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Pharmaceutical marketers have done a phenomenal job convincing Americans that antidepressant medication is the treatment for depression. Scientific research paints a different picture. Study after study shows the effects of antidepressants are barely distinguishable from placebo.*
To head off some hate mail, I believe antidepressants are highly effective for a subset of depressed people. I recommend them for some of my patients. But the number of people who get real benefits is far lower than the number of people who are convinced, with every fiber of their beings, that antidepressants are miracle drugs.
One reason antidepressants seem so powerful is that a cascade of other psychological interventions happens at the same time a person starts taking them. The first happens before the person even gets the prescription. Hopelessness and passivity are hallmarks of depression. Before making an appointment, something shifts inside, from a position of passivity to agency. The person makes an active decision to do something—and begins to feel better. (We also know this from psychotherapy research, which shows that depressive symptoms start improving when the person schedules their first therapy appointment—before any therapy begins).
Next, the patient tells their doctor what's wrong—they put words to their experience. It may be the first time some people talk openly about the extent of their pain. The mere act of putting emotional pain into words changes it. Words are powerful.
The doctor listens, takes the patient seriously, and doesn't judge or shame—yet another intervention. Finally, the doctor communicates that help is at hand and explains and normalizes symptoms that may have been confusing and frightening.
This is a cascade of powerful interventions and they happen before the patient swallows a single pill. They begin a process of remoralization—a shift away from helplessness and hopelessness toward agency and hope.
But here's where confusion enters. The moment the patient swallows a pill, doctor and patient attribute all improvement to the drug, disregarding the cascade of psychological events that led up to it.
A second reason antidepressants can seem effective is simply timing. On average, depressive episodes last about six months. But people do not call their doctor the first day they experience symptom. Most often, they struggle with their depression for months. They call their doctor at their bleakest moment, after everything else they've tried has failed. At this point, they may be three or four months into the depressive episode.
If the depressive episode follows a typical course, the depression will begin to lift on its own within the next few months. But at this juncture, the patient starts taking medication—and is told the medication can take eight to twelve weeks to work. Magic! In eight to twelve weeks, right on schedule, the patient is indeed starting to feel better.
Consider these events from the perspective of doctor and patient. Before starting medication, the patient tried everything they could think of, to no avail. They start taking medication and on cue, their depression starts to lift. From that point on, doctor and patient are convinced the drug worked wonders—and nothing will persuade them otherwise.
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Jonathan Shedler, PhD ps a psychologist in San Francisco and a Clinical Professor of Psychiatry at UCSF.
*See Newsweek and 60 Minutes for media reports. For a scholarly, book-length discussion, see: Kirsch, I. (2010). The Emperor’s New Drugs: Exploding the Antidepressant Myth. NY: Basic Books.
