Head to head: therapy, medication, or both

Transcript

SoheeA client sits down for her second session and asks the question so many clients ask. Should I be taking a pill for this? Or is talking enough? Or do I need both?

RyanIt's a fair question. And on this exam, it's a dangerous one, because it's very tempting to answer from habit instead of from evidence. Welcome to EPPP Prep, the podcast. I'm Ryan.

SoheeI'm Sohee. Last episode we learned how to read treatment research. Today we use it. Head-to-head comparisons. And our rule for the whole episode: say exactly what the source found, with its qualifiers, and don't rank beyond it.

RyanLet's start with a large meta-analysis of direct comparisons between therapy and antidepressants. Pim Cuijpers and colleagues, World Psychiatry, 2013. Sixty-seven randomized trials with 5,993 patients, comparing psychotherapy and antidepressant medication head to head for depressive and anxiety disorders.

SoheeThe overall difference after treatment was g equals 0.02. Essentially zero, and not statistically significant.

RyanSo across these disorders, overall, neither won. But they looked deeper, and a few differences appeared.

SoheePsychotherapy was significantly more efficacious than medication for obsessive-compulsive disorder, g equals 0.64. Medication was significantly more efficacious for dysthymia, g equals 0.30.

RyanWith a qualifier you must keep. When they controlled for other study characteristics in a multivariate analysis, the dysthymia difference was no longer statistically significant. The others held.

SoheeAnd two more. Medication was significantly more efficacious than non-directive counseling, g equals 0.33. And psychotherapy was significantly more efficacious than tricyclic antidepressants, g equals 0.21.

RyanSo the exam-ready version. Overall, about equal. Obsessive-compulsive disorder favored psychotherapy in this meta-analysis. The dysthymia advantage for medication didn't survive adjustment. Non-directive counseling trailed medication. Tricyclics trailed psychotherapy. And keep the authors' own limits attached: these were effects at the end of treatment, not the longer term, and they say the quality of many included studies was not optimal.

SoheeThe OpenStax psychology textbook mentions an older single comparison too, by DeRubeis and colleagues. CBT had a 43 percent success rate for depression, medication 50 percent, and placebo 25 percent. The textbook describes CBT as being as effective as medication there.

RyanNow, combined treatment. Same research group, 2014. Fifty-two studies, 3,623 patients, comparing medication alone with medication plus psychotherapy, for depressive and anxiety disorders.

SoheeThe difference was g equals 0.43, favoring combined treatment. They call it a moderately large effect, with a number needed to treat of 4.20.

RyanAnd they describe it as a clinically meaningful difference in favor of combined treatment.

SoheeThey found sufficient evidence that combined treatment is superior for major depression, panic disorder, and obsessive-compulsive disorder. The effects remained strong and significant up to two years after treatment.

RyanAnd a striking interpretation: the effects of medication and psychotherapy seem largely independent of each other, with both contributing about equally to the combined effect.

SoheeTheir conclusion is careful but pointed. Monotherapy with psychotropic medication may not constitute optimal care for common mental disorders.

RyanWhy did they bother asking? Their introduction notes that an increasing proportion of patients with mental disorders had received psychotropic medication without psychotherapy over the previous decade. So the question had real stakes.

SoheeAnd one more comparison from that paper. Against placebo, the effects of combined treatment were about twice as large as the effects of medication alone. They also flag limitations: these comparisons can't be blinded, which may have introduced bias, and some disorders had only a small number of studies.

RyanThe OpenStax text echoes this. Research suggests psychotropic medications are most effective when combined with psychotherapy, especially for the most common disorders like depressive and anxiety disorders.

SoheePause and think. A client with panic disorder has been on medication alone for six months with partial improvement. Based on the 2014 meta-analysis, what's the evidence-based suggestion?

RyanAdding psychotherapy. Panic disorder was one of the three conditions where combined treatment was shown superior to medication alone. The tempting wrong answer is switching to a different medication class as the only change. That may be reasonable medically, but it isn't what this evidence speaks to.

SoheeNow CBT versus everything, for depression. Cuijpers and colleagues again, 2023. 409 trials, 52,702 patients. They call it the largest meta-analysis ever of a specific type of psychotherapy for a mental disorder.

RyanAgainst control conditions like usual care and waitlist, CBT had moderate to large effects, g equals 0.79, still significant at six to twelve months follow-up.

SoheeAgainst other psychotherapies, CBT was significantly more effective, but the difference was small, g equals 0.06. And it became non-significant in most sensitivity analyses.

RyanSo their own summary: the superiority of CBT over other psychotherapies for depression does not emerge clearly from this meta-analysis.

SoheeAgainst medication: no significant difference in the short term. At six to twelve months, CBT's effects were significantly larger, g equals 0.34. But they note the number of trials was small, and that difference was not significant in all sensitivity analyses.

RyanAnd combined treatment was more effective than medication alone, short term and long term. But it was not more effective than CBT alone at either time point.

SoheeInteresting. So in this depression meta-analysis, adding medication to CBT didn't beat CBT alone, while adding therapy to medication did beat medication alone.

RyanOne more detail. CBT was also effective as unguided self-help, g equals 0.45, in institutional settings, and in children and adolescents, g equals 0.41.

SoheeThe OpenStax text cites an older large-scale review, by Butler and colleagues, that examined sixteen meta-analyses. It reported that CBT was equally effective or more effective than other therapies for post-traumatic stress disorder, generalized anxiety disorder, depression, and social phobia.

RyanNotice the phrase: equally effective or more effective. Not flatly more effective. That wording leaves room for the small differences the 2023 analysis found.

SoheePause and think. An answer choice says: research shows CBT is clearly superior to all other psychotherapies for depression. True to the 2023 meta-analysis?

RyanNo. The difference was small, g equals 0.06, and not robust in sensitivity analyses. The authors say superiority does not emerge clearly. A choice saying CBT has a large evidence base and robust effects against control conditions would be accurate. Superiority is the overreach.

SoheeBefore we leave medication, one plain fact from the textbook worth keeping. Medications can help people feel better so they can function day to day, but they do not cure the disorder. Some people need them briefly, others with severe disorders for a long time.

RyanAnd the National Institute of Mental Health, NIMH, frames the menu for depression plainly: treatment typically involves psychotherapy, in person or virtual, medication, or both.

SoheeLet's do biological treatments that aren't medication, because the textbook and NIMH both cover them.

RyanElectroconvulsive therapy, ECT, uses an electrical current to induce seizures to relieve severe depression. The textbook says the exact mechanism is unknown, and it helps people with severe depression who haven't responded to drug therapy. It reports about 85 percent of people treated with ECT improve.

SoheeBut memory loss with repeated treatments has led to it being used as a last resort. And a newer alternative, transcranial magnetic stimulation, was approved by the Food and Drug Administration in 2008. It uses magnetic fields to stimulate nerve cells and is used when other treatments haven't worked.

RyanNIMH says brain stimulation therapy generally is used only after psychotherapy and medication have been tried. Sometimes earlier, when severe depression has become life-threatening, such as when a person has stopped eating or drinking or is at high suicide risk.

SoheeAnd NIMH defines treatment-resistant depression as not getting better after trying at least two antidepressants.

RyanLast comparison, substance use. The textbook says group therapy is the most widespread modality in substance use treatment. But neither individual nor group therapy has been found to be more effective.

SoheeAnd SAMHSA, the Substance Abuse and Mental Health Services Administration, says research shows a combination of medication and therapy can successfully treat substance use disorders, which it calls a whole-patient approach.

RyanRecap. Psychotherapy versus antidepressants, direct comparisons: overall about equal, g of 0.02. Psychotherapy ahead for obsessive-compulsive disorder in that analysis. Medication ahead of non-directive counseling. Psychotherapy ahead of tricyclics.

SoheeCombined versus medication alone: combined wins, g of 0.43, with clear evidence for major depression, panic disorder, and obsessive-compulsive disorder, lasting up to two years.

RyanCBT for depression: strong against controls, only a small and fragile edge over other therapies, comparable to medication short term, possibly better longer term with fewer trials.

SoheeECT and TMS are for depression that hasn't responded, with ECT's memory effects making it a last resort. And in substance use, individual and group haven't been shown to differ.

RyanIf those numbers feel slippery, don't memorize every decimal. Remember the shapes: about equal overall, combined beats medication alone, and CBT's edge over other therapies is small. Shapes are easier to carry into the exam room.

SoheeYou're doing harder thinking than most people ever do about treatment evidence. Give yourself credit for that. Thanks for listening to EPPP Prep.

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