In the latest in our series dispelling common misconceptions in healthcare, Dr Peter Bagshaw discusses how psychological therapies can be just as effective as medication
Many patients will resist the suggestion of talking therapies for their depression, preferring the ‘quick fix’ of a prescription. However, the latest evidence is that talking therapies are at least as effective as antidepressants. We should take time to explain this to our patients, and dispel any misconceptions they may have.
Pros and cons of antidepressants
Many studies have confirmed that antidepressants are effective.1 The most frequently used group, selective serotonin reuptake inhibitors (SSRIs), are safer than the tricyclic antidepressants (TCAs) that used to be the mainstay of treatment. However, they are no more effective than TCAs, and share the same drawback of not offering any benefit for at least the first two weeks of taking them.
In addition, they seem to increase the suicide risk in vulnerable patients, while their association with withdrawal problems (in around one in six people who take them) and emotional blunting are now widely recognised.
Pros and cons of talking therapies
Talking therapies are as well evidenced as medication, with their effectiveness judged to be roughly equal to medication in severe depression, and superior in mild to moderate depression. Cognitive behavioural therapy (CBT) is the most widely studied. Both physical activity (particularly in nature) and mindfulness have also been shown to be effective.2
Talking therapies are available free through the NHS in all areas, though waiting lists can be long in some. Online CBT is an option which can reduce waiting times, and has been shown to be as effective as person to person therapy: inevitably, research is ongoing using AI chatbots with promising initial results.3
Talking therapies are also safer than antidepressants, without the potential drug side-effects or risk of withdrawal symptoms.
NICE, which has looked at the evidence for different treatments, ranks the treatment options as follows:
More severe depression
- Combination of individual CBT and an antidepressant
- Individual CBT
- Individual behavioural activation
- Antidepressant medication
Less severe depression (also known as mild to moderate depression)
- Group CBT
- Group behavioural activation
- Individual CBT
- Individual behavioural activation
- Self-help with support
- Group exercise
- Group mindfulness or meditation
As this shows, antidepressants do not even make it into the top seven recommended treatments for less severe depression. Although there are differing interpretations of the categories, the Patient Health Questionnaire (PHQ)-9 is the most widely used to score depression severity in primary care and NICE considers less severe (mild to moderate) depression as a PHQ-915 or below, and more severe or severe depression as a PHQ-9 score above 15.
Putting the evidence to our patients
As a recent study lamented: ‘Evidence across disciplines suggests that talk therapy is more curative than antidepressants for mild-to-moderate depression and anxiety. Yet, few patients use it.’4
When confronted by a patient reluctant to consider a form of talking therapy, despite it being the best option, we should begin by exploring their concerns. Some may have direct or indirect experience of older counselling therapies that explore previous traumatic events. We should reassure our patients that therapies such as CBT do not look back over past events, but seek to correct misunderstandings in how we interpret events: I find that explaining it as ‘physiotherapy for the brain’ can be helpful, as opposed to the ‘sticking plaster’ effect of medication.
In older people, the situation is even worse. Depression is the commonest mental health problem in older people, yet the proportion of people aged over 65 years referred to talking therapies is lower than the proportion in the general population. There is a misconception amongst many that it is of little benefit, yet older people achieve good outcomes, with more completing treatment and showing reliable recovery than their younger cohorts.5
In addition to exploring barriers to talking therapies, it is important to explain that medication is not a risk-free option. Potential side-effects, emotional blunting and the risk of withdrawal effects should all be explored, and the weight of evidence on the effectiveness of talking therapies should be discussed. Many patients, once the facts are explained, are willing to give talking therapies a try: they can of course be offered the option of antidepressants if this proves ineffective. In particular (using the physiotherapy versus sticking plaster metaphor) they will be taught skills to cope not just with the current episode of depression, but also future stressful events.
As NICE clearly states,2 ‘do not routinely offer antidepressants as a first line treatment unless that is the person’s preference,’ to which I would add that it should be an informed preference following your explanation of the pros and cons of the options.
References
- Cipriani A et al. Comparative efficacy and acceptability of 21 antidepressant drugs for the acute treatment of adults with major depressive disorder: A systematic review and network meta-analysis. Lancet 2018;391(10128):1357-1366
- Depression in adults: treatment and management. [NG222] 2022
- Sin J. An AI chatbot for talking therapy referrals. Nat Med 2024;30:350–351
- Cronin C et al. What good are treatment effects without treatment? Mental health and the reluctance to use talk therapy. The Review of Economic Studies. Published online: 30 May 2024
- NHS England. Mental health in older people: A practice primer. 2017
