“I have decided to get treatment for depression. I have been struggling with it for a while now, but I didn’t want to get professional help and wanted to solve things myself. Yesterday I talked with a friend and she convinced me that I should get help, because that may solve my problems much faster. And it is not a sign of weakness (what I thought for a long time). But now I am doubting whether I should go for antidepressant medication or talking therapy. My friend had a lot of benefits from medication, but I think I prefer a talking therapy.”
What people want vs. what people get
About three quarters of people suffering from depression and anxiety disorders prefer psychotherapy as a treatment. At the same time, the number of people taking antidepressants has been steadily increasing over the past decades. This is probably related to the fact that there are often long waiting lists for psychotherapy, the high costs of therapy, and the fact that antidepressants are often prescribed relatively easily by primary care physicians.
Which one works better?
But when you suffer from a depression, what should you do? Which of the two is more effective? The simple answer is that they have comparable effects at the short term, but at the longer term (after 1 year) psychotherapy is more effective.
Having one course of psychotherapy is even more effective than taking antidepressants for a whole year. At the end of that year the people who have had therapy in the beginning of that year are better off than the people who have used antidepressants during the whole year.
But combined treatment is the real winner
This is not the whole story, however. The most effective treatment is not psychotherapy or pharmacotherapy, but the combination of the two. Combined treatment is more effective than either psychotherapy alone or pharmacotherapy alone. And that is true at the short term and at the longer term. Adding psychotherapy to antidepressant medication probably also reduces the chance that people stop using their medication.
This does not mean that it is always better to get both treatments at the same time right at the start of a treatment. It is also very well possible to start with psychotherapy alone, and only start using drugs when the effects of therapy are not enough or the problems are not solved quickly enough.
Severity changes the calculus
But in this context it is important to distinguish between mild, moderate and severe depression. That difference is not easy to make, because all depressions are severe from the perspective of the person suffering from it. However, clinicians can differentiate depressive disorders that are relatively mild, moderate or severe. And that makes a difference for the treatment.
- In mild depressive disorders, it is generally not recommended to use antidepressants at all. Psychotherapy is the first choice treatment.
- In moderate to severe depression, combined treatment is the most effective, but starting with psychotherapy is also a good possibility.
- In some rare cases, depression is so severe that patients are not able to participate in therapy, and then treatment usually starts with medication alone.
The World Health Organization now recommends not to use antidepressants alone, without psychotherapy (unless psychotherapies are not available, like in many poorer countries).
Your preferences matter
It is always important to remember that these choices are also always related to personal preferences and choices. Some patients may prefer antidepressants above therapy, or they certainly do not want medication at all, or want to start with combined treatment right away. These are all clinical decisions that the person suffering from depression should make together with the clinician treating them.
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, 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, 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, 387–396.
- McHugh RK, Whitton SW, Peckham AD, Welge JA, Otto MW. (2013). Patient preference for psychological vs pharmacologic treatment of psychiatric disorders: a meta-analytic review. Journal of Clinical Psychiatry, 74(6), 13979.
- World Health Organization. (2023). mhGAP guideline for mental, neurological and substance use disorders. Geneva: WHO. Link