Depression psychotherapy

Like most people, I used to think that antidepressants worked. As a clinical psychologist, I referred depressed psychotherapy clients to psychiatric colleagues for the prescription of medication, believing that it might help. Sometimes the antidepressant seemed to work sometimes it did not. When it did work, I assumed it was the active ingredient in the antidepressant that was helping my clients cope with their psychological condition. 

Psychotherapy looks even better when its long-term effectiveness is assessed.17 Formerly depressed patients are far more likely to relapse and become depressed again after treatment with antidepressants than they are after psychotherapy. As a result, psychotherapy is significantly more effective than medication when measured some time after treatment has ended, and the more time that has passed since the end of treatment, the larger the difference between drugs and psychotherapy. This long-term advantage of psychotherapy over medication is independent of the severity of the depression. Psychotherapy outperforms antidepressants for severely depressed patients as much as it does for those who are mildly or moderately depressed.18... 

For example, if one were studying an herb to treat depression, one would want to control as many factors as possible that could influence the outcome. People already taking an antidepressant drug would have to be excluded. One might also balance the subjects in different groups for severity of depression, psychotherapy treatment, or even levels of physical exercise. Certainly, the subject groups should be balanced for number of males and females, because sex differences in depression could contaminate the results. 

In the case of situative depressives. psychotherapy and combined drug and psychotherapy achieved approximately the same result and both were markedly better than drug therapy alone, which in turn was better than free appointments. 

BuysseDJ, TuXM, Cherry CR, Begley AE, Kowalski J, Kupfer DJ, Frank E (1999) Pretreatment REM sleep and subjective sleep quality distinguish depressed psychotherapy remitters and nonremitters. Biol Psychiatry 45 205-213... 

Depression is treated with the use of antidepressan t drugs. Psychotherapy is used in conjunction with the antidepressant drug s in treating major depressive episodes. The four types of antidepressants are ... 

Antidepressant drugs are used to manage depressive episodes such as major depression or depression accompanied by anxiety. These drugs may be used in conjunction with psychotherapy in severe depression. The SSRIs also are used to treat obsessive-compulsive disorders. The uses of individual antidepressants are given in the Summary Drug Table Antidepressants. Treatment is usually continued for 9 months after recovery from the first major depressive episode. If the patient, at a later date, experiences another major depressive episode, treatment is continued for 5 years, and with a third episode, treatment is continued indefinitely. 

Various forms of psychotherapy are regarded as effective interventions in mild to moderate depression, but studies comparing the economics of psychotherapy and pharmacotherapy are few (Rosenbaum and Hylan, 1999). One study found that the total health-care costs for patients who received psychotherapy were no different from those for patients who received an antidepressant. However, no efficacy measure was used (Edgell and Hylan, 1997). A randomized, prospective study which evaluated the treatment of depression with nortriptyline, interpersonal therapy or treatment as usual, with outcomes expressed in quality-adjusted life years, found that nortriptyline but not interpersonal therapy was a cost-effective alternative to treatment as usual (Lave et al, 1998). 

COMMENT It is interesting in that letter that George Greer wrote to me informally, off the record, that he had seen 10 patients in psychotherapy who had been treated extensively with fenfluramine for dieting. And, after several weeks on fenfluramine, they became very depressed, and two of them committed suicide. So that is a very serious consideration. 

Interpersonal therapy and cognitive behavioral therapy are types of psychotherapy that have well-documented efficacy for the treatment of MDD. Psychotherapy alone is an initial treatment option for mild to moderate cases of depression, and it may be useful when combined with pharmacotherapy in the treatment of more severe cases of depression. In fact, the combination of psychotherapy and pharmacotherapy can be more effective than either treatment modality alone in cases of severe or recurrent MDD. Psychotherapy can be especially helpful for patients with significant psychosocial stressors, interpersonal difficulties, or comorbid personality disorders.16... 

Benzodiazepines are used commonly in SAD however, there are limited data supporting their use. Clonazepam has been effective for social anxiety, fear, and phobic avoidance, and it reduced social and work disability during acute treatment.58 Long-term treatment is not desirable for many SAD patients owing to the risk of withdrawal and difficulty with discontinuation, cognitive side effects, and lack of effect on depressive symptoms. Benzodiazepines may be useful for acute relief of physiologic symptoms of anxiety when used concomitantly with antidepressants or psychotherapy. Benzodiazepines are contraindicated in SAD patients with alcohol or substance abuse or history of such. 

The nice thing about the neural-plasticity hypothesis is that it seems to explain so much. In fact, it is a better explanation of the effects of psychotherapy than of drugs. If recovery from depression depends on learning new ways of thinking, then psychotherapy - and especially cognitive behavioural psychotherapy - ought to be effective, and indeed it is, as we shall see in Chapter 7. The... 

Although it has received the most attention, CBT is not the only form of psychotherapy that is effective for depression. Other psychological treatments include interpersonal psychotherapy, short-term psychodynamic therapy and non-directive supportive therapy. Interpersonal psychotherapy focuses on problems that arise in interpersonal relationships, such as marital conflict, the loss of a loved one and social isolation.20 Short-term psychodynamic therapy focuses on acquiring insight and understanding of unresolved conflicts arising from the person s childhood. It is based on Freud s psychoanalytic theory, but requires only months, rather than the years it takes for a full psychoanalysis.21 Non-directive supportive therapy provides a warm, supportive atmosphere in which the depressed person can explore life issues... 

If both drugs and psychotherapy alleviate depression, maybe the combination of the two would work even better. This could be true even if the effects of antidepressants are placebo effects. As we saw in Chapter 4, taking two placebos can be more effective than taking only one. 

The central theme of this book is that much - if not all - of the therapeutic effects of antidepressants are due to the placebo effect. Might this not also be true of the effect of psychotherapy on depression Could this also be a placebo effect This is one of the objections that I hear quite often when I am invited to speak about my research. Psychotherapy is no more effective than antidepressant medication, these critics contend. So if antidepressants are merely placebos, so too is psychotherapy. 

If you look back again at the graph in Chapter i (page 10) showing the results of the first meta-analysis that I published on the treatment of depression, you can see why people might conclude that psychotherapy - like antidepressants - is merely a placebo. My own analysis showed that the effectiveness of psychotherapy is about the same as that of drugs, and that although both are much better than no treatment at all, neither is much better than placebo pills.29... 

Currently, the UK government is taking steps to make psychotherapy for depression more readily available. On 20 January 2005 the Prime Minister s Strategy Unit hosted a seminar in the Cabinet Office, the focus of which was an invited... 

If the government s Pathfinder programme is a success, the problem of insufficient therapists may be solved. But what do we do in the meantime People who are depressed cannot wait until the year 2015 for help. Fortunately, there are some low-cost alternatives that are available right now. These are treatment approaches that are sometimes used in conjunction with psychotherapy, but can also be used as stand-alone treatments. Let us take a look at them. 

Physical exercise as a treatment for clinical depression has not been studied as extensively as dmgs or psychotherapy, but there are a number of clinical trials evaluating its effectiveness.41 In some of these studies, exercise was compared to no treatment at all. In others, it was compared to psychotherapy, medication or attention-control procedures intended to control for the nonspecific placebo aspects of the exercise programme. Some of the trials also looked at the combination of physical exercise with... 

There seems to be considerable reluctance in some parts of the medical community to acknowledge the benefits of exercise in the treatment of depression. One meta-analysis of clinical trials showed that physical exercise was as effective as psychotherapy or antidepressant medication and much better than no treatment. But the authors concluded that the effectiveness of exercise in reducing symptoms of depression cannot be determined ,45 and the editors of the journal introduced the article with an editorial comment entitled effectiveness of exercise in managing depression is not shown by meta-analysis .46 Why not Because there were flaws in the way many of the studies had been designed. To be fair, there were indeed shortcomings in the studies, but these shortcomings also characterize clinical trials of antidepressants.47 If clinical trials like these do not establish the effectiveness of physical exercise as a treatment for depression, neither do they establish the effectiveness of antidepressants. 

The importance of economic problems in depression has been shown in a study of psychotherapy for depression conducted by two researchers in Chicago.55 They found that during the first two sessions of treatment, more than 85 per cent of the depressed patients spontaneously brought up issues relating to inadequate financial resources, difficult working conditions or unemployment. They also found that the patients... 

Depression is a serious problem, but drugs are not the answer. In the long run, psychotherapy is both cheaper and more effective, even for very serious levels of depression. Physical exercise and self-help books based on CBT can also be useful, either alone or in combination with therapy. Reducing social and economic inequality would also reduce the incidence of depression. 

For people who are depressed, and especially for those who do not receive enough benefit from medication or for whom the side effects of antidepressants are troubling, the fact that placebos can duplicate much of the effects of antidepressants should be taken as good news. It means that there are other ways of alleviating depression. As we have seen, treatments like psychotherapy and physical exercise are at least as effective as antidepressant drugs and more effective than placebos. In particular, CBT has been shown to lower the risk of relapsing into depression for years after treatment has ended, making it particularly cost-effective. 

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