While antidepressants are the most commonly used long-term treatment for depression, the efficacy of these drugs after one year is unknown. In a commentary for The Lancet, psychiatrists Rudolf Uher and Barbara Pavlova suggest that cognitive behavioral therapy (CBT) now has the most substantial body of evidence for the long-term treatment of major depressive disorder.
Uher and Pavlova penned their commentary following the results of the CoBalt trial (see MIA’s coverage here), which found that the effects of CBT were fully maintained after three and a half years.
“CBT provides long-term benefits without continued treatment or booster sessions, which is probably because the participants learn skills that they continue practising after the treatment stops. Consequently, discontinued CBT might be as effective as continued treatment with antidepressant medication and more effective than antidepressant medication that is discontinued.”
“In combination with previous smaller studies, the results of the long-term follow-up of CoBalT suggest that CBT should be routinely offered to individuals with major depressive disorder who do not have satisfactory improvement with antidepressants alone. This conclusion leaves a quandary about the availability of high quality CBT in routine clinical setting.”
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Uher, R., & Pavlova, B. (2016). Long-term effects of depression treatment. The Lancet Psychiatry. (Full Text)
Antidepressants hardly work at all. They are only more effective at dulling down feelings in 10-15% of people, compared to placebo. So why it is something to celebrate if CBT is better than that? Walking a dog once daily is probably better than antidepressants as a “treatment” for “major depression”, whatever the hell it is.
Reading psychiatry journals is funny because psychiatrists discuss these studies about fake diagnoses and specific treatments for the illusory diagnoses with the utmost gravity and academic seriousness. It’s like going to an astrology or alchemy convention where everyone believes what they’re doing is a real science.
Do the editors read the papers-or just headlines?
Dear sirs,
1. 40% dropped out-so we dont know if they got better-or even worse from CBT. The latter being plausible due to the moderately large body of work published on worsening symptoms from psychotherapy.
2. At follow up-the “intervention group” , based upon the BDI scale would be considered to be mild-to Moderately depressed. Seeing that these numbers are averaged, it would seem reasonable to wonder how many remained moderately depressed-after CBT.
Having discussed this issue on the phone with Dr. DeRubeis ( major proponent of CBT in depression), he has yet to publish data to show the effectiveness -at all-in getting patients with moderate to severe depression-into REMISSION.
I do not think any respectable clinician would be proud of touting getting a diabetic or hypertensive to be moderately sick as a goal.
While this site continues to assail antidepressants without any scientific basis (while all agreeing upon the fact that they are both overprescribed, and can and do make symptoms worse in many people), -the first
call from a therapist treating a suicidal patient is most often-to the psychiatrist for meds.
It is sad such a mindful forum continues to publish such irrational exuberance.
Sadly, the evidence base for antidepressants is just as weak or weaker than the evidence for CBT that you properly critique. Most people who “successfully” use antidepressants improved an average of something like 3-5 points on the BDI, leaving them “moderately sick,” as you so aptly put it.
So the real question is, what else can be done? It does not appear that either of these interventions are particularly helpful, although it seems that at least the side effect profile for CBT is less severe.
—- Steve
Hi Steve,
Thank you kindly for the comment. I read the literature differently. If you look at Quitkins study in journal of clinical psychiatry 2005-remission rates (not response) can be read as anywhere between 66 and 90 percent. This is a number that more closely represents my findings in my practice. The key here was to use sequential trials when on AD failed.
In comparison, the only met analysis I know of looking at psychotherapy remission rates is Wampold in J affective disorder-where remission rates are not even mentioned. DeRubeis does talk of remission rates, but the numbers (as in other studies) can at times be misleading. For example if a few patients of the cohort fully respond, the number who did not go into remission is not clear. DeRubeis would not provide me that data saying it would be published. It never was.
If you can find me raw data on remission rates in MDD using psychotherapy, that would be appreciated.
I think many in the field believe CBT is very helpful in reducing recurrence. I think far fewer believe it to be significantly different from other psychotherapies, or placebo in mild forms of MDD,
As far as side effects, again I think the literature would disagree with you. If you google scholar search adverse response to psychotherapy, you will find a number of papers in reputable journals by smart people.
So how can it be best done? By not being an ideologue which is a problem for those who post on this site. Having researched this question since I do both psychotherapy and psychopharmacology and don’t care which works- I would say that patient preference sometimes makes a difference. The degree of genetic loading sometimes makes a difference. The degree of social support often makes a difference and duration and frequency of illness is likely a major factor in the eventual need for medication use.
None of these rules are steadfast. If they were, I too would be an ideologue.
Thanks for the reply. Any credible literature to the contrary would be enjoyed. If not , I would be yet another on the site, just mad and closed to suggestion.
Monk.
I am not talking about short-term remission rates, but about long-term recovery, and I think Whitaker’s summary of the literature, followed by more supportive evidence from Wunderlink and the 20-year followups from Harrow et. al. certainly support that medication interventions have a very disappointing long-term impact on functional recovery.
As for side effects, I’m certainly the last to say that poorly-executed therapy is free of side effects, but if we are talking about antipsychotics, we are now seeing lifespans 25 years less than the average population. Of course, some of that is attributable to life choices of those so treated, including suicide, substance abuse, and very high smoking rates. On the other hand, users of antipsychotics describe the use of cigarettes as a way to minimize the side effects of the drugs, which makes logical sense, given the dopamine effects of nicotine opposing those of the antipsychotics.
But regardless of that, it is clear that not all of the lifespan reduction is due to poor lifestyle choices. We know that antipsychotics can mess badly with metabolism, inducing large weight gain and diabetes, as well as heart problems. It should be obvious that some of the lifespan reduction is due to antipsychotic drugs, as neither smoking nor substance abuse per se are associated with that kind of reduction in life span expectation. As bad as formulaic application of CBT can be, it is unlikely to kill the subject except by driving them to suicide, which is not something I have heard occurs very frequently. Correct me if you have data to the contrary.
I completely agree with you about not being ideological, and that CBT or any other therapy can be damaging. I just think you are looking only at short-term data for your evaluation of the effectiveness of drug therapy, and that misses perhaps more than half the picture, as most people are more interested in quality of life than in immediate symptom reduction per se (quality of life would be a desired RESULT of symptom reduction in most people’s minds – being miserable with fewer symptoms is not an outcome most would desire). One need only look at the much higher recovery rates in the developing world, per the two WHO studies in the 90s, to sense that we may have a lot to learn about what really facilitates recovery. Simply saying that CBT is no better than psychotropics begs that more important question.
—- Steve