Depression: The Gap Between Science and Treatment

By: Michael G. Conner, Psy.D

What do we know about depression? What is depression and how do we treat it? The answer to these questions is a fascinating story. First of all, the gap between science and practice in mental health is alarming. There are practice guidelines in use that are not in touch with research. No where is this more evident that the treatment of depression. As a result, there are physicians who are prescribing medications based on practice guidelines that are not adequately in touch with clinical reality. There are some important findings about what helps that physicians, mental health professionals and parents don’t know about now.

Professionals and parents who talk about depression are very polarized. There is a lot of disagreement and there are "party lines". One the one side there are people who are convinced that depression is a biological illness, disease or genetic defect. On the other side there are people who say depression is learned and the consequences of our environment. Disagreements brings people to the point of anger when discussing the best ways to treatment depression.

What we call depression is not what we always thought. For example, depression is NOT the result of a chemical imbalance. In fact, there is no such thing as a chemical imbalance that causes depression. This is important. There is NO such thing. This whole idea of a chemical imbalance is the result of drug-company marketing that is not remotely supported by research. What else do we know? We also know that depression is NOT caused by a disease, an illness or a disorder. It is not in our blood. I should say that suicide, violence and self-injuring behavior are also NOT a disease or illness. Treating these behaviors like a disease or illness is misleading. There is absolutely no physical evidence that a disease or illness causes depression.

So what is the cause of depression? While there is considerable debate, the true cause of depression is probably not in our brain. We cannot find a cause in our bran. People may be vulnerable to depression, like some people have weak ankles, but depression is not caused by our brain, blood or body except in very rare cases. Depression is almost always caused by our society and our culture. The negative aspects of our society and culture include things like social pressure, intimidation, rejection, abuse, neglect, violence, illness and death. These are all potential stressors depending on our state of mind and how we were raised. The interaction of our mind with society and our culture can cause pain, fear, sadness, and shame. And the stresses in our life can change our physiology and this causes our genes to produce proteins that actually change the function and structure of our brain, and this creates physical and psychological symptoms that can last a lifetime. The longer we experience stress, the more we change our brain. This is why identical twins raised apart are not all happy or all depressed. One twin can be depressed and the other is not.

 What causes depression? In my opinion, the cause of depression is anything that creates stress. It can be things like,

  • Poorly funded schools, large class sizes and a lack of individual education
  • Not enough trade schools and a definition of success that requires a college education.
  • Too little sleep
  • Not enough exercise
  • Poor diet
  • Learning disabilities
  • Social problems
  • Family problems
  • Drug and alcohol use
  • Loss or grief
  • Abuse
  • Being neglected
  • Traumatic experience

So why do some children and adults become depressed and others don’t? We have learned more about depression in the past 5 years than we have learned in the past 50 years. We now know that depression is mostly a perfectly normal response to our experience in life. A lousy life, a tragedy, or an overwhelming stress can make anyone depressed or anxious. People are supposed to feel depressed when they are stressed, when they make bad choices or their life is meaningless or tragic. They can also become anxious, afraid and scared. Depression can be a consequence of long term anxiety and fear This is not a mental illness. It is a response to our environment and our self. We are supposed to feel sad, scared or guilty so we can do something to feel better. But what if you can’t live the life you want to live and people expect you to do things you are not good at, or even hate?

Many people live in a stressful and toxic world that some can tolerate better than others. American culture is far from easy for children to grow up in. This is especially true when children are raised to feel unloved and unable to make a difference in their world. People can become very depressed if they feel helpless and hopeless in the face of sadness, fear, pain or guilt.

But everything is not about stress and avoiding and escaping stress. There are also protective factors that can “buffer” and “insulate” children and adults against these stressors and problems like depression.

What is a buffer? How can a buffer insulate us from depression? The most powerful buffer is your mind. By that I mean how you view, think and respond. Other buffers are things like how you were parented as a child, a functional family, a good job, your friends, exercise, diet, recreation, adventure, creativity and sleep.

If you stop and think about it, our nation is focused on mental illness and not mental health. We don’t teach mental health. We are too focused in eliminating mental illness by teaching people to accept, live with or change how they look at misery. Some people focusing on changing behavior. We also want to medicate people. So let me ask you a question. How many people can tell you three things they can do every day that will insulate them from depression? Therapy is far too focused on prohibitions and eliminating things that cause depression, anxiety and things like that.

So what is better; an antidepressants or psychotherapy? Here is what we know about antidepressants. First of all, studies on antidepressants are based on subjects who usually have pure depression and no other problems. At any one time about 10% of the population is depressed. But only a very small number of these people have pure depression. Most people who are depressed have other problems like anxiety, grief, substance abuse, relationship problems, marital problems, parenting problems or economic problems. People are really confused about what drugs and therapy can do and what these things can’t do.

In a case of pure depression, meaning no other significant problems, antidepressants alone are slightly more effective than psychotherapy. Antidepressants and psychotherapy together are the most effective. But remember, that there are few cases of pure depression so these finding are questionable with respect to depression identified in every-day medical practices.

What does that really mean? What we need to recognize is that nothing we do seems to help more than 65 to 70% of people who feel depressed. That includes medication and therapy. But here is the shocking part; about 40 to 50% of the people we think we are helping would actually get better if you did nothing or you just gave them a pill or treatment that they truly thought would help. What’s really weird is that a pill that does nothing but make people feel slightly ill is more effective in treating depression than a pill that has no physical affect.

So what does that mean for people looking for help? It means that antidepressants help about 15% of the people who are depressed and prescribed medication in primary medical care. In real life, antidepressants are not as effective as they are in research studies. It also means that our mind can overcome and protect us from depression. Credible research shows that the use of antidepressants with children is not more effective than a placebo.

So this raises an important question. What is the Mind? Here is what the most brilliant people on the planet will tell you. The mind and brain are different. The brain is an action machine and it is an anticipation machine. Now get this… Our mind harnesses the activity in the brain while it rides along neuronal activity patterns. Basically, the mind is like a person riding on the tracks of a roller coaster. Isn’t that a cool image? There are 10 billion brain cells and each cell has over 10,000 connections to other cells. The mind is moving in the brain. The brain is the world’s largest and fastest roller coaster. The number of tracks is practically infinite. The mind is not located in some part of the brain. It travels along millions of tracks.

So what is psychotherapy? That’s an easy question to answer. But that also depends on what you call psychotherapy. A lot of people will feel better if they go see someone who is actually pretending to be a therapist. This is exactly why a counselors and therapists with little or no training can tell you they are helping people. Some therapists and counselors are just a placebo. Or, they just don’t do any harm and the person eventually gets better on their own. But good psychotherapy is not just talk. Talk therapy may be an inadequate term. Therapy requires thinking, talking, expressing feelings and most of all, taking action. Good therapy focuses on helping people make a choice. A choice is nothing more than discovering what is happening in your life, discovering how you feel about it and then deciding what you need and want. It is about strategic and purposeful action. Put simply, you become what you do and the reason you did it. Therapy is all about conscious doing. And it helps a lot if we do things we are proud of and make a difference.

What is the best therapy? I think it depends on the problem, the person and the circumstances in their life. I really think multi-modal therapy is very powerful. There are some trendy therapies that are being promoted but that doesn’t make them the best. Positive therapy is really impressive. That approach builds on strengths and virtues and not just eliminating your weaknesses and problems. Cognitive behavioral therapy is popular but no more effective that interpersonal therapy and brief psychodynamic therapy. Family therapy is effective when the problems and solutions can be traced to the family or solved within a family.

Hypnotherapy is also a powerful approach. Every good approach involves dealing with awareness, relationships, choices and self-mastery. I guess maybe I don’t like a disease model of therapy mostly because there is little evidence that they work.

Should people who are depressed try an antidepressant or find a therapist? Think about this. What do you think will happen when you study a group of people who stop psychotherapy after 4 months and then you look at them at one year. Four months of psychotherapy is as effective as one year of antidepressants. If you quit taking a medication after 4 months the relapse rate is two times that of psychotherapy. The people who had psychotherapy do much better. This also means that therapy is cheaper than antidepressants in the long run.

So what does this mean? It means that medications are probably forever. There is no lasting benefit to medications and there are medical side effects as well as potential health problems. Psychotherapy has a longer lasting benefit after you stop and there are no medical side effects.

There is something else worth considering. There is very good research evidence that antidepressants should be the last resort and only for the most severe depressions. In my opinion, antidepressants should not be prescribed without a psychological evaluation, close monitoring and mandatory participation in psychotherapy. There is enough research to make a good argument that prescribing an antidepressant for mild to moderate depression and not requiring psychotherapy first is negligent.

So should people stop taking antidepressants? Absolutely not without advice from a physician. Starting and stopping some of these drugs abruptly is NOT safe. Ideally, you should be in psychotherapy for at least 3 months or maybe 6 months before you even consider stopping an antidepressant. These drugs can be dangerous to start and stop. It depends on how deep your depression is and how long you have been depressed and how long you have been on medications.

Do antidepressants work on children? And are they safe? They are NOT safe enough and they are not as effective as people think. They  work only for a relatively small number of children. There is a lot of research that indicates that these drugs may not be very effective or at all. Most people who are depressed don’t benefit from medications. There is research that argues that children benefit even less. These medications may feel like they are helping but that may be a placebo effect or just the person getting better on their own. Children have difficulty tolerating the side effects of antidepressants. Very few kids consider antidepressants worthwhile. Think about it. At most, antidepressants can help about 15% to 30% of the kids who are depressed. That means that 85% to 70% experience no benefit.

If you want to take a drug then you have to decide if it is really worth it. The major studies show that use of antidepressants with children is not clinically significant. Only one study out of many shows there is a benefit. While research find changes that are statistically significant it looks like that improvement may not be all that useful. In one study by the National Institute of Mental Health it was suggested that combined medication and psychotherapy were most effective with severe depression but the difference may not be that much.

Can we identify the kids who need an antidepressant? We don’t know how to do that yet. The way we define depression is very vague. Our diagnostic system is very old and outdated. It is actually a tool that is used more by insurance companies to control services.

As far as we know there may a hundred different type of depression. The most common type of depression in teens is called “My family, my life and my school is depressing me disorder.”

Do some kids need an antidepressant? Yes! Why? Because they are unable to function and we don’t have the resources in our schools and health care system to provide alternatives. But these are extreme and pure cases of depression; not “my life is awful and I can feel it.” Medications can help some children function well enough to participate in therapy. I think medication without therapy is terrible idea and it is not safe enough.

So why do we medicate so many children? We medicate children primarily for social control and to make life easier and less of a hassle for the rest of us. If also allows parents to feel like they are doing something. We also medicate children because we prefer to think we are treating an illness or disease. Parents can’t radically change their lives because their children are depressed. I think many of these kids are feeling depressed for good reasons. Some kids can’t handle large crowds, big class rooms and kids who are bullies. The list goes on. Yet they are expected to handle it. It is easier to diagnose them with a disorder because we as a society are not willing to look at our schools, communities, economic system and families? It is easier to make a child take a pill.

What are the side effects? First of all, these drugs do not treat or cure anything. They affect more than one area in our brain and body. While they are increasing our energy they can also cause insomnia. While they increase our appetite they can cause nausea or diarrhea. We may be able to think better but we can end up with headaches. And while we might be less cranky and easier to live with we can lose our desire and ability to have sex. There are a lot of side effects. What do you think happens in the body in order to get used to these side effects? The body has to change in order to tolerate these drugs. We have no idea what this is doing to our bodies. This is a real concern when you give drugs to an 11 year old girl who is starting puberty early.

Final Comments

Here is another important point. These drugs can make only “pieces of you” feel better.  Or they can make you feel sick, or they can make you feel weird. I have seen kids who are taking antidepressants and they say things like “Everyone says I look and feel better but I really don’t like myself and I still don’t care about anything. I smile because it is easier, but I am not happy about anything in my life.”  So what do we do with a kid who doesn’t want to smile? What we can't do is increase their medications until they look like the Joker in a Batman movie.


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copyright 2006 to 2008, Michael G. Conner