Dr Edward S. Friedman mainly focused on the STAR*D trial as providing a guide to the role of cognitive therapy (CT) in the treatment of depression (he was the national CT director for STAR*D). While the article also briefly mentions some equivocal results for CT in depression treatment, I don't think any up-to-date article on the topic of the role of CT in depression treatment can be complete without mentioning another recent study by Parker and Fletcher.1 Their study was a systematic literature search that suggests that because of the general effects of the therapeutic relationship, the specificity of CT (and interpersonal psy- chotherapy [IPT]) for depression treatment has yet to be demonstrated. The review should also be lauded because it has almost become "politically incorrect" to suggest that CT may not have specific effects on major depression.
Another study that should be given more attention in relation to the cognitive distortions that are the focus of CT is by Fava and associates,2 who showed that antidepressant medication can reverse the cognitive distortions of patients with major depression. My clinical experience as well as that of others supports Fava's findings that distortions are more likely the result of biological factors in major depression, while distortions that result from one's personality style may be more of a cause of disturbed mood in milder depression and transient dysphoric mood states. I have seen many patients with major depression conclude that the problem results from a situation in their lives rather than a disorder in mood-regulating neurotransmitters because their life situations are easier to see and because the prospect of having a brain-chemical disorder is a personal weakness that is not easy for one to accept. This can itself become a "cognitive distortion" that impairs their ability to seek important medical help.
To me, it still makes clinical sense to use CT to give patients an idea of how their cognitive distortions may be contributing to their emotional trouble; however, as psychiatrists we need to clarify within our profession and with our patients what therapies actually treat an illness and what therapies help one learn to function better. As Parker and Fletcher have found, the process of learning to function better itself may alleviate symptoms of depression.