In Defense of Happy Pills

Why talk to a shrink if Prozac or Zoloft will do the trick?

Maia Szalavitz from the October 2005 issue

(Page 3 of 5)

During my transformation, I began to recognize that, although the drug companies clearly have an agenda in pushing their view of psychiatric medication, psychotherapists do too. If pills really could overcome depression and addiction without endless digging and talking, they'd be out of business. Just as the "brain chemical imbalance" that supposedly causes depression is part of the pharmaceutical companies' sales pitch, as exemplified by those Zoloft commercials in which a blob with a face turns his frown upside down, the idea that talk is better and deeper and more humanistic is part of the therapists' sales pitch (no matter how much they sincerely believe it).

Each perspective, taken in isolation, relies on an outdated, dualistic view of the mind and brain. The drug companies portray depression as a biological defect that leaves people vulnerable to getting stuck in sadness; the therapists say our thinking and emotional histories trap us there. But neither view precludes the other; both can be right simultaneously because all experience must ultimately be coded by processes in the brain. Given this reality, if the easier, faster way is just as effective, why not use it?

Studies repeatedly find that on their own, drugs and certain talk therapies are about equally effective, with a combination of the two often superior. But the talk therapies which have been proven to work are hard to find. As Vanderbilt University psychologist Steven Hollon puts it, "The treatments shown in clinical trials to be specifically effective for depression are still not widely available."

Antidepressant opponents such as Peter Breggin argue that drugs can have terrible side effects, so even unproven talk therapies are preferable. Recently, for example, evidence about the relationship between suicide and selective serotonin reuptake inhibitors (SSRIs) such as Prozac and Zoloft has begun to emerge. Not only can they increase suicidal behavior among depressed people, but a study published in 2000 in Primary Care Psychiatry found that some normal people given these medications become suicidal. In clinical trials, suicide rates are two and a half times higher in subjects given SSRIs than in those given placebos, according to David Healy, a psychiatrist at Cardiff University. He estimates that up to 5 percent of the population may have severe negative reactions to SSRIs that can, in the worst cases, lead to suicide.

But that doesn't mean the drugs don't help others. For the majority of patients, SSRIs seem to reduce suicidal thoughts and suicide itself. Suicide rates in the U.S. have declined since the introduction of these drugs. Given that at least 50 million Americans have taken SSRIs since Prozac was approved in 1987, if their main effect was to increase suicide, the opposite should be true. Further, several studies that have compared local SSRI prescribing rates with corresponding suicide rates have found that the medications are linked with fewer, not more, self-inflicted deaths.

Other SSRI critics--such as Harvard psychiatrist Joseph Glenmullen, author of the 2001 book Prozac Backlash--note that SSRIs don't seem to have much advantage over placebos in clinical trials. This argument, like the suicide warnings, overlooks the importance of individual variations. Nearly every psychiatrist who has used SSRIs has stories similar to mine and those in Listening to Prozac. When you match the right person to the right medication, the positive change is remarkable and unmistakable. David Healy's research has shown that certain personality traits are associated with extremely positive (and others with extremely negative) reactions to these drugs.

The fact that good matches occur only in a small subset for each drug--and that bad matches occur as well--means that clinical trials wash out the contrast between the drug and placebo groups. Most people have a small positive effect, some are transformed, and some are made worse; grouping them together obscures these differences. Which is why Healy, the author of the 2004 book Let Them Eat Prozac: The Unhealthy Relationship Between the Pharmaceutical Industry and Depression, still prescribes SSRIs and does not want them banned.

Side Effects of Talk Therapy

When it comes to side effects, it's also important to recognize that drugs are not the only treatments that can cause harm. Some forms of psychotherapy can be at least as damaging.

It is now clear, for example, that hundreds if not thousands of families were split, many irrevocably, by false memories of incest created in "recovered memory" therapy. Some people received lengthy prison terms as a result of false accusations; many simply lost the invaluable emotional and health benefit of having a close, loving family. Others (including children) were hospitalized for years, tied to beds, and told they had to release "alter" personalities implanted during Satanic rituals in order to be healed. This sort of thing happened in mainstream hospitals such as Chicago's Rush Presbyterian as recently as the early '90s. "The entire history of the recovered memory phenomenon, each and every example, is an example of harmful therapy," says Richard Ofshe, a University of California at Berkeley sociologist and co-author of the 1999 book Therapy's Delusions: The Myth of the Unconscious and the Exploitation of Today's Walking Worried.

Other talk side effects come from therapies that rely on cult-like tactics or become actual cults. Synanon, the Northern California�based drug rehab organization, forced men to get vasectomies and pregnant women to have abortions if they wanted to remain part of the group--and told them they would return to their addictions and die in the streets if they left. Members were made to split up with their spouses or partners and rematched with others by the cult's leader.

To this day, the largest addiction treatment providers in the U.S., Daytop and Phoenix House, base their care on the confrontational "attack therapy" of the Synanon system, and program graduates trained in Synanon's methods staff and run many programs. Although some programs have tried to eliminate the excesses of this approach, reports of humiliating treatment are still common despite research showing it is harmful.

Both Synanon and the Los Angeles�based Center for Feeling Therapy often beat patients; the New York�based Sullivanian therapy cult resulted in numerous bitter child custody cases. And then there is "rebirthing" therapy, which in 2000 killed a 10-year-old girl in Denver. The "therapy" was an attempt to improve her difficult relationship with her adoptive mother by smothering her while trying to replicate the conditions of birth.

It's not just wacky therapies that can harm. According to research by Yale psychologist Susan Nolen-Hoeksema, depression can be exacerbated by focusing obsessively on "the causes and consequences" of personal problems. Therapies that encourage people to ruminate on the origins of their depression thus can make the condition worse. According to a 1999 study published in the Journal of Personality and Social Psychology, many commonly used anger management treatments, which urge clients to "get it out" by yelling and hitting inanimate objects, actually increase rage.

Then there is the matter of all the time and money spent on therapy that could be used for more productive pursuits. Ofshe, who distinguishes between life problems that can be helped by counseling and support and major mental illnesses such as schizophrenia and clinical depression, tells me "all the evidence for years and years has shown that people who practice using psychodynamic techniques, all the therapies derived from Freud, every time anyone tried to treat any real mental disorder, it was a waste of time and money and when real treatment [was developed], they were diverted from something that could be helpful."