Drug Therapy or Psychotherapy for Depression?

There has been strong evidence for over 20 years that the right psychotherapy can be superior to drugs for depression.

In 1992, Yale psychiatrists conducted a comprehensive review of the research literature and found that (when dropout rate is considered with treatment success rates), drug therapy alone is substantially worse than psychotherapy alone or a combined treatment.

In December 1995, the American Psychological Association published a meta review of hundreds of efficacy studies in the treatment of depression. The evidence was very clear – psychotherapy was at least as effective as drug treatment on all counts and often more effective.

The Efficacy of Anti-Depressants

Studies involving adults with moderate or severe depression have shown the following:

• Without antidepressants: About 20 – 40% people who took a placebo noticed an improvement in their symptoms within 6 to 8 weeks.
• With antidepressants: About 40 – 60% people who took an antidepressant noticed an improvement in their symptoms within 6 to 8 weeks.

In other words, antidepressants improved symptoms in about an extra 20% people.

How do Anti-Depressants Work?

Neurotransmitters are chemicals in the brain involved in sending messages to different parts of the body. They are released across the synaptic gap between 2 nerve cells to engage with receptors on the other side – just like a key fits a lock.  There are about 100 neurotransmitters that we know of – one of which is serotonin. One of its functions has been thought to involve regulation of mood.

The theory behind antidepressants is that depression is caused by reduced levels of serotonin in the brain. The most frequently prescribed anti-depressants today are the SSRI’s (selective serotonin reuptake inhibitors). These have the effect of preventing the brain cells from reabsorbing serotonin, leaving it sloshing around in the synaptic gap between the cells. This means more serotonin is available to bind with receptor cells and the idea is that this elevates mood.

But more recent research, (as summarised in Hewing, 2021) has revealed that there is no good evidence to suggest that lower serotonin levels are associated with depression.

Furthermore research shows that blocking serotonin does not lead to depression.

A more recent hypothesis is that anti-depressants work by helping in the transmission of serotonin (as opposed to increasing the levels).

It is now understood that stress causes damage to brain cells. What happens is this:

• Stress damages the serotonin receptors so that fewer serotonin molecules are bound and so less serotonin is transmitted across the cells.
• Serotonin is then involved in repair of damage to brain cells caused by stress.
• Serotonin is involved in helping the brain to grow new cells to replace the damaged cells.
• This repair and replacement occurs during deep slow wave sleep.
• Serotonin reduces the amount of REM (dream) sleep which allows for more of this deep, slow wave, recuperative sleep.

So when anti-depressants work well, they are reducing the amount of REM sleep (dreaming) by supporting serotonin transmission. (Serotonin inhibits REM sleep). Thus allowing more deep, recuperative sleep which is required for repair and replacement of damaged brain cells.

BUT the problem with how anti-depressants work is:

• REM sleep is necessary for discharging emotion – its main role. So inhibiting REM sleep prevents dreaming from discharging negative emotion.
•  the unmet needs (cause of the depression in the first place) have not been addressed. (Griffin and Tyrrell, 2014)

So even when anti-depressants do work, the underlying issues have not been addressed and the anti-depressants may prevent REM sleep from calming the emotions down so that the person can focus on getting their needs met. (Hewing 2021).

Side Effects of Anti-Depressants

Thirty-eight percent of people on anti-depressants experience one or more side effects. (Cascade and Kalali, 2009)

The most common side effects were: sexual dysfunction, sleepiness, and weight gain.

Withdrawal from Anti-Depressants

Antidepressants can cause physical dependence as evidenced by the withdrawal symptoms stopping or reducing antidepressants can cause.

• More than half (56%) of people who attempt to come off antidepressants experience withdrawal effects. (Davies and Read, 2019)
• Nearly half (46%) of people experiencing withdrawal effects describe them as severe.
• It is not uncommon for the withdrawal effects to last for several weeks or months.

(Davies and Read, 2019)

Current U.K. and U.S.A. Guidelines underestimate the severity and duration of antidepressant withdrawal, with significant clinical implications.

Withdrawal symptoms include – muscle spasms, heart palpitations, arrhythmia, insomnia, restlessness, feeling unsafe, etc.

These symptoms are especially likely if you suddenly stop taking antidepressants.

Other symptoms that may occur on suddenly stopping an SSRI include dizziness, loss of coordination, fatigue, tingling, burning, blurred vision, vivid dreams. Less often, there may be nausea or diarrhea, flu-like symptoms, irritability, anxiety, and crying spells.

Stopping therefore needs to be done very carefully and gradually -even with a low dose.

 Summary

• Good psychotherapy is at least as effective in relieving depression as anti-depressants.
• Depression responds well to placebo – 20-40% of people show significant improvement .
• Anti-depressant use provides approx. an extra 20% improvement over placebo.
• Anti-depressants however don’t address the underlying issues behind the depression and too little REM sleep is also detrimental to mental health.
• More than 1/3 people experience side effects on anti-depressants
• More than half of people experience withdrawal symptoms when trying to stop anti-depressants.

Conclusion

Consult carefully with your GP before deciding to start, reduce or stop anti-depressants. Do consider psychotherapy alongside or instead of drug therapy, in particular a holistic psychotherapy which will consider the emotional, cognitive, behavioural and physiological symptoms of depression.

References

Hewing, E. (2021). Shattered dreams: how REM sleep, not ‘chemical imbalance’ explains depression. Human Givens Journal 28, 1, 13 -19. 

Depression and Primary Care, (1996), Vol. 1: Detection and Diagnosis, Vol. 2: Treatment Aspect , United States Public Health Service Agency.

Wexler, B E and Cicchetti, D V (1992). The outpatient treatment of depression: Implications of outcome research for clinical practice. The Journal of Nervous and Mental Disease, 180, 5, 277–86.

Arroll B, Elley CR, Fishman T, Goodyear-Smith FA, Kenealy T, Blashki G et al. Antidepressants versus placebo for depression in primary care. Cochrane Database Syst Rev 2009; (3): CD007954. [PubMed]

Griffin J and Tyrrell I, (2014). Why We Dream: The Definitive Answer

Cascade, E., Kalali, A.H., & Kennedy, S, H. (2009) Real World Data on SSRI Anti-Depressant Side Effects. Psychiatry, 6 (2), 16-18.

Davies, J & Read, J. (2019) A systematic review into the incidence, Severity and duration of Anti-depressant withdrawal effects: Are guidelines evidence-based? Addictive Behaviours, Vol97 2019, 111-121.