A common question asked goes something like,

“I went to see my family doctor and he prescribed me an antidepressant after I talked to him about feeling down for the past few weeks and unable to motivate myself to do anything. He didn’t mention anything about psychotherapy. Do I need it? Would it help? I’ve been on this medication now for 3 weeks and still feel depressed.”

The answer in almost every case is that psychotherapy is a valuable treatment component to anyone suffering from clinical depression. Doctors who don’t bring it up may either do so out of ignorance or embarrassment, but put their own patients’ well-being and health at risk.

Don’t believe me? Back in the 1990s, the American Psychological Association’s Monitor on Psychology wrote a nice article that summarizes the research in this area of the combination of psychotherapy and medications in the treatment of depression. Their conclusion? People get better, faster on combination treatment than on either treatment by itself.

The preponderance of the available scientific evidence shows that psychological interventions, particularly cognitive-behavioral therapies (CBTs), are generally as effective or more effective than medications in the treatment of depression, even if severe, for both vegetative and social adjustment symptoms, especially when patient-rate measures and long-term follow-up are considered (Antonuccio, 1995 [43]).

Yale psychiatrists (Wexler & Cicchetti, 1992 [50]) conducted a meta-analysis (a large, comprehensive review of the research literature). When dropout rate is considered with treatment success rates, pharmacotherapy alone is substantially worse than psychotherapy alone or the combined treatment.

The review concluded that in a hypothetical cohort of 100 patients with major depression, 29 would recover if given pharmacotherapy alone, 47 would recover if given psychotherapy alone, and 47 would recover if given combined treatment. On the other hand, negative outcome (i.e., dropout or poor response) can be expected in 52 pharmacotherapy patients, 30 psychotherapy patients, and 34 combined patients. This meta-analysis suggests that psychotherapy alone should usually be the initial treatment for depression rather than exposing patients to unnecessary costs and side effects of combined treatment (Antonuccio, 1995 [43]).

Moreover, a consistent finding across studies is a higher dropout rate among those receiving medication, either because of side effects or because the medication has not helped. These patients are treatment failures but are not included as treatment failures in the data for their studies (Karon & Teixeira, 1995 [48]).

Often times you will find doctors and researchers discussing “double-blind placebo controlled” studies as being the “gold standard” within this area of study. This simply is either ignorance or naivete. Seymour Fisher and Roger Greenberg (1993 [50]) among others, have shown the double-blind placebo controlled study is not blind. Side effects are so obvious that more than 80% of the patients know whether they are on active medication or placebo, patients are equally accurate about other patients on the ward, and nurses and other personnel are privy as well. In some studies the only people who claim to be blind are the prescribing physicians, and in other studies the prescribing physicians admit being as aware of the patients’ condition as everyone else (Karon & Teixeira, 1995 [48]).

Greenberg, Bornstein, Greenberg, and Fisher (1992 [47]) conducted another meta-analysis, covering 22 controlled studies (N=2,230). This study calls into serious question the perceived efficacy of tricyclic antidepressant medications, which are shown only to be more effective than inert placebo and only on clinician-rated measures, not patient-rated measures. If patients cannot tell that they are better off in a controlled study, one must question the conventional wisdom about the efficacy of antidepressant drugs. The newer selective serotonin reuptake inhibitors (SSRIs, such as Prozac, Paxil, and Zoloft) do not appear to fare much better (Antonuccio, 1995 [43]).

With active placebos, so that the patients and psychiatrists are not easily informed, the empirical data show that medication effect sizes are hard to distinguish from the placebo. Also not mentioned is that most antidepressant medications habituate, and the patients’ symptoms return. Most patients believe they would feel even worse if they were not taking their medication (Karon & Teixeira, 1995 [48]).

While everyone knows that it often takes years to provide evidence of safety and effectiveness and be approved by the Food and Drug Administration (FDA). But what is not known is that although these studies often have large number of participants, patients may have been given the medication for only short periods of time — much shorter periods of time than in clinical practice.

Prozac, for example, has been advertised as having been administered to either 11,000 or 6,000 patients in preapproval clinical trials. But in all the controlled preapproval trials there were only a total of 286 patients on Prozac, and the controlled trials lasted only six weeks (Breggin & Breggin, 1994). In all the preapproval data submitted, 86% of the patients received Prozac for less than three months. Only 63 patients out of thousands had taken the drug for two years or more — the way it is used in clinical practice (Karon & Teixeira, 1995 [48]).

Some important points that can be taken from the article:

  • Combined treatment of psychotherapy and medication is the usual and preferred treatment of choice for depression. This is likely the most commonly-used treatment for depression today and there is absolutely nothing wrong with it, since it, too, has been proven very effective. Never go against professional advice given with regards to your treatment, unless you have first discussed it with your treatment providers. Especially with depression, it is better to play it safe, than be sorry.
  • Psychotherapy is likely the second treatment of choice for depression, regardless of the depression’s severity or symptoms. Multiple meta-analyses have come to this conclusion, so it is not a conclusion based on just one lone case study or the like. (No one study, even the NIMH study on depression, should ever be used to draw far-reaching, generalized conclusions about a treatment’s effectiveness. Meta-analyses are always preferred by research scientists.)
  • Medication alone should be your last choice and only used as a last resort. Although you will likely gain some short-term relief of the most outward symptoms of your depression, the above-cited meta-analyses and multiple studies have shown that medications don’t work very well in the long-term.
  • Always consult your physician or psychiatrist before beginning or stopping any medications. This article is not meant as advice to your specific situation, but as overall education.
  • People who are taking psychotropic medications should better inform themselves as to the negative and adverse side effects of those medications. Ask your physician about these, or consult the insert for the medication (which you can also request from your doctor if you do not already have one). Also, drug handbooks found in many larger bookstores in the medical section might come in handy, as will the PDR. You might also benefit from a more thorough understanding of how political and un-scientific the drug approval process is in the United States by reading Breggin & Breggin’s book, Talking back to Prozac (1994 [45]). I don’t usually like Breggin or the positions he takes, but I found this to be a fascinating account of the FDA workings and the actual numbers used in the Prozac trials, obtained through the Freedom of Information Act. They concerned me and they should concern you too.

As Consumer Reports noted in their two articles, Pushing Drugs (Feb., 1992) and Miracle Drugs (March, 1992), physicians are actively marketed to by drug companies, given free gifts and vacations. That “professional” you think you’re paying to receive the best and most thorough treatment available may be in the pocket of a pharmaceutical company. So don’t be too surprised that when a new antidepressant medication is marketed that you suddenly see a whole host of psychiatrists prescribing it, not based upon the medical research, but because it’s new.

Additional research conducted since a version of this article was first published online confirms the findings discussed here. For instance, the government’s large-scale STAR*D study found that most people may have to try 2 or even 3 different antidepressants before finding relief. And the U.K.’s NICE Guidelines for Depression (PDF) emphasize the importance of psychotherapy in the treatment of most types of depression, in most people.

» Next in the Depression Series:How and Where to Get Help