Is cognitive therapy enduring or antidepressant medications iatrogenic? Depression as an evolved adaptation.

Abstract

Patients treated to remission with cognitive therapy are less than half as likely to relapse following treatment termination as patients treated to remission with antidepressant medications. What remains unclear is whether cognitive therapy truly is enduring or antidepressant medications iatrogenic in terms of prolonging the life of the underlying episode. Depression is an inherently temporal phenomenon and most episodes will remit spontaneously even in the absence of treatment. There is reason to believe that depression is an adaptation that evolved because it keeps organisms focused on (ruminating about) complex social issues until they can be resolved and that medications work not so much by addressing a nonexistent deficit in neurotransmitters in the synapse as by perturbing underlying regulatory mechanisms to the point that they reassert homeostatic control over those systems. If the latter is true then medications may work to suppress symptoms in a manner that leaves the underlying episode unaddressed and patients at elevated risk of relapse whenever they are taken away. Cognitive therapy is predicated on the notion that people become depressed because they misinterpret life events in a negative fashion and that helping them examine the accuracy of their beliefs will relieve their distress. Such an approach would not work if patients were not capable of thinking clearly (if their "brains were broken") and it is likely that cognitive therapy works by making rumination more efficient so as to facilitate the resolution of the complex social issue(s) that brought the episode about. Public Significance StatementThere is reason to think that depression may be an adaptation (like pain or anxiety) that evolved in our ancestral past to help resolve complex social problems. If true then interventions like cognitive therapy that facilitate the functions that depression evolved to serve may be preferred over antidepressant medications that merely anesthetize the distress.

Cognitive Behavior Therapy for Depression From an Evolutionary Perspective

“…For the “depression possible” clinical intervention may not be necessary but (depending on its nature) not necessarily problematic. CBT may be overkill (analytical rumination will likely help them resolve the triggering problem before it occurs to them to enter treatment) whereas ADM may be unnecessarily iatrogenic (if it prolongs the episode and leads to relapse when the medications are taken away) ( 22 ).…”

“…For those among the “recurrence prone” CBT is likely to be preferred for those who will respond to it (not all will) since it seems to facilitate the processes that depression evolved to serve with respect to resolving the problem that triggered the episode in the first place and to have an enduring effect that reduces risk for future episodes ( 22 ). We think this is a consequence of either dismantling existing depressogenic schema (accommodation) or teaching compensatory skills (compensation) that allow patients to short-circuit the episode before it starts ( 61 ).…”

“…Current convention in psychiatry is to keep patients with a history of chronic or recurrent depression (about 85% of all patients) on ADMs indefinitely. There is no indication that ADMs do anything to reduce future risk once you stop taking them and reason to think they might have an iatrogenic effect that prolongs the life of the underlying episode ( 22 ).…”

“…This leads us to suspect that ADMs may suppress symptoms (a purely palliative effect) at the expense of prolonging the length of the underlying episode ( 20 , 22 ). It is common practice in psychiatry to keep patients on ADMs for 6–9 months following initial remission to forestall relapse (the return of symptoms of the treated episode) on the presumption that the underlying episode will run its course (that spontaneous remission will proceed).…”

“…To illustrate how CBT may work within the context of the ARH, we raise nine questions likely to be of interest to clinicians, and we discuss how our evolutionary approach provides insight into each. We have addressed these questions in greater detail elsewhere, and we refer interested readers to our previous articles for more in-depth considerations ( 16 , 17 , 21 , 22 ).…”