Irving Kirsch Quotes

Our analyses of the FDA data showed relatively little difference between the effects of antidepressants and the effects of placebos. Indeed, the effects were so small that they did not qualify as clinically significant. The drug companies knew how small the effect of their medications were compared to placebos, and so did the FDA and other regulatory agencies. The companies found various ways to make the data seem more favorable to their products, and the FDA helped them keep their negative data secret. In fact, in some instances, the FDA urged the companies to keep negative data hidden, even when the companies wanted to reveal them. My colleagues and I hadn't really discovered anything new. We had merely revealed their 'dirty little secret'.

When people recover from depression via psychotherapy, their attributions about recovery are likely to be different than those of people who have been treated with medication. Psychotherapy is a learning experience. Improvement is not produced by an external substance, but by changes within the person. It is like learning to read, write or ride a bicycle. Once you have learned, the skills stays with you. People no not become illiterate after they graduate from school, and if they get rusty at riding a bicycle, the skill can be acquired with relatively little practice. Furthermore, part of what a person might learn in therapy is to expect downturns in mood and to interpret them as a normal part of their life, rather than as an indication of an underlying disorder. This understanding, along with the skills that the person has learned for coping with negative moods and situations, can help to prevent a depressive relapse.

Depression is partly a nocebo effect, in the sense that it can be produced by negative exceptions about oneself and the world. The way in which these negative expectations develop and produce their negative effects provides some clues as to how they can be reversed. Expectancy effects grow, feeding upon themselves. One reason this happens is that our subjective states - our feelings, our moods and sensations - are in constant flux, changing from day to day and from moment to moment. The effects of these fluctuations depend on how we interpret them, and our interpretations depend on our beliefs and expectations. When we expect to feel worse, we tend to notice random small negative changes and interpret them as evidence that we are in fact getting worse. This interpretation makes us actually feel worse, and it strengthens the belief that we are getting worse, leading to a vicious cycle in which our expectations and negative emotions feed on each other, cascading into a full-blown depressive episode. .. Positive expectancies have the opposite effect. They can set in motion a begin cycle, in which random fluctuations in mood and well being are interpreted as evidence of treatment effectiveness, thereby instilling a further sense of hope and countering the feeling of hopelessness that are so central to clinical depression.

Depression is a serious problem, but drugs are not the answer. In the long run, psychotherapy is both cheaper and more effective, even for very serious levels of depression. Physical exercise and self-help books based on CBT can also be useful, either alone or in combination with therapy. Reducing social and economic inequality would also reduce the incidence of depression.

For people who are depressed, and especially for those who do not receive enough benefit from medication of for whom the side effects of antidepressants are troubling, the fact that placebos can duplicate much of the effects of antidepressants should be taken as good news. It means that there are other ways of alleviating depression. As we have seen, treatments like psychotherapy and physical exercise are at least as effective as antidepressant drugs and more effective than placebos. In particular, CBT has been shown to lower the risk of relapsing into depression for years after treatment has ended, making it particularly cost effective.

Depression, we are told over and over again, is a brain disease, a chemical imbalance that can be adjusted by antidepressant medication. In an informational brochure issued to inform the public about depression, the US National Institute for Mental Health tells people that 'depressive illnesses are disorders of the brain' and adds that 'important neurotransmitters - chemicals that brain cells use to communicate - appear to be out of balance'. This view is so widespread that it was even proffered by the editors of PLoS [Public Library of Science] Medicine in their summary that accompanied our article. 'Depression,' they wrote, 'is a serious medical illness caused by imbalances in the brain chemicals that regulate mood', and they went on to say that antidepressants are supposed to work by correcting these imbalances.The editors wrote their comment on chemical imbalances as if it were an established fact, and this is also how it is presented by drug companies. Actually, it is not. Instead, even its proponents have to admit that it is a controversial hypothesis that has not yet been proven. Not only is the chemical-imbalance hypothesis unproven, but I will argue that it is about as close as a theory gets in science to being dis-proven by the evidence.

Depression is not caused by a chemical imbalance in the brain, and it is not cured by medication. Depression may not even be an illness at all. Often, it can be a normal reaction to abnormal situations. Poverty, unemployment, and the loss of loved ones can make people depressed, and these social and situational causes of depression cannot be changed by drugs.

Like antidepressants, a substantial part of the benefit of psychotherapy depends on a placebo effect, or as Moerman calls it, the meaning response. At least part of the improvement that is produced by these treatments is due to the relationship between the therapist and the client and to the client's expectancy of getting better. That is a problem for antidepressant treatment. It is a problem because drugs are supposed to work because of their chemistry, not because of the psychological factors. But it is not a problem for psychotherapy. Psychotherapists are trained to provide a warm and caring environment in which therapeutic change can take place. Their intention is to replace the hopelessness of depression with a sense of hope and faith in the future. These tasks are part of the essence of psychotherapy. The fact that psychotherapy can mobilize the meaning response - and that it can do so without deception - is one of its strengths, no one of its weaknesses. Because hopelessness is a fundamental characteristic of depression, instilling hope is a specific treatment for it it. Invoking the meaning response is essential for the effective treatment of depression, and the best treatments are those that can do this most effectively and that can do without deception.