. 12 Apr. 2012. <http://www.wellsphere.com/mental-health-article/drug-therapy-pays-talk-therapy-costs-and-is-often-being-tossed/1388263>.

"Psychiatry, Psychology, Counseling, and Therapy: What to Expect." WebMD. WebMD. Web. 12 Apr. 2012. <http://www.webmd.com/mental-health/guide-to-psychiatry-and-counseling>.

Why the Market Can't Keep You Safe From Harmful Drugs (Unless You Have a Clue)

I would like to return to the question of why psychiatrists are increasingly leaving talk therapy in the hands of psychologists. However, I am waiting on a source that I think would illuminate the matter. For this reason, I will break the promise I made in my last post. Instead, I would like to discuss why my question is important and elaborate on the manner in which I asked it. Why do I feel it is important to consider the efficacy of antidepressants? What does that "efficacy" mean?


When I first began this project, I did not want to simply compare a bunch of studies. My goal is to determine the worthiness of antidepressants from a diagnostic perspective. I feel as if lately I may seem to be getting off topic to those who do not have the same picture of a finished project in mind that I have envisioned. My result can't be a catalog of statistics because when prescribing a medicine to the individual there is so much more to consider than how often it is successful statistically. In fact, so long as it is successful at all, there is a chance that it will help the patient. From that point, part of the problem is a subjective balancing of side effects. Is being less depressed worth it if you suddenly find it extremely difficult to sleep? Consider that possibility in the long run. Consider the side effects based on how they might be affected by age. Consider the side effects versus the severity of the depression. Every case of depression is unique. I have taken to finding out as much as I can about this type of medications and the way they are used and from that,  I will draw my own conclusions about how they should be handled to improve the success of depression treatment (with medication) and minimize severe adverse reactions. At the end of this project, all I will be able to offer is an opinion. I have not performed my own study in the traditional sense. I have no original data to present to you. I am examining the various stages of antidepressant distribution and making a value judgment on how things should occur.

The first stage is production. The drugs are produced for a profit by a pharmaceutical company. The FDA regulates this to a certain extent but I have already discussed that they do not have to preform their own studies on the drug. They review studies provided by the company. They provide the public with the facts through labeling and pamphlets. As a secondary function, they consider the safety of the drugs. How can an ineffective or harmful drug slip through this process? Either the studies were flawed or not representative enough or the studies were misrepresented to benefit the company.

Then, the drugs meet the psychiatrist, who reviews the information provided by the FDA and the drug company and decides in what situations he thinks it is worth prescribing. This cannot help being a subjective decision. How can an ineffective or harmful drug be readily prescribed? The psychiatrist, much like I must, must evaluate the risks, the side effects, the potential benefits, how these all interact with the situation of the patient.  They cannot have an infallible rule for prescription.

Finally, the drug reaches the consumer. Here, one might argue, the statistics are finally enough. If the consumer finds the side effects to overwhelm the effects, they will stop taking the drug. If the people who consume the drug are harmed, the drug will be taken off the market either due to regulation or lack of demand (from either psychiatrists or patients). Antidepressants are not a drug that people take for recreation. There is no apparent reason for the patient to keep taking the drug if they find it unpleasant, seriously harmful, or completely ineffective to their depression. So why do I insist upon reviewing the worthiness of these drugs? Would not the market determine their worthlessness and insist upon their removal naturally? I think not. I do not trust the producer to be honest or all-knowing about the product. I do not trust the doctor to always prescribe the drugs without making a mistake even if he has the best intentions. I do not trust the consumer to know that they are not being helped. It is possible for harmful drugs to reach the market. Anyone who has ever seen a class action lawsuit commercial could tell you that. People are given new drugs and later, it is discovered that they produce serious health problems. Legal action is taken and perhaps they're taken off the market. But these lawsuits are not only strategically avoided by drug companies, they are also much more likely to start in a drug that is producing obvious harmful effects like heart failure. Antidepressants may not have these drastic effects but does that mean that they are 100% safe? From my research up to this point, I have determined that antidepressants can have serious side effects and are not always effective or perhaps enough to alleviate depression. It's important to remember that our attitude towards the medicine can affect the safety of it's prescription. Without greater regulation, consumers must consider the risks of accepting the drug company at it's word (without reliable independent studies) and taking a drug from a doctor that they do not even sometimes partially understand. They must think for themselves. It is important to trust your doctor's knowledge of medicine but it is also important to understand your treatment and it's possible side effects to the best of your ability.  

Which Kind of Therapy is the Best?

The best therapy is determined by the situation of the individual depressed patient. A review of the most common types of therapy will shed light on the unique values of each.

• Psychodynamic Therapy and Psychoanalysis: The goal of psychoanalysis is to help patients recover repressed memories or feelings that might be affecting their mental health in the present. Modern day psychoanalysis is an in depth, frequently-scheduled form of therapy that is meant to inspire insight that will help the patient's situation. Psychodynamic therapy works towards same goals as psychoanalysis but is less frequent, perhaps once a week. The advantage of this therapy is that it is helpful in people with deeply ingrained habits or personality defects that they wish or need to change, a concept that easily applies to depression. Another variation of this is client-centered therapy, which is inspired by the humanistic theories of Freud's protege Carl Jung. Client-centered therapy attempts the same personality improvements but is characterized by a empathetic therapist rather than an objective therapist.                                     
•  Interpersonal Therapy: Interpersonal therapy focuses on identifying issues in the interpersonal relationships of the patient. Rather than examining the past and attempting to solve personality issues, this type of therapy attempts to help the patient find solutions for the relationship problems most detrimental to them in the present. This can be useful in cases of marital, parental, and workplace issues. Real time solutions to social problems can assist patients in coping with depression.

Shown Above: An Example of Irrational Negative Thought

• Cognitive Therapy: The aim of cognitive therapy is to alter the thought process of the patient when confronted with situations that could upset him or her. This type of therapy is based on the concept that negative thoughts produce negative moods, and therefore, depression. The ideal candidate for cognitive therapy is a patient with low self-esteem and self-defeating or even irrationally negative thoughts. Cognitive therapy both attempts to raise self esteem and equip patients with long term coping solutions for negative thought.                                                  
• Behavior Therapy: Behavior therapy is exactly what is sounds like: an attempt to help the patient alter his or her behavior in ways that will eliminate destructive behaviors and replace them with more constructive behaviors. The patient sees a therapist and tells that therapist about his or her routines. The therapist will suggest things that the patient can start doing that may improve his or her mood. Other methods of behavioral change include role-playing and reward-based behavior modification.

These methods are not alone and are often combined, most famously in cognitive-behavioral therapy. Each approach has it's own advantages and all of them are accepted as possible paths to overcoming depression. I cannot stress enough that there is no one cause of depression. Just as antidepressants can only treat one aspect of the disorder and do not work equally for everyone, the same is true of each of these therapies. It strikes me that the successful depression treatment plan is most likely to be a custom fit. The small child who has conflicts with his new stepmother may be at risk on a medication but may improve after interpersonal therapy. The overworked college student with no self confidence and diminished motivation may be best off trying antidepressants while also attending cognitive-behavioral therapy. The battered wife who continually returns to her abusive husband and is extremely depressed may need a proper antidepressant and a good bit of psychodynamic soul-searching. One thing that is certain about all of these therapies is that, they give the depressed patient a support system when he or she may not have anyone else. Therapy gives a patient with major depressive disorder someone to talk to about his or her feelings and even the effects of his or her medication. Perhaps, it is not too much to demand such attention from not just our psychologists but also our psychiatrists. Why aren't the people prescribing the medicine monitoring and assisting the psychological improvement of their patients on a regular basis? I don't mean to claim that there are not psychiatrists who are highly involved in their patient's progress. However, if you were to ask the next person you see after reading this blog post, I would be willing to bet that they would be more likely to predict a fifteen-minute interview followed by a prescription and a follow-up appointment in a month from a psychiatrist than a weekly or bi-weekly psychiatrist involvement. Is the disconnect between administering medicine and therapy a simple necessity of specialization or a problem that requires reform or an overestimated anomaly brought to the conscious of the public by a few bad psychiatrists among many better ones? I will examine these questions and their direct connection to the effectiveness of antidepressant treatment for depression in my next post.

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