The two common ways of treating major depression are psychotherapy and antidepressant medications.
However, one doctor suggests that in the long run, depressed people are better off if they never take any medication to begin with.
In a letter to the editor of the journal Psychotherapy and Psychosomatics, Jeffrey R. Vittengl, PhD, professor of psychology at Truman State University in Missouri, said that while the short-term benefits of antidepressants are well established, the longer-term picture is a different story.
Over a nine-year period, Vittengl discovered that among depressed people who got adequate treatment, those who took no medication were doing better than those who took medication.
Conclusions are tough to draw
An expert interviewed by Healthline said that while these findings should not be dismissed out of hand, they should not be considered the final word on the subject either.
“Do I think it’s interesting? Yes, I do,” Dr. John Campo, chair of the department of psychiatry and behavioral health at The Ohio State University Wexner Medical Center, told Healthline.
“But what I would say is that I think the conclusions outstrip the data,” he added. “This is already mentioned in the limitations. This isn’t a randomized, controlled study. It’s observational, so we’re not really able to infer causality — all we can say is that there’s an association. There might be a lot of unmeasured factors influencing who received treatment and who didn’t receive treatment. So, the conclusion that this suggests, that medications are toxic, is probably a bit of a stretch. Could that be true? Yeah, it could be, and I do think we need to think about it.”
Campo pointed out that, when it comes to depression, many variables are at play.
These include the severity of depressive episodes and the ways that patients react to different treatments.
“What you don’t know is whether people who chose to participate in treatment might have been sicker in some way, shape, or form than those that didn’t. Given the amount of stigma around mental illness, it’s tough enough to get people through the door, and what helps get people through that door is the worse they feel or the worse they’re doing in their life,” he said.
Campo said that, in his experience, more people are comfortable with the idea of psychotherapy than they are with taking medications.
“The threshold at which somebody might choose to take a pill, it may be that they’re just sicker to begin with,” he said.
It’s also worth noting, Campo said, that of the groups studied, the adequately treated psychotherapy group was the smallest by far.
“I think that psychiatrists who just dismiss these findings are being cavalier,” said Campo. “On the other hand, while [Vittengl] may well be right, I don’t think this paper proves it.”
Long-term effects tough to gauge
“What are the long-term implications of taking antidepressants?” asked Campo. “The truth of the matter is that it’s hard to really know because we don’t do placebo-controlled trials for 20 years. We treat people and if they’re in a controlled trial, it lasts 12 weeks, maybe 6 months if you stretch it. How do you sort out the effects of the medication from the effects of the disease or from the effects of a lot of other things? These are hard questions to answer.”
Another complicating factor is that, while major depression is generally considered a single disorder, there are differing causes and even genetic factors that can be at play.
Because of this, it’s tough to know which patients will respond to which therapies — let alone how well they’ll be doing in a decade’s time.
There’s also the issue of the frequency of depressive episodes.
“For most people, depression is an episodic, and sometimes a waxing and waning, kind of illness.” said Campo. “So most people who have a depressive episode — in young people, anyway — 90 percent of them will have recovered from it within a year. The other 10 percent will have chronic major depression, but most people will recover at some point. But what’s also true is that they’re also vulnerable, then, to have a recurrence.”
Combination of psychotherapy, medication
“There seems to be some evidence now that, at least in the short term, the combination of talking therapy and antidepressant medication gets people better faster,” said Campo.
That said, the first treatment isn’t likely to get a patient all the way to remission.
In these situations, Campo said, it’s generally worth trying a different strategy — perhaps adding psychotherapy to a medication regimen, or switching up the antidepressant dosage.
Once the appropriate therapy for a given patient is found, it’s best to stick with what worked the first time for patients who suffer additional depressive episodes.
“If you’re someone who’s vulnerable to recurrence, you should probably continue the treatment that got you well initially,” said Campo. “If that was medication, the recommendation typically is to continue the medication at the same dose.