- The standard treatments for depression include medications (e.g., SSRI antidepressants) and psychotherapy (e.g., cognitive behavioral therapy).
- New research shows that psychotherapies for depression, though more effective than placebo, may not benefit over half of depressed patients.
- We need to develop more effective treatments for depression and make these treatments widely available and affordable.
Cuijpers and collaborators, in a study published in the September issue of Acta Psychiatrica Scandinavica, suggest that over half of patients who receive psychotherapy for depression do not respond to the treatment. Worse yet, only one-third remit.
Depression and Its Treatment
Depression is a common but serious mental illness characterized by emotional, mental, bodily, and behavioral symptoms—for instance, sadness, loss of interest and pleasure, concentration difficulties, appetite and weight changes, and suicidal thoughts and suicide attempts.
A variety of approaches are used to treat depression. Some patients have experienced improvements in their depressive symptoms after using dietary supplements (Zinc, probiotics) or making lifestyle changes (exercise, healthy eating, stress reduction, pet adoption). Other depressed patients have relied on effective antidepressant medications such as SSRIs and SNRIs—or drugs like ketamine and magic mushrooms, which new research suggests may reduce depressive symptoms.
Psychological Treatments for Depression
Psychological therapies are considered among the most effective ways to treat depression. Some commonly used psychotherapies are:
- Cognitive behavioral therapy (CBT). CBT modifies a depressed person’s unhelpful behaviors (e.g., avoidant behaviors) and beliefs (e.g., black-and-white thinking, catastrophizing).
- Interpersonal therapy. This therapy modality targets interpersonal functioning and relationships. For instance, it helps depressed individuals adjust to changing roles (e.g. after divorce, retirement, loss of a spouse or child).
- Problem-solving therapy. This approach includes multiple steps, starting with defining a problem, producing potential solutions, choosing the best solution, using it, and evaluating the results.
- Behavioral activation: Behavioral activation teaches depressed patients how to identify activities they find pleasant and rewarding, and furthermore, how to engage in them regularly.
Depression Treatment Response
In evaluating effective psychotherapies for depression, an important question is: What percentage of patients who receive psychotherapy for depression get better? And what percentage no longer meet the criteria for depression? The answer to these questions requires calculating the treatment response and remission rates, respectively.
In the investigation by Cuijpers and collaborators, treatment response was defined as a 50% reduction in the symptoms of depression. Remission rate was defined as the disappearance of the symptoms of depression—specifically, a score of 7 or less on the 17-item version of the Hamilton Depression Rating Scale (HAM-D). This scale contains items assessing common symptoms of depression—depressed mood (e.g., sadness, low self-esteem, hopelessness), guilt and remorse, suicidal thoughts, sleep disturbances, loss of interest and pleasure, agitation or slowing of thoughts and movements, anxiety and worry, somatic symptoms (e.g., headaches, palpitations), loss of appetite, fatigue and lack of energy, loss of sexual interest, worry about having an illness, weight loss, and lack of insight about being depressed.
Investigating the Effectiveness of Psychotherapy for Depression
For their meta-analysis, the authors conducted a comprehensive literature search (up to January 2020). Of nearly 25,000 records evaluated, 228 met the inclusion criteria—being randomized trials comparing a psychological treatment for depression with a control condition. Characteristics of the trials: 23,574 participants; 23% clinical samples, 44% community samples, and 33% other. Overall, 117 investigations used a “care-as-usual” control group, 106 a waitlist, and eight a pill-placebo condition.
There were 246 therapy conditions (some studies had two therapy conditions): cognitive behavioral therapy (60%), problem-solving therapy (10%), interpersonal psychotherapy (9%), third-wave psychotherapies (9%), behavioral activation (8%), and life review therapy (5%).
Close to 33% used an individual treatment, 25% group therapy, 20% guided self-help, etc.
- The “response rates were 0.41 for all psychotherapies together at 2 (±1)- month follow-up, when most therapies had ended.”
- The response rates were comparable, meaning different therapies appeared similarly effective.
- Over 50% of those receiving psychotherapy for depression did not respond to the treatment.
- Remission occurred in just one-third of the depressed patients receiving psychotherapy.
In summary, although psychotherapies for depression work, “more than half of patients receiving therapy did not respond and only one third remitted. Furthermore, 16%-17% also respond when they are in a waitlist or [care as usual] control conditions.”
This suggests that we need to develop more effective psychotherapies for depression. To be clear, the same could be said of pharmacotherapy for depression (i.e., medications for depression). Indeed, research suggests that medications and psychotherapy have comparable effects, at least in the short term.
What makes the situation worse is that even patients who could benefit from treatment for depression do not always receive it. Whether a person with depression is offered and eventually chooses psychotherapy or medications—or whether one seeks any treatment at all—may depend on a variety of factors beyond the effectiveness of interventions. These factors include the person’s ability to afford the cost, access to and availability of interventions, stigma, time commitment, potential side effects of medications or psychological treatments, and previous negative experiences with treatment.
At the end of the day, our goal should be not only to develop effective treatments for depression but also to make the treatments available, accessible, affordable, acceptable, and inclusive.
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