Millions of people who suffer from depression believe their antidepressants help them. But the evidence is that antidepressants work no better than “talk therapy” (aka psychotherapy, or counseling); that many different types of psychotherapy work equally well; and that what gets most of us out of an immobilizing bout of depression has little to do with the specific treatment method.
The type of psychotherapy with the most research behind it is cognitive behavioral therapy (CBT), which consists of an array of techniques aimed at transforming self-defeating thoughts, beliefs, and behaviors. For example, in this type of counseling patients learn to identify their dysfunctional thoughts—such as exaggerations and black-and-white thinking—and stop or minimize this type of damaging thinking, which contributes to making depression worse.
CBT is common-sense stuff, and many psychotherapists use it in combination with other approaches. A form of CBT was the only talk therapy treatment examined in the largest study ever done of sequential depression treatments (in which a researcher offers addtional, different kinds of treatments if previous treatments have failed), called “Sequential Treatment Alternatives to Relieve Depression” (or STAR*D for short), funded by the National Institute of Mental Health (NIMH) and reported in 2006 in the American Journal of Psychiatry.
In STAR*D, nine different psychiatric medications and one talk therapy— CBT—were examined. In the first step, all depressed patients were given only the antidepressant Celexa (without any psychotherapy or other medication), and nearly 37 percent improved. In the next step, those patients who didn’t respond to Celexa got other treatments, and if their second treatment failed, there was a third and, if necessary, a fourth step. Among those patients who initially didn’t do better on Celexa, three groups in the second step switched from Celexa to one of three other antidepressants, and their improvement rates were about 25 to 26 percent. Another group in step two remained on Celexa, but they also got sessions of CBT; this combination—of an antidepressant and this kind of talk therapy—resulted in over 29 percent of patients getting better. But this is really interesting: Yet another group in the second step was taken off antidepressants altogether and given only CBT—and nearly 42 percent improved.
That’s pretty solid evidence that CBT works as well or better than antidepressants. But does it work any better than other types of counseling?
Psychologists Pim Cuijpers and Annemicke van Straten, at the University of Amsterdam, looked at that very question. They analyzed 53 studies, each of which compared two or more different types of psychotherapies for depression. Included were varieties of CBT, psychodynamic therapy, behavioral activation therapy, social skills training, problem-solving therapy, interpersonal therapy, and nondirective supportive therapy. Their results, which appeared in 2008 in the Journal of Consulting and Clinical Psychology, concluded as follows: “We found no indication that cognitive-behavioral therapy is indeed more efficacious than other psychological treatments.” Actually, interpersonal therapy—which focuses on relationships—was most effective, by a slight margin, but the authors made clear that “no large differences in efficacy [were found] between major psychotherapies.”
So the evidence indicates that talking to a mental health pro is often more effective than taking antidepressants, but if the technique your therapist uses isn’t so important, what does matter? For his book The Great Psychotherapy Debate, psychologist Bruce Wampold, at the University of Wisconsin, reviewed the literature of outcomes (meaning whether patients get better, worse, or stay the same), examining hundreds of studies. He found that outcome effectiveness doesn’t depend on the specific techniques of psychotherapy, but instead on the alliance between a therapist and their client, as well as the client’s confidence in the therapy and in the therapist. In other words, what matters is finding a great therapist you like and trust.
How effective a depression treatment is has more to do with how much you like and trust your therapist than any particular technique.
Psychologist Michael Lambert at Brigham Young University has spent a good part of his career studying psychotherapy outcomes, too. Lambert estimates that the factors responsible for “client improvement in psychotherapy” can actually be broken down:
· 40 percent of improvement can be explained by “events external to therapy” (for example, a person getting more support from the people around them, or fortunate events happening—like finding a job you love—that have nothing to do with treatment).
· 30 percent can be explained by therapist characteristics, such as empathy, acceptance, warmth, and encouragement.
· 15 percent can be explained by “expectancy” or the placebo effect (this can be enhanced if a patient feels their therapist is very credible and trusts them).
· 15 percent can be explained by the techniques used in talk therapy; specifically, if the therapist and client believe in a technique, like CBT, that may be more important than the technique itself.
My experience from counseling depressed people for nearly 30 years is that far more important than the treatment method is a person’s support system, their determination, faith, serendipity, and luck—especially when it comes to events outside of therapy—and finding empathic, accepting, warm, encouraging helpers.
What do you think makes the biggest difference in successfully treating depression?