What is the best treatment for depression?

I attended a lecture last week by leading clinical psychologist and head of the counselling service in the University of Limerick, Dr. Declan Aherne, entitled

“Medication or psychotherapy in the treatment of depression and anxiety.”

The lecture discussed research results – from 1995 to 2011 – which examined the effects of medication and psychotherapy – given alone and in combination – on depression and anxiety. I was impressed by the lecture and by the question from the audience – many of whom were Psychiatrists, GPs, sufferers themselves and others working the area of depression and anxiety.

Let me explain some definitions and summarize a few points raised in this excellent lecture.

Some definitions:

Psychotherapy: The treatment of a behaviour disorder, mental illness, or any other condition by psychological means.

Medication (psychopharmacology): The scientific study of the actions of drugs and their effects on mood, sensation, thinking, and behavior.

Some interesting points I took from the lecture include:

1. Incidence – anxiety affects 66 million and depression affects 31 million each year in Europe alone.
2. Treatment – medication is only beneficial in severe but not moderate or mild depression while up to 30% of patients take both psychotherapy and medication.
3. Delivery – in Europe, psychotherapy is delivered mainly by non-psychiatrists (mostly psychotherapists) however there is a lack of communication between the psychotherapist and medical doctor in 22% of patients taking both psychotherapy and medication.
4. Trends – between 1998 and 2007 – the use of psychotherapy decreased from 16% to 10% and combined treatment from 40% to 32%, while the use of medication actually increased from 44% to 57% – possibly reflecting a shift in away from psychotherapy and toward medication.
5. Cost – it is estimated that the same therapeutic effect can be achieved with €70 for psychotherapy compared with €100 with medication (Prozac) over a 24 month period.
6. What actually works – the efficacy of psychotherapy is best seen using practice based evidence – while the effects of medication are seen using evidence based practice. Psychotherapy therefore, cannot be reduced to a product resembling a drug.

Neuropsychotherapy

Having been involved in this research area since I earned a Ph.D. on the psychopharmacology of depression over 25 years ago I am convinced that far from there being a debate over which of the two treatments are best – psychotherapy and medication are in fact two sides of the same coin. The recent discovery that what we experience changes the shape of the brain – allowing discrete areas in the brain to grow or change – by adding a tiny fraction of the brain’s neural circuitry and eliminating old ones. As more findings from the neurosciences inform best practices in psychotherapy a new field of neuropsychotherapy will help develop better, more effective therapies to improve brain function and mental health.

What we already know

Nerve cells or neurons are notoriously bad at dividing. Rather than divide, a neuron survives by making up to 10,000 connections to neighbouring neurons – and this is the key to how we learn and recall as memories are created and strengthened.  This compromise works well most of the time however in depression and anxiety a gradual loss in the strength of previous healthy connections in the emotional centres of the brain  – often triggered by a loss – starts to take it toll resulting in a noticeable reduction in mood as we find it harder to remain positive. As the illness progresses a vicious cycle develops whereby maladaptive thoughts and behaviours such as persistent negative thinking, phobias and apathy take hold  – driven by a new set of this time ‘faulty’ connections.

Brain wiring – making healthy connections – is the key to recovery  

Studies in animals show that medication (e.g. an antidepressant drug) not only makes the previously healthy connections in the brain work better but it also triggers the brain to grow new nerve cells. Psychotherapy on the other hand helps to rewire the faulty connections as well as wiring-up new healthy connections from the newly generated neurons. If depression and anxiety resembled a broken down car then medication is the petrol that revives the engine while psychotherapy is the tweaking of any faulty electronic wiring – allowing the car to hum along without a hitch.

Psychotherapy and medication – vive la différence

I predict that in the future – treatments for depression and anxiety will not only involve psychotherapy and medication but will also include a combination of other therapies such as social support, self-help techniques, nutrition, sleep hygiene and exercise. Furthermore, these therapies may be prescribed alone and in combination at key stages to promote the growth of new neurons, strengthen healthy connections and rewire the faulty ones. This combined approach will treat the person as a whole, and will mark the beginning of the journey back to wellness and a normal life.