1. (facts & fictions in mental health)
The Best Medicine?
How drugs stack up against talk therapy for the treatment of depression
BY HAL ARKOWITZ AND SCOTT O. LILIENFELD
IMAGINE a treatment for depression
that possesses the following proper-
ties: It is as effective as antidepressant
medications but lacks their side ef-
fects. Its therapeutic results last longer
than those of antidepressant medi-
cations after treatment has ended.
Its benefits generalize to many do-
mains of life. It causes changes in the
brain in processes associated with
depression. It usually needs to be ad-
ministered only once a week. It gener-
ally costs the same or less than medi-
cations. Sound too good to be true?
In fact, such a treatment has been
around for decades, although many
people do not know about it. It is
C O U R T E S Y O F H A L A R KO W I T Z ( t o p ) ; C O U R T E S Y O F S C O T T O . L I L I E N F E L D ( b o t t o m ) ; G E T T Y I M AG E S ( i l l u s t r a t i o n )
called psychotherapy.
Why are so many people unaware
of these facts? One reason is that phar-
maceutical companies have huge ad-
vertising budgets to aggressively mar-
ket antidepressant medications to the
public and to the physicians who write
prescriptions. In contrast, psychother-
apists have little or no budget for mar-
keting. In this column, we will try to
level the playing field by providing a
scorecard of how antidepressants
compare with psychotherapies. vidual, some antidepressants work some clients, depression is better but
better than others; no one antidepres- still present, whereas others become
Antidepressants: Pros and Cons sant has been shown to be more effec- symptom-free. Residual symptoms af-
Although a number of different tive than any other at a group level. ter treatment are problematic because
classes of antidepressants exist, we Many people undergoing treatment for they signal a significant risk factor for
will focus on the most commonly pre- depression try two or three SSRIs (or a repeat depression.
scribed class today: SSRIs, or selective other antidepressants) before they find After therapeutic effects appear,
serotonin reuptake inhibitors [see box one that works and that has tolerable clients are usually told to continue on
on opposite page]. side effects. Studies find that about 50 the drug for at least an additional six
People who take antidepressants to 70 percent of those who take SSRIs to 12 months to prevent relapse. If pa-
usually do not show improvement for are responders, showing a 50 percent tients have had several previous epi-
two to four weeks. For any given indi- or greater reduction in symptoms. For sodes or if their depression is severe,
( Imagine a treatment for depression that is as effective as
antidepressant medications but lacks their side effects. )
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2. ( Some studies have shown that combining psychotherapy and
medications is more effective than either alone for adults. )
they may be told to remain on the drug sions, although the evidence on this thinking. Interpersonal psychothera-
longer to avoid recurrence of depres- point is mixed. py (IPT) has the second greatest
sion. Using antidepressants for main- amount of supporting data. Research
tenance in this way reduces the relapse The Scoop on Psychotherapy on other therapies, such as short-term
rate as compared with a placebo. Save Despite the voluminous research psychodynamic therapy, client-cen-
for Prozac, antidepressant therapy has on psychotherapy as a treatment for tered therapy and emotion-focused
not been shown to be effective for chil- depression, scientists have evaluated therapy, has just begun, but outcomes
dren and adolescents and may not be only a few types of psychotherapy. in these few studies have been positive
safe for a small percentage of people CBT has been the most extensively [see box below]. In the remainder of
younger than 24 years old, as we studied by far. Such therapies teach this column, our discussion of psycho-
discussed in our last column, “Can and encourage new behaviors and help therapy refers to those practices that
Antidepressants Cause Suicide?” [Sci- people change excessively negative have been supported by research.
entific American Mind, August/
September 2007]. In addition, antide-
pressants can cause fetal damage, so Antidepressants and Common Side Effects
pregnant women are strongly advised Selective serotonin reuptake inhibitors, or SSRIs, can relieve depression
not to take them. but can have drawbacks.
In most drug trials, all patients
receive the same antidepressant. In Trade name Chemical name Common Side Effects of SSRIs
the real world, however, psychiatrists Paxil paroxetine >> Short-term (lasting a few weeks):
often try a different medication if one nausea, diarrhea, nervousness
Prozac fluoxetine and insomnia
prescription does not work. A recent
study by A. John Rush of the Univer- Lexapro escitalopram >> Long-term (lasting months or
sity of Texas Southwestern Medical longer): low sexual desire or
Center and his colleagues more close- Celexa citalopram sexual dysfunction (in 50 to 75
ly approximated how SSRIs are used percent of patients) and sedation
Zoloft sertraline
in practice. The researchers presented
depressed patients with a four-step set
of options to be used if necessary. All
subjects started on the same anti- Research-Supported Psychotherapies
depressant (Celexa). At each of three Scientists have evaluated only a few types of psychotherapy. The most
subsequent steps, those who either did supporting data exist for cognitive-behavior therapy and interpersonal psycho-
therapy, which have been shown to be effective in treating depression. Only
not respond or could not tolerate the a few studies have examined the performance of the other three therapies
side effects got a menu of options, listed below, but their outcomes are encouraging.
which included changing medication,
adding medication, or adding or Name Approach
switching to cognitive-behavior ther-
Cognitive-behavior therapy Teaches and encourages new behaviors
apy (CBT). This study yielded an over- to help people change overly negative
all remission rate of 67 percent, far thinking
superior to that of most studies that Interpersonal psychotherapy Focuses on the social difficulties and
show remission rates (excluding conflicts associated with depression
improvement rates) of closer to 33 Short-term psychodynamic Emphasizes understanding and correction
percent. therapy of problematic interpersonal patterns
Some studies of adults have shown
Client-centered therapy Emphasizes the therapeutic potential of
that combining psychotherapy and the therapist-client relationship
medications is more effective than ei-
ther treatment alone. Further, several Emotion-focused therapy Builds on client-centered therapy by
adding a focus on increasing awareness
studies with adults have found that of thoughts and feelings and resolving
drug therapy may be more effective persistent and problematic emotional
than psychotherapy for severe depres- reactions
COPYRIGHT 2007 SCIENTIFIC AMERICAN, INC.

3. (facts & fictions in mental health)
The findings regarding the efficacy mate the efficacy of psychotherapy for tients with coping skills that let them
of CBT are remarkably similar to depression, although that conjecture deal better with life events. In con-
those of most SSRI studies. Approxi- awaits formal research. trast, antidepressant treatments may
mately two thirds of patients who un- Numerous studies have demon- be more palliative, suppressing symp-
dergo 12 to 16 sessions of CBT show strated that after treatment has ended, toms for as long as the medications are
improvement or remission. (The rea- patients treated with medication alone taken. Even so, approximately half of
son therapy costs the same or less than relapse at twice the rate of those treat- those who respond to CBT relapse
medications is largely because people ed with CBT alone. Further, dropout within two years, suggesting that we
are usually on antidepressants far lon- rates for antidepressant treatments are psychologists still have our work cut
ger than they are in psychotherapy.) So two to three times as high as those for out for us. CBT researchers are work-
far most comparisons among different CBT, with one large-scale study find- ing on ways to further reduce post-
therapies have shown them to be about ing a 72 percent dropout rate for anti- treatment relapse. For example, recent
equally effective. As of this writing, depressants by 90 days of use. Recov- studies have found that an eight-ses-
however, no studies of psychotherapy ered patients who had received antide- sion group booster treatment known
have adopted the multistage approach pressants and continued on them for as mindfulness-based cognitive thera-
used by Rush and his colleagues with maintenance showed relapse rates py given to recovered depressed pa-
antidepressants; in practice, psycho- roughly equivalent to those who had tients during the year after the end of
therapists often switch strategies if the completed CBT with no further treat- initial treatment reduces relapse for
one they are using is not working. Be- ment. These findings suggest that CBT those who have had three or more epi-
cause psychotherapy studies use only may address some of the underlying sodes of depression.
one approach for purposes of experi- causal processes better than medica- In depressed children and adoles-
mental control, they may underesti- tion does or that it may provide pa- cents, only one of the antidepressants
Psychotherapy and the Brain
D
rug company marketing suggests that depression must be caused by that imbalance. Inferring causality from
is caused by a “chemical imbalance” in the brain. the success of a treatment is frequently a flawed endeavor:
For example, an advertisement by the maker of the aspirin is effective for headaches, but no one would
selective serotonin reuptake inhibitor (SSRI) Zoloft states: seriously claim that headaches are caused by a deficiency
“While the cause is unknown, of aspirin.
depression may be related In addition, biological
to an imbalance of natural PRE-THERAPY POST-THERAPY treatments are not unique
chemicals between nerve in their ability to cause
cells in the brain. Prescrip- changes in the brain. Using
tion Zoloft works to correct neuroimaging techniques,
this imbalance.” The imbal- many studies have shown
ance to which the SSRI ads significant brain changes in
refer is a deficit of the neu- Area of patients treated with psycho-
interest
rotransmitter serotonin at therapy alone. One study
receptor sites in the brain. PET images of a patient with obsessive-compulsive dis- with depressed patients
Such advertising is mislead- order before (left) and after (right) successful psycho- demonstrated that cogni-
ing, however, and does not therapy show decreases in glucose metabolic rates. tive-behavior therapy led to
reflect scientific findings. Such brain changes have also been found in depressed decreased activity in the
SOURCE : LEWIS R. BA XTER, JR., ET AL .
There is no clear scientific patients who have received therapy. frontal regions of the brain,
evidence that neurotransmit- some of which may be re-
ter deficits cause depression or that there is an optimal lated to rumination, a common feature of depression.
“balance” of neurotransmitter levels in the brain. More- Some studies have found brain changes identical to those
over, medications that primarily affect chemical messen- caused by antidepressant medications, whereas others
gers other than serotonin are as effective as SSRIs. have found different brain changes. These findings sup-
Undoubtedly, antidepressants are helpful in alleviating port the idea that psychotherapy produces measurable
depression. But there is a form of circular reasoning that changes in the brain, although these modifications may
goes: if SSRIs are helpful in alleviating depression, and if sometimes differ from those produced by medication.
they do change the “chemical imbalance,” then depression — H.A. and S.O.L.
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4. (Prozac) has been shown to help, to half the relapse rate of drug therapy dren and adolescents. It also can
whereas several different types of psy- over a two-year follow-up period, re- change the biology associated with de-
chotherapies have proved beneficial. In lapse rates for both remain disturb- pression [see box on opposite page].
both cases, however, treatment effects ingly high. CBT and IPT (the two best empiri-
have been only moderate. The results Psychotherapy, drug therapy and cally supported therapies for depres-
of studies on the combination of drug a combination of the two are all help- sion) and possibly other psychothera-
therapy and psychotherapy for these ful for adult depression, but effects pies with some empirical support
populations show either no advantage are weaker in children and adoles- should be seriously considered for a
( Many studies have shown significant brain changes in
patients treated with psychotherapy alone. )
or a slight advantage for the combina- cents who are depressed. Drug thera- depressed person seeking treatment. If
tion over either single treatment. py may be better for some people, psy- the response to psychotherapy is not
Although results are somewhat chotherapy for others, and the combi- adequate, other types of psychothera-
mixed, most of the evidence suggests nation for others still. We do not py may be tried or a drug regimen may
that combined psychotherapy and know which people will respond best be added. Although the combination
drug treatments are more effective for to any given treatment. Moreover, of psychotherapy and drug therapy
adults but not necessarily for children many other important questions re- may be somewhat more effective than
and adolescents. One well-designed main unanswered. Would longer psy- either alone, drug side effects can be
large-scale study in chronically de- chotherapeutic treatments such as problematic.
pressed adults compared a non-SSRI those typically used in clinical prac- We hope that the information we
antidepressant medication, a modi- tice lead to better initial outcomes have provided will counter some of
fied form of CBT that emphasized than those that result from the short- the mistaken impressions fueled by
changing interpersonal relationship term psychotherapies that have been the marketing strategies of some drug
patterns and negative thinking, as researched so far? Would a sequential companies and that it will encourage
well as their combination. Whereas strategy such as that used by Rush and readers to think of psychotherapy as
response rates for each of the single his associates for drug therapy im- a viable treatment for depression that
treatments were comparable to those prove psychotherapy outcomes? What has several advantages over drug
usually obtained in depression treat- can we do to further reduce or elimi- therapy. M
ment studies, the response rate for the nate relapse? Are some treatments
combination treatment was a dramat- better for some types of people and HAL ARKOWITZ and SCOTT O. LILIENFELD
ic 85 percent! depression than for others? serve on the board of advisers for Scientific
So, to the bottom line. We have American Mind. Arkowitz is a psychology
Putting It Together learned that psychotherapy and drug professor at the University of Arizona, and
Antidepressant medication and therapy are both fairly effective. We Lilienfeld is a psychology professor at Emory
certain forms of psychotherapy are know that psychotherapy prevents re- University. Send suggestions for column
reasonably effective for the treatment lapse better than drug therapy does topics to editors@sciammind.com. The
of adult depression, but there is con- when treatment is discontinued, that authors thank Steve Hollon of Vanderbilt
siderable room for improvement in ini- there are few, if any, negative side ef- University for his invaluable help with this
tial response rates and relapse rates. fects of psychotherapy, and that psy- column. Any statements made in the column,
Response rates (improvement or re- chotherapy is a safe and moderately however, are solely the responsibility of the
mission) for both treatments average effective treatment for depressed chil- co-authors.
at around two thirds. This means that
many people are helped but are left (Further Reading)
with some depressive symptoms,
◆ Psychotherapy and Medication in the Treatment of Adult and Geriatric Depression:
whereas others are not helped at all.
Which Monotherapy or Combined Treatment? S. D. Hollon, R. B. Jarrett, A. A. Nieren-
The combination of psychotherapy berg, M. E. Thase, M. Trivedi and A. J. Rush in Journal of Clinical Psychiatry, Vol. 66,
and drug therapy may yield better No. 4, pages 455–468; 2005.
outcomes for adults but little or no ◆ The Empirical Status of Cognitive-Behavioral Therapy: A Review of Meta-analyses.
added benefits for children and adoles- A. C. Butler, J. E. Chapman, E. M. Forman and A. T. Beck in Clinical Psychology Review,
cents. Although psychotherapy leads Vol. 26, No. 1, pages 17–31; 2006.
w w w. s c i a m m i n d .c o m
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SCIENTIFIC AMERICAN MIND 83