Talk therapy can work as well as antidepressants in severely depressed people and should also be used as a first line of defense, University of Pennsylvania researchers concluded in a study published yesterday.

In a study of 240 patients, researchers found that cognitive therapy, a type of treatment that teaches patients to think more realistically, worked as well as a popular antidepressant for moderate to severe depression.

Patients who got four months of cognitive therapy also had about the same relapse rate a year later as people who took Paxil (paroxetine) the whole time. If people quit taking Paxil after four months, their relapse rate was twice that of therapy patients'.

As a result, the authors from Penn and Vanderbilt University contend, cognitive therapy is cheaper than antidepressants in the long run.

The research adds to a growing body of evidence that this type of therapy, developed in Philadelphia by the University of Pennsylvania's Aaron Beck, works as well as the drugs.

The study is important because of its size and because it tested therapy in moderately and severely depressed patients, a group in which previous results have been mixed and much debated, said lead researcher Robert DeRubeis, a Penn psychologist.

Beck said, "It establishes I think once and for all that cognitive therapy does as well as pharmacotherapy, and what's even more important is that it has a much lower relapse rate. " Beck, 83, still does research at Penn and teaches at the Beck Institute, a nonprofit center run by his psychologist daughter, Judith Beck, in Bala Cynwyd.

The research, funded by a $4 million grant from the National Institutes of Health, was published in the Archives of General Psychiatry.

In the study, patients on medication got better quicker. At eight weeks, the response rate was 50 percent for Paxil , 43 percent for cognitive therapy, and 25 percent for placebo. But by 16 weeks, 58 percent of patients in both treatment groups were feeling better.

A call for change

DeRubeis and Steven Hollon, who led the Vanderbilt part of the study, argued that the American Psychiatric Association should change its treatment guidelines for moderate to severe depression, which currently call for antidepressants as the first-line treatment.

That change is unlikely to happen soon, said Laura Fochtmann, a psychiatrist at Stony Brook University who is the guidelines' medical editor. They were last revised in 2000, after a two-year process that involved analyzing all the available research. "We can't really revise them for every new study that comes out," she said.

Aaron Beck, a psychiatrist trained in traditional psychoanalytic methods, decided early in his career to apply science to therapy. "I tested out the psychoanalytical theories, and they simply did not hold water," he said yesterday.

Off the couch

Then he noticed that many of his depressed patients had the same type of disordered thinking. "They tend to greatly exaggerate the negative aspects and minimize the positive," he said. For example, a severely depressed patient might say, "My relationships never work out," or, "I'm worthless. "

That gave Beck a target. He got patients off the couch and started talking to them instead of just listening, which was the traditional psychoanalyst's role. His theory was that if people started thinking differently about themselves, they would feel better.

In the cognitive approach, patients typically practice thinking about how realistic their ideas really are, Judith Beck said. They also are strongly encouraged to stop lying around in bed or watching TV. They get "homework" to get out and do things they enjoyed before they got sick. Call a friend. Exercise. Do some work that is enjoyable. The goal is that people ultimately will be able to be their own therapists.

"They walk out the door with skills they can use to manage their own moods," Hollon said.

When Beck tested his new theory scientifically 40 years ago, it held up. Other researchers have since applied his approach to a host of psychological and physical ailments, making cognitive therapy the most scientifically studied talk therapy.

"This kind of therapy has appealed to the kind of people who are determined to test the results empirically with science," DeRubeis said.

In his study, more experienced cognitive therapists got better results, a finding that could be problematic for potential patients. DeRubeis estimates that 10 percent to 30 percent of therapists practice cognitive therapy. Because of Beck, Philadelphia has more than most cities, but they can be hard to find in other parts of the country.

Many people are wary of antidepressants because of side effects and the recent debate about what role the drugs play in suicidal behavior.

But some people prefer the pharmaceutical approach, DeRubeis and other therapists conceded.

"The drugs are much easier and they're much more widely available," said James Herbert, a Drexel University psychologist. "The gap between science and practice in mental health is huge. "

John Norcross, a University of Scranton psychologist who also studies different therapies, added that, while there were more good studies of cognitive therapy, several other approaches - behavior, interpersonal, short-term psychodynamic, experiential and family systems therapies - also worked well for depression.

"The mainstream psychotherapies that have been tested in randomized clinical trials tend to work about equally well when you control for the allegiance of the head researcher," he said.

Contact staff writer Stacey Burling at 215-854-4944 or sburling@phillynews.com.

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Last updated: 10/25/2005 - 09:10 AM