The paradigm is shifting with respect to how we think about depression and its treatment. Some of that shift can be attributed to new findings with respect to its epidemiology and genetics and the ...rest can be attributed to the incorporation of a new perspective derived from evolutionary theory. In brief, depression is far more prevalent than previously recognized with the bulk of additional cases involving individuals who do not go on to become recurrent. Nonpsychotic unipolar depression (but not bipolar mania which likely is a “true” disease) appears to be an adaptation that evolved to facilitate rumination in the service of resolving complex social problems in our ancestral past. Cognitive behavior therapy appears to structure that rumination so that patients at elevated risk for recurrence do not get “stuck” blaming themselves for their misfortunes, whereas antidepressant medications may suppress symptoms at the expense of prolonging the underlying episode such that patients remain at elevated risk for relapse whenever they try to discontinue. This means that patients not otherwise at risk for recurrence may be put on medications that they do not need and kept on them indefinitely whether they need to be or not.
•Depression is neither disease nor disorder rather an adaptation that evolved to serve a purpose.•Depression is so much more prevalent than currently recognized that it is “species typical”.•Antidepressants may suppress symptoms in a manner that increases risk for subsequent relapse.•Cognitive therapy works by making rumination more efficient and “unsticking” self-blame.•Adding antidepressants may interfere with any enduring effect that cognitive therapy may have.
Patients treated to remission with cognitive therapy are less than half as likely to relapse following treatment termination as patients treated to remission with antidepressant medications. What ...remains unclear is whether cognitive therapy truly is enduring or antidepressant medications iatrogenic in terms of prolonging the life of the underlying episode. Depression is an inherently temporal phenomenon and most episodes will remit spontaneously even in the absence of treatment. There is reason to believe that depression is an adaptation that evolved because it keeps organisms focused on (ruminating about) complex social issues until they can be resolved and that medications work not so much by addressing a nonexistent deficit in neurotransmitters in the synapse as by perturbing underlying regulatory mechanisms to the point that they reassert homeostatic control over those systems. If the latter is true then medications may work to suppress symptoms in a manner that leaves the underlying episode unaddressed and patients at elevated risk of relapse whenever they are taken away. Cognitive therapy is predicated on the notion that people become depressed because they misinterpret life events in a negative fashion and that helping them examine the accuracy of their beliefs will relieve their distress. Such an approach would not work if patients were not capable of thinking clearly (if their "brains were broken") and it is likely that cognitive therapy works by making rumination more efficient so as to facilitate the resolution of the complex social issue(s) that brought the episode about.
Public Significance Statement
There is reason to think that depression may be an adaptation (like pain or anxiety) that evolved in our ancestral past to help resolve complex social problems. If true then interventions like cognitive therapy that facilitate the functions that depression evolved to serve may be preferred over antidepressant medications that merely anesthetize the distress.
Cognitive behavioral therapy (CBT) is efficacious in the acute treatment of depression and may provide a viable alternative to antidepressant medication (ADM) for even more severely depressed ...unipolar patients when implemented in a competent fashion. CBT also may be of use as an adjunct to medication treatment of bipolar patients, although there have been few studies and they are not wholly consistent. CBT does seem to have an enduring effect that protects against subsequent relapse and recurrence following the end of active treatment, which is not the case for medications. Single studies that require replication suggest that patients who are married or unemployed or who have more antecedent life events may do better in CBT than in ADM, as might patients who are free from comorbid Axis II disorders, whereas patients with comorbid Axis II disorders seem to do better in ADM than in CBT. There also are indications that CBT may work through processes specified by theory to produce change in cognition that in turn mediate subsequent change in depression and freedom from relapse following treatment termination, although evidence in that regard is not yet conclusive.
Abstract Background Standardised effect sizes have been criticized because they are difficult to interpret and offer little clinical information. This meta-analyses examine the extent of actual ...improvement, the absolute numbers of patients no longer meeting criteria for major depression, and absolute rates of response and remission. Methods We conducted a meta-analysis of 92 studies with 181 conditions (134 psychotherapy and 47 control conditions) with 6937 patients meeting criteria for major depressive disorder. Within these conditions, we calculated the absolute number of patients no longer meeting criteria for major depression, rates of response and remission, and the absolute reduction on the BDI, BDI-II, and HAM-D. Results After treatment, 62% of patients no longer met criteria for MDD in the psychotherapy conditions. However, 43% of participants in the control conditions and 48% of people in the care-as-usual conditions no longer met criteria for MDD, suggesting that the additional value of psychotherapy compared to care-as-usual would be 14%. For response and remission, comparable results were found, with less than half of the patients meeting criteria for response and remission after psychotherapy. Additionally, a considerable proportion of response and remission was also found in control conditions. In the psychotherapy conditions, scores on the BDI were reduced by 13.42 points, 15.12 points on the BDI-II, and 10.28 points on the HAM-D. In the control conditions, these reductions were 4.56, 4.68, and 5.29. Discussion Psychotherapy contributes to improvement in depressed patients, but improvement in control conditions is also considerable.
Major depressive disorder (MDD) is highly disabling and typically runs a recurrent course. Knowledge about prevention of relapse and recurrence is crucial to the long-term welfare of people who ...suffer from this disorder. This article provides an overview of the current evidence for the prevention of relapse and recurrence using psychological interventions. We first describe a conceptual framework to preventive interventions based on: acute treatment; continuation treatment, or; prevention strategies for patients in remission. In brief, cognitive-behavioral interventions, delivered during the acute phase, appear to have an enduring effect that protects patients against relapse and perhaps others from recurrence following treatment termination. Similarly, continuation treatment with either cognitive therapy or perhaps interpersonal psychotherapy appears to reduce risk for relapse and maintenance treatment appears to reduce risk for recurrence. Preventive relapse strategies like preventive cognitive therapy or mindfulness based cognitive therapy (MBCT) applied to patients in remission protects against subsequent relapse and perhaps recurrence. There is some preliminary evidence of specific mediation via changing the content or the process of cognition. Continuation CT and preventive interventions started after remission (CBT, MBCT) seem to have the largest differential effects for individuals that need them the most. Those who have the greatest risk for relapse and recurrence including patients with unstable remission, more previous episodes, potentially childhood trauma, early age of onset. These prescriptive indications, if confirmed in future research, may point the way to personalizing prevention strategies. Doing so, may maximize the efficiency with which they are applied and have the potential to target the mechanisms that appear to underlie these effects. This may help make this prevention strategies more efficacious.
•CBT delivered during the acute phase, does appear to have an enduring effect.•Continuation psychological treatment appears to reduce risk for relapse.•Preventive interventions have the largest effects for ultra high-risk individuals.
The efficacy of antidepressant medication has been shown empirically to be overestimated due to publication bias, but this has only been inferred statistically with regard to psychological treatment ...for depression. We assessed directly the extent of study publication bias in trials examining the efficacy of psychological treatment for depression.
We identified US National Institutes of Health grants awarded to fund randomized clinical trials comparing psychological treatment to control conditions or other treatments in patients diagnosed with major depressive disorder for the period 1972-2008, and we determined whether those grants led to publications. For studies that were not published, data were requested from investigators and included in the meta-analyses. Thirteen (23.6%) of the 55 funded grants that began trials did not result in publications, and two others never started. Among comparisons to control conditions, adding unpublished studies (Hedges' g = 0.20; CI95% -0.11~0.51; k = 6) to published studies (g = 0.52; 0.37~0.68; k = 20) reduced the psychotherapy effect size point estimate (g = 0.39; 0.08~0.70) by 25%. Moreover, these findings may overestimate the "true" effect of psychological treatment for depression as outcome reporting bias could not be examined quantitatively.
The efficacy of psychological interventions for depression has been overestimated in the published literature, just as it has been for pharmacotherapy. Both are efficacious but not to the extent that the published literature would suggest. Funding agencies and journals should archive both original protocols and raw data from treatment trials to allow the detection and correction of outcome reporting bias. Clinicians, guidelines developers, and decision makers should be aware that the published literature overestimates the effects of the predominant treatments for depression.
Depression is one of the most prevalent and debilitating of the psychiatric disorders. Studies have shown that cognitive therapy is as efficacious as antidepressant medication at treating depression, ...and it seems to reduce the risk of relapse even after its discontinuation. Cognitive therapy and antidepressant medication probably engage some similar neural mechanisms, as well as mechanisms that are distinctive to each. A precise specification of these mechanisms might one day be used to guide treatment selection and improve outcomes.
Patients can be harmed by treatment or by the decisions that are made about those treatments. Although dramatic examples of harmful effects of psychotherapy have been reported, the full scope of the ...problem remains unclear. The field currently lacks consensus about how to detect harm and what to do about it when it occurs. In this article, we define the ways in which treatment (or the inferences about treatment) can do harm and discuss factors that complicate efforts to detect harm. We also recommend methods to detect and understand harm when it occurs, drawing from and modifying many of the same strategies that are used to detect benefit. Specifically, we highlight the value of establishing independent systems for monitoring untoward events in clinical practice, reporting descriptive case studies and qualitative research, and making use of information from randomized clinical trials, including examining potential active ingredients, mechanisms, moderators, and a broad range of outcomes measured over time. We also highlight the value of promoting discussion in the field about standards for defining and identifying harm.
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