“I am using antidepressants now for a while, and they have helped me quite a lot. I talked with a friend yesterday and she said that antidepressants do not take away the causes of depression, but that good therapy does take away these causes. Is that true? And should I stop using my medication and switch to therapy?”
The uncomfortable truth: we don’t know the causes
Unfortunately, it is not known what the exact causes of depression are. It is known that people who have experienced serious life events (such as the loss of a loved one) or chronic stressors (such as caring for an ill partner) have a depression more often than other people. However, there are also many people who have had serious life events or chronic stressors who do not get a depression. Actually, the large majority of people with these experiences do not develop a depression. This means that such events are not sufficient for getting a depression. Maybe there is some kind of biological, psychological or social vulnerability, but there is not enough knowledge about such pathways leading to depression.
We know that treatments work, not how they work
It is also not known how antidepressants work or how psychotherapies work and whether therapies can actually take away the causes of depression. There are several theories on how treatments work, and some of these do have a limited amount of empirical support. But at this moment it is not possible to say how these treatments work.
There is clear evidence that these treatments work, but not how they work.
That is related to the fact that the effects of treatments can be examined with the best scientific studies (randomized controlled trials), while such studies cannot be used to examine how they work.
So what should you do with your medication?
This means that we do not know what the exact causes of depression are and that we also do not know how therapies work. From that perspective it is not automatically the best solution to stop with antidepressants and to start with psychotherapy. But there are several considerations to take into account when you want to stop using antidepressants.
First of all, this should be discussed with your clinician. There may be reasons to stop with antidepressants, but this cannot be done on your own. Your clinician can give advice on that and help with the tapering of the medication.
It is also not necessary to stop with your medication before going into therapy. You can certainly do both. There is no reason whatsoever to assume that taking drugs reduces the effects of therapy. In fact, there is considerable evidence that the combination of medication and therapy is the most effective treatment and better than medication or therapy alone. That is true at the short and at the longer term.
What therapies actually focus on
Although there is not enough evidence on how therapies exactly work, they do focus on psychological factors that are related to depression. For example:
- In cognitive behavior therapy you learn how to identify, challenge and change negative or distorted thought patterns.
- In behavioral activation you learn to identify meaningful and enjoyable activities and to engage more in them.
- In interpersonal psychotherapy you learn how to improve interpersonal relationships.
- In brief psychodynamic therapy you can enhance your understanding, awareness and insight about repetitive conflicts.
If these are issues you struggle with and want to learn how to handle them, then psychotherapy is certainly a good choice, with or without medication.
Pim Cuijpers is professor emeritus of clinical psychology and scientific director of Metapsy. He has been involved in more than 1,100 scientific studies, mostly on psychological treatments of mental health problems. This is one of a series of evidence summaries in which Prof. Cuijpers tries to answer questions from patients and clinicians, based on what is known in science about treatments. The knowledge is mostly drawn from collective work of the Metapsy collaboration of at least 15 years. Do you have other questions you would like Prof. Cuijpers to discuss? Feel free to contact us.
Literature
- Cuijpers P, Smit F, Furukawa TA. (2021). Most at-risk individuals will not develop a mental disorder: the limited predictive strength of risk factors. World Psychiatry, 20(2), 224–225.
- Cuijpers P, Miguel C, Harrer M, Ciharova M, Karyotaki E. (2023). Does the use of pharmacotherapy interact with the effects of psychotherapy? A meta-analytic review. European Psychiatry, 66(1), e63.
- Cuijpers P, Noma H, Karyotaki E, Vinkers CH, Cipriani A, Furukawa TA. (2020). A network meta-analysis of the effects of psychotherapies, pharmacotherapies and their combination in the treatment of adult depression. World Psychiatry, 19(1), 92–107.
- Furukawa TA, Shinohara K, Sahker E, et al. (2021). Initial treatment choices to achieve sustained response in major depression: a systematic review and network meta-analysis. World Psychiatry, 20(3), 387–396.