Cognitive Behavior Therapy (CBT)
This form of therapy is considered by many to be the gold standard in depression treatment. Here, the idea is that a person first becomes aware of one’s negative thought patterns, which are presumably the underlying cause of depression, and then learns to replace them with more positive ones over time. Theoretically this rewiring of our go-to thought patterns and self-talk is a good metaphor for what’s going on in the brain, which is simultaneously being “rewired” as the method is applied and practiced over time.
Studies have found that CBT is quite effective for treating depression, and its efficacy is at least that of antidepressants. Some more recent work has suggested that CBT has lost some of its effectiveness over the years—that is, it’s not as powerful now as it was when it was first studied in the 1970s. The authors of one such study suggest part of its original effectiveness may have been due in part to the placebo effect, which may have worn away over time, or to the misconception that CBT is a quick fix and easy to learn. Others have suggested that CBT is useful mainly as an active treatment, but its effects tend to fall off more rapidly in the years after treatment has stopped (more on this in the next section).
Certainly it can be an extremely useful form of therapy some people. “For individuals who struggle with the negative thinking and poor problem-solving that comes with depression, CBT is an excellent treatment,” says Deborah Serani, PsyD, who wrote the book Living with Depression. “It addresses how to reframe thoughts and feelings and profoundly reduces depressive symptoms. One way to think about CBT: changing your thoughts and feelings reduces depression.” An alternative, psychodynamic therapy, is discussed below.
Imaging studies have supported the fact that CBT does seem to do something to our brains. For one, it’s been shown to decrease activity in the medial prefrontal cortex (mPFC), which is thought of the “me-center” of the brain, and is “on” when we’re having self-referential (and generally negative) thoughts. It may also increase activity in the hippocampus, which is known to be affected in depression. CBT is definitely not going anywhere, and it shouldn’t—it’s solid methodologically and has a strong evidence base. But whether other strategies are better for some people, or whether a combination is more effective, is also possible.
Psychoanalysis and Psychodynamic Psychotherapy
This is an interesting form of therapy, which has undergone a lot of changes in recent decades, as some schools of thought within the field have moved away from Freud’s legacy. This type of therapy is longer-term and often multiple times per week. The aim of psychoanalysis is to help a person understand their unconscious processes and beliefs, so that, once brought to the surface, they can be addressed and ultimately released. The idea is that psychoanalysis can help treat depression in a getting-to-the-roots sort of way, since for many people, depression is caused by long-held and often unconscious ideas we have about ourselves and others, and about workings of the world in general. Often these are formed through bad family dynamics and traumas early on.
“For people who may have more historical, unresolved trauma in their lives that cause depression, psychoanalysis improves insight and reduces conflicts,” says Serani. “A way to think about psychoanalysis is, bringing insight and understanding to your life story reduces depression. When I work with patients, part of my assessment at the consultation is to understand the origin of depressive symptoms. I’m trained in both CBT and Psychoanalysis, so I offer these treatments based on the unique needs of a patient.”
Though historically studies addressing the efficacy of psychoanalysis have been sparser than the behavioral methods, several studies have supported its use in mental health disorders including depression, particularly over the long term. One study a couple of years ago found that although it didn’t have much benefit over “usual care” (cognitive-behavioral therapies) in the short term (that is, at the end of the 18-month period over which treatments were given), it sure did in the long-term. As time passed, psychoanalysis became much more effective than usual care, whose efficacy fell off relatively rapidly.
At least one brain study has supported the use of psychodynamic therapy in treating depression, finding changes in brain regions that are known to be affected in depression (like the mPFC mentioned earlier, and others). Again, the form of therapy that works best for you may not be clear right away, and many people are not aware that there are many forms. Below are some additional methods that are worth researching.
There are other therapies that have been shown to be effective for treating depression, which are definitely worth considering, depending on your needs (and which probably deserve their own article). For instance, Acceptance and Commitment Therapy (ACT) is sometimes considered to fall within CBT, but it uses more elements of mindfulness to accept our current situations and work from there. Emotion-Focused Therapy (EFT) stems from attachment theory—except between adults, rather than the parent and child; it also puts emotions, rather than cognition, at the forefront. Interpersonal psychotherapy (IPT) also comes partly from attachment theory, but views “interpersonal distress” as the key contributor to a person’s psychological distress. Behavioral Activation Therapy for Depression (BATD) is another, more behavioral method, which encourages a person to think about and then change the environmental and conditions and experiences that may contribute to depression vs. alleviate it. These strategies have all been shown to work in research studies, and may be effective depending on your needs (and this you and an experienced therapist can determine).
This type of “therapy” has been shown to be as effective as other forms of treatment for mild to moderate depression. Studies have consistently shown that physical activity can help treat symptoms of depression—and on the flipside, that low activity levels are a big risk factor for depression. The antidepressant effect of exercise seems to be moderated in part through serotonin, the brain chemical that’s targeted with some antidepressants, and in part through bone-derived neurotrophic factor (BDNF). And this plays a large part in the generation of new cells in the hippocampus, an area whose “shrinkage” is linked to depression. Regular exercise, like medication, seems to make the brain more plastic (more on this below), and more capable of growing new cells. It may also work in part by reducing inflammation, which some researchers believe is a central cause of depression.
Meditation and Mindfulness-Based Treatments
The research on meditation and mindfulness-based practices for depression has been fascinating to watch build over the last 10 years or so. Both the brain studies and the behavioral outcomes (that is, measuring a person’s depression symptoms before and after a course in meditation) have shown that meditation seems to have a measurable effect, and one that’s comparable to some of other methods, namely medication. For instance, a few years ago, a meta-analysis by Johns Hopkins researchers found that meditation was as effective in treating depression, anxiety and pain as other methods, including medication, behavioral therapies and exercise. And a very recent study showed that mindfulness-based group therapy was just as effective (and cheaper) than CBT.
Brain imaging studies, at Yale and the University of Massachusetts, have found that mindfulness training reduces activity in the mPFC, mentioned earlier, which is linked to mind-wandering and worry-based and self-referential thoughts. Others, from Harvard, have found that it’s linked to changes in brain volume in key areas, known to be affected in depression and anxiety. Another Harvard study found that changes in certain regions of the brainstem (especially those that synthesize neurotransmitters) were associated with improvements in a person’s psychological well-being, suggesting that these brain changes aren’t just theoretical, they’re associated with measureable changes in mental health.
There’s no doubt that antidepressants help lots of people with depression and have changed many lives. The efficacy rate is not huge (it’s actually considered moderate), but if you’re one of the people for whom it works, it can be powerful. It’s generally thought that medication and talk therapy should be paired, however, since when people go off medication, their depression may come back. (There are also potential side effects, which can rule out medication for some.) And when the two methods paired, they seem to be more effective—this is thought to be because, like exercise, medication puts the brain into a more plastic state, so that talk therapy can better take effect. And it makes sense: if you’re not working out the root causes of the depression (assuming they are more than biochemical), it’s unlikely to change much, and may still be present when the medication is gone.
The Other Stuff
Aside from the major treatments, there’s a lot of little things we can do to help in a moment-to-moment way. Being around people is a clear one – we’re built to be around and interact with people, and loneliness is linked to depression (not to mention physical health issues and a shorter life). Journaling has also been shown to help with depression, since it serves some of the same purposes as therapy, allowing you to create a narrative around a problem, rather than leaving it an unstructured blog in your head. Expressing gratitude can also be very effective. Having hobbies—finding something you’re passionate about, and that gets you in the “zone”—is extremely therapeutic.
Being of service, volunteering, or helping others in some way is a well- and long-known therapy—for thousands of years, across many cultures and religions, helping others has been a method for self-healing. Finally, prayer and spirituality have also been linked to well-being, whether it’s a structured religious belief or just a belief in the universe; there seems to be something therapeutic about releasing control from oneself to something bigger.
The key thing to remember is that depression isn’t as unremitting as we tend to think. It often feels intractable and permanent in the moment, but in reality, it’s generally treatable. It may take some time, but it can happen; and it’s often just a matter of finding the strategy, or the right combination of strategies, that will work best for you.