Greenberg, R.P. (2016). The rebirth of psychosocial importance in a drug-filled world. American Psychologist, 71, 781-791.
In this thoughtful piece, Greenberg reviews the research on psychosocial factors that affect mental health treatment outcomes – including for medications and in psychotherapy. There has been an important shift in the last few decades to view mental disorders, including depression, as biologically based. For example, surveys indicate that the public’s belief in biological causes of mental illness rose from 77% to 88% during a 10 year period. During the same period the belief in the primacy of biological treatment for mental disorders rose from 48% to 60%. Further, 20% of women and 15% of men in the US are currently taking antidepressant medications. Some of these trends are due to direct to consumer marketing of medications by the pharmaceutical industry, which saw a 300% increase in sales in antidepressants. Some of these trends are also due to Federal agencies like the National Institute of Mental Health that vigorously pursued an agenda of biological research. But what is the evidence for a purely biological view of mental health? Greenberg notes that the evidence is poor. For example, no one has been able to demonstrate that a chemical imbalance actually exists to explain depressive symptoms – which undermines the reason for using medications to treat depression. Further, research on the efficacy of antidepressant medications shows that they perform only slightly better than a placebo pill, prompting a former editor of The New England Journal of Medicine to declare that this difference is unlikely to be clinically meaningful. The placebo effect is essentially a psychosocial effect. It refers to: the patient’s experience of a caring relationship with a credible professional, and the patient’s expectations and hopes of getting better. Placebo is a very real phenomenon that also has an impact on purely medical interventions like surgeries. In psychotherapy trials, relational/contextual factors like therapeutic alliance, expectations, therapist empathy, and countertransference likely account for more of the client’s outcomes than the particular therapeutic technique that is used. In both psychotherapy and medication treatments for depression, it appears that the more patients perceived their doctors as caring, empathic, open, and sincere, the greater their symptom improvement. There is also good evidence that psychotherapy is as effective and antidepressants for mild to moderate depression, and that antidepressants are slightly superior for chronic depression. However, even the latter should be interpreted carefully and within the context that patients prefer psychotherapy, their adherence to medications is poorer, side effects are worse for medications, and drop out rates are lower for psychotherapy.
Patients benefit from antidepressant medications, but perhaps not exactly for the reasons that they are told. Psychosocial factors likely account for a large proportion of the effects of many medically-based interventions for mental disorders. Psychosocial factors are actively used in many psychotherapies, and therapists’ qualities like their ability to establish an alliance, empathy, and professionalism account for a moderate to large proportion of why patients get better.