Depressive disorders psychotherapy

Friedman, Michael A., Jerusha B. Detweiler-Bedell, Howard E. Leventhal, Rob Horne, Gabor I. Keitner and Ivan W. Miller, Combined Psychotherapy and Pharmacotherapy for the Treatment of Major Depressive Disorder , Clinical Psychology Science andPractice 11, no. 1 (2004) 47-68... 

The efficacy of psychotherapy and antidepressants is considered to be additive. Psychotherapy alone is not recommended for the acute treatment of patients with severe and/or psychotic major depressive disorders. For uncomplicated nonchronic major depressive disorder, combined treatment may provide no unique advantage. Cognitive therapy, behavioral therapy, and interpersonal psychotherapy appear to be equal in efficacy. 

When is medication indicated in the treatment of psychiatric illness There is no short answer to this question. At one end of the continuum, patients with schizophrenia and other psychotic disorders, bipolar disorder, and severe major depressive disorder should always be considered candidates for pharmacotherapy, and neglecting to use medication, or at least discuss the use of medication with these patients, fails to adhere to the current standard of mental health care. Less severe depressive disorders, many anxiety disorders, and binge eating disorders can respond to psychotherapy and/or pharmacotherapy, and different therapies can target distinct symptom complexes in these situations. Finally, at the opposite end of the spectrum, adjustment disorders, specific phobias, or grief reactions should generally be treated with psychotherapy alone. 

Eriedman MA, Detweiler-Bedell JB, Leventhal HE, et al. Combined psychotherapy and pharmacotherapy for the treatment of major depressive disorder. Clin Psychol Sci Pract 2004 11(1) 47-68. 

Birmaher, B., Brent, D.A., Kolko, D., Baugher, M., Bridge,/., Holder, D., Iyengar S., and Ulloa, R.E (2000a) Clinical outcome after short-term psychotherapy for adolescents with major depressive disorder. Arch Gen Psychiatry 57 29—36. 

Cascalenda, N.. Perry. J.C., Looper. K Remission in major depressive disorder, a comparison of pharmacotherapy, psychotherapy and control conditions. Am. J. Psychiatry 189, 1354-1360, 2002. 

Because this book focuses on psychopharmacotherapy, it is not intended to exhaustively review the role of psychotherapy. Nonetheless, some form of counseling is usually necessary during the treatment of major depressive disorder. Broadly defined, psychotherapy covers a wide range of modalities, from simple education and supportive counseling to cognitive-behavioral to insight-oriented psychodynamically based therapy. 

Psychodynamic supportive psychotherapy (n = 107) has been compared with psychotherapy plus medication (n = 101) in patients with major depressive disorder (93). The medications included venlafaxine, selective serotonin reuptake inhibitors, nortriptyline, and nortriptyline plus lithium. Lithium was used as an augmentation strategy in the patients who took lithium and nortriptyline (number not given). There were no differences in outcomes between the two treatment groups. No adverse effects specific to lithium were reported. 

In addition to antidepressant drugs, some forms of psychological treatments have been shown effec tive for treatment of major depressive disorder. These include cognitive behavioral psychotherapy and interpersonal psychotherapy (Weissman, 1979). These therapies differ from traditional psychoanalytically oriented methods in that the therapist takes an active role, the patient is expected to do homework, and the treatment is time limited, usually for about six months. Little data are available regarding whether the combination of medications and psychotherapy is more effective than either treatment alone, but data are suggestive of an additive effect. 

She was a very successful owner of a small print shop and had a history of solid interpersonal relationships. Her depressive disorder occurred after her best friend had been tragically killed in a boating accident. After five days of hospitalization, she was discharged. Five weeks later, after twice weekly psychotherapy and antidepressants, she was virtually symptom-free. There was no hint of the primitive personality disturbance evident when she was first hospitalized. 

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. 

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... 

Ikemi, Y. and S. Nakagawa, A Psychosomatic Study of Contagious Dermatitis , Kyoshu Journal of Medical Science 13 (1962) 335-50 Imel, Zac E., Melanie B. Malterer, Kevin M. McKay and Bruce E. Wampold, A Meta-Analysis of Psychotherapy and Medication in Unipolar Depression and Dysthymia , Journal of Affective Disorders no (2008) 197-206... 

The discovery of psychopharmacological medications was revolutionary because they provided a means of treating illnesses that were otherwise intractable. With the exception of electroconvulsive treatments for severe depression, there were no medical treatments for disorders that did not respond to psychotherapy. Once established, the drugs led to an ongoing search for more effective and safer medications. A second reason for their revolutionary status is that they furthered understanding of mental illnesses and normal brain function. Investigations of their therapeutic mechanisms led to theories of the neurochemical bases of mental illnesses. 

A trial of antidepressants is highly recommended in the treatment of dysthymic disorder. Although transference attitudes toward medications should always be explored, this may be especially true in treating a dysthymic patient. These patients commonly view their depressive symptoms as an integral part of their personality therefore, an antidepressant may be seen not as a treatment for an illness but as a confirmation of their defectiveness. In addition, the apathetic and pessimistic outlook of the dysthymic patient occasionally compromises treatment compliance. Because of these transference issues, a psychotherapy that does not ignore but explores the meaning of taking medication is indispensable to successful treatment. 

Dependent Personality Disorder (DPD). Apart from psychotherapy, which is essential, there is simply no data at this time to guide us in making psychopharma-cological treatment recommendations for DPD. However, these patients often suffer from comorbid depression or anxiety disorders that invariably require medication treatment. 

From our clinical experience, we have found that youth with more severe and chronic depressions and those with significant comorbid disorders or who experience parental conflict often fail to respond to either monotherapy alone (Clarke et ah, 1992 Brent et ah, 1998 Emslie et ah, 1998). Therefore, severe and chronic depressions should be treated with both antidepressants and psychotherapy, and other risk factors for poor outcome (e.g., parent depression, ADHD) should be addressed with additional psychosocial and/or pharmacological interventions. 

The initial choice of therapy is also dictated by the severity of the depression (e.g., the severity of depressive symptoms impedes an adequate trial of psychotherapy), subtype of depression (e.g., presence of psychosis, seasonal depression, or treatment-resistant depressions) presence of comorbid disorders, prior treatment history, child and parent motivation toward treatment, and the clinician s motivation and expertise in implementing any specific intervention. 

Comorbid anxiety has been associated with differential treatment response. This association predicts at times a better response to CBT and TCAs (Hughes et ah, 1990 Brent et ah, 1998). Treatment of comorbid anxiety, which most often precedes depression, is essential because the treatment contributes to improvement and may prevent future depressive episodes (Ko-vacs et ah, 1989 Hayward et ah, 2000). Fortunately, pharmacotherapy and psychotherapy treatments found useful for the treatment of MDD have also been found to be beneficial for treatment of youths with anxiety disorders (Kendall, 1994 RUPP Anxiety Group, 2001). 

Practically, unless there is any contraindication (e.g., medication side effects), the treatment that was efficacious in inducting remission of the acute episode should be used for maintenance therapy. Patients who are maintained only on medication should be offered psychotherapy to help them cope with the psychosocial scars induced by the depression. Further, many depressed youths live in environments charged with stressful situations and their parents usually have psychiatric disorders. In these instances multimodal treatments are particularly needed. 

Comorbid personality disorders have long been associated with TRD and a poor response to antidepressant treatment. For example, Pfohl et al. (1984) observed only a 16% response rate in inpatients with comorbid depression and personality disorder compared with a 50% response rate in patients with pure depression. Similar results were reported from a study by D. W. Black et al. (1987), in which, with the use of ECT in addition to a TCA, the response rate among those with a comorbid Axis II disorder was lower, 42% compared with a 60% recovery in those without Axis II pathology. The best approach for these patients may be a combination of psychotherapy and medication. This approach was recently borne out by the Treatment of Depression Collaborative Research Project (Shea et al. 1990), which found that cognitive-behavioral therapy yielded a better response than either imipra-... 

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