Should I Start Therapy or Take an Antidepressant?

"I'm thinking about starting therapy but maybe an antidepressant would be faster and easier. Which one should I pick?"

As a psychiatrist, I get to work with both sides of the mental health coin—biological and psychological. As psychiatry continues to explode with neurobiological discoveries, we are seeing with increasing clarity that the two "sides" are inextricably linked.

And that just makes sense. Our thoughts, feelings, and actions must be grounded in a biological substrate, namely the queen brain and her worker bees, the spinal cord and peripheral nervous system.

Which brings us back to a question I commonly get in my practice: between therapy and medication, which one is better for treating depression? The research helps illuminate an answer.

A meta-analysis of studies, including outcomes from the National Institute of Mental Health Treatment of Depression Collaborative Research Program, shows that psychotherapy (such as cognitive behavioral therapy, CBT or interpersonal psychotherapy, IPT) is as effective as antidepressant medication for treating depression, even among people who have severe depressive symptoms. Even more interesting is that the two modalities combined tend to lead to even better outcomes than either alone.

What, then, are some of the factors that might lead people to choose one, the other, or both?

Antidepressants: Good While They Last?

Let's start with antidepressants. A clear benefit for some—but not all—patients is the often rapid onset of action. Improvement in mood and function can be as early as 1-2 weeks. Antidepressants can also be adequately prescribed by primary care physicians for some types of uncomplicated depression, leading to a solid range of clinician options.

However, medication is far from foolproof as there are side effects, and it's not uncommon to wait up to 12 weeks to see full remission of symptoms. It's also not a guarantee, as the response rate to any antidepressant is about 70 percent.

Lastly, medications tend to be fair-weather friends and are most effective when on board. The rates of depressive relapse once the medications are stopped is significant, ranging from 50 percent in the first year after an initial episode to 75 percent within five years if the patient has had two episodes. Once patients have had three or more episodes, it is common practice to recommend maintenance or lifelong treatment with antidepressants.

Psychotherapy: Teach a Person to Fish

Now let's look at psychotherapy, including two of the most widely studied ones, cognitive behavioral therapy (CBT) and interpersonal therapy (IPT). One benefit is that there are generally more non-M.D. therapists than psychiatrists, so wider availability is a big plus.

However, in the cases of CBT and IPT, not all therapists have the extra training required to use those modalities. A secondary issue is that psychotherapy may take longer to have an impact. A typical course of CBT/ IPT can last between 8-20 sessions and in reality, therapy often lasts longer as patients begin to integrate new psychological understanding into their everyday lives.

Another positive, however, is that the re-wiring of the neural circuitry through therapy is a long-lasting change. Patients have now permanently learned a new set of psychological skills that they can draw from in the future.

Two Can Be Better Than One

What about the option of both therapy and antidepressants? This joint modality tends to have the best clinical outcome and is the one most clinicians favor when depression is more severe—for example, when it affects a person's ability to function in everyday life. Practically, antidepressants can act as a stabilizer to help patients get into an upright position so they can engage effectively with therapy.

The improved joint outcome may be due to the fact that patients now have two neural paths with which to reach their destination. The synergy between both neuropsychological and biological systems may allow each to enhance the other, leading to more complete, longer-lasting healing for patients. Additionally, if or when patients discontinue antidepressants, the therapy skills gained continue to provide enhanced protection against the recurrence of depression.

Summary

When it comes to treatment for depression, patients have several options to choose from, including a range of effective psychotherapies or antidepressant medications. For some people, the best of all possible worlds involves both.