Marketers have done a phenomenal job convincing Americans that antidepressant medication is good treatment for depression. Scientific research is painting a different picture. Study after study shows that when antidepressants are compared to placebo in controlled trials, they are nearly indistinguishable.1
This blog is not about whether or when antidepressants help. To head off a certain amount of hate mail, I will just say upfront that I believe antidepressants are highly effective for a small percentage of people who suffer from depression. And that percentage represents far fewer people than are convinced, with every fiber of their being, that antidepressants work wonders for them.
One reason antidepressants can seem effective is that a cascade of psychological interventions occurs in conjunction with starting medication. The first occurs before the person ever sees a doctor. Helplessness, hopelessness, and passivity are hallmarks of depression. Before calling for an appointment, something shifts inside the person. There is internal movement, from a position of helplessness and passivity to a position of greater agency—and the person starts to feel better. (We know this from psychotherapy research, which shows that depressive symptoms improve almost immediately upon starting treatment, before the therapist introduces any specific therapeutic interventions).
Next, the patient describes to the doctor what is going on—she engages in the process of putting words to experience. For some, it may be the first time they have talked openly and candidly about the extent of their suffering. We know from clinical experience and scientific research both that putting experience into words has powerful psychological benefits. The doctor listens with sympathetic interest—another psychological intervention. Finally, the doctor communicates in word and manner that the patient’s symptoms are familiar and treatable. She explains and normalizes symptoms the patient may have experienced as confusing and frightening, and she communicates that help is at hand.
These psychological interventions occur before the patient ever swallows a pill. They begin a process of “remoralization” which leads the patient to feel better. But the moment the patient swallows the pill, both doctor and patient attribute all improvement to the chemical ingredients of the drug. They overlook all the psychological factors at work and instead develop an unshakeable belief in the biological benefits of the medication—benefits that, for most patients, could be duplicated with a sugar pill.
The second reason antidepressants seem effective is simply timing. On average, an episode of major depression lasts about six months. Patients do not seek help the day they become depressed. They struggle with their depression and try everything they can think of to overcome it. Seeing a doctor is usually the last resort, not the first. By the time patients decide to see a doctor—often three or four months into a depressive episode—they feel they have tried everything else.
If the depressive episode follows a typical course, the depression will begin to remit on its own in two to three months. But at this juncture, the patient starts taking medication—and is told the medication may take eight to twelve weeks to work. Voilà. In eight to twelve weeks, the patient is indeed feeling better.
I have described things from the perspective of an impartial observer. Now consider things from the perspective of doctor and patient: Before starting medication, the patient tried everything she could think of, to no avail. She starts taking medication and, on cue, her depression begins to lift. From that point forward, doctor and patient believe that antidepressant medication is powerful treatment for depression—and nothing will convince them otherwise.
Jonathan Shedler, PhD practices psychotherapy in Denver, CO and online by videoconference. He is a Clinical Associate Professor at the University of Colorado School of Medicine. He lectures and leads workshops for professional audiences nationally and internationally and provides online clinical consultation and supervision to mental health professionals worldwide.
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Kirsch, I. (2010). The Emperor’s New Drugs: Exploding the Antidepressant Myth. NY: Basic Books.