Talking therapy is equally if not more effective as drugs at preventing the return of severe depression over time, yet is cheaper than drugs in the short run.
A new study that says so-called cognitive therapy may trump medication for severe depression may strike many therapists as improbable. Psychiatric practice guidelines state most people with moderate or severe mood problems will need drugs.
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However, over the course of the 16-month study, the risk of relapse was no higher, and perhaps even lower, for those who received cognitive therapy than it was among patients taking antidepressants, the researchers found. Although mood medication led to much faster improvements in symptoms, that gap closed as the study progressed.
"If this were a new drug, people would be getting enthusiastic about it," says Steven Hollon, a Vanderbilt University psychologist and a co-author of the study. Hollon says that while a single study would be unlikely to change practice guidelines, the new results should help move the field forward.
The researchers were to present their findings today at a meeting of the American Psychiatric Association in Philadelphia.
Helping people cope
Cognitive therapy helps people with depression cope with stresses that might buffet them in the future. It teaches them to examine their thinking for whiffs of unreality, and asks them to test those beliefs against real events.
Hollon and his colleagues followed 240 people with severe depression for 16 months. The first four months focused on resolving the acute mood problem, while the next year involved preserving the gains for those who improved.
A third of the patients received cognitive therapy, a third got an antidepressant and the rest were given placebo pills. People in the drug and placebo groups also received help and encouragement taking their medication, though neither they nor the therapists knew who was receiving what.
After the first eight weeks, the active drug proved superior to either therapy or sham treatment at improving symptoms of depression on a standardised scale, the researchers found. However, by 16 weeks, 57 percent of people in both treatment groups showed significant improvement. The rate of full recovery was somewhat higher in the drug group.
For the next 12 months, people who improved on cognitive therapy stopped regular treatment, undergoing at most three more sessions through the end of the study. Half the rest either stayed on medication or were switched, with their consent, to placebo pills.
Yet, despite effectively suspending treatment, only a quarter of those receiving cognitive therapy suffered at least a partial relapse during the 12-month follow-up, compared with 40 percent of the patients on antidepressants. The third group fared much worse, with 81 percent relapsing.
Lasting effect
Robert DeRubeis, a University of Pennsylvania psychologist and study co-author, says the results show cognitive therapy has a lasting effect while medication only helps as long as it's being taken.
"It ought to make psychiatrists feel that there are still additional ways to treat" severe depression beyond writing prescriptions. Psychiatrists, but not psychologists, can prescribe medication.
Still, while the two therapies may be equally effective, not all patients with depression are the same. In a related study, Dr. Richard Shelton, a Vanderbilt University psychiatrist, analysed the 240 patients to see if some were more likely to respond to treatment than others.
Shelton, who also presented his findings at the psychiatry meeting, found people with underlying anxiety disorders did much better on medication than they did on cognitive therapy. Meanwhile, patients with chronic depression or a history of post-traumatic stress disorder were less likely to improve with either treatment.
Shelton's group also found that patients with a history of mood problems or chronic depression, and those whose depression appeared early in life, were most likely to suffer relapses during the year of follow-up.
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