At the first page, I wrote that psychotherapy has negligible effectiveness, and there is evidence for this. It would be appropriate to present it.
However, I immediately point out that the chapter is not a persuasion to abandon treatment. I simply believe that the patient has the right to make an informed decision, based on full knowledge of the issue. If there is a strong controversy around a treatment, the patient should be aware of it. It is not permissible in the name of crooked “patient protection” to lie to the patient, and it is a lie to say that everything is fine with the therapies discussed here. The ideal situation is when the patient learns about these problems with SSRIs or psychotherapy from the doctor himself, and with him can clarify doubts. If that were the case, sites like this one probably wouldn’t be needed.
The problem with psychotherapy
To start with a bit of theory. How is it assessed whether a therapy works? The accepted method in medicine is a placebo-controlled clinical trial. Some patients get a drug, some get something that is not it, but looks identical. The important thing is that no one, neither the patient nor the doctor, knows what is what. After the therapy is completed, how many people recovered in both groups is evaluated and compared. To be sure, the study is repeated in other centers.
An intelligent reader should already see the problem. How do you create a placebo of psychotherapy?
The inactive substance should be IDENTICAL to both patient and doctor. Indistinguishable. I don’t think there is a person in the world who can’t tell the difference between sitting in a psychotherapist’s office and sitting at home watching TV series. Anyway, not even that is the biggest problem.
The main reason is that psychotherapy consists of many elements that are not treatment, but which can have a very, very big impact on the course of the disease. Just the fact that the patient has to leave the house to come to the office can make a big difference. In one study, people suffering from depression who were forced to be physically active had better recovery than is observed with medication. Clearly, the patient will have the usual “feeling” of working on the disease and trying to cure it, which enhances the placebo effect. It is one thing to take a pill with the hope that it will make a difference in one’s life, and another to put in dozens of hours of effort. Even a completely meaningless effort will make a person believe in its effectiveness. It is also important that the patient simply has someone to talk to.
What is the solution to this problem? It is necessary to create “placebo therapy.” During it, everything will be done as similarly as in ordinary psychotherapy, only no treatment will be given. The patient will go to the office for the same amount of time, he will be forced to stay with the therapist for the same amount of time, he will be able to talk himself out. But no one will give him treatment.
The effects?
https://www.researchgate.net/publication/9005111_Establishing_Specificity_in_Psychotherapy_A_Meta-Analysis_of_Structural_Equivalence_of_Placebo_Controls
The closer the “placebo therapy” was to active therapy, the smaller the differences between it and actual psychotherapy. Moreover, with the best-arranged placebo therapies, the differences were no longer detectable. This means that psychotherapy is literally as effective as chatting about life with a colleague or a bartender.
The situation gets a bit more complicated with behavioral-cognitive therapy, because no one has done such a thorough study. What is known, however, is that the therapy was quite effective when compared with no action at all, and its effect diminished significantly when compared with placebo therapy, to the point that in one study the placebo was more effective:
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4311105/
SSRI registration fraud
With SSRIs, selective serotonin reuptake inhibitors, we have a more serious problem. Much more serious. These lozenges should perhaps not have been approved for marketing at all, due to the scam that took place at the time.
https://www.nejm.org/doi/full/10.1056/NEJMsa065779#t=article
In this rather large nutshell, a drug is approved if its effects are clearly greater than a placebo and it has no side effects, in a number of clinical trials. What if you want to sell people a drug that has side effects, with efficacy comparable to a placebo? One pays for dozens of clinical trials, but publishes only those that have produced good results. And that’s exactly what was done with the SSRI!
The drug proved more effective than placebo in 94% of clinical trials. Well great, what’s there to cling to? And it would have all worked, if it weren’t for those nasty scientists who looked at the sources and checked what results the unpublished clinical trials had. After taking them all into account, the drug’s effectiveness dropped to… 51%. That is, it ceased to exist in practice.
It’s not even so much the effectiveness itself anymore, but the side effects, which can be disastrous. One of them is impotence. What’s worse, it can be permanent, record-breakers lost their prowess right after the introduction of these pills on the market and have not regained it so far. For such a patient, it won’t matter that he feels slightly less anxious when going to work, his life is in ruins.
Some scientists are demanding more trials, and a change in the way they are conducted for all registered drugs (there’s a pretty strong movement around the world of leading scientists pushing for this, but its success would mean we’d be treating what’s effective, not what the richest have pushed through research), and some are outright suggesting that this is one big scam:
https://pubmed.ncbi.nlm.nih.gov/18505564/
What are the lessons from this for the patient? It’s hard to say. There are quite a few drugs that really help strongly, for example, in schizophrenia. You can’t dismiss all medicine because of one scam. Certainly, there are also cases where SSRIs have helped more than anything. On the other hand, in the U.S., the law requires that there be a giant “increases the risk of suicide in young people” sign on their packaging, similar to what we have on cigarette packaging. Who knows what the next few years will bring, perhaps SSRIs will one day be looked at the way we look at therapies that were popular decades ago, but are now considered a crime against patients, such as frontal lobotomy?