By Sharon Begley
June 18, 2007 issue – No one bats an eye when a drug for a severe mental illness such as schizophrenia or depression causes serious side effects such as nausea, weight gain, blurred vision or a vanishing libido. But what few patients seeking psychotherapy know is that talking can be dangerous, too—and therapists have not exactly rushed to tell them so
For treatments that come in a bottle, the Food and Drug Administration requires proof of safety and efficacy. For treatments that come from the lips of psychologists and psychiatrists, there’s no such requirement. But while therapists fight over whether they should use only treatments for which there is rigorous scientific evidence for efficacy, they have largely ignored something more fundamental. “The profession hasn’t shown much interest in the problem of treatments that can be harmful,” says psychology professor Scott Lilienfeld of Emory University. “Of the few psychotherapies that have been tested for safety, too many cause harm to at least some patients.”
The failure to heed Hippocrates reflects the assumption that psychotherapy is, at worst, innocuous. That naive trust should have been blown out of the water when “recovered memory” therapy actually created false memories, often of childhood sexual abuse, tearing families apart. But the “Handbook of Psychotherapy and Behavior Therapy,” the clinicians’ bible, devotes only 2.5 pages out of 821 to adverse effects, even though documented risks of therapies could fill a small book.
“Stress debriefing,” for instance, is designed to prevent symptoms of posttraumatic stress disorder in those who have suffered or witnessed a trauma. In a three- to four-hour group session, a therapist pushes patients to discuss and “process” their feelings and to describe in detail what they experienced or witnessed. Many of those who undergo stress debriefing develop worse PTSD symptoms than those who deal with the trauma on their own, controlled studies show, probably because the intense reliving of the trauma impedes natural recovery. Burn victims who underwent stress debriefing, for instance, had worse PTSD 13 months later than victims who had no psychotherapy; people who went through it after being in a car crash had greater anxiety about travel three years later than those who did not.
Psychotherapy for dissociative-identity disorder (formerly called multiple-personality disorder) can pose even greater risks. Some therapists believe that the best treatment for these fractured souls is to bring out the hidden identities, called “alters,” through hypnosis or helping alters leave messages for one another. Unfortunately, many alters cause “self-injurious behavior, suicide attempts, and verbal and physical aggression,” notes Lilienfeld in a paper in the journal Perspectives on Psychological Science. In addition, the “let’s meet the alters!” techniques can actually create alters in suggestible patients. “As more alters come out, it gets harder to get the patient back to having one identity,” Lilienfeld says. The longer someone stays in therapy, the more alters show up, evidence that “many and perhaps most alters are products of inadvertent therapist suggestion.” So much for “First, do no harm.”
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Few of us will need therapy for multiple-personality disorder. But everyone will experience grief—and counseling for normal bereavement may not always be benign. A 2000 study found that four in 10 people who lost a loved one would have been better off without grief counseling (based on a comparison with people who were randomly assigned to a no-therapy group). That was especially so for those who experienced normal grief. In that case, counseling sometimes prolonged and deepened grief, leaving more depression and anxiety than in those who worked through their loss on their own.
That 40 percent figure is likely inflated, argues psychologist Dale Larson of Santa Clara University. But he agrees with Lilienfeld’s estimate that 10 to 20 percent of people who receive psychotherapy are harmed by it. Even the American Psychological Association acknowledges that too many clinicians practice “psychoquackery,” as psychologist John Norcross of Scranton University puts it. If we had FDA-style regulation of psychotherapies—difficult though that would be to do, especially since the effects of psychotherapy depend on the therapist—”fringe therapies would not be on the market.”
How fringe is “fringe”? In percentage terms, very. But the number of people undergoing potentially risky therapies reaches into the tens of thousands. Vioxx was yanked from the market for less. To be sure, even risky psychotherapies don’t harm everyone, just as most people who took Vioxx will never have a heart attack. What is remarkable about psychotherapies, though, is that few patients have any idea that “just talking” can be dangerous to their mental health.
New generation anti-depressants have little clinical benefit for most patients, research suggests.
The University of Hull team reviewed published clinical trial data, and unpublished data secured under Freedom of Information legislation.
They found the drugs helped only a small group of the most severely depressed, and in most cases had no more effect than taking a dummy pill.
The Royal College of Psychiatrists said the findings were “very important”.
In total, the Hull team, who published their findings in the journal PLoS Medicine, reviewed data on 47 clinical trials.
They focused on drugs in the class known as Selective Serotonin Reuptake Inhibitors (SSRIs), which work by increasing levels of the mood controlling chemical serotonin in the brain.
These included fluoxetine (Prozac), venlafaxine (Efexor) and paroxetine (Seroxat) – all commonly prescribed in the UK.
There seems little reason to prescribe anti-depressant medication to any but the most severely depressed patients
Professor Irving Kirsch
University of Hull
The number of prescriptions for anti-depressants hit a record high in England in 2006 – even though official guidance stresses they should not be a first line treatment for mild depression.
The researchers found that even the positive effects seen on severely depressed patients were relatively small, and open to interpretation.
The seemingly good result came from the fact that these patients’ response to the placebo decreased, rather than any notable increase in their response to anti-depressants.
Lead researcher Professor Irving Kirsch said: “The difference in improvement between patients taking placebos and patients taking anti-depressants is not very great.
“This means that depressed people can improve without chemical treatments.
“Given these results, there seems little reason to prescribe anti-depressant medication to any but the most severely depressed patients, unless alternative treatments have failed to provide a benefit.”
Professor Kirsch said the findings called into question the current system of reporting drug trials.
Dr Tim Kendall, deputy director of the Royal College of Psychiatrists Research Unit, has published research concluding that drug companies tend only to publish research which shows their products in a good light.
He said the Hull findings undermined confidence in the ability to draw meaningful conclusions about the merit of drugs based on published data alone.
He called for drug companies to be forced to publish all their data.
The National Institute for Health and Clinical Excellence (NICE) is currently reviewing its guidance on the use of antidepressants.
A spokesman for GlaxoSmithKline, which makes Seroxat, said the study only looked at a “small subset of the total data available”.
And Eli Lilly, which makes Prozac, said that “extensive scientific and medical experience has demonstrated it is an effective anti-depressant”.
I find these reports rather depressing.
One of my meditators is taking prescribed drugs for a bipolar disorder. I don’t know if he will ever be able to practise meditation effectively while taking these drugs. If he comes off the drugs he will get withdrawal symptoms, so how and when will he ever get off them?
I think whatver reality appears is an object that should be known. Whether feeling dorwsy, excited, sad, depressed, doubtful or drugged it doesn’t really matter for the development of insight.
Anyway interesting articles I thought.