Skeptic. For people satisfied with their standard depression treatments, debunking myths about them may be troubling. Many depressed people, for example, report that their antidepressants have been effective for them, and they sometimes are enraged to hear anyone question the value of these drugs. However, for critically thinking depression sufferers who have not been helped by antidepressants, psychotherapy, or other standard treatments, discovering truths about those treatments can provide ideas about what may actually work for them.
Critical thinkers aware of the research have difficulty placing faith in any depression treatment because science tells them that these treatments often work no better than placebos or nothing at all; and if one lacks faith in a depression treatment, it is not likely to be effective. Many studies have found that it is belief and faith—or what scientists call expectations and the placebo effect—that is mostly responsible for depression treatment working. People can find a way out of depression when their critical thinking about depression treatments is validated and respected, and they are challenged to think more critically about their critical thinking. There are five controversial beliefs about depression treatment that I discuss in greater depth in my book Surviving America’s Depression Epidemic.1
1. Antidepressants Are More Effective Than Placebos
2. If the First Antidepressant Fails, Another Antidepressant Will Likely Succeed
3. Electroconvulsive Treatment (ECT) Is An Effective Last Resort
4. Cognitive Behavior Therapy (CBT) Is The Best Psychotherapy for Depression
5. No Treatment For Depression Works
1. Antidepressants Are More Effective Than Placebos
There are millions of people who swear by their antidepressants, however, the scientific question is: For depressed people as a group, do antidepressants work any better than a placebo sugar pill? Irving Kirsch, professor emeritus at the University of Connecticut and author of The Emperor’s New Drugs, has been trying to answer that question for a significant part of his career.2 In 2002, Kirsch and his team examined 47 depression treatment studies that had been sponsored by drug companies on the antidepressants Prozac, Paxil, Zoloft, Effexor, Celexa, and Serzone. Many of these studies had not been published, but all had been submitted to the Food and Drug Administration (FDA), so Kirsch used the Freedom of Information Act to gain access to all the data. He discovered that in the majority of the trials, antidepressants failed to outperform sugar pill placebos. “All antidepressants,” he reported, “including the well-known SSRIs (selective serotonin reuptake inhibitors), had no clinically significant benefit over a placebo.” While in aggregate, antidepressants slightly edge out placebos, the difference is so unremarkable that Kirsch and others describe it as “clinically negligible.” 3
While antidepressants do about as well as placebos for moderately depressed patients, a common question is: Are antidepressants more effective for severely depressed patients? The answer is somewhat complicated. While there is no increased responsiveness to antidepressants among severely depressed patients, the placebo is slightly less powerful for this group. In a 2008 paper published in PLOS Medicine, Kirsch, now also a professor of psychology at the University of Hull in the United Kingdom, explained it this way:
Drug-placebo differences in antidepressant efficacy increase as a function of baseline severity, but are relatively small even for severely depressed patients. The relationship between initial severity and antidepressant efficacy is attributable to decreased responsiveness to placebo among very severely depressed patients, rather than to increased responsiveness to medication.4
Why are so many doctors unaware of the general lack of superiority of antidepressants as compared to placebos? The answer became clear in 2008 when researcher and physician Erick Turner, at the Department of Psychiatry and Center for Ethics in Health Care, Oregon Health and Science University, discovered that antidepressant studies with favorable outcomes were far more likely to be published than those with unfavorable outcomes. Analyzing published and unpublished antidepressant studies registered with the FDA between 1987-2004, Turner found that 37 of 38 studies having positive results were published; however, Turner reported, “Studies viewed by the FDA as having negative or questionable results were, with three exceptions, either not published (22 studies) or published in a way that, in our opinion, falsely conveyed a positive outcome (11 studies).”5
2. If the First Antidepressant Fails, Another Antidepressant Will Likely Succeed.
In The Noonday Demon, the popular 2001 book about depression, writer and depression sufferer Andrew Solomon repeated the then urban legend that “more than 80% of depressed patients are responsive to medication.” Solomon accurately cites a journal article that states this statistic; however, following the “reference trail,” I discovered that the journal article that Solomon cited refers to a second article for evidence of this statistic, but this second journal article mentions nothing about 80% of depressed patients responding to some medication.6
The National Institute of Mental Health (NIMH) was aware that there was no research to back up the assertion that 80% of depressed patients improve if they keep trying different medications, so NIMH funded “Sequential Treatment Alternatives to Relieve Depression” (STAR*D), the largest ever study of sequential depression treatments. STAR*D results were published in 2006. In Step One of STAR*D, all depressed patients were given the antidepressant Celexa, and in Step Two, patients who failed to respond to Celexa were divided into different groups and received other treatments (mostly different drug treatments) in place of or in addition to Celexa. If their second treatment failed, there was a third and, if necessary, a fourth treatment step.
In every STAR*D treatment step, remission rates were either equal to or significantly lower than the customary placebo performance in other antidepressant studies, but to the exasperation of many scientists, there was no placebo control in this $35 million U.S. taxpayer funded STAR*D study. And to make matters worse, STAR*D researchers disclosed receiving consulting and speaker fees from the pharmaceutical companies that manufacture the antidepressants studied in STAR*D.
In March 2006, NIMH triumphantly announced that 50% of depressed people saw remission of symptoms after the first two STAR*D steps. However, NIMH failed to mention in its press release that in the same time it took to complete these first two steps—slightly over six months—previous research shows that depressed people receiving no treatment at all have a spontaneous remission rate of 50%.
In November 2006, following the completion of all four STAR*D steps, STAR*D authors claimed a 67% cumulative remission rate, which again exasperated many scientists because this number failed to incorporate STAR*D’s extremely high relapse and dropout rates. In an American Journal of Psychiatry editorial that accompanied STAR*D authors’ report, J. Craig Nelson stated, “I found a cumulative sustained recovery rate of 43% after four treatments, using a method similar to the authors but taking relapse rates into account.”7 However, even 43% turns out to be an inflated rate.
Separate analyses of STAR*D in 2010 by psychologist Ed Pigott and medical reporter Robert Whitaker revealed that STAR*D researchers had inflated remission numbers by switching mid-study to a more lenient measurement, and also by including patients who were not depressed enough at baseline to meet study criteria.8 But even taking the STAR*D data as is, Pigott’s analysis revealed that less than 3% of the entire group of depressed patients who began the STAR*D study can be ascertained as having a sustained remission (i.e., actually participated in the final assessment without relapsing and/or dropping out).9
3. Electroconvulsive Treatment (ECT) Is An Effective Last Resort
Andrew Solomon in The Noonday Demon also states, “ECT seems to have some significant impact between 75 and 90% of the time. About half of those who have improved on ECT still feel good a year after treatment.”10 Is ECT really that effective?
In 2004, medical researcher Joan Prudic and her team at New York State Psychiatric Institute conducted a major study of ECT involving 347 patients at seven hospitals. Reported were both the immediate outcomes and the outcomes over a 24-week followup period. With respect to immediate outcomes, Prudic reported: “In contrast to the 70 to 90% remission rates expected with ECT, remission rates, depending on criteria, were 30.3 to 46.7%.” Even worse for ECT advocates, Prudic noted that, “10 days after ECT, patients had lost 40% of the improvement.”11
There are also studies comparing ECT with a placebo (called “sham ECT”). In sham ECT, patients receive muscle-relaxing and anesthetizing drugs that routinely accompany ECT, and they are hooked up to the ECT apparatus, but they receive no electric voltage. Psychiatrist Colin Ross reports, “No study has demonstrated a significant difference between real and placebo (sham) ECT at one month post-treatment.”12
4. Cognitive Behavior Therapy (CBT) Is The Best Psychotherapy For Depression
First, the good news about CBT. The only non-drug treatment examined in the STAR*D study was a form of cognitive therapy that was not fully detailed by the authors and only administered in Step Two. Among those who failed Celexa in the first step, three groups in Step Two switched from Celexa to one of three antidepressants, and their remission rates ranged from 25 to 26.6%; but one group in Step Two switched from Celexa to cognitive therapy, and its remission rate was 41.9%. STAR*D researchers did not assess whether any differences in treatment effectiveness were statistically significant.
Another group in Step Two maintained Celexa and added cognitive therapy, and this “Celexa plus cognitive therapy” group’s remission rate was 29.4%, not as high as the group that received cognitive therapy without medication. This begs the question: Is it also a myth that “antidepressants plus psychotherapy” works better than either treatment alone? Research psychologist David Antonuccio at the University of Nevada School of Medicine reports, “Combined psychotherapy and drug treatment do not appear to be superior to therapy or drug treatment alone.”13
What psychotherapy is best for depression? While Americans hear most about CBT, it turns out that CBT or some form of cognitive therapy is no more effective for depression than any of several other types of psychotherapy. In 2008, psychologists Pim Cuijpers and Annemicke van Straten at the University of Amsterdam reported on a meta-analysis of 53 studies, each of which compared two or more different types of psychotherapy for depression. Included were varieties of cognitive behavior therapy, psychodynamic therapy, behavioral activation therapy, social skills training, problem-solving therapy, interpersonal therapy and nondirective supportive therapy. The major finding? “No large differences in efficacy between major psychotherapies for mild to moderate depression.”14
So, if psychotherapy technique is not all that important, what is? Psychologist Bruce Wampold at the University of Wisconsin reviewed the psychotherapy outcome literature, examining hundreds of studies and meta-analyses, for his book The Great Psychotherapy Debate. Wampold unequivocally states that outcome effectiveness does not depend on the specific techniques of psychotherapy, but instead depends on so-called “non-specific” factors such as the nature of the alliance between therapist and their client, and clients’ confidence in the therapy and in their therapist. “Simply stated,” Wampold concludes, “the client must believe in the treatment or be led to believe in it.”15
5. No Treatment For Depression Works
In April 2002, an NIMH-funded study on the antidepressant Zoloft, the herb St. John’s Wort, and a placebo had some curious results. The findings were that 32% of placebo-treated patients experienced remission, better than the 25% remission for the Zoloft-treated patients or the 24% remission for the St. John’s Wort-treated patients.16 Most scientists would say that this study shows that neither Zoloft nor St. John’s Wort worked, but those subjects who had positive outcomes with these two treatments would disagree. So, does this study show that antidepressants and St. John’s Wort are not helpful, or does it show that expectations, belief and faith are the likely factors that make all treatments work?
When assessing whether a specific treatment is effective, scientists are trained to rule out the effect of expectations. Researchers evaluate a depression treatment as effective if, in a controlled study, the treatment outcome is significantly better than a placebo. However, the reality of depression treatments is that expectations, faith, belief and the placebo effect are—far and away—the most important reasons why anything works.
In 2004, Heather Krell, M.D. and her group at the University of California in Los Angeles examined the influence of patient expectations on the effectiveness of an experimental antidepressant. They found that among those depressed patients expecting that the medication would be very effective, 90% had a positive response; while among those expecting the medication would be somewhat effective, only 33% had a positive response.17 No depressed people were included in this study who expected the experimental drug to be ineffective, but such nonbelievers, in my experience, rarely report a positive response with antidepressants. All treatments can work, but rarely do so if one doesn’t believe in them.
A Path For Treatment Resisters: Critical Thinking About Critical Thinking
Critical thinking and an absence of self-deception are crucial for success in many areas of life, but these same talents can be problematic with respect to depression. A more accurate notion of how truly powerless one is in a situation (such as family, an organization, or society) can result in a greater feeling of helplessness, pain and depression.
From several classic studies, we know that moderately depressed people are, in a sense, more critically thinking than are non-depressed people. These studies show that depressed people are more accurate than are non-depressed people in both their assessment of control over events and in judging people’s attitudes toward them. Researchers Lauren Alloy and Lyn Abramson at the University of Pennsylvania in 1979, studying non-depressed and depressed subjects who played a rigged game in which they had no actual control, found that depressed subjects more accurately evaluated their lack of control when either losing or winning. 18 And researcher Peter Lewinsohn at the University of Oregon in 1980, found that depressed subjects judge other people’s attitudes toward them more accurately than non-depressed subjects.19
Critical thinking also creates a problem for depression treatment, as skepticism makes one stubbornly resistant to much of what helps others. Specifically, to the extent one has uncritical faith in a treatment, it is far more likely to be experienced as successful; but to the extent that one is more skeptical about the effectiveness of treatment, one is less likely to have expectations that it will be effective, and this becomes a self-fulfilling prophesy.
Before modern research borne out this problematic relationship between depression and critical thinking, the American psychologist and philosopher William James (1842-1910) recognized this reality based on his personal experience. James had a history of severe depression, which helped fuel some of his greatest wisdom as to how to overcome depression. In The Thought and Character of William James, Ralph Barton Perry’s classic biography on his teacher, we learn that at age 27 James said he went through a period of a “disgust for life” that Perry describes as an “ebbing of the will to live…a personal crisis that could only be relieved by philosophical insight.” What was James’s transformative insight?
James was a critical thinker and had no stomach for smiley-faced positive thinking, but he also concluded that his pessimism might just destroy him. With his critical thinking, he came quite pragmatically to “believe in belief.” He continued to maintain that one cannot choose to believe in whatever one wants (one cannot choose to believe that 2 + 2 = 5 for example); however, he concluded that there is a range of human experience in which one can choose beliefs. He came to understand that, “Faith in a fact can help create the fact.” So, for example, a belief that one “has a significant contribution to make to the world” can keep one from committing suicide during a period of deep despair, and remaining alive makes it possible to in fact make a significant contribution.
Critical thinkers are skeptics who have difficulty with belief based on faith, but depression treatments work to the extent that one has faith in them. Instead of viewing themselves as failures for not improving with standard treatments, depressed critical thinkers can logically acknowledge the downside of their temperament. Myth busting about standard treatments enables critically thinking treatment resisters to release their pain over “treatment failure.” The pain of failure is one of the many pains that results in depression as well as substance abuse and other compulsions that are fueled by a need to shut down one’s pain. Releasing any pain, including the pain of treatment failure, can be helpful.
When skeptics discover that there have been others like themselves who have escaped this conundrum by finding something that they could believe in without giving up their critical thinking, this can jump start them into finding their own particular antidote to depression. William James ultimately let go of his dallying with suicide, remained a tough-minded thinker with scientific loyalty to the facts, but also developed faith that, “Life shall be built in doing and suffering and creating.”
1. Levine, B.E. 2007. Surviving America’s Depression Epidemic. Chelsea Green Publishing.
2. Kirsch, I. 2010. The Emperor’s New Drugs: Exploding the Antidepressant Myth. New York: Basic Books.
3. Kirsch, I., et al. 2002. “The Emperor’s New Drugs: An Analysis of Antidepressant Medication Data Submitted to the U.S. Food and Drug Administration,” Prevention & Treatment, 5 (23).
“57% of the trials funded by the pharmaceutical industry failed to show a
significant difference between drug and placebo,” in Kirsch, I., et al., “Response to the Commentaries: Antidepressants and Placebos: Secrets, Revelations, and Unanswered Questions,” Prevention & Treatment, 5:33 (July 15, 2002), http://journals.apa.org/prevention/volume5/pre0050033r.html
4. Kirsch, I., et al. 2008. “Initial Severity and Antidepressant Benefits: A Meta-Analysis of Data Submitted to the Food and Drug Administration,” February, PLos Medicine http://www.plosmedicine.org/article/info:doi/10.1371/journal.pmed.0050045
5. Turner, E. H., et al. 2008. “Selective Publication of Antidepressant Trials and Its Influence on Apparent Efficacy,” New England Journal of Medicine, 358(3):252-260.
6. Solomon, A. 2001. The Noonday Demon: An Atlas of Depression, New York: Touchstone. Solomon refers to Mary Whooley and Gregory Simon, “Managing Depression in Medical Outpatients,” New England Journal of Medicine 343:26 (2000), who indeed report “more than 80% of depressed patients have a response to at least one medication” pp. 1942-1949. Whooley and Simon refer these statistics to H.C. Schulberg, W. Katon, G.E. Simon, and A.J. Rush, “Treating Major Depression in Primary Care Practice: An Update of the Agency for Health Care Policy Research Practice Guidelines,” Archives of General Psychiatry 55 (1998) pp. 1121-1127, where there is, however, no mention of 80% responding to at least one medication.
7. Nelson, C. 2006. “The STAR*D Study: A Four-Course Meal That Leaves Us Wanting More,” American Journal of Psychiatry, 163 (11):1864-66. See also: Rush. A. J. et al. 2006. “Acute and Longer-Term Outcomes in Depressed Outpatients Requiring One or Several Treatment Steps: A STAR*D Report,” American Journal of Psychiatry, 163(11):1905-17; Trivedi, M. H., et al. 2006. “Evaluation of Outcomes with Citalopram for Depression Using Measurement-Based Care in STAR*D: Implications for Clinical Practice,” American Journal of Psychiatry, 163:28-40.
8. Whitaker, R. 2010. “The STAR*D Scandal: A New Paper Sums It All Up,” Psychology Today Blog, August 27. http://www.psychologytoday.com/blog/mad-in-america/201008/the-stard-scandal-new-paper-sums-it-all
9. Pigott, H. E. 2010. “Efficacy and Effectiveness of Antidepressants: Current Status of Research,” Psychotherapy and Psychosomatics, 79 (5): 267-279.
10. Solomon, 2001.
11. Prudic, J., et at. 2004. “Effectiveness of Electroconvulsive Therapy in Community Settings,” Biological Psychiatry, 55(3):301-12.
12. Ross, C. A. 2006. “The Sham ECT Literature: Implications For Consent to ECT,”Ethical Human Psychology and Psychiatry, 8(1):17-28.
13. Antonuccio, D. O., et al. 1999. “Raising Questions about Antidepressants,”Psychotherapy and Psychosomatics, 68:3-14.
14. Cuijpers, P. et al. 2008. “Psychotherapy for Depression in Adults: A Meta-Analysis of Comparative Outcome Studies,” Journal of Consulting and Clinical Psychology, 76 (6):909-922.
15. Wampold, B. 2001. The Great Psychotherapy Debate: Models, Methods, and Findings. Mahweh, NJ: Lawrence Erlbaum.
16. Davidson, J. R. T., et al. 2002. “Effect of Hypericum Perforatum (St John’s Wort) in Major Depressive Disorder,” Journal of the American Medical Association, 287 (14):1807-14.
17. Krell, H.V. et al. 2004. “Subject Expectations of Treatment Effectiveness and Outcome of Treatment with an Experimental Antidepressant,” Journal of Clinical Psychiatry, 65 (9):1174-79.
18. Alloy, L.B. and Abramson, L.Y. “Judgment of Contingency in Depressed and Nondepressed Students: Sadder but Wiser?” Journal of Experimental Psychology: General 108:4 (1979): 441-85.
19. Lewinsohn, P. M. et al. 1980. “Social Competence and Depression: The Role of Illusory Self-Perceptions,” Journal of Abnormal Psychology 89:203-12. McKenzie, K. et al. 2004. “Learning from Low Income Countries: Mental Health,” BMJ 329:1138-40.