Cognitive Therapy in the Treatment and Prevention of Depression: A Fifty-Year Retrospective with an Evolutionary Coda

In the 50 years since it was first introduced, cognitive therapy has been shown to be as efficacious as antidepressant medications (on average) in the acute treatment of nonpsychotic depression, although some patients will do better on one than on the other. Moreover, patients treated to remission with cognitive therapy are less than half as likely to relapse following treatment termination as patients treated to remission with medications. However, a recent study suggests that adding medications interferes with any such enduring effect and medications themselves may have an iatrogenic effect that suppresses symptoms at the expense of prolonging the underlying episode. Neural imaging suggests that cognitive therapy works from the “top down” to facilitate cortical regulation of affect processes whereas medications work from the “bottom up” to dampen the stress response. Adaptationist theory suggests that depression is an evolved adaptation that served to keep our ancestors ruminating about complex social problems until they arrived at a solution; if true then any intervention that facilitates problem solving is likely preferable to one that merely anesthetizes distress.