Cognitive therapy effective as drugs in long-term treatment of severe depression

By David F. Salisbury
July 3, 2002

A type of therapy that encourages severely depressed patients to challenge the judgments and misperceptions that underlie their condition can be as effective as medication over the long term.

That is the conclusion of a new study conducted by researchers at Vanderbilt University and the University of Pennsylvania comparing the relative effectiveness of cognitive therapy and medication for the long-term treatment of severe depression. The findings were discussed last month at the annual conference of the American Psychiatric Association in Philadelphia.

Cognitive therapy was developed at Penn in the 1960's. Cognitive therapists lead patients to explore harmful ideas — such as "I'm a bad person and don't deserve to have any fun" or "I'll never get that job, so I won't even apply" — and encourage them to test the misperceptions that shape their negative feelings.

"In this study, we looked at depression somewhat differently than prior studies," says Steven D. Hollon, professor of psychology at Vanderbilt, who co-directed the investigation with Robert J. DeRubeis, professor of psychology at Penn. "The question that has most often been asked in studies is, 'What gets people better faster?' We asked, 'What will keep depression away over the long term?'"

Compared to past research on more severely depressed patients - some depressed nearly enough to require hospitalization — Hollon and DeRubeis' study was unusually comprehensive in its size, 240 patients in Philadelphia and Nashville, and in its duration, 16 months.

The study involved a four-month period of acute treatment. Patients who responded to therapy then discontinued treatment, except for an occasional booster session. Those who responded to medications either continued to take meds or were withdrawn onto a placebo pill. The patients were then tracked for an additional year.

During the second phase of the study, 75 percent of patients who underwent cognitive therapy avoided a relapse, compared to 60 percent of patients who continued on medication and 19 percent of those withdrawn onto a placebo pill.

"Statistically, both cognitive therapy and medication were more effective than a placebo, and a brief course of cognitive therapy was better than a similarly brief course of medication in the yearlong continuation phase," DeRubeis says. "These results suggest that even after termination, a brief course of cognitive therapy may offer enduring protection comparable to that provided by ongoing medication."

Hollon, DeRubeis and colleagues also found that cognitive therapy enjoys a long-term cost benefit compared to drugs. During the 16 months, treatment with medication cost an average of $2,590, compared with $2,250 for cognitive therapy. This gap grows with time, since antidepressants must be administered continually to be effective.

"Some proponents of medication for severely depressed patients have suggested that cognitive therapy is impractical on the basis of cost," DeRubeis says. "Our study indicates that isn't true, especially over the long term.

"This will be a surprising, controversial finding for many psychiatric professionals," he continues. "Most believe quite strongly in the efficacy of medication, and psychiatric treatment guidelines call unequivocally for medication in cases of severe depression."

DeRubeis and Hollon's colleagues in the study include Richard C. Shelton, Ronald M. Solomon and Margaret L. Lovett of Vanderbilt's Department of Psychiatry along with Jay D. Amsterdam and John P. O'Reardon of the Department of Psychiatry in Penn's School of Medicine and Paula R. Young, formerly of Penn's Department of Psychiatry.

The study was funded by the National Institute of Mental Health and SmithKlineBeecham.

- VU