How doctors and patients get fooled by antidepressants
Posted Feb 10, 2015
Marketers have done a terrific job persuading Americans that antidepressant medication is good treatment for depression. Scientific research is painting a different picture. Study after study shows antidepressants are nearly indistinguishable from placebo.1
This blog is not about whether or when antidepressants help. To head off some hate mail, I will say upfront that I believe antidepressants are highly effective for a small percentage of depressed people. It's just that this percentage represents far fewer people than are convinced, with every fiber of their being, that antidepressants have changed their lives.
This blog is about the creation of superstition: It is about how large numbers of intelligent people come to believe something that cannot, statistically, be true for most of them.
One reason antidepressants seem effective is that a cascade of psychological interventions occurs in conjunction with starting medication. The first happens before the person even sees a doctor. Helplessness, hopelessness, and passivity are hallmarks of depression. Before making an appointment, something shifts inside. There is internal movement from a position of helplessness and passivity to a position of greater agency. The person makes an active decision to do something to help themselves—and starts to feel better. (We also know this from psychotherapy research, which shows that depressive symptoms start improving immediately, before therapeutic interventions begin).
Next, the patient describes to the doctor what is wrong—she puts words to experience. It may be the first time some people have talked openly to another person about the extent of their pain. The mere act of putting painful experience into words has psychological powerful benefits. The doctor listens with sympathetic attention—yet another intervention. Finally, the doctor communicates in word and manner that the person's symptoms are familiar and treatable. She explains and normalizes symptoms the patient may have experienced as confusing and frightening.
These interventions occur before the patient has swallowed a single pill, and begin a process of “remoralization” crucial to recovery. But the moment the patient swallows a pill, doctor and patient attribute all improvement to the chemical effects of the drug, and overlook the cascade of interventions that accompanied this. They instead develop an unshakeable belief in the biological benefits of the medication—benefits that, for most patients, can be duplicated with a sugar pill.
A second reason antidepressants seem effective is simply timing. On average, a major depressive episode lasts about six months. Patients do not seek help the day they become depressed. They struggle with their depression for weeks or months, trying everything they can to overcome it. Seeing a doctor is 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 lift on its own in two to three more months. But at this juncture, the patient starts taking medication—and is told the medication can take eight to twelve weeks to work. Voilà. In eight to twelve weeks, the patient is indeed feeling better, on schedule.
Now consider these events 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—and nothing will change their minds.
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.