Treatment of Mood Disorders: Psychotherapy
Although the Agency for Health Care Policy and Research has published a set of practice guidelines on depression in the primary care/medically ill sector that encourages physicians to provide pharmacotherapy to their depressed patients, one area not addressed is the intervention of psychotherapy. One review has estimated that 25% of all psychotherapy is provided in the general medical setting. Most psychotherapy in the medically ill is time limited and takes the form of either interpersonal psychotherapy, cognitive-behavioral therapy (CBT), or supportive therapy. Any of these modalities can easily provide a significant degree of success in the treatment of mild to moderate depression in the medically ill. Psychological interventions clearly would be much more favorable for those patients with mild to moderate mood symptoms who are currently being treated with multiple medications, which could cause concern regarding drug interactions, but most research supports combined psychopharmacology/psychotherapy for optimal treatment in depression. Additionally, some studies in the psychiatrically ill have shown improved outcomes when psychological and psychopharmacological therapies are combined. Unfortunately, many acutely ill patients may be unable to tolerate the level of activity required to engage in a psychotherapeutic alliance, and so this intervention may be delayed until their medical illness is stabilized.

Psychotherapy has been characterized as a process of helping the patient to alleviate the psychiatric symptomatology by listening, explaining, and providing perspective and support. Additionally, it is hoped that this intervention may reduce recurrences and prevent the progression of the depressive conditions. In the medically ill population, flexibility is often the key in providing this type of treatment. Brief, goal-directed interventions are often the only treatment in the initial psychotherapeutic intervention in the hospitalized medically ill patient. Much of the time limitation is necessary as a result of increasingly shorter lengths of hospital stay for medical and psychiatric treatment. CBT may be the most appropriate therapy in this setting by beginning a time-limited directive therapy in an effort to reduce patients’ negative views of their future and their ability to reduce symptoms. The goals of therapy are to improve self-esteem and correct misconceptions and maladaptive behaviors; in the medically ill, the goals are to help the patient to accept the limitations imposed by the medical illness and to grow from this knowledge. A new multicenter clinical trial involving a CBT intervention in patients with coronary artery disease is currently under way, and hopes are to show a significant effect with this intervention.

Supportive therapy, although perhaps not recognized as such by many primary care providers who provide it, is classically practiced by many in a general health care environment. Medically oriented supportive psychotherapy can occur during the standard general medical encounter, in addition to the evaluation and management of the patient’s underlying general medical condition. The primary initiative of the treatment is the process of helping the patient’s mood symptoms improve by listening, explaining, and providing perspective and support. This might take only a few minutes but often provides an effective method for improving the mental state of the patient and also can improve compliance of the patient with regard to his or her own individual medical treatments. This in itself could easily provide a method by which psychiatric treatment could reduce morbidity and mortality by improving the patient’s understanding of and adherence to a medical regimen.

Interpersonal psychotherapy focuses on and emphasizes realistic evaluation of current relationships and explores how these relationships have led to the current mood symptoms. Relationships that are often explored are those of family, friends, and community relations that are pertinent. Much of the psychological intervention is based on attempting to assist in augmentation of deficits that the patient may be having or assist in resolution of disputes that provoke the mood symptoms. During the initial evaluation, an interpersonal inventory is obtained to gain focus on basic issues involved with the depressive symptoms. Later in the course of treatment, common themes explored include unresolved grief, social role disputes, and interpersonal deficits. Much of this time-limited intervention is based on educating, reassuring, testing perceptions, and helping to develop or augment interpersonal skills.