For depression, which is better: Therapy or meds?

Many people suffer from depression and just take their doctor’s word for it on whether or not they should be medicated (not to mention which drug) and/or seek psychotherapy.

There really hasn’t been a ton of research looking at how a doctor can or should make these decisions. With drug choice especially, it is kind of a roll of the dice. There’s not a lot of rhyme or reason behind why one drug makes sense for one person and not another.

And there are times when therapy could really make a difference on its own, taking out the entire issue of side effects or dependence that come with antidepressants. But now some new research is taking a closer look at the differences.

A study from Dr. Helen Mayberg, a professor of psychiatry at Emory University, recently published in JAMA Psychiatry examines whether or not a depressed patient would be better off with therapy or medication based on a potential biomarker in the brain.

The New York Times explained how the study worked and what they found:

Using PET scans, she randomized a group of depressed patients to either 12 weeks of treatment with the S.S.R.I. antidepressant Lexapro or to cognitive behavior therapy, which teaches patients to correct their negative and distorted thinking.

Over all, about 40 percent of the depressed subjects responded to either treatment. But Dr. Mayberg found striking brain differences between patients who did well with Lexapro compared with cognitive behavior therapy, and vice versa. Patients who had low activity in a brain region called the anterior insula measured before treatment responded quite well to C.B.T. but poorly to Lexapro; conversely, those with high activity in this region had an excellent response to Lexapro, but did poorly with C.B.T.

So what does this mean? The insula is a key part of the brain involved in the capacity for emotional self-awareness, cognitive control and decision making. If a patient has low insula activity, they could respond better to therapy because they actually need to learn and be walked through the process of controlling their emotions, which obviously a drug can’t do.

It should be said that these treatment differences aren’t relevant the same way for those with psychotic depression.

But these findings are interesting because it could mean that instead of just switching between different antidepressants in a trial-and-error fashion when a patient isn’t seeing results, trying cognitive behavior therapy could be a better option.

Whether or not a patient suffered from some form of trauma as a child (like losing a parent or experiencing abuse) makes a difference too.

In a large, multicenter study, Dr. Charles Nemeroff, a professor of psychiatry at Emory, found that for depressed adults without a history of abuse, there was a clear ranking order of treatment efficacy: Combined psychotherapy (using a form of cognitive behavior therapy) and an antidepressant (in this case, Serzone) was superior to either treatment alone. But for those who had a history of childhood trauma, the results were strikingly different: 48 percent of these patients achieved remission with psychotherapy alone, but only 33 percent of these patients responded to an antidepressant alone. The combination of psychotherapy and a drug was not significantly better than psychotherapy alone.

Ideally in the near future doctors will be able to do a MRI or PET scan and just figure out what’s going on in the brain and have an easy understanding of what treatment will be affective for each individual.

For now, it seems that the best plan for depressed patients who aren’t seeing results in one area might have luck either switching tactics or trying both.

Photo: Flickr user darcyadelaide