Depression: Therapy vs. Medication?

This is a very interesting topic to me, because when I started psychiatry residency, I was convinced that I was going to be a therapist, not a pharmacologist. I quickly learned, though, that therapy requires a great deal of time, and motivated patients (not to be confused with patience, which you also need). Unfortunately insurance companies also don’t compensate for therapy the way they do for medication appointments, and so to be profitable, I would have to practice fee-for-service (cash only, with patients requesting partial reimbursement from their insurance). I also learned that I enjoyed the hospital setting more than an office-based setting, and would be bored sitting in an office all day.

So for me, it turns out, I was not going to be a therapist, but the residency I chose emphasized therapy training, which is unusual nowadays. The good thing is that I apply what I learned every day at work, even if I’m not doing formal “therapy” with patients. I get to approach patients from a broad point of view, and I know when to address underlying issues, versus just letting things be superficial (which is appropriate sometimes).

Now to answer the question of medication versus therapy for someone who is depressed, there’s some general rules of thumb. One is that each case is different, and generalities have exceptions of course. For the most part, therapy is equally efficacious to medications, and doing both at the same time is even better. That’s what the evidence shows. A lot of it comes down to severity–the more severe the depression, the more likely you are to start with medication. The less severe, the more likely you could start with therapy. Some people also have a personal preference–not wanting to to use pills, or not wanting to talk to someone (I used to think that most people would prefer not to use pills, but surprisingly some people really prefer a pill to a person). Medications have side effects which some people want to avoid, or they may not like the idea of being on a psychotropic medication. Cost may be another issue–it’s cheaper usually to go to see a doctor for medications than therapy. Time is also a factor, as good therapy is definitely a time commitment. Another thought to keep in mind when choosing a doctor is that psychologists practice therapy, whereas psychiatrists are MDs and can prescribe medication (and they may or may not also practice therapy due to the above issues I mentioned).

Personally I can’t say that one is better than the other, just that they each have their place including their benefits and drawbacks. At least when deciding, those are some of the issues to consider. As always, I would love to hear your thoughts.

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6 Comments on “Depression: Therapy vs. Medication?”

  1. Y Says:

    I really enjoyed this entry, definitely a good way to start looking at things, when considering treatment for yourself or a loved one. I think it’s also important to keep in mind that it’s not an “either/or” choice. Especially for moderate to severe depression a combination of both, medication and therapy, may be the optimum approach.

  2. Akire Says:

    As a patient (Bipolar Disorder with Psychotic Features), I have found that the combination works best – and by the same person, as well. I do not prefer pills, and only went on them when it was absolutely necessary for my safety (and came off of them when it wasn’t, with my psychiatrist’s encouragement/guidance. Despite what is most accepted, it is possible to maintain high functioning off of them, with the right support, even when the diagnosis is considered more severe. Not every patient; but some, as my case can show). If I had only taken medication, however, I would not have recovered to the extent I have. It is the relationship that gets people better, no matter the disorder or the severity. Even at times when my psychiatrist and I were not working on any specific goal or actively exploring something, those 45 minutes or so were vital. Unfortunately, had he not been the one providing the therapy, I would not have sought it out from another professional. I was already so ill, that managing and learning to trust two people (especially in light of my additional trauma history) would not have happened. More so, when I was disoriented, delusional, severely depressed and suicidal, I am not sure I would have made an emergency appointment with anyone had I been seeing two people, or had I only been seeing the psychiatrist for medication management. Too many questions and considerations that I wouldn’t had been able to sort at that moment (which do I call?, for example. I also don’t think I would have been able to build a strong enough trust in either situation – seeing two or only seeing one for < 15 – 20 minute visits). I trust my psychiatrist with my life and feel comfortable telling him anything, no matter how troubling, and that only happened because he was willing to provide both.

    That is outpatient, though. The goals of inpatient treatment are quite different, at least in today's system. In actuality, no therapy – from psychiatrist, social worker, psychologist – can be undertaken in that environment. Seven – ten days is enough time to stabilize most people to a point of safety, not to explore any underlying issues, or develop the strongest foundation of coping skills (though some are gained).

  3. Akire Says:

    Just as an added note on inpatient treatment. In many cases, I am doubtful effective pharmaceutical treatment can occur in that time span, either. You don’t truly see how well a drug works (especially in comparison to others), or what the reaction will be. At least in my experience, the treating professionals at the hospital were just trying to get the dosages up to a point where the patient could be safely discharged without harming him/herself, at which point the rest was handed to their outpatient psychiatrist (most of whom only do 15 – 20 minute medication checks, which, as stated, I do not find work well. Patients will only say so much if they know their time is limited). Medication is then changed again and, though the patient may not be at risk for killing themselves/others, they’re still not stable nor healthy. Many times, re hospitalization only occurs.

    And to all of this, I suppose all I can say is “damn insurance companies!” Medication management alone is not adequate. In most cases, having to see two professional is not adequate. Discharge from hospital based on the decision of someone who has never seen the patient to stop paying is not adequate, either.

  4. Dr. G Says:

    Thanks for the comments, especially from Akire–it’s always good to hear how patients are affected from the patients’ perspectives themselves.

  5. Shelly Says:

    I am of the belief that both are necessary although as stated by Akire, people’s disorders are on a spectrum and preferences need to be taken into consideration. I have bipolar II. I had been seeing a therapist for what we thought was Major Depressive Disorder. When I couldn’t get on top of mood swings, she referred my to my primary doc who prescribed a mood stabilizer. When it got to be uncomfortable for her to keep adjusting the med, she referred me to a psychiatrist. He does a bit of history/talking but mostly med checks. I now see him quarterly. My therapist is the one who has helped me the most with CBT, positive, strength’s based, and psychodynamic combination therapy. I am now stable for the most part and due to the recommendation of the psychiatric nurse that leads the bipolar support group that I attend, I will check in with my therapist quarterly. She is there should I need more intensive help. For me, it takes a team approach along with the personal utilization of lots of non-medical/professional modes of treatment like mindfulness, massage, chiropractic, relaxation techniques, eating right, exercising, yoga.

  6. Carole Says:

    I have bipolar and am under the care of both a psychiatrist and psychologist. I feel lucky to have a good relationship with both of them. They also communicate well, exchanging treatment notes regularly. Although I expect my psychologist to recall details about my life, I am always amazed by how much my psychiatrist recalls. I believe most people with mental illness function better having both professionals in their lives.

    As for inpatient treatment I greatly appreciate it when my hospital psychiatrist confers with my regular psychiatrist. I was recently hospitalized and the willingness of the hospital psychiatrist to work with my psychiatrist meant we could go ahead with my psychiatrist’s new treatment plan.


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