Introduction:
Depression is a common mental health condition, characterised by persistent low mood, loss of interest or pleasure in once-enjoyable activities (anhedonia), and a range of other symptoms which affect mental health and wellbeing, which can include increased or decreased appetite, feelings of helplessness and difficulty concentrating on tasks.
Cognitive behavioural therapy (CBT) is a psychotherapeutic modality, commonly used within psychotherapy for depression; Cujipers et al. (2023) note that it is the most commonly examined form of psychotherapeutic treatment for depression.
CBT is underpinned by cognitive reframing, where negative thoughts about an event, memory or situation are reinterpreted (Curtiss et al., 2022) or replaced (Chand et al., 2023) in light of new evidence and/or perspectives regarding the event, memory or situation.
Antidepressant medications are pharmaceutical drugs used in the treatment of depression; Moncrieff (2008) notes that the concept of an antidepressant implies a drug which acts in a disease-specific manner to reverse the neuropathological basis of depression symptoms.
This guide aims to compare cognitive behavioural therapy with antidepressant medication in the treatment of depression, and is intended to be informative, drawing upon peer-reviewed academic research.
What is CBT?
CBT (cognitive behavioural therapy) is a psychotherapeutic modality which helps clients to identify and change their negative thought patterns and behaviours. CBT helps individuals to understand the relationship between their thoughts, feelings and behaviours, and reframe, or change (Fordham et al., 2021), negative, or unhelpful, thoughts.
The goal of CBT, ultimately, is to change cognitive distortions (negative biases in human thinking (Rnic et al., 2016) which cause individuals to perceive reality improperly (Wang et al., 2023) and thereby positively change behaviours and thought processes.
As mentioned, CBT is underpinned by cognitive reframing, which drives the change (i.e. reinterpretation or modification) of cognitive distortions and other negative thought proceses.
Another key component of CBT is behavioural activation (van Genugten et al., 2021) which can be briefly described as a psychological technique aimed at increasing positive interactions between individuals and their surrounding environment (Cujipers et al., 2021).
More specifically, behavioural activation can be defined as a structured psychotherapeutic approach which aims to increase engagement in adaptive (constructive, pleasurable) activities, decrease engagement in activities which increase depressive feelings/symptoms, and solve problems which limit access to reward and/or maintain (or increase) aversive control (Dimidjan et al., 2017)
Both of these psychotherapeutic techniques are used within CBT (Wenzel, 2017) to treat depressive symptoms; these techniques improve emotional regulation by promoting the development of positive feelings and emotions, while conversely. reducing the frequency of negative thoughts and feelings.
What Are Antidepressants?
Antidepressant medicines are pharmaceutic drugs which act on neurotransmitters involved in modulating mood such as serotonin, norepinephrine and dopamine, facilitating improved mood in addition to reducing depressive symptoms.
There are a number of different classes of antidepressant, the most popular class being SSRIs (selective serotonin reuptake inhibitors), generally considered a first-line therapy for depression.SSRIs work by increasing the levels of the neurotransmitter serotonin, involved in regulating mood, by binding to the serotonin transporter and blocking the reuptake of serotonin, increasing its extracellular levels.
SNRIs (serotonin and norepinephrine reuptake inhibitors) are a related class of antidepressants, which raise norepinephrine levels as well as serotonin levels. Norepinephrine is involved in modulating energy, focus and pain sensitivity in addition to mood; thus, SNRIs could be beneficial for individuals experiencing symptoms such as chronic pain and/or low energy in addition to depression, as well as those who do not respond to first-line SSRI therapy.
There are other types of antidepressant as well, including tricyclic antidepressants, monoamine oxidase inhibitors (MAOIs) and atypical antidepressants; tricyclic antidepressants include medicines such as amitriptyline and imipramine, which work by increasing the levels of norepinephrine and serotonin in the brain. MAOIs work by blocking the breakdown of the three main neurotransmitters, serotonin, norepinephrine and dopamine, by inhibiting the enzyme monoamine oxidase. Atypical antidepressants do not neatly fall into the 4 previously mentioned categories, and include bupropion, a norepinephrine-dopamine reuptake inhibitor (NDRI) and agomelatine.
These types of antidepressant are not used as often as SSRIs or SNRIs, but are prescribed for individuals who do not respond as effectively to first- and second-line treatments such as SSRIs, or (sometimes) as an adjunctive pharmacotherapyto other antidepressants.
For example, Kent and Medway NHS and Social Care Partnership Trust (2021) guidelines suggest that bupropion can be used off-label in the UK for depression, either by itself or as an adjunctive medicine to SSRI antidepressants; bupropion is recommended by the Maudsley Prescribing Guidelines compendium (Taylor et al., 2025) of off-label psychotropic prescription recommendations for refractory depression.
CBT vs. Medication Treatment Efficacy
Both antidepressant medications and cognitive behavioural therapy have been found efficacious in treating depression (Boschloo et al., 2020), in their review (ibid. 2020) of treatment efficacy of antidepressants compared to CBT in treating specific depressive symptoms.
Confirming this, DeRubeis and colleagues (2008) note that studies show that cognitive behavioural therapy (CBT) is as effective as antidepressant medication in treating depression. In addition, DeRubeis et al. suggest that CBT seems to reduce the risk of relapse (i.e. depressive episodes following treatment) even following discontinuation.
An article by Menzel and Hoffmann (2022) discusses whether CBT reduced the recurrence of depression, and notes that CBT therapy alone reduced the recurrence of depressive episodes in major depressive disorder (MDD) by 50% after 12 months, and 24% after 24 months, and when implemented alongiside antidepressant medication tapering and/or cessation, CBT reduced the risk of recurrence of depressive episodes in MDD by 55% after 4 years and 64% after 6 years of therapy, respectively.
This assertion is corroborated by previous research (Cujipers et al., 2020) which concludes that combinations of psychotherapies (such as CBT) and pharmacotherapies (such as antidepressants) are likely to be more effective than solely utilising pharmacotherapies or psychotherapies alone.
Conclusion:
Both cognitive behavioural therapy (CBT) and antidepressant medications are effective treatments for depression, each with distinct advantages and drawbacks; CBT facilitates recognition of negative thought patterns and changing them, supporting long-term adaptive strategies and potentially reducing the incidence of further depressive episodes, whereas antidepressants can directly alter neurochemical pathways in the brain associated with emotional and mood regulation.
Research suggests that a combination of cognitive behavioural therapy and antidepressant medication can be more efficacious in treating depression than solely utilising either approach, psychotherapeutic (e.g. CBT) or pharmaceutic (antidepressants). This holistic approach addresses both the neuropharmacological and psychological facets of depression, potentially enhancing overall treatment effectiveness.
The choice between CBT, antidepressant medication, or a combination of both approaches is ultimately one that should be tailored to individual needs and preferences, alongside the clinical profile of the individual.
Engaging in a collaborative discussion with health professionals such as psychiatrists and psychologists can help you to determine which approach is best for you personally.
References:
Boschloo, L., Hieronymus, F. & Cuijpers, P. (2022) ‘Clinical response to SSRIs relative to cognitive behavioral therapy in depression: a symptom-specific approach’, World Psychiatry, 21(1), pp. 152–153. doi: 10.1002/wps.20944.
Chand, S., Kuckel, D., & Huecker, M. (2023) ‘Cognitive Behavior Therapy’, in StatPearls. Treasure Island (FL): StatPearls. Available at: https://www.ncbi.nlm.nih.gov/books/NBK470241/ (Accessed: 5 May 2025).
Curtiss, J.E., Levine, D.S., Ander, I. & Baker, A.W. (2021) ‘Cognitive-behavioral treatments for anxiety and stress-related disorders’, Focus, 19(2), pp. 184–189. doi: 10.1176/appi.focus.20200045.
Cuijpers, P., Noma, H., Karyotaki, E., Vinkers, C. H., Cipriani, A. and Furukawa, T. A. (2020) ‘A network meta‐analysis of the effects of psychotherapies, pharmacotherapies and their combination in the treatment of adult depression’, World Psychiatry, 19(1), pp. 92–107. doi: 10.1002/wps.20701.
Cuijpers, P., Quero, S., Noma, H., Ciharova, M., Miguel, C., Karyotaki, E., Cipriani, A., Cristea, I. and Furukawa, T.A., 2021. Psychotherapies for depression: A network meta-analysis covering efficacy, acceptability and long-term outcomes of all main treatment types. World Psychiatry, 20(2), pp.283–293. Available at: https://doi.org/10.1002/wps.20860. [Accessed 5th May 2025]
Cuijpers, P., Miguel, C., Harrer, M., Plessen, C.Y., Ciharova, M., Ebert, D. &Karyotaki, E. (2023) ‘Cognitive behavior therapy vs. control conditions, other psychotherapies, pharmacotherapies and combined treatment for depression: a comprehensive meta-analysis including 409 trials with 52,702 patients’, World Psychiatry, 22(1), pp. 105–115. doi: 10.1002/wps.21069.
DeRubeis, R.J., Siegle, G.J. & Hollon, S.D. (2008) ‘Cognitive therapy versus medication for depression: treatment outcomes and neural mechanisms’, Nature Reviews Neuroscience, 9(10), pp. 788–796. doi: 10.1038/nrn2345.
Dimidjian, S., Goodman, S.H., Sherwood, N.E., Simon, G.E., Ludman, E., Gallop, R., Welch, S.S., Boggs, J.M., Metcalf, C.A., Hubley, S., Powers, J.D. and Beck, A., 2017. A pragmatic randomized clinical trial of behavioral activation for depressed pregnant women. Journal of Consulting and Clinical Psychology, 85(1), pp.26–36. Available at: https://doi.org/10.1037/ccp0000151. [Accessed 5th May 2025]
Fordham, B., Sugavanam, T., Edwards, K., Hemming, K., Howick, J., Copsey, B., Lee, H., Kaidesoja, M., Kirtley, S., Hopewell, S., das Nair, R., Howard, R., Stallard, P., Hamer-Hunt, J., Cooper, Z. & Lamb, S.E. (2021) ‘Cognitive-behavioural therapy for a variety of conditions: an overview of systematic reviews and panoramic meta-analysis’, Health Technology Assessment, 25(9), pp. 1–378. doi: 10.3310/hta25090.
Kent and Medway NHS and Social Care Partnership Trust (2021) Guidelines for the use of Bupropion V4. December 2021 (reviewed December 2024) [PDF]. Available at: https://www.kmptformulary.nhs.uk/media/1109/guidelines-for-the-use-of-bupropion-dec-21docx.pdf[Accessed: 10thMay 2025]
Menzel, E.R. and Hoffman, K. (2022) ‘Does cognitive behavioral therapy reduce the recurrence of depression?’, Evidence‐Based Practice, 25(7), pp. 21–22. doi: 10.1097/EBP.0000000000001643
Moncrieff, J. (2008) ‘The creation of the concept of an antidepressant: an historical analysis’, Social Science & Medicine, 66(11), pp. 2346–2355. doi: 10.1016/j.socscimed.2008.01.047.
Rnic, K., Dozois, D.J. & Martin, R.A. (2016) ‘Cognitive distortions, humor styles, and depression’, European Journal of Psychology, 12(3), pp. 348–362. doi: 10.5964/ejop.v12i3.1118.
Taylor, D.M., Barnes, T.R.E. and Young, A.H. (2025) The Maudsley Prescribing Guidelines in Psychiatry. 15th edn. Chichester: Wiley-Blackwell.
van Genugten, C.R., Schuurmans, J., Hoogendoorn, A.W., Araya, R., Andersson, G., Baños, R., Botella, C., CergaPashoja, A., Cieslak, R., Ebert, D.D., García-Palacios, A., Hazo, J.B., Herrero, R., Holtzmann, J., Kemmeren, L., Kleiboer, A., Krieger, T., Smoktunowicz, E., Titzler, I., Topooco, N., Urech, A., Smit, J.H. and Riper, H. (2021) ‘Examining the theoretical framework of behavioral activation for major depressive disorder: Smartphone-based ecological momentary assessment study’, JMIR Mental Health, 8(12), p. e32007. doi: 10.2196/32007.
Wang, B., Zhao, Y., Lu, X. and Qin, B. (2023) ‘Cognitive distortion based explainable depression detection and analysis technologies for the adolescent internet users on social media’, Frontiers in Public Health, 10, p. 1045777. doi: 10.3389/fpubh.2022.1045777.
Wenzel, A., 2017. Basic strategies of cognitive behavioral therapy. Psychiatric Clinics of North America, 40(4), pp.597–609. Available at: https://doi.org/10.1016/j.psc.2017.07.001. [Accessed 5th May 2025]
