From neuroleptics to neuroscience and from Pavlov to psychotherapy: more than just the #x201C;emperor#x0027;s new treatments#x201D; for mental illnesses?

“T he drugs don’t work” was one of the hit singles from The Verve’s album Urban Hymns, released in 1997. The song was written by lead singer Richard Ashcroft relating to his drug abuse, but it might well relate to the modern treatments for mental illnesses. More than half a century after neuroleptics, antidepressants, benzodiazepines, antipsychotics, behavior therapy, and cognitive treatment were introduced, it is prudent to ask whether “the drugs don’t work”. During the past 50 years, the industrialized world has seen a dichotomy between loudly proclaimed therapeutic breakthroughs and rapidly rising numbers of people on disability payments because of mental illness. We hear that antipsychotic, antidepressant, and anti-anxiety drugs as well as behavior therapy and newer treatments have radically improved what was described as a dismal fate of people suffering from mental disorders. Simultaneously, the percentage of disabled mentally ill patients in the USA has risen by more than 600% since the 1950s (Whitaker, 2010) and similar rates are seen in European countries. Most epidemiologists agree that this “epidemic” is not caused by increased incidence. Moreover, the once rapid succession of new therapeutic developments seems to have halted, at least in pharmacology, as big companies are withdrawing from research on mental disorders. How can this apparent contradiction be explained? Could it be that therapeutic progress is much less than we think or are being told? Could it be that the course of depression, anxiety, schizophrenia, or ADHD has been altered for the worse? Could it be that we cannot make therapeutic progress because the concept of mental illness and its treatment is deeply flawed? There are strong reasons to assume that all three suspicions are in fact true. So, what do we know about the efficiency of pharmacological and psychological treatments? In regard to short-term outcomes, pharmacotherapy is clearly inferior to cognitive behavior therapy (CBT) in treating anxiety disorders; for depression, the two modalities appear to be roughly equivalent, and most clinicians would argue that drug treatments are superior to psychotherapy for treating psychotic disorders. Neither drugs nor CBT show convincing efficacy against ADHD. However, mental disorders are fluctuating and chronic conditions. What really counts therefore is lasting improvement. Here, the picture looks radically different: Lasting success after the end of treatment has only been shown for psychotherapy (typically CBT), whereas the effects of drug treatments vanish rapidly once the drugs are withdrawn. This is obvious for anxiety disorders, depression, and ADHD and may also apply to schizophrenia. There are now plenty of data and evidence that, in the long term, the drugs do not work. CBT undoubtedly outperforms drug treatments (benzodiazepines, antidepressants) for anxiety disorders such as panic and phobias. Since the 1980s, Western governments have also been warning that benzodiazepines are addictive and should not be used on a long-term basis. Moderate to strong withdrawal syndromes, worsened anxiety, cognitive impairment, and functional decline are consistent consequences of long-term use, and there is a clear dose– response relationship. Regarding depression, it was initially claimed that 70% of the patients responded to antidepressants and 30% to placebo. Today, these numbers are actually closer to 40 and 30% (Khan & Brown, 2015). The average effect size of antidepressants in trials submitted to the FDA is 0.30 (Gibertini et al, 2012), and when looking at clinical significance and “real-world” patients, they are on average not better than placebo (Kirsch, 2010). Even more dubious results in children and adolescents led official institutions such as the UK’s MHRA to conclude that most selective serotonin reuptake inhibitors (SSRIs) to treat depression are both ineffective and harmful. With respect to long-term results after end of treatment, psychotherapy, especially CBT, generally outperforms antidepressants (Voderholzer & Barton, 2016): For patients with major depression, relapse after withdrawal is the rule for antidepressants