From neuroleptics to neuroscience and from Pavlov to psychotherapy: more than just the “emperor’s new treatments” for mental illnesses?- Margraf & Schneider - 2016 - Article

In regard to short‐term outcomes, pharmacotherapy is clearly inferior to cognitive behavior therapy in treating anxiety disorders; for depression, the two methods are equivalent, drug treatments are superior to psychotherapy for treating psychotic disorders. Neither drugs nor CBT show convincing efficacy against ADHD. Lasting success after the end of treatment is shown for psychotherapy (CBT), whereas the effects of drug treatments vanish rapidly once the drugs are withdrawn. In fact, most selective serotonin reuptake inhibitors (SSRIs) to treat depression are both ineffective and harmful. Adding drugs to psychotherapy works less well than therapy alone. For instance, using neuroleptics, atypical antipsychotics, and clozapine for treating schizophrenia is associated with smaller brain tissue volumes that cannot be attributed to severity of illness or substance abuse. Most mental disorders begin before the age of 14 and continue to evolve over the whole life span. Brain development persists into the early 20s and coincides with a main risk period for negative effects of interfering with neurobiology. 

In regard to short‐term outcomes, pharmacotherapy is clearly inferior to cognitive behavior therapy in treating anxiety disorders; for depression, the two methods are equivalent, drug treatments are superior to psychotherapy for treating psychotic disorders. Neither drugs nor CBT show convincing efficacy against ADHD. Lasting success after the end of treatment is shown for psychotherapy (CBT), whereas the effects of drug treatments vanish rapidly once the drugs are withdrawn. In fact, most selective serotonin reuptake inhibitors (SSRIs) to treat depression are both ineffective and harmful. Adding drugs to psychotherapy works less well than therapy alone. For instance, using neuroleptics, atypical antipsychotics, and clozapine for treating schizophrenia is associated with smaller brain tissue volumes that cannot be attributed to severity of illness or substance abuse. Most mental disorders begin before the age of 14 and continue to evolve over the whole life span. Brain development persists into the early 20s and coincides with a main risk period for negative effects of interfering with neurobiology. 

It was assumed that mental disorders result from chemical imbalance. However, in order to qualify as a causal factor, pathophysiology has to exist before the onset of the mental disorder. In contrast to various psychosocial risk factors, there is not enough evidence for this. Besides, categories with dubious validity miss the relevant dimensions of human behavior. One prominent classification is based on behavioral dimensions and neurobiological measures, omitting the social level. Recent findings show that the effect of social factors depends on psychological mechanisms; sense of control, mental activity, delay of gratification. Also, improving social factors also improves mental health in a lasting way.

We need to tighten the interlocking of etiological and therapeutic research strategies and of the bio‐, psycho‐, and social levels of analysis of mental disorders. Second, we need a broad and narrow focus. the UK′s IAPT (Improving Access to Psychological Therapies) program provides evidence‐based short‐term psychotherapy for anxiety and depression. The problem in psychotherapy, as opposed to drug treatment, is not efficiency. Rather it is availability for those in need and the quality of the treatment itself.