Depression

Description

Alternative Names

Psychotherapy

Among the various psychotherapies, cognitive-behavioral therapy at this time appears to be the most effective approach for most adult patients. A 2000 study suggested that there was very little difference among major psychotherapeutic approaches -- cognitive-behavioral therapy, family therapy, and supportive therapy. There are other effective therapies as well, such as problem-solving therapy, and interpersonal therapy.

Psychoanalytic or psychodynamic approaches have not been helpful. (Based on Freudian theory, psychodynamic psychotherapy concentrates on working through unresolved conflicts from ones childhood. Depression is viewed as a grieving process for the loss of a parent or other significant person or for the loss of their love.)

In any case, if psychotherapy is being used along without medications, benefits should be evident within eight weeks and symptoms should be fully resolved by 12 weeks. If these conditions are not met, then the patient should strongly consider antidepressant agents.

Cognitive Behavioral Therapy

In a major analysis of four randomized comparative studies, cognitive behavior therapy was as effective as antidepressants in treating severe depression for many patients. Much of the success of psychologic therapy, in any case, depends on the skill of the therapist. Many studies suggest that combining cognitive therapy with antidepressants offer the greatest benefits for many patients, particularly for dysthymia (chronic depression). Some studies also report that in these patients the benefits of cognitive therapy persist for these patients after treatment has ended, with the risk of relapse reduced by up to 50%.

Best Candidates. Cognitive therapy may be particularly helpful for the following patients:

• Patients with atypical depression.
• Adolescents with mild symptoms of major depression.
• Women with non-psychotic postpartum depression.
• Children of parents with the disorder. In this case, therapy should involve the whole family.
• Cognitive therapy does not appear to be as beneficial as antidepressants for most patients with dysthymia.

Approach. This approach focuses on identification of distorted perceptions that patients may have of the world and themselves, on changing these perceptions, and on discovering new patterns of actions and behavior. These perceptions, known as schemas, are negative assumptions developed in childhood that can precipitate and prolong depression. Cognitive therapy works on the principle that these schemas can be recognized and altered, thereby changing the response and eliminating the depression.

• First, the patient must learn how to recognize depressive reactions and thoughts as they occur, usually by keeping a journal of feelings about, and reactions to, daily events.
• The patient is often given "homework" that tests old negative assumptions against reality and demands different responses.
• Then, the patient and therapist examine and challenge these entrenched and automatic reactions and thoughts.
• As the patient begins to understand the underlying falseness of the assumptions that cause depression, he or she can begin substituting new ways of coping.

Over time, such exercises help build confidence and eventually alter behavior. Patients may take group or individual cognitive therapy. Cognitive therapy is a time-limited treatment, typically lasting 12 to 14 weeks. Extending this period, however, may help prevent relapse. In one study, therapy was continued for 10 sessions over an additional eight months. This extended treatment significantly reduced the risk of recurrence. In fact, some experts believe that short-term therapy is not at all effective for patients with chronic or relapsing psychiatric disorders.

Interpersonal Therapy (IPT)

Based in part on psychodynamic theory, interpersonal therapy acknowledges the childhood roots of depression, but focuses on symptoms and current issues that may be causing problems. IPT is not as specific as cognitive or behavioral therapy, and all work is done during the sessions. The therapist seeks to redirect the patients attention, which has been distorted by depression, toward the daily details of social and family interaction. The goals of this treatment method are improved communication skills and increased self-esteem within a short period (three to four months of weekly appointments) of time. Among the forms of depression best served by IPT are those caused by distorted or delayed mourning, unexpressed conflicts with people in close relationships, major life changes, and isolation.

Supportive Psychotherapy or Attention Intervention

The intent of supportive psychotherapy or attention intervention is to provide the patient with a nonjudgmental environment by offering advice, attention, and sympathy. Supportive therapy appears to be particularly helpful for improving compliance with medications by giving reassurance, especially when setbacks and frustration occur. A 2000 study reported that it was as effective as other therapies for depressed adolescents.

Problem Solving Therapy

Problem solving therapy trains patients to address current problems by breaking them into smaller manageable parts. They then identify the steps they should make toward positive change. It involves six individual sessions, and some evidence suggests it is as effective as medication in some patients with major depression.