If you’ve ever been depressed and needed treatment, you may have faced a dilemma: Should I take medication or try psychotherapy?

It’s hard to know what the best treatment is without first understanding something about the nature of depression. One of the most widely believed stories about depression is that it’s caused by a “chemical imbalance.”

The basics of the theory state that low levels of neurotransmitters like serotonin and norepinephrine cause depression. If this explanation were true, it would make sense that a biological treatment is best.

Thus medications like the selective serotonin reuptake inhibitors (SSRIs;  e.g., fluoxetine [Prozac], sertraline [Zoloft])—were believed to be the best treatments for depression.

Cognitive behavioral therapy (CBT) and other talk therapies were thought to be possibly useful additions to medication, but weren’t considered serious treatments on their own (except for less serious forms of depression).

I was shocked to discover in graduate school that there was no good evidence for the chemical imbalance theory. It simply was not supported by scientific research.

Unfortunately this account of depression was sold so well that it’s still widely assumed to be true.

Is Medication the Most Effective Depression Treatment?

If depression isn’t caused by low levels of serotonin, what does that say about the best way to treat it? Can major depression can only be helped by medication, or can talk therapy actually help?

The most tested psychological treatment for depression is cognitive behavioral therapy (CBT), and many studies have compared its efficacy to that of drugs. A meta-analysis of 20 such studies showed that medication and CBT work equally well in relieving depression.

For example, a large study found that 16 weeks of CBT or medication (an SSRI) led to equivalent improvement for those with moderate to severe depression, with 58% in each group getting significantly better. Both groups beat placebo (this trial was completed by one of my advisors when I was at Penn).

Thus the story about CBT not being a “real” treatment for depression also turned out to be false.

While these findings give us multiple options for treating depression, they also pose a new question: How can we choose between therapy or medication—or their combination—as the best option? The following questions can guide selection of treatment:

1. How Severe Is the Depression?

I often hear that “the best treatment for depression is a combination of medication and therapy.” But is that always true? The benefits of combined treatment would need to outweigh the significant costs of doing two treatments at the same time, including additional time and money and potential side effects.

For those with moderate to severe depression, getting both CBT and a medication leads to better outcomes than with medication alone or CBT alone—especially when the depression is chronic.

When a person is mildly depressed or hasn’t been depressed for long, CBT is equally effective with or without medication. These findings are reflected in the treatment guidelines of the American Psychiatric Association.

Good treatment is not cheap, and the cost varies greatly depending on several factors:

• Insurance coverage. Many mental health professionals practice outside of insurance networks, so the out-of-pocket cost for either treatment can be considerable, even prohibitive (often $120-200 for a CBT session and $100-180 for brief psychiatry check-ups). Insurance coverage is more likely when the medication is prescribed by one’s primary care doctor, but s/he probably has less expertise than a psychiatrist in treating depression.
• Length of treatment. A longer course of treatment obviously leads to higher costs.
• Type of psychotherapy. In my experience, CBT therapists tend to be out-of-network providers more often than do other kinds of therapists, and in-network providers often don’t provide CBT. Thus the cost to the patient for CBT tends to be higher.
• Type of medication. The majority of drugs used to treat depression are available in generic form, making them much more affordable than brand name drugs. Insurance coverage can also vary depending on the medication.

Psychotherapy tends to be cheaper than medication in the long run because of the lasting effects. One analysis found the cost of CBT to be double that of meds for the first 16 weeks of treatment, but that the need for ongoing medication led to higher costs in the months that follow.

3. How Long Will Treatment Last?

Most of us would like to get what we need from treatment and get on with our lives as quickly as possible. Treatment length with medication can vary a lot. The APA guidelines recommend staying on medication indefinitely for individuals with more chronic or recurring depression, or with other risk factors for relapse.

Otherwise the guideline is that those who respond well to medication should continue to take it for an additional 4-9 months to reduce the risk of relapse. Thus a typical short-term treatment with medication may last 6-12 months.

The prescribing doctor should closely monitor medication discontinuation, and it should be done gradually to minimize the risk of withdrawal effects (e.g., fatigue, nausea, dizziness, headache, insomnia).

A typical course of CBT includes about 12-16 weekly sessions of 45-60 minutes. Treatment includes building more enjoyable and rewarding activities into one’s days, and changing thought patterns that contribute to depression.

Treatment often continues with additional sessions spaced further apart (e.g., every 2-4 weeks), while individuals keeps practicing the skills on their own. Thus the full round of treatment may last 3-6 months, and longer in some cases. The APA recommends that those with a long history of depression continue to receive therapy on an ongoing basis, often with a reduction in session frequency.

4. What Are the Side Effects?

Some of the most common side effects associated with the SSRIs–Prozac, Zoloft, Paxil, etc.—are nausea, weight gain, agitation, insomnia, loss of sex drive, and difficulty reaching orgasm. Older drugs like the monoamine oxidase inhibitors (MAO-Is) and tricyclics generally have more severe side effects.

Some people choose to tolerate medication side effects because they find the benefits outweigh the costs, while others forego medication because of the side effects.

People often promote therapy as having “no side effects,” but this is not exactly true. Effective therapy is hard work, and often triggers difficult emotions like anger and sadness on the road to feeling better. It might involve confronting painful parts of our past, or aspects of ourselves we’d rather not see.

As with medication, a person might decide to avoid the potential downsides of talk therapy and choose a treatment like medication instead.

5. How Long Will the Benefits of Treatment Last? 

Depression treatment is a big investment, and we’d like the benefits to be long-lasting.

In general, the benefits of CBT continue long after treatment has ended—not surprising given CBT’s emphasis on acquiring skills that can continue to be used beyond treatment. The goal is to become one’s own therapist.

For example, one large study followed patients who received CBT and had recovered from depression; 69% were still depression-free one year later. Only 24% of patient in the same study who had recovered with an SSRI maintained recovery after the medication was discontinued.

In fact, 47% of those who stayed on medication relapsed in the same time period. So in this study, having had CBT in the past was at least as effective as ongoing medication at keeping people well.

This finding is typical of similar studies; based on a review, patients who had received medication for depression were 56% more likely to relapse over the next 15 months after treatment ended, versus those who got CBT. Thus there appears to be a greater risk associated with stopping medication than with stopping CBT (which is why the APA recommends staying on medication even after the depression has lifted).

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If you’re struggling with depression and haven’t been able to kick it on your own, why not explore your treatment options today? The right treatment can help you reclaim your life. Start by talking with a loved one who can think it through with you and assist you in getting the help you need.

Find a CBT therapist through the Association for Behavioral and Cognitive Therapies’ search tool.