Antidepressant use has increased in the United States while psychotherapy use has decreased: Is this a healthy trend?

by Michael D. Anestis, M.S.

When I am contemplating my next article, I use a variety of resources to aid in my decision making process.  At times, I reflect on things I have read in the past that I think might be interesting.  Other times, I react to something I believe was misrepresented in popular media.  On other occasions, I browse newly released issues of prominent psychological journals and search for interesting findings.  Today, however, my article was prompted by a different resource.  While posting updates for PBB on Twitter yesterday, I noticed a user named BPDinOKC had posted a link to an article declaring that antidepressant use in the United States had spiked dramatically in recent years.  I followed up on this link and read a strong review of the study on the excellent website Psych Central.  I highly recommend following that link if you would like to read a more in depth summary of the findings.

The original source of this finding was a recent study by Mark Olfson and Steven Marcus, published in the current issue of Archives of General Psychiatry.  The authors reported that, between the years of 1996 and 2005, the use of antidepressant medications in the United States doubled from 13.3 million individuals to 27.0 million individuals.  Additionally, amongst individuals receiving antidepressant treatment, co-occurring prescriptions of antipsychotic medications increased whereas the use of psychotherapy declined.  It is not my goal today to go into further detail on these findings - the Psych Central article did a great job of accomplishing that task - but rather to provide some evidence that this trend is not our nation's best path towards decreasing the rates of depression onset and relapse.

Before presenting my evidence, let me preface this article with a bit of a disclaimer.  PBB wholeheartedly supports the use of pharmacological interventions when empirical evidence indicates that it is the best option.  In the case of depression, the focus of today's article, there is compelling evidence that antidepressant medications can be highly beneficial.  In this sense, we are not arguing against the use of medication in the treatment of depression, but rather attempting to clarify the entire picture so that individuals in need of help can more fully understand their options.

So...why did the finding that antidepressant use has doubled while psychotherapy use in that same population has declined prompt me to write an article?  Quite simply, because the evidence does not support the use of antidepressant medication in place of psychotherapy as a long term solution to depression. Below is a quick sampling of studies indicating that certain forms of psychotherapy are at least as effective as antidepressant medication in the treatment of depression:

• Keller and colleagues (2000) compared cognitive behavioral analysis system of psychotherapy (CBASP), nefrazadone (an antidepressant), and the combination of the two for the treatment of depression.  They found that, of those who completed the study, 85% of individuals who received both antidepressant medication and CBASP recovered from depression.  Only 55% of individuals receiving medication only and 52% of individuals receiving CBASP only recovered.

• DeRubeis and colleagues (2005) reported that, at 16 weeks, individuals receiving cognitive therapy (CT) had recovered from depression at the same rate (58%) as individuals receiving antidepressant medication.

• Dimidjian and colleagues (2006) found that behavioral activation was just as effective as antidepressant medication in the treatment of depression and both were superior to CT.

• Faramarzi and colleagues (2008) reported that cognitive behavioral therapy (CBT) was more effective than antidepressant mediation in treating depression in infertile women.

• Melvin and colleagues (2006) found that CBT was more effective than antidepressant medication in the treatment of depression, and that the combination of the two offered not significant benefits over CBT alone.

The above mentioned findings, on their own, are fairly compelling, but this is only the beginning of the story.  What these findings show is that, when an individual presents with depression, both antidepressant medication and various forms of CBT can effectively treat acute symptoms.  These findings, however, do not address the degree to which either approach to treatment prevents symptoms from coming back after treatment is over. 

Depression is, by nature, episodic.  In other words, it tends to flare up, recede, flare up again, and so on.  As such, simply being able to diminish symptoms is not enough.  Effective care must also prevent those same symptoms from reoccurring once treatment is over.  One way to do this would be to remain in treatment forever.  This is the approach taken by practitioners who prescribe antidepressant medications with no intention of ever discontinuing use for that patient.  Is this the best approach though?  The evidence says "no."  Below is another sampling of studies, this time with a focus on the degree to which various treatments prevent relapse:

• Bockting and colleagues (2005) found that including CT sessions after remission in clients treated with antidepressant medication significantly reduced rates of relapse at 2-year follow-up.  This was particularly true for individuals with a history of five or more prior depressive episodes, as relapse rates in this group decreased from 72% to 46%.
  

• Dobson and colleagues (2008) reported that, at 1-year follow-up, individuals who had received behavioral activation or CT or who were still taking antidepressant medication had relapsed at a significantly lower rate than individuals who had discontinued antidepressant use.  This same result was found at 2-year follow-up as well.

• Hollon and colleagues (2006) found that individuals withdrawn from CT were less likely to relapse (30.8%) than were individuals withdrawn from treatment with antidepressants (76.2%).  Additionally, individuals who had completed CT and were withdrawn from treatment following remission were no more likely to relapse than were individuals who continued to take antidepressant medications after remission.

This is only a small sampling of research on this point, but they are consistent with other results and these findings are the key in this entire debate.  Many individuals who argue for the use of antidepressant medication instead of CBT or its various alternative forms and components (e.g., CBASP, behavioral activation) maintain that symptom reduction occurs more quickly with antidepressants than in psychosocial approaches and, as such, is more cost effective.  The problem with this argument, however, is that an extremely high percentage of individuals treated with antidepressants relapse once they discontinue the use of their medication.  So, they either have to pay for medication permanently, which is in no way cost effective, or they can pay a smaller amount for acute treatment and face a substantial risk of relapse.  CBT, on the other hand, offers a short term (often 12-20, 1-hour weekly sessions) treatment that substantially reduces the risk or relapse without requiring ongoing treatment after remission.  That, in the long term, is significantly more cost-effective.

Again, it is important to point out here that I am not arguing against the use of antidepressants.  The evidence for their utility in treatment depression as well as other mental illnesses (e.g., obsessive-compulsive disorder) is strong.  The point, rather, is that antidepressants are no more effective than several psychotherapeutic approaches at reducing symptoms and are, in fact, worse than those approaches at preventing relapse.  As such, a trend towards increased antidepressant use and decreased psychotherapy use is not an overall positive development. 

It is great that more people are seeking treatment.  This indicates that the stigma of mental illness is decreasing and effective care is becoming more accessible.  At the same time, this trend indicates that many clinicians and individuals suffering from depression are unaware of all of their options for treatment and that many clinicians - particularly in primary care settings - are not providing consumers with their most effective paths towards sustained health.

If you would like to learn more about cognitive behavioral therapy, CBASP, or depression, we recommend the following resources, all of which are available through our online store:

Cognitive Therapy of Depression - Aaron Beck, M.D.

Feeling Good: The New Mood Therapy Revised and Updated - David Burns, M.D.

Treatment Plans and Interventions for Depression and Anxiety Disorders - Robert Leahy, Ph.D.

Cognitive Therapy Techniques: A Practitioner's Guide - Robert Leahy, Ph.D.

Treatment for Chronic Depression: Cognitive Behavioral Analysis System of Psychotherapy (CBASP) - James McCollough, Ph.D.

Patient's Manual for CBASP - James McCollough, Ph.D.

Handbook of Depression, Second Edition - Ian Gotlib, Ph.D. and Constance Hammen, Ph.D.

Mike Anestis is a doctoral candidate in the clinical psychology department at Florida State University.