Covers psychotherapy's many benefits in the treatment of depression, as well as types of psychotherapy and who should treat your depression.

The efficacy of psychotherapeutic treatments specific to depressive mood disorder has been shown to be comparable to that of pharmacologic treatments in alleviating symptoms of depression. 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.

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. (see: "Combination of Antidepressants and Therapy Best Treatment for Depression")

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.