Psychodynamic therapies of depression have been studied less rigorously than cognitive-behavioral therapy and interpersonal psychotherapy. Nevertheless, both brief and extended psychodynamic psychotherapies, and in some cases psychoanalysis, have a significant role to play in the treatment of depressed patients. A wealth of clinical experience has demonstrated that certain patients require in-depth exploration of unconscious conflicts, depleted self-esteem, and problematic internal object relations to obtain relief from their depression. Moreover, psychodynamic thinking may be extremely useful in understanding transference, countertransference, and resistance issues that arise in other forms of treatment, such as pharmacotherapy, cognitive-behavioral therapy, and interpersonal psychotherapy.
Empirical research available to date is of only limited assistance in predicting which patients are likely to respond preferentially to the psychodynamic therapies. One study shed some light on the question of which depressed outpatients are most likely to respond to brief psychodynamic therapy. The results of this investigation suggested—retrospectively, not predictively—that the elderly patients with major depressive disorder who responded best to brief dynamic therapy had lower expectations for treatment and better interpersonal relationships at the end of treatment. In a more recent investigation, depressed caregivers of elderly family members were randomly assigned to either brief psychodynamic therapy or cognitive-behavioral therapy. After 20 sessions, 71% of the caregivers were no longer clinically depressed. Overall, no differences were found between the two treatment groups. Symptom-oriented measures suggested that those who had been caregivers for more than 3.5 years improved more with cognitive-behavioral therapy, whereas those who had been caregivers for shorter periods of time showed more improvement from brief psychodynamic therapy. Beyond research data, however, clinicians must take patients’ preferences into account. Certain patients view their depression as growing out of a psychological matrix that requires understanding and mastery. Patients sometimes refuse medications because they harbor consciously or unconsciously held negative attitudes about taking antidepressants or because medications are imbued with specific unconscious meanings.
Systematic studies are not available on extended dynamic psychotherapy and psychoanalysis to help clinicians determine or predict differential response. Most therapists would agree, however, that these modalities are not indicated as the exclusive treatment for most patients in the acute phase of major depression. These modalities are certainly indicated for some patients who have failed to respond fully to pharmacotherapy or reeducative psychotherapies. A reanalysis of the data from the National Institute of Mental Health (NIMH) Treatment of Depression Collaborative Research Program suggested that highly perfectionistic and self-critical patients are not likely to respond to either brief pharmacological or psychological treatments. This subgroup of depressed persons may be particularly suited to more extended psychodynamic approaches. Two naturalistic follow-along studies suggested that long-term psychodynamic therapy may be effective with the self-critical and perfectionistic patients who do not respond to the brief modalities. Many of these patients probably have significant obsessive-compulsive or narcissistic traits.
Also, when patients have significant Axis II pathology in addition to major depressive episodes, extended psychodynamic psychotherapy or psychoanalysis may be required. The clinician may need to wait for an acute episode to resolve before these characterological features become apparent. At that point, continued interpersonal problems, chronically low self-esteem, and other conflicted areas can be more completely assessed.
A growing body of literature demonstrates that personality disorders may complicate the treatment of depression. An 18-year follow-up study of 89 depressed patients revealed an interactive effect between the personality measure of neuroticism and melancholia that led to poor outcomes in patients with both features. Shea et al. examined the NIMH collaborative data and noted that patients with personality disorders had poorer outcomes in social functioning and were more likely to have residual depressive symptoms than patients who did not have personality disorders.
Psychoanalytic clinicians have long noted that certain personality disorders and characterological factors may contribute to maintaining a depressed state once it has occurred and may also adversely influence compliance with medication regimens. Psychodynamic understanding in therapy can be extremely useful in dealing with the interface of personality and depression. This interface can be subdivided into three discrete categories: 1) Axis I major depression with Axis II comorbidity, 2) characterological depression in the context of personality disorders, and 3) depressive personality.
The latter category, depressive personality, has been controversial despite a long-standing psychoanalytic tradition. In Appendix B of DSM-IV (American Psychiatric Association 1994), the criteria for the disorder emphasize a constellation of personality traits, whereas the criteria for dysthymia focus on somatic symptoms. These traits include a mood dominated by unhappiness, dejection, and gloominess; a self-concept centered on worthlessness and low self-esteem; a tendency to blame and criticize oneself; a proneness to feel guilt or remorse; a pessimistic attitude; a negativistic and judgmental stance toward others; and a tendency to brood and worry.
Much of the controversy has revolved around whether depressive personality disorder is truly distinct from dysthymia. However, emerging data suggest that the distinction between the two is valid and clinically useful. In a study of 54 patients with early-onset, long-standing mild depressive features, Phillips et al. identified 30 subjects with and 24 without depressive personality disorder. Sixty-three percent of the subjects with depressive personality disorder did not have dysthymia, whereas 60% did not have current major depression. The patients with depressive personality disorder were more likely than the comparison group to have another personality disorder, but 40% of them had no such disorder. Those who were comorbid for personality disorder tended to have Cluster C or anxious personality disorders, suggesting that defenses and conflicts at a neurotic level were most prominent, which is in keeping with the psychoanalytic view of depressive personality disorder as a character neurosis (Kernberg 1984). Finally, the duration of psychotherapy was significantly longer for subjects who had depressive personality disorder than for those who did not (Phillips et al. 1998).
Suitability for psychodynamic approaches must also be determined by the clinician before recommending brief dynamic therapy or extended dynamic treatments. A capacity for abstract thinking, motivation to understand, psychological mindedness, the ability to form meaningful relationships, and a reasonably stable environmental situation are all factors that augur well for psychodynamic therapies. By contrast, low motivation, severe ego weaknesses (such as impulse-control problems and poor reality testing), a tendency toward concrete thinking, poor object-relatedness, and an unstable family or home environment are likely to predict poor response in dynamic treatment.
Antidepressant and Antimanic Medications
Combined Medication and Psychotherapy
Treatment-Resistant Mood Disorders
Treatment of Mood Disorders in the Medically Ill Patient
Strategies and Tactics in the Treatment of Depression
Revision date: July 9, 2011
Last revised: by Dave R. Roger, M.D.