Why, for some, psychotherapy might be a better treatment for depression than drugs

Nigel Mulligan for The Conversation

Dublin: During a psychotherapy session, one of my patients reported to me that the antidepressants he’d been prescribed by his GP had “killed his desire”. He felt “dead inside”, he told me. Unfortunately, this wasn’t an isolated case. I’ve heard similar descriptions of the effects of antidepressants from many patients. Many say they feel like “zombies”.

However, some patients report that these drugs are helpful – even essential – in the management of their mental health.

Antidepressants, known as selective serotonin reuptake inhibitors (SSRIs), and popular anti-anxiety medication benzodiazepines can offer a sense of hope to those suffering with debilitating mental health issues.

They can also help patients to foster a sense of confidence, optimism and belief in their own ability to recover. Some patients feel that the medication functions as a “stepping-stone” to improved health.

Other patients complain that the side effects of the medication, which can include nausea, headaches, drowsiness, dizziness, fatigue, agitation, nervousness and weakness, can be worse than the symptoms of depression and anxiety. Many of these adverse effects are well documented by the pharmaceutical industry and written in small print in medication guidelines. But they are often not communicated by the doctor prescribing them.

Some of these side effects will wear off after a few weeks or months of taking the medication. However, others such as author and psychiatrist David Healy argue that it can radically reduce patients’ quality of life.

Some of the less common – but more extreme – side effects, for example, have attracted controversy and criticism. Patients have reported insomnia, sexual dysfunction, anorexia, hallucinations and suicidal thoughts. Some antidepressant drugs carry a “black box warning” about increased risk of suicide while using the medication.

It’s imperative that patients are fully informed of potential risks and side effects and closely monitored for behavioural changes. Research shows that less than 1 per cent of the patients studied “had been told anything about withdrawal effects or dependence” by the person prescribing the medication.

While studies demonstrate that some antidepressants and anti-anxiety drugs are addictive, pharmaceutical companies insist that habit may be mistaken for dependence.

These medications are recommended for short periods of up to six months – but patients can be left on them for years. Some patients report that they’ve had no consultations with their doctor about dose reduction or end of treatment plan.

In most cases, it’s not beneficial for patients to be on antidepressants indefinitely so a plan to manage the body’s withdrawal from the drug is essential. Withdrawal side effects from anti depressants can include dizziness, vertigo, flu-like symptoms, lethargy and sleep disturbances. There are also reports of psychological disturbances including anxiety, agitation, crying spells and irritability.

Doctors can interpret the effects of withdrawal from antidepressant medication as returning depression symptoms, and put clients back on medication – and, in some cases, even increase it. The patient, then, can feel caught in a cycle of symptoms, side effects, sickness, and medication adjustments.

While patient experience of antidepressants and anti-anxiety medication differs, what’s certain is that prescriptions for these drugs is increasing alongside rising rates of mental health diagnoses. While this is making psychopharmacology one of the most lucrative and profitable industries in the world, it’s a situation that concerns some medical professionals.

For example, Joanna Moncrieff, a professor of critical and social psychiatry, argues that depression diagnoses are designed to not only monitor and control behaviour but also legitimise pharmacological treatment.

Consultant psychiatrist Stephen Stahl suggests that it is not possible for some of these drugs to act on particular neurotransmitters, arguing that they “must act everywhere”. Stahl suggests that side effects are the “cost of doing business.”

This chemical imbalance theory of depression was once considered the gold standard reason for why people take antidepressants but is heavily criticised now. For example, there’s a renewed interest in research on the use of psilocybin, a naturally occurring compound found in magic mushrooms. A recent study has shown psilocybin to be more effective than anti-depressant medication for major depression with side effects considered minor and transient.

The National Institute for Health and Care Excellence also recommends psychotherapy for the treatment of symptoms of depression and anxiety. Psychotherapy is an evidenced-based listening and talking method of addressing psychological and psychosomatic problems and change.

The clinical reality for many patients is that they are not always consulted about their treatment preference and are not always offered psychotherapy. Fewer psychiatrists are providing psychotherapy in part due to increased financial incentives for providing pharmacotherapy.

Treatment with medication alone is to miss out on vital aspects of considering the person as the locus of control or the agent of change, and fails to emphasise their role in the own recovery.

The psychotherapist, with the client, can collaboratively distinguish between symptoms of illness and side effects of medication, of what is a “cure” and what is the “poison”.

Psychotherapy can be about the rewriting of a new script by the patient concerning what they know about their sickness, healing and recovery.

(Nigel Mulligan is an Assistant Professor in Psychotherapy at School of Nursing, Psychotherapy and Community Health, Dublin City University)