Depression-Focused Psychotherapies: Conclusions
The depression-focused psychotherapies, as exemplified by IPT, several models of behavior therapy, and Beck’s CT, are practical and effective outpatient treatments of mild to moderately severe major depressive disorder. From differing vantage points, each therapy assesses the depressed patient’s current state and problem areas, provides psychoeducation, explicitly instills hope, and guides the selection of model-specific strategies to help patients “work out” of the depressive episode. No one form of psychotherapy has emerged as superior to the others; interest, aptitude, and opportunities for supervised training may have more to do with a therapist’s choice of a model than empirical evidence. It remains to be seen if an eclectic model of psychotherapy for depression will emerge, one that fuses the more clinically germane aspects of IPT, behavior therapy, and CT (e.g., Karasu 1990). Caution should be exercised before automatically adopting such integrated therapies, however, because several studies have established that combinations of various behavioral, marital, and cognitive strategies are not more effective than single models of treatment (N. S. Jacobson et al. 1991, 1996; Rehm et al. 1987; Rude 1986).
The depression-focused psychotherapies probably do best alone, without concomitant pharmacotherapy, for more acutely depressed patients with higher levels of premorbid functioning and adequate social support (e.g., Klerman and Weissman 1982; Safran et al. 1993; Teri and Lewinsohn 1986). This indication should not be trivialized as a nonspecific response, because these psychotherapies have been consistently shown to be superior to waiting-list or low-contact control conditions.
Shared Features of Depression-Focused Psychotherapies
The greater initial cost of psychotherapy relative to pharmacotherapy is based on the assumption of a short course of treatment with a generic formulation of an older antidepressant (e.g., Lave et al. 1998). The actual greater cost of 16 weeks of psychotherapy is, in practice, largely offset by taking into account the expense of prescription of name-brand antidepressants and the necessary length of continuation and maintenance pharmacotherapy. More difficult to factor into such equations are the possible benefits of late-emergent improvements in social adjustment of patients treated with IPT (e.g., Weissman et al. 1974, 1981) or enduring prophylactic effects of CT.
The depression-focused psychotherapies should be conducted by appropriately trained clinicians and, ideally, should be preferentially recommended for patients who are motivated to participate in a psychosocial treatment. When these therapies are used as the primary treatment of major depressive disorder, clinicians would be wise to follow the AHCPR’s (Depression Guideline Panel 1993) suggestion to reevaluate the need for pharmacotherapy after several months of therapy. Unfortunately, this is not always done. For example, a survey by Kendall et al. (1992) indicated that nonmedical psychotherapists typically wait between 6 and 14 months before concluding that patients are not progressing in therapy. In such cases, months of unproductive suffering might have been circumvented by more timely use of antidepressant medication. For example, our group found that more than 70% of IPT nonresponders responded to a sequential trial of imipramine or fluoxetine.
The depression-focused psychotherapies remain novel treatments within the mainstream of American psychiatry. Greater emphasis on the training of psychiatric residents and current practitioners and further research to help better define the boundaries of efficacy will lead to a fuller capitalization of the benefits of these useful treatments.
Revision date: June 18, 2011
Last revised: by Andrew G. Epstein, M.D.