What Is the Best Way to Treat Depression?

Those of us who experience depression face an important decision: What's the best way to treat it? The most common options are medication and psychotherapy.

Years ago when I was interviewing for graduate school, the consensus seemed to be that medication was the "real" treatment for depression. This was at a time when the "chemical imbalance" theory of depression was alive and well.

The basic version of the theory was that depression was caused by low levels of neurotransmitters in the brain—chemicals like serotonin and norepinephrine. If these biological factors were driving depression, it made sense to assume that the best way to fix the underlying problem was with a biological solution.

Thus treatments like cognitive behavioral therapy (CBT) were considered to be possibly useful additions to medication, but not serious treatments in their own right (except perhaps for brief, mild forms of depression).

When I was in graduate school I thought the chemical imbalance theory was true. So when I reviewed a wide range of potential risk factors for depression, I expected to find many studies confirming the link between depression and low serotonin. I was in for a shock. It turned out there was no good evidence for the chemical imbalance theory. What had seemed like solid science was in fact unsupported by research.

Nevertheless, this explanation infused our collective understanding of depression and other psychiatric conditions, so much so that it's still widely believed.

Effectiveness of Medication and Cognitive Behavioral Therapy (CBT)

While I was a doctoral student one of my advisors completed a large research trial that compared CBT with antidepressant medication (a selective serotonin reuptake inhibitor, or SSRI) among people with moderate to severe depression. If "real" depression could only be helped through medication, the CBT group should have fared much worse.

The results surprised a lot of people. After 16 weeks of treatment, 58% in each group had experienced significant improvement, and both groups beat a placebo 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.

While these findings suggest that those with depression have at least two viable treatment options, it also introduces a dilemma: How should we decide when therapy or medication—or combination—is the best option?

1. How Bad Is the Depression?

A common refrain is that "the best treatment for depression is a combination of medication and therapy." But is that always true? There are obvious downsides to doing two treatments at the same time, including additional time and money and potential side effects. Any benefits would need to outweigh these significant costs.

When a person is mildly depressed or hasn't been depressed for long, CBT is equally effective with or without medication. However, for those with moderate to severe depression, getting both CBT and a medication leads to better outcomes than CBT alone—especially among those with chronic depression. This result would seem to confirm the idea that "serious" depression requires medication.

But a more accurate statement would be, "More severe depression requires both medication and therapy." A meta-analysis that compared CBT+meds to meds alone found a fairly large advantage for the combined group, suggesting that, in general, adding CBT to medication leads to greater benefit.

Based on these and other studies, the American Psychiatric Association (APA) recommends psychotherapy or medication as first-line treatments for mild to moderate depression; for individuals with more severe depression they recommend a combination of both.

2. How Much Will Treatment Cost?

Good treatment is not cheap, and the cost varies greatly depending on several factors:

• Insurance coverage. Many mental health professionals practice outside of insurance networks because of the low payments in-network providers must agree to and the administrative burden, among other factors. The out-of-pocket cost for either treatment can be considerable, even prohibitive—often $120-200 for a CBT session and $100-180 for brief psychiatry check-ups. Getting medication from one's primary care doctor makes insurance coverage more likely, but s/he probably has less expertise in treating depression compared to a psychiatrist.
• Type of medication. The vast majority of drugs used to treat depression are available in generic form, making them much more affordable than brand-name medication. Insurance coverage might also vary depending on the drug, which can greatly affect the cost of treatment.
• 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. Another study estimated that over two years, treatment with the SSRI fluoxetine (Prozac) would be 33% more than with CBT.

3. How Long Will I Be in Treatment?

Most of us would like to get what we need from our treatment and be done with it as quickly as possible. A typical course of CBT is around 12-16 weekly sessions of about 45 minutes each. During this time a person will learn to plan and complete activities that bring enjoyment and reward, and to change thought patterns that contribute to depression.

Treatment may continue for additional sessions that are spaced further apart, while the person keeps practicing the skills on his or her own. Thus the full course of treatment may last from 3 to 6 months, and longer in some cases if needed. The APA recommends that those with a long history of depression continue to receive therapy on an ongoing basis, often with a reduction in frequency of sessions.

The length of treatment with medication can vary widely. APA guidelines recommend that individuals with more chronic or recurring depression, or with other risk factors for relapse, should stay on their medication indefinitely. Otherwise the guideline is that those who had a good response to medication should continue to take it for an additional 4 to 9 months to reduce the risk of relapse. Thus a typical short-term treatment with medication may last 6-12 months.

Discontinuing medication should be done gradually and in close consultation with the prescribing doctor to minimize the risk of withdrawal effects (e.g., dizziness, fatigue, nausea, headache, insomnia).

4. Will There Be Side Effects?

The newest drugs for depression tend to have milder side effects than earlier medications. Some of the most common side effects associated with SSRIs–Prozac, Zoloft, Paxil, etc.—are nausea, weight gain, agitation, insomnia, loss of sex drive, and difficulty reaching orgasm.

Some people decide against medication because of the side effects, while others choose to tolerate them because of the medication's benefits.

While people often promote therapy as having "no side effects," this is not strictly true. Effective therapy is hard work, and can involve difficult emotions like anger, sadness, and frustration on the road to feeling better. It might involve confronting aspects of ourselves that we'd rather not see, or painful parts of our past.

As with medication, a person might decide to avoid the potential downsides of talk therapy and choose instead a treatment like medication.

5. How Long Will the Benefits of Treatment Last?

Depression treatment is a big investment, and we'd like the benefits to be long-lasting.

In general, the benefits of CBT continue long 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; one year later 69% were still depression-free. In the same study, only 24% of those treated with an 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, versus those who got CBT. Thus there appears to be a greater risk associated with stopping antidepressant medication than with stopping CBT, which is why the APA recommends continuing medication even after the depression has lifted.

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Clearly there are many issues to consider in choosing the right treatment for one's depression. Thankfully we have options, including ones I haven't covered here (e.g., TMS). 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's my area of specialty and it has the most evidence for working.

The right treatment can help you 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.

For more, consider Retrain Your Brain: Cognitive Behavioral Therapy in 7 Weeks.

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