AWA: Academic Writing at Auckland

Depression incurs significant personal and societal costs. People who are depressed have less fulfilling relationships at work and home and achieve less financial success overall (Kessler, 2012). Diagnostic features include feelings of sadness, irritability, and emptiness associated with clinically significant changes in somatic and cognitive functioning (American Psychiatric Association, 2013). The World Health Organization (2017) estimates that, worldwide, 322 million people, or 4.4% of the global population, suffer from depression. Those with depression are more likely to die by suicide than any other psychiatric disorder (Hawton, Comabella, Haw, & Saunders, 2013). Fawcett (1993) suggests that approximately 15% of depressed individuals will take their lives over a 10-20 year period. In New Zealand, the annual suicide statistics report that the suicide rate in New Zealand is the highest it has been since records began 12 years ago (Coronial Services of New Zealand, 2019). 

Suicide, though a troubling and ultimate act, is predictable and preventable among those with depression (Rihmer, 2007). In the United States, a variety of antidepressants and psychotherapies constitute the predominant treatments for depression (Olfson, Marcus, Druss, Elinson, Tanielian & Pincus, 2002). Within the New Zealand context, however, antidepressants and psychological treatments comprise only a fraction of interventions available (Malhi et al., 2015). Despite this, a recent New Zealand government inquiry on the state of mental health has brought to bear the lack of access to psychotherapies and a tendency to rely on antidepressant medications (Mental Health & Addiction Inquiry, 2018). In this essay, the advantages and disadvantages of antidepressants and psychotherapeutic approaches, in particular, psychodynamic psychotherapy, are compared in their treatment of depression. 

Clinicians who prescribe antidepressants view the pathophysiology of depression through biological explanations, namely the monoamine hypothesis (Hirschfield, 2000). Put otherwise, symptoms of depression can be traced to abnormal levels of three key monoamine neurotransmitters in the brain. These three neurotransmitters: serotonin, dopamine, and noradrenaline, each play vital roles in arousal and mood regulation. According to this proposition, deficiencies in these key monoamine transmitters cause depression. Thus, antidepressants work to alleviate depressive symptoms by chemically elevating the relevant neurotransmitters. Five classes of antidepressants exist, each working to allay the symptoms through slightly different mechanisms (Hirschfield, 2000). 

For those with depression, antidepressants can be appealing for a variety of reasons. Fisher and Greenberg (1997) posit that reducing one’s symptoms can be far more convenient than dealing with external issues. Indeed, for some, assigning responsibility to one’s biological predisposition is a more acceptable option; for the prospect of dealing with root causes can feel intimidating or impossible (Fisher & Greenberg, 1997). Other explanations refer to antidepressants’ accessibility and affordability. Lastly, antidepressants can sometimes provide relatively quick relief with symptoms reducing after two to six weeks (Harmer, Goodwin & Cowen, 2009). Anderson and Roy (2013) found that the depressed patients in their study had positive experiences from taking antidepressants. In the initial stages of treatment, patients reported that the experience of being prescribed antidepressants alone provided relief. Most participants felt that they were in control of their health, viewed antidepressants as central to their wellbeing, and came to accept their depression. Furthermore, participants expressed that being on antidepressants gave them the opportunity to socialise as well as to find other, complementary, ways of alleviating their depressive symptoms (Anderson & Roy, 2013). 

Gibson, Cartwright, and Read (2016) conducted research which collected New Zealanders’ responses to an anonymous, online questionnaire about experiences with antidepressants. Of the 939 participants, 54% reported positive experiences. For some, it freed them from feelings of hopelessness and they viewed antidepressants as a way of relieving distress. Others saw the rationality in receiving treatment for their depression, expressing its likeness to receiving medication for other physical ailments such as diabetes (Gibson et al., 2016). While this research has its value in providing opportunities for individuals to express themselves with honesty by virtue of anonymity, findings must be considered alongside their inherent limitations. As Gibson and colleagues (2016) rightly state, volunteers who hold strong opinions are more likely to provide feedback and, as a result, the general consensus of the research may be inapplicable to the general population. Furthermore, given the anonymous nature of the surveys, it is impossible to ascertain the veracity of the participants’ identities and, therefore, hold the results with weight. 

While some people report positive experiences when taking antidepressants, others express adverse effects. A survey of 1,829 adult New Zealanders who have taken antidepressants found that many individuals have negative emotional and interpersonal experiences (Read, Cartwright, & Gibson, 2014). Of the twenty adverse effects noted, over half of the participants expressed having sexual difficulties and feeling emotionally numb. Authors posit that many of the adverse effects can be described as a ‘closing down’ of the individual; that is “a withdrawal from the emotional and interpersonal world” (Read et al., 2014, p. 70). The authors note the irony of these results, voicing that adverse effects such as feelings of suicidality are often the very problems for which antidepressants are prescribed (Read et al., 2014). For long-term antidepressant users, similar research has found users to have experienced adverse effects in physiology, namely weight gain, addiction, and withdrawal symptoms (Cartwright, Gibson, Read, Cowan, & Dehar, 2016). It begs the question: if taking antidepressants exacerbates depressive symptoms or brings about other, harmful effects, then what value do they bring to those seeking help? 

Recently, Cipriani et al. (2018) conducted a meta-analysis which reviewed previous studies in order to compare the efficacy of antidepressant treatments for major depression with placebos. The researchers scoured the literature and tallied 116,477 patients from 522 double-blind studies. Their results suggest that compared to placebos, antidepressants are more efficacious for treating major depressive disorder. The strength of this research lies in its analysis of an unprecedented number of studies; it is the largest meta-analysis of its kind. It is also robust due to its inclusion criteria which required studies to be randomised-controlled and to utilise the Hamilton Depression Rating Scale which are touted as the gold-standard of clinical research design and depression assessment scales respectively (Makhinson, 2012; Williams, 1988). 

Cipriani et al.’s (2018) meta-analysis on the efficacy of antidepressants seems, on the surface, to hold firm evidence for depressive patients wishing to undergo antidepressant treatment. A closer inspection, however, leads us to believe otherwise. For one, 82% of the studies used in the research had moderate to high risk of bias, with 78% disclosing research funding from pharmaceutical companies. Therefore, bias in this instance refers to sponsorship bias (Doucet & Sismondo, 2008) where researchers are influenced to produce and publish results which adhere to outcomes befitting the very companies which sponsor them. After all, if researchers publish data which convinces clinicians and clients that antidepressants work, then companies are more likely to profit, and therefore provide researchers with more funding. In truth, this cycle of pernicious quid pro quo between researchers and the pharmaceutical industry may explain the abundance of antidepressant research. With this in mind, it is imperative that clinicians and clients ground themselves in the knowledge that antidepressant research is evidently sullied by commercial interests. 

Misdiagnosis is a very important factor to consider when endeavouring to explain why antidepressants may benefit some, but are detrimental to others. The problem of misdiagnosis stems from the reliance of clinicians on patients reporting their own symptoms. Modern measurements require clinicians to observe behaviours displayed during a session or to elicit answers from statements for input on a scale (DeVellis, 2016). A question is thus begged: if antidepressants seek to resolve issues in the brain, then what validity can we garner from diagnoses absent of biological verification? To be sure, verifying biological causes is important; biopsies or radiological imaging can rule out or reveal macromolecular explanations such as brain tumours or abnormalities in hormone reproduction. 

In a recent article, Allsop, Read, Corcoran, and Kinderman (2019) illuminate the heterogeneous nature of psychiatric classifications. Highlighting the potential for misdiagnosis, Young, Lareau, and Pierre (2014) calculate that in the DSM-5 (American Psychiatric Association, 2013), there exists 270 million symptoms that, when combined, meet the diagnostic criteria for both post-traumatic stress disorder and major depressive disorder. Furthermore, when other common diagnoses are made alongside these two, the number rises to one quintillion symptoms. These criticisms pose a concern, not least due to the adverse effects experienced by patients as a result of misdiagnosis, but also for the potential for misdiagnosis to exacerbate symptoms from other disorders for which major depression has overlapping symptoms (American Psychiatric Association, 2013). 

Given the evident potential for errors in diagnosis, it is imperative that patients receive care from practitioners with the utmost expertise. Criticisms of research notwithstanding, there are more reasons to be skeptical of the supposed efficacies heralded in the literature. For the vast majority of patients, the level of clinical attention given in vivo differs to that in vitro. In fact, approximately 74% of patients receive antidepressants from general practitioners, not psychiatrists (Mojtabai & Olfson, 2008). It is unsurprising then, that patients receiving prescriptions from general practitioners are less likely to continue to take their prescriptions after a month (Mojtabai & Olfson, 2008). The differences in clinical management between research settings and clinical settings is also an important consideration as the therapeutic setting has a direct influence on the placebo components of treatment (Rutherford & Roose, 2013). Kirsch and Sapirstein (1998) argue that half of the overall responses to clinical trials can possibly be attributed to the therapeutic setting alone. Taken together, the literature suggests that outcomes in clinical trials may not necessarily be a reflection of what patients experience in clinical settings. As such, results advocating for antidepressants may instead reflect on the high degree of care shown by clinicians in experiment trials, not the antidepressants themselves. 

To summarise, patients who have been prescribed antidepressants have varied experiences. For some, it reduces symptoms, provides a sense of relief and agency in their suffering, and helps them to function in desired ways. For others, the detrimental effects outweigh the supposed benefits, and ironically, exacerbate the very symptoms they hoped to alleviate. Although there exists substantial research which advocates the efficacy of antidepressants, we cannot be certain that these have not been biased by permeating commercial interests. Finally, even if research results prove robust and unbiased, the differences between clinical trials and clinical settings put into question their ecological validity. 

Whereas pharmacotherapy views depressive symptoms as a result of biological underpinnings, psychodynamic therapy believes psychological suffering comes from inner conflicts and unconscious issues rooted in the mind. Psychodynamic therapy, in essence, works with a client to explore aspects of the individual unbeknownst to themselves. As a result of the relationship between therapist and client, these unknown aspects of self become manifest (Horvath, 2000). For therapists, there exists a belief that suffering weaves through the fabric of a person’s life and is writ large in emotional blind spots, inner contradictions, and relationship patterns (Gabbard, 2017). Given that clients’ problems are localised in places unknown to them, therapists place an emphasis in eliciting self-reflection and self-examination by patients. Indeed, for Yalom (1980), psychotherapy ultimately “embraces the goal of unflinching self-exploration.” 

Much like antidepressants, psychodynamic psychotherapy can differ in its approach, but therapists of each therapy practice tend to concur in their chief concerns regarding the goal of treatment. That is, psychodynamic practitioners believe in bringing to the conscious awareness processes underlying the manifestation of patients’ symptoms (Busch, Rudden, & Shapiro, 2016). For example, psychodynamic therapists of a Freudian disposition investigate early experiences which reveal a perceived loss of a significant individual for whom a client’s ambivalent feelings for might uncloak conflicted anger that has become targeted at the self (Busch et al., 2016). Therefore, different therapists may approach depression with different models; similar to how psychiatrists can approach depression with antidepressants of varying mechanisms. 

Because psychotherapy seeks to elucidate unconscious conflicts which influence and produce detrimental symptoms, much controversy has arisen regarding the existence of the unconscious (Turnbull & Solms, 2007). This can be traced back to Freud, who espoused that much of an individual's mental activity exists unbeknownst to themselves. Given the inadequacies of technology in Freud’s time, it is easy to see why critics claimed that his assertions were untenable and untestable. In the last several decades however, remarkable scientific research has provided evidence of such unconscious processes. Phenomena such as blindsight (Weiskrantz, 1986), implicit awareness in neglect (Marshall & Halligan, 1988), nondeclarative learning in spite of amnesia (Turnbull and Evans, 2006a), and the observations of the split-brain (Gazzaniga, 1995) lay such criticisms to rest. 

While the existence of unconscious processes that underpin psychodynamic perspectives may have been proven, what of the evidence regarding the efficacy of psychodynamic psychotherapy itself? For Chambless and Hollon (1998), research purporting empirically supported therapies requires randomised-controlled trials; measures for diagnosis and outcomes which are reliable and valid; utilisation of treatment manuals or manual-like guidelines; and a specific, targeted population. Following these criteria, Leichsenring, Leweke, Klein, and Steinert (2015) conducted a meta-analysis of 39 studies and found that psychodynamic psychotherapy is efficacious in treating a variety of common mental disorders including major depressive disorder. 

Further evidence suggests that therapists’ facilitation of psychodynamic treatment elicits in patients the expression and experience of emotions conducive to positive outcomes (Diener, Hilsenroth, & Weinberger, 2007). Given that psychodynamic therapies place an emphasis on facilitating self-exploration and self-expression within a client (Busch et al., 2016), it is unsurprising that the more this occurs, the more positive the treatment results are (Diener et al., 2007). In several randomised-controlled trials, psychodynamic therapy has been found to be more efficacious in treating depression when compared to waiting list control conditions or alternative treatments (Knekt et al., 2008; Maina, Forner, & Bogetto, 2005; Thompson, Gallagher, & Breckenridge, 1987). A recent meta-analysis by Driessen et al. (2015) demonstrated that short-term psychodynamic therapy among adults with depression resulted in better symptom reduction and improvement in function when compared to control conditions. Furthermore, the authors found that these gains had been maintained or improved upon during follow-up appointments (Driessen et al., 2015). 

As aforementioned, caution is advised whenever garnering evidence of the efficacy of research. For example, in Driessen et al.’s meta-analysis (2015), a third of the studies analysed were not randomised-controlled clinical trials. Moreover, a number of the studies included did not disclose pertinent information pertaining to the use of medication in conjunction with therapy, the qualifications of therapists, or the control groups. 

Another criticism of psychodynamic therapy pertains to the limitations of its non-definitive guidelines regarding who can potentially benefit from, and therefore undertake, treatment. A client might be diagnosed with depression but may not necessarily receive treatment if they do not demonstrate certain proclivities (Busch et al., 2016). Three examples out of the seven proclaimed guidelines follow (Busch et al., 2016, p. 6). Firstly, depressed patients must have the inherent motivation to understand the origins of their symptoms. Secondly, they must also demonstrate the ability to think psychologically, which is to say that patients must be able to associate their behaviour with their thoughts and feelings. Thirdly, depressed patients should display potential for being able to form and think about meaningful and complex relationships with others. Given that depression is characterised by a lack of motivation, low self-esteem, pessimism, and general disengagement (Nesse, 2000), it must be asked: how can clinicians expect depressed patients to fulfill such expectations if the very characteristics which define them are the very ones that exclude them from treatment? Such arbitrary prerequisites seem entirely contradictory to Wallerstein’s (1989) proposition that obligates clinicians to balance their practice with clients on the interpretative-supportive continuum. 

In addition to the contradictory guidelines limiting patient access to psychodynamic therapy, other factors also pose limitations. Compared to antidepressants, psychodynamic psychotherapy differs markedly in its length of treatment which can be burdensome on patients’ time. For patients who aim to reduce symptoms alone, brief psychodynamic psychotherapy lasts approximately three to six months. Otherwise, if the treatment of deeper vulnerabilities and intrapsychic conflicts is the goal, treatment lasts between six months to two years. Furthermore, costs remain steep despite, in some cases, clients being provided adaptive payment options dependent on income (Olfson & Pincus, 1994). Given that depression is associated with material hardship and lower socioeconomic status, accessing psychodynamic treatments becomes increasingly difficult (Heflin & Iceland, 2009). We can look in awe at the research evidencing beneficial outcomes and appreciate psychodynamic psychotherapy’s efforts in working with individuals through issues which constrain them, however, if the treatment is inaccessible and unnecessarily cumbersome, its evidence and practical impressions are for naught. 

Taken together, psychodynamic psychotherapy represents treatment founded on long-standing views of the mind. Therapists seek to explain ailments and alleviate symptoms by bringing awareness to unconscious processes. As discussed, evidence exists which supports the origins of these machinations, as well as the efficacy of treatment for those with depression. In truth, the therapeutic relationship plays a large role in these outcomes, but its criteria for inclusion, length of treatment, and limited accessibility render it a luxury. 

In an ideal world, someone suffering from depression could test for themselves which treatment works best for them. A depressed person privileged with resources may find that both antidepressants and psychodynamic psychotherapy work simultaneously, allowing one the opportunity for full exploration of root causes in conjunction with the reduction of symptoms (Busch et al., 2016). In truth, it is unreasonable to suggest that one treatment is better than the other for treating depression. With both methods, there are as many reasons to trust evidence as there are to distrust it. Furthermore, even if evidence was clear, people themselves are undoubtedly complex; what works for one person may not work for someone else. Perhaps the only guarantee is that patients with depression seeking help want to get better. As such, it is recommended that they do their utmost to access available treatment whether it be antidepressants, psychodynamic psychotherapy, or both.

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