In the current practice environment, two ideas have gained professional and popular acclaim: (1) that drugs are more effective for "severe" psychological problems; and (2) that combining medication with psychotherapy is better than either treatment alone. On this page, studies related two these two popular myths are summarized.

Is therapy on the way out?
When it comes to the treatment of depression, recent research shows that drugs are in and therapy is out. Comparing data from two large national surveys, researchers found the following trends:

	Three times as many Americans sought outpatient treatment for depression in 1997 as in 1987.
	Antidepressant use doubled during the 10-year period among patients seeking treatment.
	A total of 74% of patients used drugs to treat their depression in 1997, compared to 37% a decade earlier.
	Among those seeking treatment, the proportion receiving psychotherapy declined from 71% to 60% during the 10-year period.
	And the average number of visits to a therapist declined from 12.6 in 1987 to 8.7 in 1997.

What could account for such a shift given that ALL the data indicate that therapy is as effective, less expensive (in the long run), and has fewer problems than drug treatment? Perhaps consumers appreciate the ease of a prescription, the wide availability (they can get it from the family doc rather than have to go see a mental health specialist). Or, perhaps the drugs are being overprescribed by family physicians. Or perhaps the billions spent on advertising have achieved their desired effect. Or perhaps, therapists have simply lost touch with consumers? Tell us what you think. Click here to send an email to ISTC.

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Counseling versus Psychotherapy . . .
For some reason, the accepted clinical wisdom is that medications plus psychotherapy results in better overall outcomes for the treatment of depression in clinical trials studies. Another study–this one in the United Kingdom–shows that the empirically bankrupt status of this widespread belief. In the study, researchers Navjot Bedi, Claire Chilvers,Richard Churchill et al. The study set out to determine whether counseling is as effective as anti depressants for depression in primary care and whether allowing patients to choose their treatment affects their response. Here's what they found: (1) treatment and follow-up were identical in randomized and patient preference arms; (2) there was no difference in the two treatments in either the 103 randomized patients and 220 preference patients in the trial; (3) there were no differences at base line in the characteristics of the 2 groups; (4) patients preference for either treatment conferred no additional benefit; and (5) for every 1 patient who chose drug treatment 3 chose counseling. The conclusion: "these data challenge several assumptions about the most appropriate treatment for depression in primary care."

The British Journal of Psychiatry (2000). "Assessing effectiveness of treatment of depression in primary care. 177, 312-318

Couples Therapy versus Anti-Depressants for Depression
So what works better for depression: (1) anti-depressants; or (2) couples therapy? Well, if you listen to the mental health professional organizations, you'd think it was anti-depressants. Indeed, practicing therapists seem to believe that anti-depressants are the "treatment of choice" for people who are depressed. The data, of course, suggest something else entirely. In this most recent study, researchers compared couples therapy with an anti-depressant and found that: (1) those in the anti-depressant group had significantly higher drop out rates; and (2) significantly greater improvement in the couples group which were maintained at one-year follow up. The results, interestingly enough, are not all that surprising. Most studies show higher drop out rates for those taking drugs. Similarly, most studies favor psychotherapy over drugs in terms of outcome. What is perhaps most surprising about these results is how non-drug prescribing mental health professional organizations continue to tout the "drug-em Dano" line even though the research clearly favors talk therapy . . .

Leff, J. et al. The london depression intervention trial (June 2000). British Journal of Psychiatry, 177, 95-100.

Talk Therapy for Schizophrenia? Yeah, and especially the most difficult to treat!
Talk therapists have never gotten over the shame that's been heaped upon them by the medical profession for suggesting that the family might have something to do with the development or maintenance of the condition known as schizophrenia. Instead, they've relegated themselves to counseling the "worried well." Now comes research which shows that talk therapy–both cognitive-behavioral and simple supportive therapy–resulted in significant reductions in global schizophrenic, negative, and depressive symptoms with clients who did not respond to neuroleptic drugs! Moreover, changes were maintained at 9 months follow up! It's time for therapists to remove the cloak of shame and stand up for the value of talk therapy!

Sensky, T. et al. (2000). A randomized controlled trial of cognitive behavioral therapy for persistent symptoms in schizophrenia resistant to medication. Archives of General Psychiatry, 57, 165-72.

On a related note . . .

So the new atypical anti-psychotic drugs don't cause Tardive Dyskinesia, eh?
On May 26, 2000, a jury in the circuit court of Philadelphia awarded $6.7 million to a patient afflicted with tardive dyskinesia caused by the neuroleptic ("antipsychotic") drug Risperdal (generic name, risperidone). In Liss vs. Doeff, the jury found the psychiatrist negligent in his treatment of Mrs. Elizabeth Liss. The case is among the first involving Risperdal, a relatively new neuroleptic that was put on the market in 1994 and originally promoted as relatively free of the risk of tardive dyskinesia. Ms. Liss developed tardive dyskinesia during a fourteen-month period of exposure to Risperdal as a maintenance treatment for manic-depressive (bipolar) disorder. In previous years, she had several relatively brief exposures to other neuroleptics. Tardive dyskinesia is a movement disorder caused by neuroleptic or "antipsychotic" medications. It can afflict any voluntary muscles of control. It can become severe and disabling, and there are no effective treatments. Studies of older neuroleptics such as Haldol, Navane, Prolixin, and Thorazine have demonstrated a cumulative risk of 4%-8% per year for the development of this disorder. Thus, the risk developing tardive dyskinesia during a five-year exposure to neuroleptics is in the astronomical range of 20%-40%. Among the elderly cumulative rates can surpass 20% per year. Tardive dyskinesia also afflicts children. As yet there is insufficient data to predict the exact rates of tardive dyskinesia for newer, atypical neuroleptics such as Risperdal, Zyprexa (olanzapine), and Seroquel (quetiapine). However, prudent physicians should assume that all neuroleptic drugs are associated with a high risk of tardive dyskinesia. Mrs. Liss suffered from a form of tardive dyskinesia called tardive dystonia. The dystonia caused Mrs. Liss to suffer from disfiguring facial grimaces and painful neck spasms. In addition, she was afflicted with abnormal movements of her tongue, jaw, and mouth, impaired swallowing, occasionally irregular breathing, and abnormalities in her hands and walking.

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Putting the Panick-ed on Drugs . . .
Drugs are the treatment of choice for panic disorder, right? Well, if you listen to the pharmaceutical companies you'd think so. And yet, the data indicate clearly that drug treatment is not only less effective, it may actually make matters worse over the long haul. Such empirical findings lead one to wonder why so many people troubled by panic are put on psychotropic drugs and not referred to treatment. Researchers Hofmann and Spiegel puzzle over the question. They reviewed the data and found higher treatment effect sizes, lower attrition rates, and favorable cost profiles for talk therapy as compared to medication treatment for this disorder. Do you think anyone will listen though? AH, BE QUIET and take your medication . . .

Hofmann, S.G. (1999). Panic Control and its applications. Journal of Psychotherapeutic Practice and Research, 8(1), 3-11.

Recent Reviews . . .

Really, Truly, Severely Depressed People Need Medication. Right? Ah Baloney!
You hear it on the TV, you hear it at conferences, you even hear non-medical helping professionals saying it . . . "Oh yeah, severely depressed people need medication." How is it that so many believe so much based on so little evidence? Now, a more definitive study addresses the issue and finds the idea empirically bankrupt. Researchers DeRubeis, Gelfand, Tang, & Simons completed a mega-analysis of studies comparing medication with cognitive-behavioral therapy and found, "antidepressant medications should not be considered . . . superior to . . . therapy for the acute treatment of severely depressed outpatients" (p. 1007). It's time for the non-medical helping professionals to stop kowtowing to the medical profession and deal with their perpetually low professional-esteem. A good place to start? Look at the empirical data!

DeRubeis, R., Gelfand, L., Tang, T., & Simons, A. (1999). Medications versus cognitive behavioral therapy for severely depressed outpatients. American Journal of Psychiatry 156(7), 1007-1012.

Psychotherapy and Schizophrenia: An Oxymoron?
It is is you listen to American Psychiatry or the pharmaceutical industry. Therapists seem unable to embrace the idea that therapy is an effective treatment for people with this debilitating condition. Perhaps due to the beating the field took in the 1950's for exploring psychological reasons (e.g., family dynamics) for the condition, talk therapists have virtually ignored the population and turned families and sufferers over to the pill pushers. And yet, the data have always pointed to the utility if not superiority of the talk therapies. In the latest study, researchers conducted a meta-analysis found that people treated with talk therapy in addition to medication were significantly better off than those treated with medication alone (.39 standard deviations). Moreover, treatment effects for the dreaded negative symptoms were significantly greater! In addition, people were less likely to suffer relapses. No evaluation of talk therapy alone was included in the study of course as virtually no one has done (read: funded) such research in the last two decades.

Mojtabai, R. et al. (1998). Role of psychosocial treatments in management of schizophrenia. Schizophrenia Bulletin, 24, 569-587.

Psychotherapy and Schizophrenia: Put the Two Words Together and You'll be Accused of Everything from Incompetence to being Schizophrenic
In the treatment of schizophrenia, the biological perspective rules. Family therapists have been lambasted for suggesting that other factors (e.g., the family) may play a role. The National Alliance for the Mentally Ill (more like, the National Alliance of Families of the Mentally Ill) have adopted the biological perspective with a vengeance–attacking anyone who might suggest otherwise. And then there's the research. Israeli researchers have found that kids who lose a parent through divorce or death prior to age 17 are significantly more likely to develop major depression, schizophrenia, and bipolar disorder. Those who'd lost a parent through divorce or abandonment were more prone to these disorders than those whose parent had died! Didn't the systems-theorists get it right in the beginning? Problems are a result of and maintained by interacting systems (e.g., family, environment, genetics, etc.).

Lerer, B. (March 1999) Molecular Psychiatry.

The Role of the Therapeutic Alliance in Biologically-Oriented Treatment:
Is biological intervention the "treatment of the future" as it has been touted?
Is biology destiny? Are drug therapies as effective as talk therapies? These questions were addressed in a recent large-scale, multi-site, carefully-controlled research study known as the TDCRP. In a recent article, researchers found that the quality of the therapeutic relationship was just as important in producing a successful outcome in biologically-oriented (e.g., drug therapy) treatment as it was in traditional talk therapy. In fact, this is the first study to demonstrate empirically what many in the biologically-oriented treatment industry have long disputed: a strong, collaborative relationship matters even when the treatment is biological in nature. Indeed, this finding may in part explain the poorer outcomes frequently observed in the biological treatment of depressed clients by primary care physicians since these doctors often spend little time (and have little training in) forming alliances with clients.

Krupnick, J.L. et al. The role of therapeutic alliance in psychotherapy and Pharmacotherapy outcome: Findings in the National Institute of Mental Health Treatment of Depression Collaborative Research Program. Journal of Consulting and Clinical Psychology, 64 (3), 532-9.

Three Valuable Resources Every Therapist Should Have in their Library on Psychiatric Drugs
Want to know what the data really say about the "biochemical imbalance," the effectiveness of most psychotropic meds, or the dopamine hypothesis of schizophrenia? Then read these books. Packed full of up-to-date research on the biological perspective, these books from the field's leading scientists will go a long way to making you a fully informed treatment professional or consumer of mental health services.

From Placebo to Panacea : Putting Psychiatric Drugs to the Test

The Antidepressant Era

Blaming the Brain : The Truth About...

Therapy may deplete your pocketbook but at least it doesn't cause brain damage . . .
A recent research study reveals that SSRI's cause morphologic changes in brain tissue (normally called, "brain damage') similar to those caused by Ecstasy–that's right!. In an article published in Brain Research, Dr. Kalia and others found that SSRI's caused swelling in axon terminals, thickening of axons, and corkscrew-like profiles in the brains of rats following their use of Fluoxetine, sibutramine, and sertaline. Such findings may help explain why these drugs are well known to "wear off" after long term use. The reason? Perhaps they are actually destroying the nerve tissue they target.

Brain Research (March 6, 2000). Vol. 858, 92-105.

Drugs and Therapy Equally Effective in the Treatment of Severe Depression
In the aftermath of the failure to find any differences in efficacy between the methods of treatment tested in the TDCRP, some early analyses seemed to suggest that medications were better if the client were severely depressed. Giving away their pro-drug bias, the American Psychiatric Association jumped on the results and recommended drugs as the first line of treatment in people who are severely depressed. Now, all too quietly, the truth emerges. Not based on a single study, this "mega-analysis" of 4 separate studies comparing CBT to anti-depressants found a slight but non-significant difference favoring the therapy over drugs! The authors conclude, "there are no empirical grounds for favoring either form of therapy and that the unique needs of the individual should continue to guide therapeutic choices."

DeRubeis, R.J. et al. (1999). Medications versus cognitive behavior therapy for severely depressed outpatients. American Journal of Psychiatry, 156, 1007-1013.

Are Meds the only therapy for Schizophrenia?
When a man with schizophrenia requested psychotherapy recently in addition to his antipsychotic medication, his insurer said there was, "no evidence that psychotherapy helps people with schizophrenia." The story is all too familiar to therapists. The notion behind it is that people with schizophrenia are either too sick to be reached by psychotherapy or, thanks to medication, too well to need it. Indeed, psychiatry with it's meds-are-the-only-way policy for the last 30 years, and talk therapists with their hands-off-the-seriously mentally-ill-folk policy helped to create this mistruth. Two studies published in November in The American Journal of Psychiatry by Hogarty et al.showed that a three-year course of the treatment, as little as two times a month, was extremely helpful to many patients in preventing relapses and improving social adjustment. Indeed, the group receiving supportive therapy had the fewest complications or relapses. The only thing more surprising about these studies than the results is the surprise about the results. The bulk of data show that medications are not the answer to the problem posed by people suffering from this debilitating condition. Even with neuroleptic drugs, only 10% of the total number of people with this problem are employed. Moreover, neuroleptic drugs prevent relapse in only 1/3 of the people who take them. That means, 66% will need something else.

Grady, D. (January 20, 1998). Personal Therapy for Schizophrenia. NY Times.

Dispelling Treatment Myths: Combining Drugs and Psychotherapy is not more effective.
The standard "party line" of many professional groups is that combining drugs with psychotherapy is better than either type of treatment alone for the treatment of depression. In a recent article, however, senior researcher and editor of the prestigious Journal of Consulting and Clinical Psychology, Larry Beutler, challenged anyone to find current literature that supports this belief. In his article, Beutler shows that this "myth"–which started twenty years ago as a result of some consensus panels at Yale University–is not supported by the literature. Indeed, he states that "contemporary literature has almost universally determined that the mean effects of even a very unspecified and non-specific form of psychotherapy is as good as a highly specific medication" (p. 4). In addition, studies which have shown some advantage in terms of the speed of the effect have usually been offset by increased drop-out and relapse rates.

Beutler, L.E. (1997). Fact and fiction about prescription privileges. Psychotherapy Bulletin, 32(2), 4-6.

Do people want to take medications?
Ask any physician and they'll say, compliance with medication regimens is a serious problem. Estimates are that half of all patients on prescribed medication take less than the amount thought to cause therapeutic benefit. The question is why? In most cases, the person went to the doctor not the other way around. Research conducted by Williams goes a long way toward answering this question. Basically, the study found that client's perception of personal choice and perceived support from their physician were strongly positively correlated with medication compliance and mattered a great deal more than external or self-imposed pressure to comply. In other words, honoring the client's perception and experience is more important than the treatment itself in helping people start the healing process. The researcher recommends that physicians offer choices to their clients, minimize the pressure to "behave," and validate their client's opinions! The sheer basic-ness of such recommendations indicates how far the field needs to go to become more customer oriented. The finding, however, confirms tons of other research on compliance which shows that honoring the client's view and ideas increases cooperation and collaboration.

Check out this data on compliance with medication. Used to tout the effectiveness of Sertaline in the treatment of adults and children with Obsessive and Compulsive behaviors, the study actually shows how clients would prefer an alternative to drugs. The authors note that 42% of the recipients of the active drug were "very much or much improved" as compared to 26% of those receiving a placebo. They go on to say that "few subjects dropped out of the study." However, looking closely one finds something the authors do not say–of those who dropped out, participants receiving the drug were 400% more like to have received the drug than the placebo. Now what do you think this means? Curiously, the authors make no comment. Neither do they make much of the fact that the results were based on only 38% of the original sample and that less than 50% of the final sample actually improved! Perhaps, it isn't so curious after all as the study was funded by the pharmaceutical industry!

Williams, G.C. (1998). Autonomous regulation and long-term medication adherence in adult outpatients. Health Psychology, 17, 269-276.

Keller, M.B. et al. (1998). Maintenance phase efficacy of Sertaline for chronic depression. JAMA, 280, 1665-72

March, J.S. (1998). Sertaline in children and adolescents with obsessive compulsive disorder. JAMA, 280, 1752-6.

What matters most in pharmacotherapy? You've heard the hype, now hear the data!
In this re-examination of data from the TDCRP–the single-largest ever multi-site, comparative study of alternate treatments for depression–researchers found that the strength of the therapeutic relationship at the second session as rated by independent judges was a better predictor of outcome than assignment to a treatment condition (e.g., CBT, IPT, placebo, or active anti-depressant). Indeed, the results showed that the alliance had a significant and "very large effect" on outcome that was equally visible across both drug and nondrug treatments!

Krupnick, J.L., Sotsky, S.M., Simmons, S., Moyer, J. et al. (1996). The role of the therapeutic alliance in psychotherapy and pharmacotherapy outcome. Journal of Consulting and Clinical Psychology, 64(3), 532-539.

Drugs more effective than psychotherapy . . . NOT!
Well controlled and executed studies most often fail to find a difference favoring drugs over psychotherapy or an additive benefit from combining drugs with psychotherapy. For example, in a study of 91 people given an antidepressant drug and 93 given interpersonal psychotherapy, treatment outcomes were virtually identical when matched for severity of depression!

Shulberg, H.C., Pilkonis, P., and Houck, P. (1998). The severity of major depression and choice of treatment in primary care practice. Journal of Consulting and Clinical Psychology, 66(6), 932-938.

Drugs are cheaper than psychotherapy . . . NOT!
First the APA and drug companies said that drugs were more effective than therapy. When that didn't pan out, then they said that combining the two was more effective than using either individually (see below). Now, that this conclusion has proven false, they are arguing that medications are cheaper than therapy. Well, a recent study by researcher Antonuccio (1997) proves this assertion FALSE. A two year study of Prozac, showed that treatment with the drug may result in 33% higher costs relative to individual therapy. These costs were due to a combination of: (1) high cost of the medication; (2) comorbid costs of other health problems; and (3) clinical success probabilities.

Antonuccio, D.O. (1997). A cost-effectiveness analysis of cognitive-behavioral therapy and fluoxetine (Prozac) in the treatment of depression. Behavior Therapy, 28, 187-210.

Effective Therapists are Psychologically not Biologically oriented!
Researchers returned to the massive amount of data from the TDCRP to determine if there characteristics that distinguished effective from in (or less) effective therapists. As many researchers have pointed out, the literature has always shown that the variance attributable to the therapist generally and greatly overshadows any difference between the forms of treatment that are offered. In this large-scale comparative study of IPT, CBT, Pharmacotherapy, and placebo for the treatment of depression, researchers once again found that differences in outcome were more "related to differences among patients and therapists than types of treatment" (p. 1277). The researchers found that effective therapists: (1) had more experience treating depression prior to the study; (2) were more likely to treat with psychotherapy alone; and (3) rarely used medication either alone or in combination in their treatment of depression. They conclude that, "more effective therapists have a psychological rather than a biological orientation in their treatment approach.

Blatt, S.J., Sanislow, C.A., Zuroff, D.C., and Pilkonis, P.A. (1996). Characteristics of effective therapists: Further analysis of data from the national institute of mental health treatment of depression collaborative research project. Journal of Consulting and Clinical Psychology, 64(6), 1276-1284.