Why CBT Beats Medication in the Treatment of Depression

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Key Points:

• Recent research findings suggest that cognitive behavioral therapy and similar modalities are more effective than SSRIs in the treatment of depression.
• Patients who are treated with therapy experience shorter depressive episodes and are less likely to relapse.
• Therapy's effectiveness is likely because it helps patients identify the cause of their depression, rather than just manage their symptoms, the researchers posit.

A recent paper published in the journal Cognitive Therapy and Research argues that talk therapy is, in most cases, more effective at treating depression than antidepressant medications.

This conclusion is based on fifty years of data and theory comparing the effectiveness of traditional modes of talk therapy, such as cognitive behavioral therapy (CBT), and antidepressant medications, such as Prozac, Zoloft, and other selective serotonin reuptake inhibitors (SSRIs) and monoamine oxidase inhibitors (MAOIs).

The authors, led by Steven Hollon of Vanderbilt University, point to a series of studies showing that people who talk through their depression with a mental health professional are more likely to (1) reduce the duration of depressive episodes and (2) to address the root cause of the depression, making relapse less common. By their estimates, patients treated to remission with talk therapy are half as likely to relapse following treatment as patients treated with antidepressant medications.

“Depression is the most prevalent of the psychiatric disorders and the second leading cause of burden worldwide,” state the researchers. “Cognitive therapy is the most extensively tested of the psychosocial interventions and has been found to be as efficacious as and more enduring than antidepressant medications.”

Why Might Therapy Be More Effective Than Medication?

Their conclusions speak to the power of talk therapy while simultaneously casting doubt on the efficacy of antidepressant medications. In fact, it is their view that antidepressant medications can in certain cases have an “iatrogenic,” or harmful effect, in the treatment of depression. Here’s a summary of their logic:

1. Depression is an “evolved” response to help people find solutions to complicated social problems. The authors view depression as an adaptive phenomenon—one that kept our ancestors “safe” by ruminating about complex social problems until they arrived at a solution. For instance, evidence suggests that people are more likely to engage in causal analysis and deep thinking when they are depressed. Studies suggest that depression-like symptoms such as lassitude and the loss of interest in hedonic pursuits serve as the body’s way of redirecting energy to the brain to solve important problems. They state, “In melancholia, energy flows to the cortex and makes it resistant to distraction, presumably to keep the individual focused on the problem at hand (ruminating) until he or she arrives at a solution.”
2. Antidepressant medications anesthetize us from feeling the physical and emotional effects of depression. Depression medication may help treat the symptoms of depression, but it comes at the cost of allowing people to identify the problems that are causing the depression in the first place. The authors use a classic experiment from biology to make their point. In this study, a team of scientists examined the evasive behavior of squid in response to an attack by one of their natural predators, the sea bass. They state, “Sea bass eat squid and squid try to avoid being eaten. Each species goes through an intricate series of maneuvers when they encounter one another that involve orientation and approach on the part of the sea bass culminating in attack and protective coloration and evasive maneuvers (including spurting out of an ink jet) on the part of the squid. Survival for the squid depends on how soon it starts its evasive maneuvers once a sea bass appears.” To study the effect of physical pain on a squid’s ability to outmaneuver the predatory sea bass, the researchers amputated squids’ swimmers in a test environment, making them more susceptible to predation. The catch was this: they either performed the amputation with or without anesthesia. They found that the squid that had been operated on without anesthesia started their evasive maneuvers earlier and were less likely to be eaten by the sea bass. Applying this logic to humans, the anesthetizing properties of antidepressant medications may help ameliorate the emotional pain caused by depression, but it doesn’t resolve the underlying “threat” that the depression is exposing.
3. Talk therapy gets us to the solution faster. Talk therapy, on the other hand, is a way to reduce the length of a depressive episode by providing a method through which people can root out the problems that are causing their depression. Therapeutic approaches such as cognitive behavioral therapy have been shown to speed up recovery time and to protect people from relapse. While cognitive behavioral therapy may not dull the pain of the depression per se, it is a true treatment for depression, not a mollification.

Whether or not you agree with their logic, there are a number of important learnings contained in their research. For one, it is almost always unrealistic to view medications as a panacea for any psychological disorder. If that were the case, prevalence rates for psychological illnesses would not be nearly as high as they are, especially in countries where prescription medications are widely available. Second, it reaffirms talk therapy as the first line of defense in the treatment of non-psychotic depression. The authors conclude, “Just as pain serves to signal to squids that have been maimed to begin their evasive maneuvers sooner, we think that depression signals to the individual that there are problems to be solved and that focusing attention on those problems (rumination) is the first step toward finding a solution.”

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