Drugs and Talk Therapy Affect the Brain in

Different Ways
Psychiatric drugs and psychotherapy mostly have the same purpose: to make us feel better mentally
and emotionally. However, it seems like common sense to assume that they do so by very different
means, the former acting chemically on your brain and the latter altering your mind and thoughts.
Yet if you ponder this some more and consider that our brains are our minds after all, every lived
thought and feeling has its basis in the brain it follows that if you spend time on the therapists
proverbial couch, any benefit will ultimately register not only in changes to how you think, but also
in changes at a neural level. The fact is, any kind of psychological technique is associated with
brain changes consider how mindfulness meditation has been linked with shrinkage to the
amygdala, a neural region involved in processing emotions.
This raises an interesting question: Are the brain changes induced by psychotherapy the same or
different from those induced by antidepressant medication? A new meta-analysis (the kind of
research that looks at results across many previous studies) published recently in Brain Imaging
and Behavior looks at this very question in relation to major depression. The researchers, based at
several institutions in Italy, say their results suggest psychotherapy and drugs affect the brain in
different but complementary ways.
Maddalena Boccia and her colleagues looked at brain-scan results from 38 experiments that
involved hundreds of patients treated with drugs (mostly Prozac-like drugs known as selectiveserotonin re-uptake inhibitors that work to increase the amount of serotonin available to neurons),
and 18 experiments that involved hundreds of patients who undertook psychotherapy (mostly
cognitive behavioral therapy, usually abbreviated to CBT, but also including interpersonal therapy
and psychodynamic therapy).
The studies that the researchers analyzed generally took the form of comparing patterns of activity
in patients brains after treatment compared with before treatment. Averaging across these results
showed that some of the brain changes associated with drug and psychotherapy treatment were
overlapping, but there were also some striking and important differences.
Drug treatments tended to be associated with increases in brain activity in the limbic system and
other sub-cortical structures, including in the insula. These areas are broadly associated with
emotional processing, and the insula in particular is involved in representing our internal bodily
states. Boccia and her colleagues characterized these therapeutic effects as bottom up and said
they could be related to the alleviation of the psychosomatic symptoms, such as chest pain and
fatigue, that are often associated with major depression.
In contrast, psychotherapy appeared to lead to changes to activation patterns in parts of the frontal
cortex and temporal cortex brain areas known to be associated with thinking about ourselves and
to storing and processing memories. The researchers characterized these effects as top down,
related to how we interpret the world and our place in it, which makes sense given that a major goal
of CBT is to alter unhelpful thinking habits.
The researchers said these distinct neural effects of antidepressants and psychotherapy suggest that
the two kinds of treatment are not simply doubling up, prompting the same changes by different
means. Instead, the brain-scan results suggest the two forms of treatment are having contrasting,

complementary effects, one of them altering activity in higher brain areas in the frontal cortex, and
the other targeting deeper emotional structures. In the best cases, these effects could reinforce one
another: Perhaps someone who has fewer physical symptoms is less likely to slink into a deep
depression, and someone with fewer intrusive negative thoughts is less likely to develop physical
symptoms.
This idea that drug treatments and psychotherapy have different but complementary effects on the
brain is consistent with research showing that depressed patients often recover most successfully
when they undertake a combination of psychotherapy and psychiatric medication. For example,
theres research suggesting that complementing drug treatment with psychotherapy can lead to
longer-lasting remediation of patients symptoms. The new findings also make sense given that the
brain areas revealed here as altered by drugs and psychotherapy are the same areas where,
according to past research, depressed patients often show abnormal functioning compared with
healthy controls. In this sense, medications and talking treatments can be seen as returning different
parts of the brain to a mode of functioning that resembles that seen in people who arent depressed.
Although these new findings seem to paint a neat picture, its important to realize that things get a
lot more complicated when you broaden the question to other forms of mental illness. For example,
a review published last year of 42 articles found that in the case of obsessive-compulsive disorder
(OCD) and panic disorder, psychotherapy and drug treatments appeared to have largely similar
effects on the brain. Also, whereas drug and talk therapy for OCD acted to return brain activation
patterns to those seen in healthy people (as was also the case for the depressed patients in the new
research), treatments for panic disorder did not. You could say that in the case of panic disorder, the
brain changes brought about by treatment appeared to be compensatory rather than normalizing
the brain didnt return to its healthy state as such, but other neural changes were brought about
that helped offset the difficulties associated with the illness.
Clearly, this is a complicated area of study. And its very early days for the field, too. This new
research looked at how drugs and psychotherapy altered activation patterns in the brains of
depressed patients, but what about changes to brain structure or to the way different brain regions
are connected and communicate with each other? Its also worth noting that many of the studies
conducted to date fail to include comparison brain scans of patients on a waiting list for treatment.
This means that at least some of the brain changes attributed to psychotherapy could really just be
part of the natural course of the illness and recovery from it, rather than a direct result of the process
of psychotherapy (a similar methodological problem afflicts research into the effectiveness of
treatments for mental illness, since peoples moods and symptoms vary naturally; suitable control
groups are always needed to check that patients wouldnt have gotten better with a placebo or just
recovered naturally possibly even more quickly without any treatment).
These shortcomings aside, this is an exciting field to watch with time, although some
psychologists and patients may not find the idea appealing, its possible we may be able to use brain
scans to monitor whether a course of psychotherapy is having hoped-for effects on the brain. Also,
finding out more about how talk therapy changes the brain could signpost new directions for drugtreatment research. Its sometimes tempting to see psychotherapy as a mysterious process,
impenetrable to scientific inquiry. But the emerging neuroscience of psychotherapy could generate
new clues toward more effective forms of talk therapy, better drugs, and more efficient ways to
combine the two all improving the odds that those who are suffering will get and stay better.
Dr. Christian Jarrett (@Psych_Writer), a Science of Us contributing writer, is editor of the British
Psychological Society's Research Digest blog. His latest book is Great Myths of the Brain.