The People's Perspective on Medicine

Is Therapy Better Than Drugs for Depression?

Why has the American health care system given up on psychotherapy and embraced drugs for depression? A new study says CBT could save money in the long run.
Mature man suffering from depression lies sadly covered with a blanket on his bed and holds a bottle of antidepressants in his hand

Americans are depressed. According to our calculations, roughly 40 million people are taking antidepressant medications. The CDC concludes that’s 12.7% of people over 12 years of age (NCHS Data Brief No. 283, Aug. 2017). Every year, they fill more than 200 million prescriptions for drugs for depression like sertraline, trazodone, citalopram, escitalopram, bupropion, fluoxetine, duloxetine, paroxetine and venlafaxine. If you multiply 200 million times 30 pills in a bottle, that equals 6 billion pills annually. Could cognitive behavioral therapy (CBT) be as good as or better than drugs for depression?

Why Do Doctors and Insurance Companies Like Drugs for Depression?

For decades, antidepressants have been the standard of care for people with depression. Insurance companies are usually comfortable paying for such drugs, especially when generic versions of Prozac, Paxil, Zoloft, Effexor, Cymbalta, Celexa and Lexapro are available at relatively low cost. Instead of paying $140 to $290 for a 45 minute CBT counseling session, a month’s supply of fluoxetine or sertraline is only $4 to $8.

Primary care providers also like antidepressants. Most are not trained in psychotherapy. And they do not have time to spend 45 minutes talking with depressed patients. Writing a prescription for bupropion or citalopram takes a few minutes at most.

CBT (Cognitive Behavioral Therapy) vs. Drugs for Depression:

Because antidepressant medications seem like a simple solution for people who are severely depressed, psychotherapy has become a bit of a dinosaur. As a result, medications have largely displaced older approaches such as talk therapy.

However, a new analysis published in the Annals of Internal Medicine (Oct. 29, 2019) shows that cognitive behavior therapy (CBT), while more expensive to start with, actually saves money after five years. The authors note that medications and cognitive behavioral therapy are about equal in effectiveness.

The authors of this study state that:

“…for payers and policymakers, our results highlight the potential for long-term cost savings with CBT. Although not statistically significant, our base-case analysis projected an $1800 lower health care sector cost per patient treated with CBT at 5 years.”

They conclude their research analysis with this:

“In the absence of clear superiority of either treatment, shared decision making incorporating patient preferences is critical. Given many patients’ preference for psychotherapy over pharmacotherapy, efforts to improve patients’ access to CBT are warranted.”

In other words, payers, policy makers and clinicians should consider the patients’ values and preferences in determining the best therapeutic approach for major depression.

One More Thing About Drugs for Depression:

This new comparison of cognitive behavioral therapy vs. drugs for depression did not take into account antidepressant pros and cons. These drugs do not work for everyone. In fact, some studies suggest that they are barely better than placebo.

A government-sponsored trial called STAR*D (Sequenced Treatment Alternatives to Relieve Depression) was one of the best funded ($35 million) and most carefully conducted trials of drugs for depression. The results were discouraging. Only about one out of four depressed patients actually recovered after taking the first medication prescribed (New England Journal of Medicine, March 23, 2006). 

Other analyses conclude that drugs for depression work about 50% of the time, whereas placebos are effective on average between 31 to 45% of the time (Walsh et al, JAMA, April 10, 2002Stolk et al, Annals of Pharmacotherapy, Dec. 2003). Not a huge difference, eh?

Antidepressants and Side Effects:

Drugs for depression are not without side effects. People may complain about nausea, abdominal pain, dry mouth, insomnia, anxiety, tremor, dizziness, sweating, headache, sexual dysfunction, skin reactions and even suicidal thoughts. Getting off antidepressants can also be challenging. Here is a link to an article on this topic.

Antidepressant Withdrawal Feels Like Circles of Hell

We recognize that some people do extremely well on drugs for depression. Here is an overview you may find of interest:

Balancing the Benefits and Risks of Antidepressants

People’s Pharmacy Perspective:

We think that people suffering from serious depression deserve choices. Many may opt for antidepressants like sertraline, escitalopram or fluoxetine. If these medications work without triggering unpleasant side effects, great.

Others might prefer CBT as an alternative. It is time for the American health care system to embrace psychotherapy as a viable option and be willing to pay for it. Sadly, we don’t have enough qualified therapists to offer CBT to everyone who would like it. That needs to change!

Share your thoughts about drugs for depression and cognitive behavioral therapy in the comment section below. Check out our guide to Dealing with Depression. You can also listen to our free interview on “Intriguing Approaches to Overcoming Depression.” Click on the green arrow under the photo of Dr. Elizabeth Ballard. 

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    About the Author
    Joe Graedon is a pharmacologist who has dedicated his career to making drug information understandable to consumers. His best-selling book, The People’s Pharmacy, was published in 1976 and led to a syndicated newspaper column, syndicated public radio show and web site. In 2006, Long Island University awarded him an honorary doctorate as “one of the country's leading drug experts for the consumer.” .
    Show 983: Intriguing Approaches to Overcoming Depression
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    Nondrug approaches could replace or complement drug treatments for depression; one medication could lift severe depression within hours instead of weeks.

    Show 983: Intriguing Approaches to Overcoming Depression
    Citations
    • Ross, E.L., et al, "The Cost-Effectiveness of Cognitive Behavioral Therapy Versus Second-Generation Antidepressants for Initial Treatment of Major Depressive Disorder in the United States: A Decision Analytic Model," Annals of Internal Medicine, Oct. 29, 2019, DOI: 10.7326/M18-1480
    • Stoik, P., et al, "Meta-analysis of placebo rates in major depressive disorder trials," Annals of Pharmacotherapy, Dec. 2003, DOI: 10.1345/aph.1D172
    • Kirsch, I., et al, "Initial severity and antidepressant benefits: a meta-analysis of data submitted to the Food and Drug Administration," PLoS Medicine, Feb. 2008, doi: 10.1371/journal.pmed.0050045
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    I was on the generic of Paxil for several years. I experienced leg pain. I decided that I needed to find a way to come o sff of the drugs. One thing I did was discover how to see my me story (read Eckhart Tolle). The other thing was to go plant based and cut out 98 percent of the animal products from my meals. I stopped Paroxitine in the spring, about 6 months ago. It got me through a rough time in my life but, I hope to never take it again. Looking back I can’t swear that actually helped that much. Eckhart Tolle and a plant based diet did far better for me.

    As a psychotherapist, I would like to point out that this is not necessarily an either/or situation, but possibly a both/and situation. Sometimes the most effective treatment is psychotropics plus psychotherapy. This can especially be true with the more serious forms of depression. The psychotropics may enable the client to regain sufficient functioning to be able to productively engage in the psychotherapeutic process.

    Psychotropics do not, it is true, work for everyone. But they can work very well for some, and should not be ruled out as an option under some blanket condemnation. Also, before one labels Freud a fraud, one might actually wish to read his works, and some informed commentaries on his works. CBT is not the only form of psychotherapy available; there are other forms, such as brief psychodynamic therapy, which can also be helpful to some clients.

    Check into Transcendental Meditation (TM). There are numerous scientific research studies that confirm the benefits.

    I have been told that one may not add CBT to one’s psychiatric meds and that replacing the meds with CBT will create more anxiety. Keen to know what others say about this!

    I was diagnosed with chronic depression with episodes of major depression starting in 1984. I took a variety of drugs with talk therapy until 2003. When I decided I wanted off drugs because of the side effects, my psychiatrist and therapist said I’d be fine on my own without support from them. I think they were sure I was going to fail and call them to get back into treatment in a week or two. It has not always been easy, but I feel so much better physically that I have been able to cope with my feelings on my own, relying mostly on meditation, exercise, and interaction with nature. I will never again take psychiatric drugs. My experience is that they might make me feel “better”, or more likely feel nothing, on a temporary basis but they do nothing to address the underling aspects of my life that lead to perfectly normal and valid feelings of despair. The side effects are not worth that “benefit”.

    Beginning in my 30s, various doctors tried anti-depressants on me. The results were uniformly disastrous — agitation and difficulty focusing both my eyes and my attention. Finally, when I was 50, I found a psychiatrist who diagnosed me with seasonal affective disorder (SAD) and prescribed a light box. It’s been life-changing.

    I discovered that I actually need to use the light daily all year (although for a shorter time in summer), but it’s a small inconvenience for a major benefit. My insurance coverage was through a federal employee program, and they refused to cover the initial purchase. I appealed, citing the definitive work done on this disorder by a scientist in the federal government. I also pointed out that the box was much cheaper than paying for years and years of psychiatric meds, and I won my appeal. They agreed to pay for the initial light box. But they also revised the benefits handbook the next year specifically to exclude light boxes, which seems very short-sighted to me.

    I would encourage anyone who has problems with depression, especially if it’s more serious in the winter months, to do some investigating on light boxes (to be effective, it should be 10,000 lux/lumens) and, if possible, find someone who can advise them on their use and perhaps write a prescription for one. I’ve used my light box for over 20 years and it’s been a huge help.

    I also found a counselor who used CBT and went to her for a number of years, but for me it was an adjunct to the light box.

    You hit the reason on the head right in the article. It’s less lucrative. As ALWAYS it is about the money. While there are surely many doctors who care about their patients, the medical machine that rules “health care” in the country does not.

    Drugs are a joke. I’m a PhD clinical psychologist with 40 years experience. I’ve seen literally thousands of patients over the years with depression. Some have been thru the gamut of antidepressants for decades. In reading the chart notes of some of these patients the psychiatrist or family doc says ‘Drug X is working great, no more depression’ and then a few months later BAM! they’re switched to a new drug. I wonder why?

    I also ask patients ‘Is this drug doing anything for you?’ If you ask a person with a bad infection like pneumonia ‘Did the antibiotic you took help?’ they can offer a definitive ‘Yes! I could breathe better within a day or two, my lungs were back to normal in a week, everything is great again.’ Know what I hear roughly 99% of the time from depressed patients on meds? “I don’t know, I can’t tell any difference.” Not a rousing endorsement.

    You should read some books by Goetzche (a Danish psychiatrist who used to work for the drug industry), Kirsch (a psychologist), Whittaker (an investigative journalist) and Healy (a psychiatrist). They offer blistering documentation about how atrocious the whole class of psych meds is, including antidepressants. I could go on and on. I’ve never liked the antidepressant class of drugs in all my years of practice. I used to recommend, begrudgingly, that patients talk to a psychiatrist if they wanted such drugs. Now I argue against them, and give a handout I’ve written on the subject. When they hear a brief summation from me as to why I’m so opposed to the poison they then nod and say ‘That’s what I’ve been thinking too’ as to wanting alternative approaches to dealing with depression. Check out http://www.nutritionfacts.org on the relationship between diet and depression. Look at the research on exercise and depression that dates back to the mid-’70s, or a more recent study done at Duke (SMILE was the name of it). Exercise trounced drugs for dealing with depression.

    Because its too expensive

    Therapists charge an arm and a leg for a consult and they keep people coming for more sessions.

    Taking a pill is cheaper
    Also medical insurance caps payments to therapists/psychiatrists, some of who have bizarre ideas-I mean mourning the death of a loved one for more than 2 weeks is classed as pathological in the DSM-V?

    Give me a break.
    Also the plight of some people in this country with the poverty, returning veterans etc is sad, but they don’t have these resources available. Many subsist on a diet of takeaway foods which is cheaper.

    And quite frankly, I would never see one of them if I needed to.
    I have a healthy distrust of “shrinks.”
    Freud was a fraud-and they all learn this Freudian rubbish.
    It is all down to chemical changes in the brain in the brain.
    Eating a healthy diet with fish oil and curcumin etc helps depression, as does exercise, hobbies etc

    I feel it would also be interesting to note how one’s faith can often have a positive affect on depression and anxiety; I have read several articles on this.
    I recall the late Archbishop Sheen commenting on psychiatry and faith and enjoy his YouTube videos.

    Of course, there is certainly a place for medication, especially in the more severe cases. I don’t think that can be ignored. And, sometimes it’s a must.

    I have taken a number of different antidepressants since the late 1990’s. First it was Prozac. I think it was the wonder drug of the time. Did it help? I wanted to think that it did. But in the next decade, starting 2000, I’ve tried paxil, celexa, lexapro, zoloft and probably others that I don’t recall.

    In the current decade, I’ve had and am still using Wellbutrin SL150, although technically not an antidepressant, or its generic, bupropion SL150 when my insurance stopped paying for Wellbutrin.

    One may ask why did I go through so many different brands? When one stopped working, if it worked at all, a different one was prescribed until it was my internist who introduced Wellbutrin. Wellbutrin might have worked for awhile. But now I can’t say that it really did, and here’s why. The summer of 2016, I sat in a dark room every day and cried uncontrollably. At one point, I called the behavioral hospital in my city because I recognized that I needed help.

    It was that summer that I searched for a therapist and started seeing my psychiatrist mainly because he was the only one in my area of that huge city. I didn’t find any relief but again I wanted to believe that it did help at the time. He introduced Brintellix which is now called Trintellix to take along with and boost the bupropion SL.

    Fast forward, 2019, I now live in a different city, have a new pcp, a very warm kind and gentle lady. Three months in with her, last week in fact, I told her I think I tapered off of the very expensive Trintellix. And during the visit, I crumbled and admitted to her, and myself, that bupropion isn’t really working either. I started to get emotional, the first doctor that I ever pour my heart out to. And asked if she thought therapy was a good idea? She was so kind. My visit time should have been over, but she talked with me gently, and I left armed a list of about five psychologist practices to start my search. Notice, she didn’t direct me to just one, so I search for one I might be comfortable with. Because I don’t want to take drugs any more.

    A few months ago, I was diagnosed with CKD and I’ve done a lot of medical reading about drugs and intravenous drugs etc. Oh, she warned me that most don’t take insurance. This is the first time ever that I feel I have a doctor who showed that she truly understands and wants what’s best for me and guide me gently to try therapy. I’m not in this all alone now and that’s a good feeling.

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