The American Psychological Association1 describes cognitive therapy (CT), behavioral activation (which can be administered alone but is also an important component of CT), interpersonal psychotherapy, and problem-solving therapy as having strong evidence of effectiveness in the treatment of major depressive disorder (MDD) using the criteria for evidence-based psychotherapies originally formulated by Chambless and Hollon.2 Short-term dynamic psychotherapy is listed as having only modest evidence of effectiveness.
In contrast, the American Psychiatric Association3 recommends CT, interpersonal therapy, problem-solving therapy, and psychodynamic psychotherapy as effective interventions for depression but limits the recommendation to only mild to moderate depression. Recent evidence on the effectiveness of psychotherapies in the treatment of depression suggests that another look should be taken at these guidelines. There is emerging evidence supporting the effectiveness of CT for severe depression and the effectiveness of dynamic psychotherapy for depression. In this article, I review some of the recent studies and possible changes to the guidelines that should be considered.
The efficacy and effectiveness of CT for MDD has been well established in controlled efficacy trials as well as in real world effectiveness trials.4-7 Given the substantial pain and suffering experienced by those who will encounter an episode of MDD in their lifetime, the research to date validating the effects of CT justify the time and costs necessary to implement this intervention in outpatient settings.
Hollon and colleagues8 demonstrated that CT reduced the risk of relapse after treatment was completed with continuation effects comparable to keeping patients on medication. The trial included only patients with severe depression, which indicates that the APA might reconsider its limited recommendation of psychotherapies for only mild to moderate depression.
Short-term dynamic psychotherapy
In contrast to the solid evidence base for CT in the treatment of depression, there has been substantial debate in the literature over the past 20 years regarding whether short-term dynamic psychotherapy, which targets maladaptive interpersonal patterns as the source of symptomatology, has sufficient research to support its dissemination as an intervention for MDD. Although dynamic psychotherapy has been and is currently practiced worldwide, the research literature across mental disorders is flooded with reviews that debate whether it has adequate evidence of effectiveness.
A comprehensive review concluded that dynamic psychotherapy has large pre-and post-effects that are maintained at 1 year and medium effect sizes relative to control conditions.9 Two trials provide strong evidence that dynamic psychotherapy combined with medication is superior to medication alone in the treatment of depression.10,11 These studies provide valuable insight into the utility of dynamic psychotherapy in real world practice where psychotherapies are often combined with medication treatment.
A recent trial of longer-term psychoanalytic treatment demonstrated superiority over treatment as usual for treatment-resistant MDD.12 At the 2-year follow-up, 44% of patients in the psychoanalytic treatment no longer met criteria for MDD compared with 10% of those receiving treatment as usual.
Dr Gibbons is Associate Professor Psychology, Department of Psychiatry, University of Pennsylvania, Philadelphia, PA.
The author reports no conflicts of interest concerning the subject matter of this article.
1. Society of Clinical Psychology. Psychological treatments. https://www.div12.org/diagnosis/depression. Accessed May 24, 2018.
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