Psychotherapy for Depression - Longer Lasting Benefits

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The Attributes Of Psychotherapy For Depression

by Susan E. Erbaugh, PhD, LP

The efficacy of psychotherapeutic treatments specific to depressive mood disorder has been shown to be comparable to that of pharmacologic treatments in alleviating symptoms. In addition, these therapies reduce residual psychosocial impairments, improve psychosocial function, and prevent depression relapse. Depression-specific psychotherapeutic approaches include cognitive-behavioral, interpersonal, behavioral, and short-term dynamic therapies, which are often integrated in clinical practice. The effectiveness of depression-specific psychotherapy can be enhanced by medical-psychotherapeutic collaboration and use of guided self-directed change efforts, marital or family therapy, and participation in therapy groups. A coordinated program of care combining the benefits of pharmacologic and psychosocial interventions and drawing on the expertise of physicians and psychotherapists is recommended for the treatment of depression.

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Who should treat depression?
The high incidence of clinical depression has led to some encouragement for treatment to be delivered by primary care physicians, who are likely to offer medications and some form of limited supportive counseling. Findings indicating substantial and lasting benefits of a range of psychotherapeutic strategies suggest that quality of care may be better achieved when timely referral to qualified mental health therapists is incorporated into treatment plans.

The sequencing and coordination of care that encompasses appropriate, timely, and active use of biologic, psychological, and social interventions can be challenging, but quality of care standards are best met when psychotherapy and pharmacotherapy are combined. A collaborating team of healthcare providers who support and respect each other’s work and merge their efforts can achieve increased effectiveness and efficiency in the treatment of depressed patients.

Why choose psychotherapy?
Of the many alternative approaches available for treating various mental conditions, none have been more thoroughly researched than those for depression. Findings from studies based on the "scientist-practitioner model" have clearly demonstrated the benefits of psychotherapy for depression. According to meta-analyses of outcome study data, numerous forms of depression-specific psychotherapy compare favorably with antidepressant drug therapy in terms of effectiveness. Results of the Depression Guideline Panel’s meta-analyses have revealed efficacy rates of about 50% for initial intervention with pharmacotherapy alone or psychotherapy alone, with modest gains achieved when both approaches are used in combination.1 Consequently, the efforts of clinicians and healthcare managers may be more productive when they address how and when best to use psychotherapy rather than whether to include it in active treatment programs for depression.

Research findings have indicated that although psychotherapy may take slightly longer to begin alleviating the specific and acute symptoms of depressive mood disorder than does active treatment with the faster-acting antidepressants, it does improve symptoms in appropriate patient groups. Further, when compared with pharmacotherapy, psychotherapy appears to result in longer-lasting benefits and maintenance of a higher quality of psychosocial adjustment. Although the risk of relapse or recurrence of depression is significant with either medication or psychotherapy, the interval between cessation of active treatment and subsequent episodes of depression appears to be lengthened after psychotherapeutic intervention.

In addition to reducing or eradicating specific symptoms, psychotherapy can be exceedingly helpful in monitoring and managing suicide risk and compliance with both medical and psychosocial intervention programs. Moreover, it can be beneficial in dealing with impairments of psychosocial function and reactions to stress, disappointment, loss, bereavement, and the other psychosocial issues that are common triggers or consequences of the persistence or recurrence of depression. Residual psychosocial impairments that remain after stabilization of acute depressive symptoms also respond to psychotherapy. When other medical conditions or treatments, pregnancy or lactation, or sensitivity to medications in elderly patients complicates the situation, physicians may prefer to recommend psychotherapy as the treatment of choice.

Pharmacotherapy, Psychotherapy, or combination treatment?
The preferences of the professional discipline practiced by the first clinician who sees a patient for depressive mood disorder and/or family preferences for psychotherapy or pharmacotherapy are often decisive in designing an initial treatment plan. However, patients are better served when they are given well-informed and balanced education regarding the benefits, efficacy, and risks of available treatments and thus the opportunity to share in decision making. In the presence of a significant family history of affective disorders, recurrent episodes of mood disorder, severe symptoms, and/or the risk of self-destructive behavior, referral to a psychiatrist for consultation regarding use of medications is indicated.

In addition to patient preferences, deliberation about the choice of treatment should take into account the patient’s history of compliance with previously recommended medical or behavioral interventions and the presence of concurrent medical or psychiatric conditions. The therapeutic alternatives must also be compared in terms of availability, access, expense, and investment of personal effort and time. If the depressed patient is a child, a vulnerable adult, or an elderly person, his or her family should be given the opportunity to participate in decision making regarding treatment.

From an empirical standpoint, across large patient groups, combination treatment of depression has not produced dramatic increases over the immediate benefits achieved with drug therapy alone or psychotherapy alone. However, its use appears helpful and appropriate when the response to the initial course of treatment of several months’ duration is unsatisfactory, when symptoms recur, or when longer-range outcomes and lengthening of the interval between episodes of relapse or recurrence are the focus of attention.

What type of Psychotherapy?

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In the past two decades, several specific therapies developed to address the symptoms and associated features of depression have produced benefits superior to those provided by nonspecific psychotherapies, as demonstrated by results of outcome studies. These approaches tend to be structured (in some cases, being presented in a "treatment manual" format), directive, time-limited, and focused on identified target symptoms and on current rather than long-past issues. Moreover, they de-emphasize personality, character, and early-life relationships. None of these approaches prescribe therapy "by the book." Rather, each assumes a base of general clinical and therapeutic training and experience on the part of the therapist, a positive patient-therapist alliance, and use of nonspecific elements of empathy, nonpossessive warmth, concern, and optimism regarding the patient’s capacity to apply personal resources to his or her own benefit.

Specific Approaches—Four specific psychotherapeutic approaches have demonstrated benefits or "value-added" effects. Often, experienced psychotherapists combine these various depression-specific techniques in individual psychotherapy for depressed patients. Although the integrated-eclectic approach used clinically by many "master therapists" does not afford the same clarity that outcome research programs do, it frequently adds the benefit of clinical wisdom and expertise, which represents the practitioner side of the scientist-practitioner model.

Cognitive-Behavioral Therapy^2,3—The goals of cognitive-behavioral therapy are to alleviate depressive symptoms and prevent their recurrence by helping patients (1) identify, test, and reshape negative cognitions about themselves, the world, and the future, (2) develop new and more flexible cognitive patterns or schema that are alternatives to depressogenic ways of viewing life experiences, and (3) rehearse new cognitive and behavioral responses.

Interpersonal Psychotherapy^4-7—In interpersonal therapy, depression is defined as a disorder that happens to the patient and requires treatment. The patient can then assume the "sick role" with little concern for assigning blame to self or significant others.

Interpersonal therapy focuses on improving current social function in four problem areas:

1. Grief reaction to "exit events," losses, and bereavement, which is treated by facilitating grief work and encouraging the patient to compensate for losses by engaging in other relationships

2. Interpersonal role disputes and conflicts with significant others, which are treated by strategies for resolving disputes or facilitating the process of ending negative relationships

3. Role transitions and changes that add stress and threaten self-esteem, which are treated by helping the patient develop a sense of mastery in new roles

4. Interpersonal deficits reflected in the patient’s history and current circumstances involving inadequate or unsatisfying relationships, which are treated by strategies to reduce social isolation by building the social skills and opportunities needed to develop and maintain supportive relationships

Behavioral Therapies—Behavioral approaches to treating depression include social learning therapy, self-control therapy, social skills training, and multimodal therapies. All these therapies make use of the following techniques:

• Self-monitoring and self-evaluation of mood and activity
• Scheduled increases in levels of general, social, and pleasurable activity and behavioral productivity
• Decrease in or management of aversive events
• Development of self-reinforcement patterns
• Cognitive skills training to modify self-statements and attributions and to improve cognitive self-control, problem-solving and decision-making skills, and time management
• Relaxation and mental imagery training to encourage active stress management by development of positive coping and mastery images
• Assertiveness training, improvement of communication skills, and role play to enhance social skills and interpersonal effectiveness

Short-term Dynamic and Psychoanalytic Therapies—These therapies are not narrowly focused on symptoms of depression, and their efficacy rates are somewhat less definite than those achieved with symptom-specific therapies. They tend to organize brief interventions around the selection of a specific dynamic focus (usually an interpersonal problem) with links to core conflicts that often originated earlier in life. The current conflict is used as a focus, or "microcosm," for addressing negative patterns in the patient’s life.

Factors that affect treatment planning—For patients in special-risk groups, modification of treatment planning in light of prognosis for positive responses to intervention is necessary. For example, when depression occurs concurrently with other medical illnesses or mental conditions (especially personality disorders, substance abuse, and anxiety disorders), the benefits of brief and symptom-focused therapies may be limited. "Double depression," in which an acute episode of major depression is superimposed on chronic dysthymia, is likely to be associated with pervasive patterns of psychosocial impairment and residual dysfunction that may require longer-term therapy. When major depression occurs as part of bipolar illness, more active and longer-term therapeutic case management support may be needed to enhance compliance with both medical and psychotherapeutic treatment and to monitor mood and behavioral changes.

Age, gender, ethnicity, and social circumstances bring with them factors that may require specialized or extended therapeutic care.

Of what value are ancillary and collateral interventions?
Many psychotherapists have competencies not only in individual psychotherapies but also in other interventions that extend the effectiveness of treatment. When it is possible to mobilize patient and family resources for self-directed recovery and health maintenance efforts, the treatment process can be extended by means of self-help and independent reading. Guided practice in applying program approaches such as those described by Burns8,9 can be quite effective in changing patterns of self-talk, assertiveness, communication, activity scheduling, problem solving, and decision making. Self-help efforts can serve as a useful metaphor and focus for empowerment and countering feelings of helplessness and passivity.

The lack of close, confiding, supportive relationships, coupled with cycles of depressed mood and marital and other family role and interactive issues that may lead to separation or divorce, often triggers episodes or recurrences of depression. Family or marital therapy to improve family function or reduce the risk of family dissolution may be a therapeutically or clinically appropriate component of psychotherapeutic programs for depression.

Several of the specific approaches to psychotherapy for depression readily lend themselves to use in therapy groups. Group interventions can also provide support for patients whose depression is associated with such psychosocial stresses as concurrent medical illness, grief, and loss.

Conclusion
The personal, social, and economic costs and impairment in function caused by untreated or inadequately treated depression have tremendous and widespread effects. This impact can be most effectively controlled by integrated interdisciplinary approaches that offer patients the combined benefits of medications and psychosocial treatments of known and demonstrated efficacy, including psychotherapy.

Dr Erbaugh is a clinical psychologist, Minneapolis Clinic of Neurology, Ltd.

Source: Winter 1995, The Medical Journal of Allina Healthcare. References here.

The Attributes Of Psychotherapy For Depression

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