Updated February 17, 2022

Untreated depression can affect all facets of life. It can ruin relationships at work and home, disrupt sleep, increase the chance of risky behaviours such as drug or alcohol addiction, and make it difficult to overcome physical illnesses. Appropriate treatment, however, can help most people with depression. Most people do best with depression treatment using psychotherapy, medications, or a combination of both. So what should be tried first? New research shows that medication makes therapy more effective.

Depression treatment options

Talk therapy (psychotherapy) involves a person speaking with a trained therapist who can help them understand certain feelings and behaviours. It can help people deal with these issues by teaching coping skills or by working to eliminate them.

For example, cognitive behaviour therapy (CBT) focuses on developing practical strategies and skills to cope with problems that come up in day-to-day life. In some cases, psychotherapy can be as effective as antidepressants. However, for many, psychotherapy alone may not be enough to ease the symptoms of a mental health condition. Antidepressants are often considered an alternative to psychotherapy in managing common mental illnesses. Medication treatments are often more accessible and equally effective.

However, different kinds of mental health problems will respond differently to various treatments. Therefore, choosing the right treatment can be complicated. Here are some things to consider.

Personalizing your treatment: is therapy or medication better for depression?

Medications, psychotherapy and their combination have been shown to help people with emotional or behavioural problems. Your choice of treatment should be based on your doctor’s advice, the best available scientific evidence, as well as your own willingness to stick with it.

Antidepressants and psychotherapy have similar effectiveness and are complementary. For people with moderate depression, the combination of psychotherapy and pharmacotherapy seems to be the best choice. Studies have shown that a combination of antidepressants and psychotherapy increases the response by 25% compared with medication therapy or talk therapy on their own.

What should I try first?

The meta-analyses of talk and medication therapies show that starting psychotherapy after achieving medication response provides the best results. If you have unmanaged depression, it’s best to start on antidepressants as soon as possible. Starting talk therapy after you have already gotten some symptom relief from an antidepressant will maximize your chances of fully recovering and reducing the risk of relapse.

New depression treatment protocol proposed by expert psychiatrists Perlis RH & Fava M JAMA Psychiatry 2022  recommends starting with escitalopram or citalopram as the first line of therapy along with app-based CBT (Level 1). They also suggest pharmacogenetic testing in order to make informed decisions on drug therapy options if the Level 1 therapy does not work.

How to find an optimal medication for me?

Over 65% of patients try more than one antidepressant before finding one that works for them. In addition, some people are reluctant to start antidepressants because of stigma and fear of side effects.

Response to antidepressants is significantly affected by genetic variations in drug metabolic enzymes. Therefore, it is important to gradually increase the dose of antidepressants over the first four weeks of therapy to reduce the risk of side effects. If your first medication trial did not work, it is wise to consider taking a DNA test to assess your drug metabolism.

Genetic analysis for drug response, also known as pharmacogenetics, can show how your body processes various medications and guides selecting appropriate antidepressants and the right dose. Knowing which medications may pose side effects due to inherently reduced drug metabolism can help you avoid trial and error and undesired side effects. Pharmacogenetics is now recognized as one of the key tools in mental health management and can help accelerate recovery from depression and anxiety.

Your doctor and pharmacist can help you monitor your drug response and assess the symptom severity. The Perlis RH & Fava M protocol suggests psychiatrist-guided CBT along with additional medications. The psychiatrist will re-evaluate your condition and evaluate alternative treatments, including anticonvulsants and antipsychotic drugs (Level 2) that are sometimes useful for people with more severe depression and other mental health conditions.

Psychotherapy reduces the risk of relapse

Once you feel that antidepressant therapy has started to work, you may find it helpful to try an online CBT therapy or seek a referral to a therapist to help you build a path towards full recovery.

There are many types of therapy which can be adapted to your needs and condition. The goal of psychotherapy is to develop coping mechanisms and build mental health resilience to help you live a productive life, ideally without antidepressants.

In addition, psychotherapy is essential to reduce the risk of relapse while gradually reducing the antidepressant dose. Stopping antidepressants too abruptly can lead to withdrawal symptoms that range from flu-like feelings, persistent itch or pain, seizures or even Parkinson’s-like conditions that can last for weeks.

Medication tapering takes time. Even a gradual reduction in antidepressants can increase anxiety and depression symptoms. Therapists will advise you when you can start tapering off your medications and support you through the recovery phase.

Summary

• Medication therapy and talk therapy are equally important for facilitating recovery from depression and anxiety. A combination of antidepressants and psychotherapy is more effective than either treatment option alone.
• Sequential application of psychotherapy after achieving response to antidepressants tends to provide the best results. Pharmacogenetic analysis, such as Pillcheck, a precision medicine approach, can help find the right medication and correct dose to accelerate recovery.
• Pharmacogenetic results can guide your primary care doctor and psychiatrist in selecting the treatment options that are safer and more effective for you and accelerate your recovery.
• Psychotherapy provides essential support, particularly during the medication tapering period.
• Referral to a psychiatrist is needed if your symptoms do not improve after trying multiple medications and psychotherapy.

References

Cuijpers, P., Noma, H., Karyotaki, E., Vinkers, C. H., Cipriani, A., & Furukawa, T. A. (2020). A network meta‐analysis of the effects of psychotherapies, pharmacotherapies and their combination in the treatment of adult depression. World Psychiatry, 19(1), 92-107.

Guidi J and Fava GA Sequential Combination of Pharmacotherapy and Psychotherapy in Major Depressive Disorder A Systematic Review and Meta-analysis JAMA Psychiatry. 2021 Mar 1;78(3):261-269.

Perlis & Fava Is It Time to Try Sequenced Treatment Alternatives to Relieve Depression (STAR*D) Again? JAMA Psychiatry. Published online February 9, 2022. doi:10.1001/jamapsychiatry.2021.4281

Milosavljević F et al., Association of CYP2C19 and CYP2D6 Poor and Intermediate Metabolizer Status With Antidepressant and Antipsychotic Exposure

A Systematic Review and Meta-analysis JAMA Psychiatry. 2021;78(3):270-280. doi:10.1001/jamapsychiatry.2020.3643

Eap CB et al., Tools for optimising pharmacotherapy in psychiatry (therapeutic drug monitoring, molecular brain imaging and pharmacogenetic tests): focus on antidepressants World J Biol Psychiatry. 2021 May 12;1-68. DOI: 10.1080/15622975.2021.1878427.

Senese NB and Rasenick MM Antidepressants produce persistent Gαs associated signaling changes in lipid rafts following drug withdrawal Mol Pharmacol 2021 May 19. MOLPHARM-AR-2020-000226.