Therapy vs. Medication: The Great Debate

It’s a difficult call to decide whether therapy or medication is better in the treatment of mental illness. Treating a mental health problem can be quite daunting, with a flood of advertising dedicated to selling antidepressants and that niggling thought that seeing a therapist is inconvenient and for some people still stigmatised. We here at Mind Warriors have taken the time to look at the evidence regarding the efficacy of treatments for mental illness. A large portion of the data out there deals with Cognitive Behavioural Therapy and depression, so we’ll stick to discussing these.

What is CBT?
Cognitive Behavioural Therapy is an umbrella term encompassing all therapies in which the therapist seeks, in a variety of ways, to produce cognitive change – change in the patient’s thinking and belief system – in order to bring enduring emotional and behavioural change. CBT was partly formed as a response to popular Freudian psychoanalysis being done at the time. Two popular forms of CBT developed independently of each other are Albert Ellis’s rational-emotive therapy and Aaron Beck’s cognitive therapy (Beck, 1995).

Throughout life, we are faced with situations and how we perceive those situations affect our thoughts, emotions and behaviour. If someone rejects you from a job and you form the thought, “I’m not good enough” you might start feeling pretty lousy and not go for another job interview like that one for a little while; however you can stop this process by taking a moment before the negative thought occurs to stop you from feeling badly. This is what cognitive therapy helps you to do – to help you become aware of a thought and the behavior that might be reinforcing that thought. These thoughts most likely are distortions and assumptions that are tainting your reality and creating unhappiness.

What are antidepressants?
Alongside therapy sit antidepressants, the most commonly prescribed drug in the U.S. (CNN, 2007). The majority of antidepressants prescribed today are SSRIs or selective serotonin reuptake inhibitors. These include well known drug, Prozac, amongst others including Zoloft, Lexepro, Paxil, Celexa and Luvox. These drugs work by blocking or inhibiting the reuptake of serotonin, which in turn increases the amount of serotonin in the brain (Breggin, 1994). Research has shown that there may be a link to low serotonin levels and depression. Much of the research relies on the fact that these SSRIs work and therefore scientists theorise backwards, recognising that if these drugs work by increasing the level of serotonin then serotonin might be linked to depression.

How do CBT and antidepressants compare?
So now that you know a bit more about each method specifically, you might be asking in what parts of the brain these methods work. A review article on treatment outcomes and neural mechanisms of both CBT and antidepressants explains their neural underpinnings, saying that in clinically diagnosed depression, the activity of the amygdala (responsible for your feelings and identifying danger) increases while the prefrontal cortex (which mediates higher processes like making choices) activity is decreased. Antidepressants work to treat this by directly decreasing amygdala activity and CBT instead works by increasing prefrontal cortex activity (DeRubeis, RJ, et al, 2008). This research shows that CBT and antidepressants appear to be working in different ways to achieve a similar outcome and balance.

Research has shown that in regard to efficacy, both CBT and antidepressants are on a level playing field when treating depression. In a study done in 1999, cognitive behavioural therapy did just as well in treating severely depressed outpatients suffering from depression. Both methods of treatment were compared in four different trials within each trial and across patients of the four trials (DeRubeis, RJ, et al). A later study done in 2007, found that patients who went through CBT took around one month longer to achieve remission, but those who were on antidepressants experienced more side effects than those involved in CBT (http://www.womensmentalhealth.org ). In other studies, CBT has also proven to be a valuable resource for preventing relapse. The coping skills developed from CBT may be responsible for this. A study done with depressed teens by Johns Hopkins University showed the outcome of antidepressants working together with CBT. John Walkup, M.D., co-author of the study and a child and adolescent psychiatrist at the Johns Hopkins Children's Center, said “Not only do the results support the use of antidepressants for depressed teens, but when used in conjunction with talk therapy, these medications actually provide teens with the best chance to alleviate their depression"(http://www.innovations-report.com ).

Controversy surrounding antidepressant use
Some debate has surrounded the use of antidepressants mainly focusing on its affect in young people and side effects that may occur. Bernadette Melnyk, founder and chairwoman of the National Association of Pediatric Nurse Practictioners' Keep Your Children/Yourself Safe and Secure Campaign says, “There are so many providers that are dispensing antidepressants to children and teens without appropriate knowledge and skills to administer these medications, as well as without accompanying cognitive behavior therapy, which is critical in the improvement of depressive symptoms” (ABC News, 2004).

Another key player in the debate over antidepressant use is Dr. Peter Breggin, a psychiatrist and author of many books thoroughly detailing the effects of psychiatric drugs. He sees much of today’s psychiatrists as prescription-happy. He notes that power is taken out of patients’ hands when they’re told they have a chemical imbalance which they need to take drugs for, and in turn, the clients can become more reliant on the drugs and experience a feeling of disempowerment. Dr. Breggin provides several articles on his website, http://www.breggin.com which specifically discuss the relatively newer antidepressants like Prozac and Zoloft and their proven side effects listed by the American FDA, the organisation who supervises the safety of food and drugs amongst other things in the U.S. Included in these side effects are anxiety, agitation, panic attacks, insomnia, irritability, hostility, impulsivity, akathisia (severe restlessness), hypomania and mania. He also makes speculations linking antidepressants to suicide and violence, citing cases of adults and children becoming violent and hurting others, although because of their nature, neither has been scientifically proven (Breggin, 2004).

The Bottom Line
Without getting caught up in the debate over side effects, it appears that most positive outcomes point to a combination of both CBT and antidepressants to help those with depression. Both CBT and antidepressants offer pros and cons. With CBT, there is a longer and perhaps more time consuming road to recovery, but it can have lasting, positive effects in all areas of life that can help avoid relapse. On the other hand, antidepressants are a quicker fix; they offer help in the short term and therefore may be a convenient solution for some. The downside to antidepressants is the possible side effects and reliance on them, which may leave some people feeling disempowered.

The practical combination of CBT and antidepressants means that medication could be used in the short-term to ready patients’ mindsets for CBT and CBT can prepare patients to cope with real world scenarios. Because some people do often see antidepressants as a quick, easy fix, they may tend not to fit therapy into their lives and instead reach for the pill bottle. Recognising the importance of therapy alongside medication is important and led the FDA in 2004 to recommend those using newer antidepressants to see a doctor once a week for the first month of use and then three more times in the following two months (Fox News, 2006). If you are feeling unhappy, then you have to remember that you are entitled to a happy life. Do your research on different types of therapy and medications and seek help from a medical professional. There are many ways to feel better and just remember that you’re in control of your life; so make the choice to feel good!

References:
“Antidepressants plus ’talk therapy’ are effective therapy for teen depression.” (2004). http://www.innovations-report.com.

Beck, Judith S. (1995). Cognitive Therapy: Basics and Beyond.

Breggin, Peter R. M.D. (1994). Talking Back to Prozac: What Doctors Aren’t Telling You About Today’s Most Controversial Drug.

Breggin, Peter R., M.D. (2004). “The Proven Dangers of Antidepressants.” http://www.breggin.com/.

“CDC: Antidepressants most prescribed drugs in U.S.” (2007). http://edition.cnn.com.

“Cognitive Therapy versus Medication in the Treatment of Depression.” (2007). http://www.womensmentalhealth.org/posts/cognitive-therapy-versus-medication-in-the-treatment-of-depression/.

DeRubeis RJ, Gelfand LA, Tang TZ, & Simons AD. (1999). Medications versus cognitive behavior therapy for severely depressed outpatients: mega-analysis of four randomized comparisons.
Am J Psychiatry. 156(7):1007-13.

DeRubeis, RJ, Siegle, GJ & Hollon, SD. (2008). Cognitive therapy versus medication for depression: treatment outcomes and neural mechanisms. Nature Reviews Neuroscience 9, 788-796.

“Pills vs. Talking When It Comes to Mental Illness, Parents Face Dilemmas Over Medication, Talk Therapy”. (2004). http://www.abcnews.com.

“Study: Patients on Antidepressants Skipping Therapy”. (2006). http://www.foxnews.com.

Article by Jessica George (Mind Warriors)