Research Assessment #5

Date: October 26, 2018

Subject: What’s the Best Way to Treat a First Bout of Depression

MLA Citation:
Gillihan, Seth J. “What's the Best Way to Treat a First Bout of Depression?” Psychology
Today, Sussex Publishers, 24 Oct. 2018, www.psychologytoday.com/us/blog/think-act-
be/201810/whats-the-best-way-treat-first-bout-depression.

Analysis:
The article was written by Seth J. Gillihan, a professor’s assistant at the University of
Pennsylvania with his Phd in psychology, which, when considering the website he is publishing
for, makes him an extremely credible and qualified source for this information. The article is a
interview between the author and another psychologist, Robert J. DeRubeis of the University of
Pennsylvania, about the three main methods of curing first time depression and their respective
effectiveness along with common misconceptions about depression. The author proceeds
questions with information regarding the topic of siad question, then follows some question
with his opinions on the topic of the question.
The majority of the article is focused on comparing and contrasting the three main types
of therapy, namely; psychotherapy, medicine, and combining therapy and medicine. Dr. Gillihan
and Dre. DeRubeis present a surprising amount of evidence to support the idea that
psychotherapy is just as effective as medicine when attempting to cure depression in the short
term, but psychotherapy takes the lead in the long term for preventing return depression. Dr.
DeRubeis also mentions how they both take around the same amount of time to cure
depression. This is extremely beneficial information to me, as an aspiring psychologist, as I have
been concerned about how effective my therapy would be compared to medicine, because
medicine something that is rapidly evolving making human psychological care irrelevant in the
eyes of many. With this information in mind, considering how recent this article is, unless a
brand new medicine is created that is more effective than psychotherapy and current medicine
at curing depression in the long term, the field of clinical psychology is secured, especially
considering that a large portion of our society has or has had depression. Another topic
discussed in the article is the effectiveness of a combination of drugs and psychotherapy, which,
although 10% more effective than either individually, may cause complications later on.
According to Dr. DeRubeis, after treatment, some people may question what was it, exactly, that
cured their depression, which may lead them to continue to purchase antidepressants in order
to avoid relapsing and abandoning what their psychologist taught them, leading to a potential
relapse. The opposite is true too, which is why Dr. DeRubeis prescribes those looking to be cured
of first-time depression go to a psychologist or psychiatrist. This, along with the fact that only
50% of people diagnosed with depression deal with it more than once, was the most surprising
part of the article, because one would think that combining the two best methods of dealing with
depressing would produce better, longer lasting results than one individually.
The information presented by the article has been really beneficial to my education in the
field of psychology, because, although it has not informed me of any therapy techniques or
illnesses I may encounter in the field, it has bolstered my confidence in my choice of the field,
and taught me how important psychology is to curing depression, the quickest growing mental
illness (besides anxiety).

Article:
What's the Best Way to Treat a
First Bout of Depression?
An expert in depression treatment research shares his
knowledge.
Posted Oct 24, 2018

Source: Photographee_eu/Adobe Stock

Every year, millions of individuals come to know the pain of major depression
for the first time. It can be a bewildering experience, with many people not
even realizing their struggles are related to depression (as I've written about
before: Can You Be Depressed Without Knowing It? I Was).

In the midst of these difficulties, a person faces an important decision: What is

the best way to treat my depression? Options include talking with close friends
and family members, self-help books and apps, over-the-counter remedies,
psychotherapy, and prescription medication, among others. Many people find
these choices overwhelming and are not sure where to begin, especially
because it's their first time dealing with depression.
Thankfully many people have thought really carefully about this decision, and
none more than psychologist Robert J. DeRubeis of the University of
Pennsylvania. I recently interviewed Rob to discuss the current state of the
science in depression treatment research.

Do I Have a Chemical Imbalance?

First, let's think about what causes depression, which may affect choice of
treatment. An explanation that seems to have saturated popular culture is that
depression is caused by a "chemical imbalance." Most often the imbalance is
said to involve too little serotonin—with the understanding that a drug is
needed to fix it. I asked Rob for his perspective on this theory:

Seth J. Gillihan: What causes depression? Is it a chemical imbalance?

Robert J. DeRubeis: The chemical imbalance theories that came around in

the 1950s were quite intriguing and they captured the imagination of the
profession. There's no doubt that whenever we are in a particular mood or
when we come out of that mood, there are associated events in the brain.
That's a given and we all understand that.

But theories that led some to talk about a 'chemical imbalance' as a rather
simple matter have really not panned out. There's nothing simple about the
neurotransmitters and their relation to depression. The brain's a very
complicated organ, and current thinking is more focused on the regulatory
systems in the brain that are more active in some people than in others.
SJG: And yet that simple account of a chemical imbalance has been
surprisingly persistent given how little data there have been to support it.

RJD: Yes, and of course it's connected to the predominant treatments in the
US and many other Western countries for people with mood difficulties—that
is, the antidepressant medications. And so there are some kind of interesting
links between what we think the antidepressant medications are doing and
what we know about what happens at the synapses in certain areas of the
brain, but the connections are not very tight, strong, or well understood. And
indeed as I've read these literatures and contributed a bit to them, it's common
enough that what we find about a given neurotransmitter system is the
opposite of what was first proposed."

article continues after advertisement

Importantly, our thoughts and behaviors affect our brains, so we are not
merely passive recipients of our brain states. See also this post on the limited
evidence for a chemical imbalance in depression: Do You Need Drugs for
Your "Chemical Imbalance"?

Can Psychotherapy Really Help with Severe Depression?

The lack of evidence for a chemical imbalance in depression might call into
question whether the condition requires a chemical solution. I asked Rob
about existing research comparing the effectiveness of meds and
psychotherapy, particularly for severe cases of depression.

SJG: When I started in my doctoral program at Penn in 2001, the idea was
that medication was like a key that fit in the lock of your chemical imbalance,
which fed the idea that the real treatment for real depression was medication.
Someone I interviewed with at Penn actually predicted that in a study you
were doing at the time, 'the meds were going to beat up on the therapy' in the
head-to-head comparison of CBT and an SSRI. So I wanted to get your
perspective on why it was widely assumed that medication was better than the
best therapy for treating severe depression.

RJD: In the 1970s and '80s, the possibility that we could correct a simple
imbalance was very exciting, and the medications that were being used were
more effective than placebo pills, on average, for people with substantial
depression. So the idea was that 'Here we have a real and serious treatment
for depression.'

article continues after advertisement

Then along came a relatively small study—but an intriguing one—that found
that cognitive therapy outperformed medication in that randomized trial. This
was surprising to many who believed that 'real' depression needs a 'real,'
physical treatment, and there were many skeptics, as there should have been.
But then a couple of other studies showed very similar kinds of effects that
were encouraging about the benefits of cognitive therapy in comparison to
medication.

And then in what was thought to be a large study comparing medications with
cognitive behavioral therapy, there were reports that medications
outperformed CBT for those with the most severe symptoms [Elkin et al.,
1989—a study that's been cited over 3200 times]. This finding confirmed
preexisting notions among the psychiatric community, and also spread to the
public. The belief was that 'now that we've done the real study and we've
looked at more severe depression, we can see that we were too optimistic to
think that CBT could work as well as meds.'"

This 1989 study did indeed seem to have a lot of sway over the depression
treatment field; it was frequently cited as evidence for the superiority of
medication over psychotherapy. But as Rob explains, the implications of that
study's findings appear to have been overblown.

RJD: It turns out that in that study, the comparison that everyone was excited
about and took very seriously was a comparison of 27 patients in each group.
Now, that's not nothing, and it certainly is data that one needs to take into
account. In the 1999 paper we wrote, those 27 patients who got medication in
that trial did significantly better than those in cognitive therapy, but it turned
out that study was unusual in that regard. Clinical science is a larger
enterprise than one study, and when we were able to look across several
studies, there was no advantage of the medications at all in the short run.
Cognitive therapy and medications, on average, performed essentially exactly
the same.

article continues after advertisement

Rob and his colleagues completed a subsequent study of 240 patients that
again found that cognitive behavioral therapy and medication were equally
effective in the short term—and that CBT was better in the long run at
preventing a return of depression.

Does Medication Work Faster Than Psychotherapy?

While CBT and medication appear to be equivalent in their short-term
effectiveness, some have suggested that medication works faster, and thus
can lead to quicker relief.

SJG: One of the other common arguments for giving antidepressant

medications right away is that they work faster than psychotherapy. Is that the
case?

RJD: They don't. And this belief again somehow meets up with
preconceptions, but in the analyses we've done, there really isn't a difference
in speed of the effects, and if there are any, they're really slight. Of course, it's
going to depend a bit on what the medication is and how active and directive
and potent the psychotherapy is. But if you're talking about an effective
antidepressant and an effective cognitive behavioral therapy, the rates of
change are pretty much on top of each other, on average.

Should I Get Medication Plus Psychotherapy for Best Results?

SJG: Many people say that the head-to-head comparison of CBT versus
medication isn't really important because 'we all know the best approach is to
combine medication and therapy'—that the meds do one thing, the therapy
does something else, and they work together. And it's true, on average, that
depression responds better to a combined treatment in the acute treatment
phase. How much better is that combination as opposed to having just one
treatment?
RJD: If we think in terms of the percentage of patients that get better over a
period of time, a representative finding is that sixty percent get better if they
have one of the two treatments, and seventy percent get better if they get
both."

SJG: In your recent writing you've suggested caution about combining meds
and therapy for everyone at the outset of treatment. Why is that?

RJD: We recognize that there is this, on average, say 10% benefit of having
the two treatments together. But we've thought about some other things that
make it not so simple. For example, let's say I've been given both treatments
and now I'm feeling better, but I wonder—what got me better? Was it the
medications? Maybe it was, and maybe that means I should stay on the
medications. And I might also wonder, Did the cognitive behavioral therapy
really help? And I'd better be really convinced that the CBT helped if I'm going
to do the kind of work that it requires, especially using the kinds of skills that I
learned in therapy. But if I think it was the medications that did it, the best
thing is for me to just stay on the medications.

But let's imagine we go back a couple months, and I'm beginning treatment
and I'm being given the psychotherapy and the medication, and I'm really
hoping the medication works, because doing treatment is difficult. It requires
effort, it requires looking at things that are a bit painful, looking at some
behavior patterns, changing things.... If I'm hoping the medications do the
trick, I might not be so motivated to engage the therapy in the way that I would
if the medication weren't around. We have some evidence to suggest that this
is what can happen to individuals who are getting both treatments.
Now think of me as someone who's only getting the psychotherapy. Well now
if I'm feeling better after a few months, I have a pretty good idea that this
cognitive behavioral therapy treatment was a good thing, and that maybe I'd
better keep it up. Maybe I'd better practice the kinds of things I've been
working on with my therapist. And if I run into a bit more trouble than I can
handle, maybe I check in with my therapist a few months down the road to get
a bit of a boost. So it really does affect how treatment proceeds depending on
whether you're getting a combined treatment or CBT alone.

The most common thing in the US is that I talk with my doctor about my
depressive symptoms and they're going to start me on a medication. And then
maybe if I'm struggling with the medication, then I'm given a referral for
therapy. Again, we've got a mixed message about what is really going to be
helpful to me if I end up getting both treatments.

Less common would be when someone starts with therapy alone, maybe
because they don't want to take medication or their doctor isn't very keen to
prescribe it. In that case, they can start medication after a few weeks or a
couple months if they're struggling a bit to make progress—that can always
happen. And I think as practitioners we need to be supportive of that kind of
sequence where if someone is really taking on a therapy and we're not
making as much progress as we'd like, then medication is still an option. But if
we start those medications right away and we get benefit from them, we're
going to learn that it's the medication that we need. If we don't get better from
them then we're going to need to add the therapy. But if we start them at the
same time, we're going to be left in that position of wondering what it is that
helped, and what will help me in the future.
Does This Mean I'll Deal with Depression the Rest of My Life?

Depression is usually thought of as a recurring condition, meaning if you've

had it once, you're bound to get it again. Based on that understanding, I was
surprised to learn from Rob's work that that is not necessarily the case.

SJG: It also seems like we've come to believe that depression is a recurrent
condition, and it's true that if you've had an episode of depression then you're
at increased odds of having future episodes. Is it a guarantee? How likely is it
that the depression will recur for people who have had a single episode.

RJD: It does seem to have become accepted wisdom, that depression is a

recurrent problem. If you take individuals who have their first episode of
depression, the question is then, how many will have a second one? And the
answer is, only about half. What that suggests is that many of us go through a
period in our life when we're struggling. And I like to use the word 'struggling'
because I think there's a positive connotation to it as well as the painful one.
We're trying to reconfigure things in our life, or at least are made to by
disappointments and setbacks.

And about half of individuals who go through one of these rather rough
patches are going to have to deal with another rough patch, and perhaps
another rough patch, of major depression. So it really has been surprising
when careful research is done to see how recurrent depression actually is
when we make sure we include individuals who don't go on to have more and
more depressions. So having only a single episode of depression is a rather
common experience.
This fact has particular relevance to the discussion above about whether to
start with therapy, medication, or a combination. Among those who take a
medication, many will continue to take it indefinitely as a preventative
measure, and because there are often withdrawal effects from stopping the
medication. Many of these individuals would have recovered had they
received psychotherapy alone. Thus it is likely that a substantial percentage of
people may be taking long-term medication even though they would in fact
never experience another episode of depression.

The Bottom Line

To summarize, medication and psychotherapy can both be quite effective in

treating depression (for a list of evidence-based therapies, see the Society of
Clinical Psychology's webpage). The treatments tend to provide relief equally
quickly, with psychotherapy being better at preventing future depression once
treatment ends. And while a combination of meds and therapy can provide
somewhat better results, there are other factors to consider when deciding
whether to start both treatments at once versus one at a time.

Keep in mind that all of these findings are based on average effects. In reality,
some individuals will fare better with psychotherapy while others will get more
relief from medication. Similarly, some people will need a combined treatment
to recover whereas others will do quite well with a single treatment.

Rob's latest work is aimed at figuring out in advance which treatment is better
for a given individual, to maximize each person's chance of recovering from
depression. Bringing precision medicine to psychiatry could prevent people
from wasting time on treatments that are unnecessary or unlikely to work,
thereby saving time and money and avoiding needless suffering.

The full conversation is available here.

Note: This post is provided for informational purposes only. Follow your
doctor's or other mental health professional's guidance for your treatment
decisions.

References
Cohen, Z. D., & DeRubeis, R. J. (2018). Treatment selection in depression. Annual Review
of Clinical Psychology, 14, 209-236.
DeRubeis, R. J., Gelfand, L. A., Tang, T. Z., & Simons, A. D. (1999). Medications versus
cognitive behavior therapy for severely depressed outpatients: Mega-analysis of four
randomized comparisons. American Journal of Psychiatry, 156, 1007-1013.
DeRubeis, R. J., Hollon, S. D., Amsterdam, J. D., Shelton, R. C., Young, P. R., Salomon, R.
M., ... & Gallop, R. (2005). Cognitive therapy vs medications in the treatment of moderate to
severe depression. Archives of General Psychiatry, 62, 409-416.