Psychotherapy and medication each has its pros and cons in treating depression; then, will a combined treatment work better?
How Depression Psychotherapy Works
The efficacy of antidepressant medication (ADM) has been established in literally thousands of placebo-controlled clinical trials. However, studies have shown that psychotherapy is also effective in treating severely depressed patients.
Cognitive therapy is a relatively short-term, focused psychotherapy for a wide range of psychological problems. In cognitive therapy for depression, therapists aim to help patients acquire the abilities to:
identify the thoughts and images that accompany and precede the experience of upsetting emotions
distance themselves from the beliefs that are embedded in, or implied by, these thoughts and images
question, often through experiments, the validity of their beliefs (for example, what is the evidence for this belief? Are there alternative explanations for the event that triggered the beliefs?)
identify the themes in the content of the thoughts and images that occur across a range of situations
Comparing Psychotherapy and Medication
In comparison, antidepressant medications (ADMs) seem to be symptom-suppressive rather than curative. That is, although ADM is effective in treating acute depressive episode and is preventive so long as its use is maintained, ADMs do not reduce future risk of depressive episodes once patients stop using ADMs.
This suggests that causal mechanisms of depression are unchanged by ADM treatment, and so patients are left with an elevated risk for subsequent episodes if they stop taking their medications.
Cognitive therapy, on the other hand, is based on the premise that inaccurate beliefs and maladaptive information processing (forming the bases for repetitive negative thinking) have a causal role in depression. This “cognitive model” posits that when maladaptive thinking is corrected, both acute distress and the risk for subsequent symptom return will be reduced.
Research studies support the lasting effects of psychotherapy for depression. For instance, in a one-year randomized controlled trial study, 267 women with current major depression were randomly grouped to receive antidepressants, cognitive behavioral therapy (CBT), or referral to community mental health services.
Among participants with severe depression, CBT appears to have more lasting effects, as participants receiving CBT continued to improve over the course of the study, while medication participants got worse after 6 months.
Researchers say that the worsening of symptoms among the medication participants may have been due to the ending of study treatment. Further, the continued improvement of CBT patients suggests that CBT had provided patients with a set of adaptive coping skills that allowed them to sustain their clinical gains.
Will a Combined Treatment Work Better?
To find out if combining psychotherapy and medication is more effective in treating depression, some researchers analyzed 17 research studies that involve randomized treatment control study of major depression; these 17 studies all compared a combined treatment condition to at least one active single treatment.
The findings suggest that combined treatment is associated with a small improvement in efficacy, and that this finding appears consistent across studies.
Trends in the literature suggest that adding psychotherapy to antidepressant medication may be particularly efficacious among chronic or severely depressed patients. Further, adding cognitive-behavioral therapy to medication may be particularly efficacious in preventing relapse, particularly among individuals discontinuing medication use.
In another analysis of 52 studies with 4,734 depressed patients, researchers concluded that medication is probably the best treatment for dysthymia, and combined treatments are more effective in depressed outpatients, as well as in depressed older adults.
Specifically, in patients with dysthymia, medication is significantly more effective than
psychotherapy, whereas combined treatment is not significantly more effective than either medication or psychotherapy alone. Therefore, medication seems to be the best first-line treatment in these patients, at least in the short term.
In older adults, no significant difference between medication and psychotherapy was found, but combined treatment is significantly better than medication alone. Combined treatment seems to be the best treatment option in this group.
In outpatients, combined treatment is significantly more effective than either psychotherapy alone or medication alone, and seems to be the best treatment for this group.
Cuijpers, Pim, et al. “Personalized Treatment of Adult Depression: Medication, Psychotherapy, or Both? A Systematic Review.” Depression and Anxiety, vol. 29 2012, pp. 855–864.
DeRubeis, Robert J., et al. “Cognitive therapy versus medication for depression: treatment outcomes and neural mechanisms.” Nature Reviews | Neuroscience, vol. 9, 2008, pp. 788-796.
Friedman, Michael A., et al. “Combined Psychotherapy and Pharmacotherapy for the Treatment of Major Depressive Disorder.” Clinical Psychology: Science and Practice, vol. 11, no. 1, 2004, pp. 47-68.
Siddique, Juned, et al. “Comparative Effectiveness of Medication Versus Cognitive-Behavioral Therapy in a Randomized Controlled Trial of Low-Income Young Minority Women with Depression.” Journal of Consulting and Clinical Psychology, vol. 80, no. 6, 2012, pp. 995–1006.