New research shows anti-pathology approach to depression is successful for most people

Dr Jess discusses a must-read new study by Kostic et al.

A study of 83 people has shown that using anti-pathologising, supportive, trauma-informed approaches to people who are feeling depressed are successful in most people, even after a three month follow up period.

So let’s get into it!

I am a psychologist who champions an APTI approach.

APTI means anti-pathology, trauma-informed approach. Simply put, I believe that human distress and trauma is natural, normal, and expected when people are going through really hard times in their lives. Rather than diagnosing them as mentally disordered and medicating them with pills for months or years (or decades), I believe we should be supporting that human being with compassion, time, respect, and validation whilst helping them to explore and understand why they feel the way they do.

Radical, apparently. Enough that I am laughed at and attacked every single day.

I don’t think it’s radical at all. I think this is common sense. Humans don’t suddenly develop mental illnesses and disorders when they are struggling. They are simply responding to the extreme stress they are put under. Some people have panic attacks, some people sleep more, some people stop eating, some people feel suicidal.

The problem is, we have pathologised depression and feeling suicidal to such an extent that the moment those words leave your mouth, every system around you goes into overdrive. Everyone kicks into risk-averse practice, and the so-called ‘safeguarding’ begins. You are assessed over and over. You are told to tell your doctor that you are depressed. Told you need urgent professional help. To call the police if you feel you want to die. You might even be sectioned for weeks or months of your life.

But what if we supported people with their sadness in a supportive, calm, watchful way?

A new study published 13th Feb 2024 by Kostic et al. in the Journal of Affective Disorders worked with 83 people who were depressed, and instead of pathologising them, putting them on medication or locking them in a ward, they simply supported them and used ‘watchful waiting’. Simply: they supported them for long enough, and well enough, that the depths of depression passed.

Their study found that watchful waiting, advice, shared decision making, depathologising their feelings, and good support 64.5% of the participants meant that three months later, they were feeling much better despite never accessing medication or psychotherapy.

Fascinating. It’s almost as if validating their feelings, empowering their own choices, explaining that their feelings are totally normal and natural, and supporting them with advice might actually work.

This is what academia is for, after all. Explaining absolutely basic common sense back to us.

The authors of this study argued that people with depression usually had an objective set of problems that were impacting them - and that they had not just developed some (now debunked) chemical imbalance in their brain. Further though, the authors go on to criticise the fact that there are no scientific or biological tests for depression, and it is nothing more than a social construct we use to understand deep sadness, hopelessness and emotional exhaustion.

Finally, the authors suggested that most people have been so influenced by society and medical messages that they seek support, and usually expect medication. They have been told so many times by so many people that they need to go to their doctor for this illness, and they will be given pills that will help them. This is despite increasing evidence antidepressants cause serious side effects, and that placebo works better than antidepressants in medical trials.

On that basis, they wondered if it would work if they depathologised the experience of depression, explained and validated their feelings, supported them, gave them advice about their problems, and waited to see if they started to feel better.

I also noted interestingly, that almost 70% of the participants sought help for depression because their family or friends told them to go and see a doctor. This is a common experience, and I wonder if this contributes to the feeling of pathologisation (opening up to a family member or friend, only for them to panic and tell them to see a doctor for medication).

One other intriguing finding made me think about placebo effect.

The authors noted that the only participants who ended up taking antidepressants or benzodiazepine did so because they absolutely insisted they needed them, and believed they were the only things that would make them feel better. Fascinating then, that they reported the same increase in wellbeing as the 64.5% of participants who did not take any medication, did not access psychotherapy, and instead learned about anti-pathology approaches to their feelings.

Could this be an example of placebo effect? The people who were supported by the researcher team to understand their feelings, depathologise depression, and were given advice that helped them feel much better had just as successful outcomes as the seven participants who insisted they needed medication. Or did they?

Arguably, we could say that the seven participants who took the medication are now taking medication that has serious side effects, has very real withdrawal impacts, and the ones that were taking benzodiazepines are likely to have to face their dependence on the drug at some point - whereas the 64.5% of participants who were supported in a completely anti-pathology, trauma-informed approach have no such issues to face. They simply feel much better, and carried on their lives with additional, useful knowledge that demystified and validated their feelings of depression.

I would say that one group has ended up much better off than the other.

One final note from me: I read with interest the author’s discussions of the preconceived ideas of the participants when they sought help. Many of them had already decided that they ‘had depression’ and that they needed medication to get better. This is a very powerful assumption, and one that would likely induce the nocebo effect.

I’ve been waiting to talk to you all about nocebo effect for months!

If you do not know what the nocebo effect is, it is the opposite of the placebo effect. Where placebo effect causes us to feel better physically or mentally from something that has no physical impact on us (taking a sugar pill, but believing it will help us), the nocebo effect causes us to feel worse from something that also technically has no impact on us (like believing the sugar pill we are taking will give us headaches, and then we get a headache).

Nocebo effect is extremely powerful. One study a few years back gave men a load of dummy pills with no active ingredient, and warned them that it may give them erectile dysfunction. Most of the men reported that the pills caused them to develop erectile dysfunction. They couldn’t get an erection and couldn’t climax. But what caused that? The pills were made of nothing but sugar. It was nocebo effect, it was the power of the mind. The power of suggestion.

So applying this to mental health and trauma, what happens when we convince people, and ourselves, that we have a mental disorder? What happens when the screening process itself causes us to see ourselves as mentally ill? Depressed? Bipolar? ADHD?

Could the nocebo effect mean that we begin to believe we are disordered, and then begin to believe that the only thing that could help us is the psychiatric medication everyone tells us about, which we then take, tolerate the terrible side effect, and experience the placebo effect because we believe it is making us better and correcting some mythical chemical imbalance in our brain?

I know, rabbit hole stuff, huh?

Anyway, back to the study. This isn’t the only example of success when using an anti-pathology approach to trauma and distress - organisations all around the world are beginning to realise that psychiatry isn’t exactly the ‘science’ we once thought it was, and that people need time, compassion, validation, help, patience, and dare I say it… love?

I am currently working with several organisations, police forces and authorities, helping them to move their practice, policies and training over to a true anti-pathology, trauma-informed, anti-oppressive model - and you know what? It’s working.

Depathologising so-called mental disorders is the future. APTI is the future.

We are finally moving towards an approach that validates the suffering and experiences of human beings, and doesn’t attempt to reframe their distress as a mental illness inside their head. When someone confides in us that they are depressed, not coping anymore, and want to give up - we don’t have to respond with pills and forced therapy - there is a better way.

You can read the full paper here: https://www.sciencedirect.com/science/article/pii/S2666915324000386

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