Abstract
Psychotherapy and antidepressant medications are the two preeminent treatment choices for depression. This article puts each of these treatments into perspective by presenting an overview of what is currently known about their effectiveness either singly or in combination. Discussion of placebos, common factors among therapies, relapse rates, depression severity, patient treatment preferences and exaggerations in pharmaceutical advertising provide guidance for clinicians in deciding on the best course of treatment. Overall, research reveals the importance of psychosocial factors, no matter what the mode of treatment, and the need for fostering a collaborative bond between clinicians and their patients. We argue that empirical evidence points to making psychotherapy the initial treatment choice for most cases of depression.
Similar content being viewed by others
References
Abramson, J. (2004). Overdosed America: The broken promise of American medicine. New York: Harper Collins Publishers.
Angell, M. (2005). The truth about the drug companies: How they deceive us and what to do about it. New York: Random House.
Antonuccio, D. O., Danton, W. G., & DeNelsky. (1995). Psychotherapy versus medication for depression: Challenging the conventional wisdom with data. Professional Psychology: Research and Practice, 26, 574–585.
Antonuccio, D. O., Danton, W. G., DeNelsky, G. Y., Greenberg, R. P., & Gordon, J. S. (1999). Raising questions about antidepressants. Psychotherapy and Psychosomatics, 68, 3–14.
APA Presidential Task Force on Evidence-Based Practice. (2006). Evidence-based practice in psychology. American Psychologist, 61, 271–285.
Baldwin, S. A., Wampold, B. E., & Imel, Z. E. (2007). Untangling the alliance-outcome correlation: Exploring the relative importance of therapist and patient variability in the alliance. Journal of Consulting and Clinical Psychology, 75, 842–852.
Blatt, S. J., Sanislow, C. A., Zuroff, D. C., & Pilkonis, P. A. (1996a). Characteristics of effective therapists: Further analyses of data from the national institute of mental health treatment of depression collaborative research program. Journal of Consulting and Clinical Psychology, 64, 1276–1284.
Blatt, S. J., Zuroff, D. C., Quinlan, D. M., & Pilkonis, P. (1996b). Interpersonal factors in brief treatment of depression: Further analyses of the NIMH treatment of depression collaborative research program. Journal of Consulting and Clinical Psychology, 64, 162–171.
Brugha, T. S., Bebbington, P. E., MacCarthy, B., Sturt, E., et al. (1992). Antidepressants may not assist recovery in practice: A naturalistic prospective survey. Acta Psychiatrica Scandinavica, 86, 5–11.
Conte, H. R., Plutchik, R., Wild, K. V., & Karasu, T. B. (1986). Combined psychotherapy and pharmacotherapy for depression: A systematic analysis of the evidence. Archives of General Psychiatry, 43, 471–479.
de Maat, S. M., Dekker, J., Schoevers, R. A., & de Jonghe, F. (2007). Relative efficacy of psychotherapy and combined therapy in the treatment of depression: A meta-analysis. European Psychiatry, 22, 1–8.
Depression Guideline Panel. (1993). Clinical practice guideline no 5. AHCPR pub 93-0551. Rockville, Md: Agency for Health Care Policy and Research.
DeRubeis, R. J., Hollon, S. D., Amsterdam, J. D., Shelton, R. C., Young, P. R., Salomon, R. M., et al. (2005). Cognitive therapy vs. medications in the treatment of moderate to severe depression. Archives of General Psychiatry, 62, 409–416.
Donohue, J. M., Cevasco, M., & Rosenthal, M. B. (2007). A decade of direct-to-consumer advertising of prescription drugs. New England Journal of Medicine, 357, 673–681.
Edwards, J. G. (1995). Drug choice in depression: Selective serotonin reuptake inhibitors or tricyclic antidepressants. CNS Drugs, 4, 141–159.
Elkin, I., Gibbons, R. D., Shea, M. T., Sotsky, S. M., Watkins, J. T., Pilkonis, P. A., et al. (1995). Initial severity and differential treatment outcome in the national institute of mental health treatment of depression collaborative research program. Journal of Consulting and Clinical Psychology, 63, 841–847.
Elkin, I., Shea, M. T., Watkins, J. T., Imber, S. D., Sotsky, S. M., Collins, J. F., et al. (1989). National institute of mental health treatment of depression collaborative research program: General effectiveness of treatments. Archives of General Psychiatry, 46, 971–982.
Elkin, I., Yamaguchi, J. L., Arnkoff, D. B., Glass, C. R., Sotsky, S. M., & Krupnick, J. L. (1999). “Patient-treatment fit” and early engagement in therapy. Psychotherapy Research, 9, 437–451.
Evans, M. D., Hollon, S. D., DeRubeis, R. J., Piasecki, J. M., Grove, W. M., Garvey, M. J., et al. (1992). Differential relapse following cognitive therapy and pharmacotherapy for depression. Archives of General Psychiatry, 49, 802–808.
Eysenck, H. J. (1952). The effects of psychotherapy: An evaluation. Journal of Consulting Pyschology, 16, 319–324.
Eysenck, H. J. (1960). Behavior therapy and the neuroses. Oxford, England: Pergamon Press.
Eysenck, H. J. (1969). The effects of psychotherapy. New York: Science House.
Fava, M., Rush, A. J., Trivedi, M. H., Nierenberg, A. A., Thase, M. E., Sackeim, H. A., et al. (2003). Background and rationale for the sequenced treatment alternatives to relieve depression (STAR*D) study. Special Issue: Drug therapy: Predictors of Response, 26, 457–494.
Fisher, S., & Greenberg, R. P. (Eds.). (1997). From placebo to panacea: Putting psychiatric drugs to the test. New York: John Wiley & Sons Inc.
Frank, J. D. (1973). Persuasion and healing (2nd ed.). Baltimore: John Hopkins University Press.
Frank, E., Kupfer, D. J., Buysse, D. J., Swartz, H. A., Pilkonis, P. A., Houck, P. R., et al. (2007). Randomized trial of weekly, twice-monthly, and monthly interpersonal psychotherapy as maintenance treatment for women with recurrent depression. American Journal of Psychiatry, 164, 761–767.
Friedman, M. A., Detweiler-Bedell, J. B., Leventhal, H. E., Horne, R., Keitner, G. I., & Miller, I. W. (2004). Combined psychotherapy and pharmacotherapy for the treatment of major depressive disorder. Clinical Psychology: Science and Practice, 11, 47–68.
Givens, J. L., Houston, T. K., Van Voorhees, B. W., Ford, D. E., & Cooper, L. A. (2007). Ethnicity and preferences for depression treatment. General Hospital Psychiatry, 29, 182–191.
Gloaguen, V., Cottraux, J., Cucherat, M., & Blackburn, I. M. (1998). A meta-analysis of the effects of cognitive therapy in depressed patients. Journal of Affective Disorders, 49, 59–72.
Greenberg, R. P. (1999). Common psychosocial factors in psychiatric drug therapy. In M. A. Hubble, B. L. Duncan, & S. Miller (Eds.), The heart and soul of change: Common factors in effective psychotherapy, medicine, and human services (pp. 297–328). Washington. D.C.: APA Books.
Greenberg, R. P., Bornstein, R. F., Greenberg, M. D., & Fisher, S. (1992). A meta-analysis of antidepressant outcome under “blinder” conditions. Journal of Consulting and Clinical Psychology, 60, 664–669.
Greenberg, R. P., Bornstein, R. F., Zborowski, M. J., Fisher, S., & Greenberg, M. D. (1994). A meta-analysis of fluoxetine outcome in the treatment of depression. Journal of Nervous and Mental Disease, 182, 547–551.
Greenberg, R. P., Constantino, M. J., & Bruce, N. (2006). Are patient expectations still relevant for psychotherapy process and outcome? Clinical Psychology Review, 26, 657–678.
Greenberg, R. P., & Fisher, S. (1989). Examining antidepressant effectiveness: Findings, ambiguities and some vexing puzzles. In S. Fisher & R. P. Greenberg (Eds.), The limits of biological treatments for psychological distress: Comparisons with psychotherapy and placebo (pp. 1–37). New Jersey: Lawrence Erlbaum Associates, Inc.
Greenberg, R. P., & Fisher, S. (1994). Seeing through the double-masked design: A commentary. Controlled Clinical Trials, 15, 244–246.
Greenberg, R. P., & Fisher, S. (1997). Mood-mending medicines: Probing drug, psychotherapy, and placebo solutions. In S. Fisher & R. P. Greenberg (Eds.), From placebo to panacea: Putting psychiatric drugs to the test (pp. 115–172). New York: John Wiley & Sons, Inc.
Hawley, L. L., Ho, M.-H. R., Zuroff, D. C., & Blatt, S. J. (2007). Stress reactivity following brief treatment for depression: Differential effects of psychotherapy and medication. Journal of Consulting and Clinical Psychology, 75, 244–256.
Healy, D. (2004). Let them eat Prozac: The unhealthy relationship between the pharmaceutical industry and depression. New York: New York University Press.
Hollon, S. D., DeRubeis, R. J., Shelton, R. C., Amsterdam, J. D., Salomon, R. M., O’Reardon, J. P., et al. (2005). Prevention of relapse following cognitive therapy vs. medications in moderate to severe depression. Archives of General Psychiatry, 62, 417–422.
Hollon, S. D., DeRubeis, R. J., Shelton, R. C., & Weiss, B. (2002). The emperor’s new drugs: Effect size and moderation effects. Prevention & Treatment, 5(8). Available at journals.apa.org/prevention/volume5/toc-jul15-02.html. Accessed August 2.
Iacoviello, B. M., McCarthy, K. S., Barrett, M. S., Rynn, M., Gallop, R., & Barber, J. P. (2007). Treatment preferences affect the therapeutic alliance: Implications for randomized controlled trials. Journal of Consulting and Clinical Psychology, 75, 194–198.
Jackson, G., Greenberg, R. P., & Kinchin, K. (2004). The myth of the magic pill. In B. Duncan, S. Miller, & J. Sparks (Eds.), The heroic client: A revolutionary way to improve effectiveness through client-directed, outcome-informed therapy (pp. 147–177). San Francisco: Jossey-Bass.
Jindal, R. D., & Thase, M. E. (2003). Integrating psychotherapy and pharmacotherapy to improve outcomes among patients with mood disorders. Psychiatric Services, 54, 1484–1490.
Kessler, R. C., Chiu, W. T., Demler, O., & Walters, E. E. (2005). Prevalence, severity, and comorbidity of twelve-month DSM-IV disorders in the national comorbidity survey replication (NCS-R). Archives of General Psychiatry, 62, 617–627.
Khan, A., Detke, M., Khan, S. R., & Mallinckrodt, C. (2003). Placebo response and antidepressant clinical trial outcome. Journal of Nervous and Mental Disease, 19, 211–218.
Kirsch, I., Deacon, B. J., Heudo-Medina, T., Scoboria, A., Moore, T. J., & Johnson, B. T. (2008). Initial severity and antidepressant benefits: A meta-analysis of data submitted to the food and drug administration. PLoS Medicine, 5, 260–268.
Kirsch, I., Moore, T.J., Scoboria, A., & Nicholls, S.·S. (2002). The emperor’s new drugs: An analysis of antidepressant medication data submitted to the U.S. food and drug administration. Prevention & Treatment, 5(23). Available at journals.apa.org/prevention/volume5/pre0050023a.html.
Krupnick, J. L., Sotsky, S. M., Simmens, S., Moyer, J., Elkin, I., Watkins, J., et al. (1996). The role of the therapeutic alliance in psychotherapy and pharmacotherapy outcome: Findings in the national institute of mental health treatment of depression collaborative research program. Journal of Consulting and Clinical Psychology, 64, 532–539.
Lambert, M. J., & Ogles, B. M. (2004). The efficacy and effectiveness of psychotherapy. In M. J. Lambert (Ed.), Bergin and Garfield’s handbook of psychotherapy and behavior change (5th ed., pp. 139–193). New York: John Wiley & Sons, Inc.
Lambert, M. J., Whipple, J. L., Hawkins, E. J., Vermeersch, D. A., Nielsen, S. L., & Smart, D. W. (2003). Is it time for clinicians to routinely track patient outcome? A meta-analysis. Clinical Psychology: Science and Practice, 10, 288–301.
Landman, J. T., & Dawes, R. M. (1982). Psychotherapy outcome: Smith and Glass’ conclusions stand up under scrutiny. American Psychologist, 37, 504–516.
Lau, M. A. (2008). New developments in psychosocial interventions for adults with unipolar depression. Current Opinion in Psychiatry, 21, 30–36.
Lin, P., Campbell, D. G., Chaney, E. F., Liu, C.-F., Heagerty, P., Felker, B. L., et al. (2005). The influence of patient preference on depression treatment in primary care. Annals of Behavioral Medicine, 30, 164–173.
Lipsey, M. W., & Wilson, D. B. (1993). The efficacy of psychological, educational, and behavioral treatment: Confirmation from meta-analysis. American Psychologist, 48, 1181–1209.
Luborsky, L., Singer, B., & Luborsky, L. (1975). Comparative studies of psychotherapies: Is it true that “everyone has won and all must have prizes”? Archives of General Psychiatry, 32, 995–1008.
Martin, D. J., Garske, J. P., & Davis, M. K. (2000). Relation of the therapeutic alliance with outcome and other variables: A meta-analytic review. Journal of Consulting and Clinical Psychology, 68, 438–450.
Nelson, J. C. (2006). The STAR*D study: A four-course meal that leaves us wanting more. American Journal of Psychiatry, 163, 1864–1866.
Ogles, B. M., Lambert, M. J., & Sawyer, J. D. (1995). Clinical significance of the national institute of mental health treatment of depression collaborative research program data. Journal of Consulting and Clinical Psychology, 63, 321–326.
Rush, A. J., Fava, M., Wisniewski, S. R., Lavori, P. W., Trivedi, M. H., Sackeim, H. A., et al. (2004). Sequenced treatment alternatives to relieve depression (Star*D): Rationale and design. Controlled Clinical Trials, 25, 119–142.
Rush, A. J., Trivedi, M. H., Wisniewski, S. R., Nierenberg, A. A., Stewart, J. W., Warden, D., et al. (2006). Acute and longer-term outcomes in depressed outpatients requiring one or several treatment steps: A STAR*D report. American Journal of Psychiatry, 163, 1905–1917.
Schramm, E., van Calker, D., Dykierek, P., Lieb, K., Kech, S., Zobel, I., et al. (2007). An intensive treatment program of interpersonal psychotherapy plus pharmacotherapy for depressed inpatients: Acute and long-term results. American Journal of Psychiatry, 164, 768–777.
Shadish, W. R., Matt, G. E., Navarro, A. M., Siegle, G., Crits-Christoph, P., Hazelrigg, M. D., et al. (1997). Evidence that therapy works in clinically representative conditions. Journal of Consulting and Clinical Psychology, 65, 355–365.
Shadish, W. R., Navarro, A. M., Matt, G. E., & Phillips, G. (2000). The effects of psychological therapies under clinically representative conditions: A meta-analysis. Psychological Bulletin, 126, 512–529.
Shea, M. T., Elkin, I., Imber, S. D., Sotsky, S. M., Watkins, J. T., Collins, J. F., et al. (1992). Course of depressive symptoms over follow-up: Findings from the national institute of mental health treatment of depression collaborative research program. Archives of General Psychiatry, 49, 782–787.
Smith, M. L., & Glass, G. V. (1977). Meta-analysis of psychotherapy outcome studies. American Psychologist, 32, 752–760.
Smith, M. L., Glass, G. V., & Miller, T. I. (1980). The benefits of psychotherapy. Baltimore: The Johns Hopkins University Press.
Smith, A., Traganza, E., & Harrison, G. (1969). Studies on the effectiveness of antidepressant drugs. Psychopharmacology Bulletin, 5, 1–53.
Spielmans, G. I., Thiegles, S. A., Dent, A. L., & Greenberg, R. P. (2008). The accuracy of psychiatric medication advertisements in medical journals. Journal of Nervous and Mental Disease, 196, 267–273.
Teasdale, J. D., Fennell, M. J., Hibbert, G. A., & Amies, P. L. (1984). Cognitive therapy for major depressive disorder in primary care. British Journal of Psychiatry, 144, 400–406.
Turner, E. H., Matthews, A. M., Linardatos, E., Tell, R. A., & Rosenthal, R. (2008). Selective publication of antidepressant trials and its influence on apparent efficacy. The New England Journal of Medicine, 358, 252–260.
van Schaik, D. J. F., Klijn, A. F. J., van Hout, H. P. J., van Marwijk, H. W. J., Beekman, A. T. F., de Haan, M., et al. (2004). Patients’ preferences in the treatment of depressive disorder in primary care. General Hospital Psychiatry, 26, 184–189.
Vittengl, J. R., Clark, L. A., Dunn, T. W., & Jarrett, R. B. (2007). Reducing relapse and recurrence in unipolar depression: A comparative analysis of cognitive-behavioral therapy’s effects. Journal of Consulting and Clinical Psychology, 75, 475–488.
Wampold, B. E. (2001). The great psychotherapy debate: Models, methods, and findings. New Jersey: Lawrence Erlbaum Associates.
Weissman, M. M., Prusoff, B. A., DiMascio, A., Neu, C., Goklaney, M., & Klerman, G. L. (1979). The efficacy of drugs and psychotherapy in the treatment of acute depressive episodes. American Journal of Psychiatry, 136, 555–558.
Westen, D., & Morrison, K. (2001). A multidimensional meta-analysis of treatments for depression, panic, and generalized anxiety disorder: An empirical examination of the status of empirically supported therapies. Journal of Consulting and Clinical Psychology, 69, 875–899.
Williams, J. W., Rost, K., Dietrich, A. J., Ciotti, M. C., Zyzanski, S. J., & Cornell, J. (1999). Primary care physicians’ approach to depressive disorders. Archives of Family Medicine, 8, 58–67.
World Health Organization. (2004). The world health report 2004: Changing history, annex table 3: Burden of disease in DALYs by cause, sex, and mortality stratum in WHO regions, estimates for 2002. Geneva: WHO.
Author information
Authors and Affiliations
Corresponding author
Rights and permissions
About this article
Cite this article
Greenberg, R.P., Goldman, E.D. Antidepressants, Psychotherapy or their Combination: Weighing Options for Depression Treatments. J Contemp Psychother 39, 83–91 (2009). https://doi.org/10.1007/s10879-008-9092-2
Received:
Accepted:
Published:
Issue Date:
DOI: https://doi.org/10.1007/s10879-008-9092-2