Every year, 15 million adults in the US will experience major depression. For those who seek treatment, the most common options are medication and psychotherapy.
Choosing between these options can be difficult because of the many factors to consider: Will it work? Will the benefits last? Will I have side effects? And can I afford it?
A depression researcher I spoke with in 2001 had a clear opinion on this issue. One of his colleagues was completing a research trial comparing antidepressant medication with cognitive behavioural therapy (CBT) for people with moderate to severe depression.
The consensus at that time among both psychiatrists and psychologists was that talk therapies like CBT could be helpful for people with mild depression, and might be a useful addition to medication for people with more severe symptoms. But talk therapy was not considered by many to be a ‘serious’ treatment for more severe depression.
This was at a time when the ‘chemical imbalance’ theory of depression was still seen as valid, and so a chemical treatment was thought to be necessary. In fact there is scant evidence that depression is caused by low levels of neurotransmitters like serotonin.
‘We know what’s going to happen,’ this researcher told me. ‘The medication’s going to beat up on the CBT. These patients have major depression – they need meds.’
Except that’s not what happened. Participants in the therapy and medication groups were equally likely to improve during the 16 weeks of treatment (58% did in each group).
Recent reviews confirm what this study found, including a meta-analysis of 20 studies showing that medication and CBT work equally well in relieving depression.
Many people believe that the combination of medication and therapy is always better than either individual treatment. Of course there are downsides to doing two treatments at once, including additional time, money, and possible side effects. When might the benefits outweigh these costs?
Is combined therapy better than meds or therapy alone?
Many of the people who come to me for depression treatment are referred by their psychiatrist. They’re often taking a medication like fluoxetine (Prozac) or sertraline (Zoloft), and are looking for additional symptom improvement.
Other people I treat may start CBT without a medication, and at some point I’ll refer them to a psychiatrist for a consultation. A third group starts and ends CBT without medication, and is satisfied with the progress they make.
What determines when combined treatment is the best choice? The meta-analysis described above also compared CBT+meds to meds alone. They found a fairly large advantage for the combined group, suggesting that, in general, adding CBT to medication leads to greater benefit.
An earlier summary of treatment studies provides guidelines for when those receiving CBT should consider adding medication. When depression was mild and/or not chronic, combined treatment offered no additional benefit over psychotherapy alone. For those with moderate to severe depression, medication plus therapy led to better outcomes, especially when the depression was chronic.
Based on these studies, the American Psychiatric Association (APA) recommends depression-focused psychotherapy and medication as first-line treatments for mild to moderate depression. For individuals with more severe depression they recommend a combination of psychotherapy and medication.
How long will treatment take?
A typical course of CBT is around 12–16 sessions of about 45 minutes each. During this time a person will learn a set of skills such as planning and completing life-giving activities and changing depression-related styles of thinking.
After the acute phase of treatment, the person will meet less frequently with the therapist while continuing to practise the skills on his or her own. Depending on the individual’s needs, the full course of treatment may last from 3 to 6 months, and longer in some cases.
The APA guidelines recommend that those receiving medication continue to take it for 4 to 9 months to reduce the risk of relapse. Discontinuing medication should be done gradually and in close consultation with the prescribing doctor to minimise the risk of withdrawal effects (e.g., dizziness, fatigue, nausea, headache, insomnia).
The guidelines also state that individuals with more chronic or recurring depression, or with other risk factors for relapse, should stay on their medication indefinitely. Those receiving psychotherapy should also continue with “a reduced frequency of sessions.”
Will the benefits of treatment continue?
Depression treatment is a big investment, and we’d like the benefits to be long-lasting. In general, the benefits of CBT continue after treatment has ended. This ongoing benefit is not surprising given CBT’s emphasis on acquiring skills that can continue to be used beyond treatment – in effect, becoming one’s own therapist.
For example, one large study followed patients who had recovered from depression following treatment with CBT; a year later 69% were still depression-free. In the same study, only 24% of those treated with selective serotonin reuptake inhibitors (SSRI) maintained recovery from depression once the medication was discontinued.
In fact, 47% of those who stayed on medication had a relapse in the same time period. So in this study, having had CBT in the past was at least as effective as ongoing medication at keeping people well.
This finding is typical of similar studies. A review study found that patients who had received medication for depression were 56% more likely to relapse over the next 15 months after treatment ended. Thus, there appears to be a greater risk associated with stopping antidepressant medication than with stopping CBT.
How much do treatments cost?
The cost of treatment for depression will vary greatly depending on several factors:
- Insurance coverage. Many psychotherapists and psychiatrists do not participate in insurance networks because of the administrative burden and low reimbursement rates, among other factors. Depending on a person’s out-of-network benefits, the cost of either treatment can be considerable – often $120–$200 for a CBT session and $100–$180 for brief medication check-ups with a psychiatrist. Insurance coverage is more likely if one’s primary care physician is the prescribing doctor, although they probably have less expertise in treating depression than does a psychiatrist.
- Type of medication. Most drugs used to treat depression are available in generic form, making them much more affordable than brand name drugs. Insurance coverage might also vary depending on the medication.
- Length of treatment. Obviously a longer course of treatment will lead to higher costs.
Because of the lasting effects of psychotherapy, it tends to be cheaper than medication, at least in the long run. One analysis suggested that the cost of CBT is about double that of medication for the first 16 weeks of treatment, but that the need for ongoing medication leads to higher costs in the months that follow.
What are the possible side effects?
People who are considering medication often have concerns about side effects. Thankfully the newest drugs for depression tend to be easier to tolerate than older ones.
Some of the most common side effects associated with SSRIs – Prozac, Zoloft, Paxil, etc – are nausea, agitation, sleep disturbance, loss of sex drive, difficulty reaching orgasm, and weight gain.
Not everyone who takes an SSRI will have these side effects, and some may have ones that aren’t listed here. In some cases a person may decide the side effects aren’t worth the benefit the medication may provide, and opt for a different treatment. Others choose to stay on the medication and tolerate the unpleasant side effects, some of which may improve over time.
While therapy is often sold as having ‘no side effects’, this is not strictly true. It might involve confronting aspects of ourselves that we’d rather not see, or painful parts of our past. Effective therapy is hard work, and can involve difficult emotions like anger, sadness, and frustration on the road to feeling better. As with medication, a person might decide that the potential downsides of talk therapy outweigh the possible benefits, and choose instead a treatment like medication.
What are your options?
Clearly, there are many issues to consider in picking the right treatment for one’s depression. For those who are mildly to moderately depressed and are hesitant to take medication, good therapy is likely to be just as effective as medication or even combined treatment.
On the other hand, medication by itself can be just as effective as CBT for those who prefer this option and have non-chronic, mild to moderate depression. Thus, there is no need for a person to engage in months of intensive psychotherapy if they’d prefer a more medical approach.
For those with more severe depression, a combination treatment is likely to give the best result. It’s important to note that other psychotherapies besides CBT can be quite effective in treating depression (see a list here); I’ve focused on this form of treatment because it has the most evidence for working, and it’s my specialty.
Thankfully we have options when we’re looking for help with our depression, including ones I haven’t covered here (e.g., TMS). The most important thing is to find a treatment that can help you feel better and get your life back.
If you’re struggling with depression and haven’t been able to kick it on your own, why not explore your treatment options today? Start by talking with a loved one who can think it through with you and assist you in getting the help you need.
Seth Gillihan, PhD is a clinical assistant professor of psychology in the Psychiatry Department at the University of Pennsylvania Perelman School of Medicine.
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