What Works Best to Treat Depression?
"Talk therapy" for depression may cost more than medication initially, but in the long run, both may have a similar payoff, a new study finds.
The study estimated the cost-effectiveness of the two treatments. It found that over one year, antidepressants offered more value for the money. But when the researchers looked at the five-year picture, talk therapy seemed to provide more benefit for the cost.
Experts said the point is not to declare a "winner" in the realm of depression treatment.
Instead, the findings support guidelines saying that antidepressants and cognitive behavioral therapy (CBT) are both "reasonable" choices as an initial therapy, said study leader Dr. Eric Ross.
What's important for patients is that they know there is more than one effective option, according to Ross, a psychiatrist with McLean Hospital in Belmont, Mass., and Massachusetts General Hospital, in Boston.
Dr. Mark Sinyor, a psychiatrist at Sunnybrook Health Sciences Centre, in Toronto, agreed that there is no one-size-fits-all.
A patient's personal preferences are a critical piece, said Sinyor, who wrote an editorial published with the findings Oct. 28 in the Annals of Internal Medicine.
"If someone doesn't want CBT," he said, "it's unlikely to help, since you have to engage with it."
There's also the matter of depression severity: CBT and antidepressants are, on average, equally effective for milder to moderate depression, Sinyor explained, but people with severe symptoms typically need medication.
"Depression can make you feel hopeless," he said. "But we do have effective treatments, and if one doesn't help you, we can try another."
CBT is not the only form of psychotherapy for depression, but it is well-studied and recommended in guidelines. It involves individual or group sessions with a therapist. Simply put, the goal is to identify and reshape the negative thought patterns that may be driving depression symptoms, and develop healthier ways of coping.
Up front, CBT costs a lot more than medications, which are often available as a generic. A single session costs upwards of $100, versus $100 a year for many antidepressants, Ross and his team pointed out.
But people usually have a limited number of CBT sessions, and over time, the cost-effectiveness shifts, the new analysis suggests. In the first year, medication generally provided a greater "net monetary benefit" -- a measure that considers how much money has to be spent to gain a year of life in good health, the researchers noted.
But at year five, CBT generally offered a greater benefit for the money. The researchers projected that at that point, health care costs could be up to $1,800 lower for every patient treated with CBT; the finding was not significant in statistical terms, however, which indicates some uncertainty, the study authors said.
A caveat is that the projections are based on statistical modeling. The researchers used data from past studies and real-world cost figures to make estimates on cost-effectiveness. They had to make certain assumptions -- that CBT, for instance, would involve four individual sessions and eight group sessions over three months, and then individual sessions once a month.
Using study data, they projected that about 40% of first-time antidepressant patients would see their symptoms go away, and about 63% would show an improvement. Those success rates would be similar among CBT patients, but at a greater initial cost.
However, when the researchers weighed other evidence -- patients on medication being more likely to relapse, for example -- antidepressants were not more cost-effective in the long run.
According to Ross, research has found that most people with depression would prefer to try talk therapy first. Yet less than one-quarter of U.S. patients get it.
There can be big obstacles, Ross said. People may live far from a CBT provider, or be unable to manage the time commitment.
So the mental health system may need to get creative. Sinyor pointed to one potential solution: training non-psychologists, such as social workers, to deliver CBT.
Technology could also help, he and Ross said, by, for instance, allowing patients in rural areas to receive CBT by video chat. However, Sinyor added, while that might work for some people, there will always be those who need face-to-face counseling.
There's more on depression at the U.S. National Institute of Mental Health.
SOURCES: Eric L. Ross, M.D., psychiatrist, McLean Hospital, Massachusetts General Hospital, Boston; Mark Sinyor, M.D., M.Sc., associate scientist and staff psychiatrist, Sunnybrook Health Sciences Centre, and assistant professor, psychiatry, University of Toronto, Toronto, Ontario, Canada; Oct. 28, 2019, Annals of Internal Medicine, online
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