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Guideline: Psychotherapy alone to reduce the symptoms of major depressive disorder may be considered a first-line treatment if the major depressive episode is mild to moderate and the patient desires psychotherapy as the first-line therapy. (Strength of Evidence = B.)
Psychotherapy, a generic term, refers to a variety of verbal and nonverbal techniques, packages, and procedures that differ in their immediate, intermediate, and long-term objectives. More than 250 types of psychotherapy have been described (Parloff, 1982). Table 10 provides an overview of the various potential objectives of psychotherapy and examples of therapies aimed at each.
Table 10. Objectives of acute phase psychotherapy Primary Objectives
| Primary Objectives1 | Examples | ||
|
|||
1While the tactics of a specific therapy package may change depending on the objectives (e.g., symptom removal versus adherence), the term (e.g., “cognitive therapy”) is retained as it refers to the theoretical basis and broad strategies involved in the approach.
Guideline: As the sole treatment for major depressive disorder, the initial objectives of acute phase psychotherapy are the same as for medication: symptom removal and restoration of normal social and occupational functioning. Acute phase psychotherapy may be considered as the sole treatment for major depressive disorder of mild to moderate severity that is not chronic, psychotic, or melancholic. This recommendation assumes the availability of a trained, competent therapist. (Strength of Evidence = B.)
Clinical experience and logic suggest that this recommendation may particularly apply if (a) the patient expresses a preference for psychotherapy as the initial treatment, (b) medication is contraindicated for the particular patient, or (c) the patient exhibits prominent psychosocial difficulties or evidence of a personality disorder.
Symptom removal and functional restoration are the goals of therapies targeted at symptom relief (e.g., cognitive or behavioral therapy) or current psychological problems (e.g., interpersonal or brief dynamic psychotherapy) that theoretically cause or maintain symptoms. It is hoped (though not established) that acute phase psychotherapy will prevent subsequent relapses and recurrences once treatment ends. (For recent reviews, see Hollon, DeRubeis, and Seligman, 1992; Persons, in press; Rehm, in press). Psychotherapies in combination with medication may also be used to augment symptom relief or to address collateral issues, such as adherence or secondary psychosocial problems (Rush, 1986).
Many commonly used forms of psychotherapy have not been subjected to randomized controlled trials in patients with major depressive disorder. That is, their efficacy has not been proven or disproven. Whether all psychotherapies are equally effective and whether they are differentially effective in different patient groups is unknown. The efficacy of psychotherapies studied to date is more similar than different, though only a few studies have included two psychotherapy cells to allow a direct comparison. In addition, most psychotherapies have many common features, although they may differ in specific procedures, tactics, or techniques. Whether these differences result in differential efficacy or whether they are of therapeutic value for some, but not other, patients is not known.
Randomized controlled trials of time-limited psychotherapies that have been codified in manuals reveal a significant benefit over wait-list controls for patients with mild to moderate forms of major depressive disorder (Depression Guideline Panel, forthcoming). However, there is minimal evidence that psychotherapy alone is effective in severe or psychotic forms of depression. There is strong evidence for the efficacy of medication (or ECT) for severe or psychotic depressions (Depression Guideline Panel, forthcoming).
A key problem in fully understanding the role of psychotherapy in major depressive disorder is identification of an adequate placebo control. Formal therapies nearly always exceed the effects of no treatment, minimal contact, or wait-list controls. Whether efficacy can uniquely, specifically, and with certainty be attributed to the particular therapy still remains an open question. That is, whether the beneficial outcome with therapy would have occurred with nonspecific interpersonal interactions of equal time and frequency has not been fully investigated.
On the other hand, studies directly comparing medication (as the “gold standard”) to psychotherapy alone have generally found equal efficacy in acute phase treatment in mild to moderate depression (Beck, Hollon, Young, et al., 1985; Covi and Lipman, 1987; Hersen, Bellack, Himmelhoch, et al., 1984; Murphy, Simons, Wetzel, et al., 1984; Roth, Bielski, Jones, et al., 1982; Rush and Watkins, 1981). However, equivalent response rates do not imply that the same patient would have responded to these two different treatments. It is logical to consider that some would have responded to one, while others would preferentially respond to the alternative treatment. For this reason, a time-limited treatment trial is recommended for acute phase treatment with psychotherapy, just as it is for medication.
If some patients do respond to psychotherapy, while others respond to medication, then patients’ recent treatment history will influence response rates. Yet, to date, only one study has attempted to evaluate this variable (Blackburn, Bishop, Glen, et al., 1981). This omission limits the utility of these studies in developing algorithms for which patients should receive which treatment. Furthermore, time-limited psychotherapies codified in manuals may not be particularly representative of actual clinical practice, which limits generalizability of the trials performed to date (Persons, 1991).
The psychotherapies that have been tested rarely differ from each other in efficacy. Failure to find that psychotherapies have different comparative response rates is not evidence that all are either ineffective or effective. In addition, most such studies have used small patient groups so that the ability to detect group differences is limited.
Guideline: As with a medication trial, if psychotherapy alone is selected as the initial treatment, the practitioner is advised to monitor symptom response. If the psychotherapy is completely ineffective by 6 weeks or if it does not result in nearly a full symptomatic remission within 12 weeks, a switch to medication may well be appropriate since there is clear evidence of its specific efficacy. (Strength of Evidence = A.)
During the course of therapy, criteria-based symptoms should be reviewed at 6 and 12 weeks to gauge response. Self-report or interviewerrated symptom scales are useful in following patient progress.
The possibility that psychotherapy prevents relapse/recurrence desert special comment. There is suggestive evidence from some post-acute treatment followup studies that those who respond to therapy, particular! cognitive therapy, as acute treatment have a lower relapse rate over the ensuing 6 months to 2 years than do those who respond to medication (s Hollon, DeRubeis, and Seligman, 1992; Depression Guideline Panel, forthcoming). However, methodological limitations make interpretation o these findings quite tentative. First, all studies to date are naturalistic, meaning that the patients’ treatment in the follownp period is not controlled. Second, it is possible that those who respond to medication have a poorer prognosis, if untreated, than do those who respond to therapy. Thus, there may be a sample bias favoring a better prognosis for responders to psychotherapy. (For a recent review, see Hollon, DeRubeis and Seligman, 1992.) Third, not all these followup studies reveal a better prognosis in those receiving acute phase psychotherapy versus medication Given these methodological limitations, interpretive difficulties, and inconsistent results, the panel concludes that acute phase psychotherapy not yet been shown to be of prophylactic value for recurrent major depressive disorder.
Peer-reviewed publications that report patient diagnoses using a specified descriptive system and a specified form of psychotherapy constitute the evidence for psychotherapeutic efficacy. Adult and geriatric studies were pooled for this synopsis because the number of geriatric studies that met criteria was small and there is no evidence yet for differences in adult and geriatric efficacy rates.
Table 11 summarizes the number of randomized controlled trials for each form of therapy found in the panel’s literature review. To include tl’ maximum number of studies in meta-analysis, the panel relied, whenever possible, on response as defined by the BDI (a self-report). The panel conducted analyses on intent-to-treat samples, which were calculated from the original reports. Most reports focused on completer samples (i.e., patients who completed the full trial), which likely biases the outcome in favor of the treatment studied. Thus, in a number of studies subjected to intent-to-treat meta-analysis, psychotherapy response rates are lower than those reported by the authors using either the completer sample or those with “adequate exposure.” The panel’s analysis includes no studies of partial therapy packages that attempted to isolate the “active” ingredients a particular therapy. Also omitted are studies that added a psychotherapy an otherwise unspecified “treatment as usual,” since the specific efficacy the therapy alone could not be inferred from this design.
Table 11. Number of randomized controlled psychotherapy trials in patients with major depressive disorder
| Therapy | Adult | Geriatric | ||||
| Acute | Cont | Maint | Acute | Cont | Maint | |
| Cognitive Behavioral Interpersonal Brief dynamic Marital
|
19 [10]2 11 [8] 2 [1] 5 [5] 1 [0] |
12 [0] 0 13 [0] 0 0
|
0 0 1 [0] 0 0
|
3 [2] 2 [1] 0 3 [1] 0
|
0 0 0 0 0
|
0 0 0 0 0
|
1Not randomized (open trial of responders to acute phase).
2Number in brackets is the number of cells for which meta-analysis was possible. Studies published only as dissertations or in non-peer-reviewed sources were not included
3Trial included responders to acute phase interpersonal psychotherapy plus imipramine.
Note: Cont = Continuation. Maint = Maintenance.
For depression, cognitive therapy aims at symptom removal by identification and correction of the patient’s distorted, negatively biased, moment-to-moment thinking and theoretically aims at prevention of relapse/recurrence by identifying and correcting silent assumptions (personal beliefs or schemes) (Beck, Rush, Shaw, et al., 1979; Dobson, 1989; Shaw, 1989; Wilson, 1989).
Twenty-two acute phase randomized controlled trials were conducted with cognitive therapy alone in adult or geriatric patients (Beck, Hollon, Young, et al., 1985; Blackburn, Bishop, Glen, et al., 1981; Covi and Lipman, 1987; de Jong, Treiber, and Henrich, 1986; Elkin, Shea, Watkins, et al., 1989; Gallagher and Thompson, 1982; Hogg and Deffenbacher, 1988; Murphy, Simons, Wetzel, et al., 1984; Neimeyer and Feixas, 1990; Neimeyer, Heath, and Strauss, 1985; Neimeyer and Weiss, 1990; O’Leary and Beach, 1990; Pecheur and Edwards, 1984; Ross and Scott, 1985; Rush, Beck, Kovacs, et al., 1977; Rush and Watkins, 1981; Scott and Stradling, 1990 [two trials]; Selmi, Klein, Greist, et al., 1990; Steuer, Mintz, Hammen, et al., 1984; Thompson, Gallagher, and Breckenridge, 1987; Turner and Wehl, 1984). Nearly all were conducted on outpatients. Certain pivotal studies (e.g., Blackburn, Bishop, Glen, et al., 1981) could not be included in the meta-analysis because the number randomized to each cell was not reported. In other cases, outcome was not reported in a categorical form. When outcome was reported categorically by a measure other than the BDI, the panel included the study in the analysis. Based on analysts means of the confidence profile method (CPM), the overall efficacy of cognitive therapy alone was 46.6 percent. For adult outpatients efficacy was 46.9 percent; for geriatric outpatients, it was 51.3 percent. In the only inpatient study available for CPM meta-analysis, the response rate was 58.3 percent (de Jong, Treiber, and Henrich, 1986).
Table 12 shows a comparison of cognitive therapy alone and alternative acute phase treatments. Overall, cognitive therapy was similar in efficacy to all other psychotherapies taken together. Cognitive therapy exceeded pill placebo with clinical management by only 9.4 percent (Elkin Shea, Watkins, et al., 1989). Compared to medication alone, cognitive therapy had a slight advantage.
Table 12. Meta-analysis of psychotherapy trials in outpatients with major depresiive disorder
| Therapy1,2 | Overall Efficacy | Therapy vs. Wait List | Therapy vs. Placebo | Therapy vs. Other Therapy | Therapy vs. Drug Alone |
| Behavioral therapy alone3 |
55.3% (9.3)4 [10]5 |
17.1% (34.0) [5] |
N/A | 9.1% (19.9) [6] |
23.9% (11.6) [2] |
| Brief dynamic psychotherapy alone |
34.8% (17.8) [6] |
N/A | N/A | -7.6% (14.6) [8] |
8.4% (21.3) [2] |
| Cognitive psychotherapy alone |
46.6% (6.9) [12] |
30.1% (22.0) [2] |
9.4% (8.3) [1] |
-4.4% (16.9) [6] |
15.3% (26.1) [3] |
| Interpersonal psychotherapy alone |
53.3% (6.1) [1] |
N/A | 22.6% (8.4) [1] |
13.3% (8.6) [1] |
12.3% (8.6) [1] |
| Martial psychotherapy alone |
N/A | N/A | N/A | N/A | N/A |
| Totals | 50.0% (5.3) [29] |
26.0% (23.5) [7] |
15.7% (13.0) [2] |
4.7% (8.5) [12] |
14.0% (11.2) [8] |
1Intent-to-treat sample.
2Adult and geriatric patient studies are combined.
3Behavioral therapy includes one cell with behavioral therapy plus placebo (Hersen, Bellack, Himmelhoch, et al., 1984).
4The numbers in parenthesis are the standard deviations of the estimated percentage of responders.
5The bracketed numbers are the numbers of cells on which these estimates are calculated.
These analyses combined group and individual cognitive therapy. Separating these two treatment formats, the overall efficacy of group cognitive therapy was 39.2 percent, and the overall efficacy of individual cognitive therapy was 50.1 percent. However, these response rates come from different trials. The one small study that directly compared these two formats found both to have equal efficacy (Rush and Watkins, 1981). Whether the group format is less effective than is individual cognitive therapy remains an open question that is particularly germane to the issue of cost containment. Of special note is a study that showed the efficacy of computer-assisted cognitive therapy to equal that of standard individual cognitive therapy (Selmi, Klein, Greist, et al., 1990). Further research on this potentially cost-effective approach is needed.
The prophylactic effects of cognitive therapy once acute phase treatment has been discontinued have not been established. They have not yet been fully evaluated because of methodological problems, such as brief followup periods, lack of controls, difficulties in defining relapse/ recurrence, inclusion of acute phase nonresponders in followup, naturalistic rather than controlled followup, and interpretive limitations. (For a recent review, see Hollon, DeRubeis, and Seligman, 1992.) Seven studies included a 1-year followup (Beck, Hollon, Young, et al., 1985; Gallagher and Thompson, 19X2; Kovacs, Rush, Beck, et al., 1981; O’Leary and Beach, 1990; Ross and Scott, 1985; Scott and Stradling, 1990; Simons, Murphy, Levine, et al., 1986), one included a 2-year followup (GallagherThompson, Hanley-Peterson, and Thompson, 1990), and one included an 18-month followup (Shea, Elkin, Imber, et al., 1992). All followups were naturalistic. Three studies showed that acute phase cognitive therapy was followed by fewer depressive symptoms at follownp than was wait-list (Gallagher-Thompson, Hanley-Peterson, and Thompson, 1990; O’Leary and Beach, 1990; Ross and Scott, 1985). When compared to patients treated with acute phase pharmacotherapy without a formal continuation or maintenance medication phase, patients treated with cognitive therapy showed fewer self-reported depressive symptoms (Kovacs, Rush, Beck, et al., 1981) or a lower relapse rate (Simons, Murphy, Levine, et al., 1986) at followup. In the 18-month followup of patients treated in the multisite NIMH collaborative study, all four treatments tested (cognitive-behavioral therapy, interpersonal psychotherapy, imipramine, and placebo plus clinical management) were associated with relatively high relapse rates (Shea, Elkin, Imber, et al., 1992). No one acute phase treatment was associated with a better prognosis in this naturalistic followup. Of all patients who entered the acute study (intent-to-treat sample), only 15 to 28 percent suffered no further major depressive disorder and needed no further treatment in the 18-month followup period.
Several different treatment packages (manuals), all of which are based on a functional analysis of behavior (Ferster, 1973) and/or social learning theory (Bandura, 1977), are involved in behavioral therapy for depression. They include activity scheduling (Lewinsohn, Antonuccio, Steinmetz, et al., 1984; Lewinsohn and Clarke, 1984), self-control therapy (Rehm, 1979), social skills training (Bellack, Hersen, and Himmelhoch, 1983), and problem solving (Nezu, 1986).
In the panel’s analysis, the overall efficacy of behavioral therapy was 55.3 percent. Compared to wait-list, behavioral therapy was 17.1 percent more effective; compared to all other forms of psychotherapy, behavioral therapy was 9.1 percent more effective. Compared to medication alone, it was 23.9 percent more effective. Behavioral therapy has not been compared to a pill placebo. Group behavioral therapy had a response rate of 51.1 percent, while individual behavioral therapy had a response rate of 57.7 percent. Thus, these two formats appear equally effective. In the one study that allowed for meta-analysis by providing a head-to-head comparison of group versus individual behavioral therapy (Brown and Lewinsohn, 1984), individual therapy had a response rate of 58.8 percent, while group therapy had a 52.9 percent response rate. The minimal contact group, however, had a higher response rate than did either “active” treatment (84.4 percent), as determined from the intent-to-treat sample.
Studies of the prophylactic value of acute phase behavioral therapy, once discontinued, are insufficient to draw firm conclusions. Only four studies involved a control or another formal acute phase treatment for depression (Brown and Lewinsohn, 1984; Gallagher and Thompson, 1982; Gallagher-Thompson, Hanley-Peterson, and Thompson, 1990; McLean and Hakstian, 1990). All four used naturalistic followup. In general, most between-group comparisons in these studies showed no difference in depressive symptoms for patients treated with behavioral therapy in the acute phase and those treated otherwise. One of the two comparisons that did reveal a difference found that only 11 percent of depressed elderly outpatients treated with either cognitive or behavioral therapy relapsed, compared to 44 percent of those treated with relational insight-oriented psychotherapy (Gallagher and Thompson, 1982); the other found that behavioral therapy was significantly more effective than was nonspecific treatment (relaxation training) on improving mood at follownp (McLean and Hakstian, 1990). Rehm, Kaslow, and Rabin (1987) found that 87 percent of their depressed sample had subsequent episodes in a 6-month followup. Gonzales, Lewinsohn, and Clark (1985) found that 50 percent of their sample, who had been treated with group or individual behavioral therapy, relapsed within a 1- to 3-year period. Several previous depressive episodes, positive family history, poor health, greater dissatisfaction with major life roles, greater pretreatment severity, and younger age were all predictive of relapse.
The aims of interpersonal psychotherapy are the clarification and resolution of one or more of the following interpersonal difficulties: role dispute, social isolation, prolonged grief reaction, or role transition. The patient and therapist define the nature of the interpersonal difficulty and work to resolve it. Interpersonal difficulties are viewed as either causal, concomitant, or exacerbating/maintaining factors for depression. Initial treatment sessions focus on patient education about the nature and course of the depressive syndrome, while subsequent sessions aim at resolving interpersonal difficulties.
Interpersonal psychotherapy for depression (Klerman and Weissman, 1987; Klerman, Weissman, Rounsaville, et al., 1984) has been studied in two acute phase randomized trials in outpatients with nonpsychotic major depressive disorder (Elfin, Shea, Watkins, et al., 1989; Weissman, Prusoff, DiMascio, et al., 1979). It is reported to be more effective than nonscheduled supportive treatment over 12 weeks of acute treatment and as effective as amitriptyline alone and the combination of interpersonal psychotherapy plus amitriptyline in reducing depressive symptoms. Although amitriptyline improved vegetative symptoms earlier in treatment, interpersonal psychotherapy improved mood, suicidal ideation, work, and interest earlier (DiMascio, Klerman, Weissman, et al., 1979; DiMascio, Weissman, Prusoff, et al., 1979). Patients in combined treatment were least likely to refuse treatment or to drop out (Weissman, Prusoff, DiMascio, et al., 1979).
In the only study for which meta-analysis was feasible (Elkin, Shea, Watkins, et al., 1989), the efficacy of interpersonal psychotherapy exceeded that of cognitive therapy by 13.2 percent, that of placebo plus clinical management by 22.6 percent, and that of imipramine by 12.3 percent, based on the BDI as the outcome measure and the intent-to-treat sample.
In a comparison of interpersonal psychotherapy with and without involvement of the spouse, the two approaches reduced depressive symptoms equally, but interpersonal psychotherapy with addition of the spouse was more effective in improving marital satisfaction (Foley, Rounsaville, Weissman, et al., 1987; cited in Jacobson, HoltzworthMunroe, and Schmaling, 1989).
The initial naturalistic study of the potential prophylactic effects of acute/continuation phase interpersonal psychotherapy, once stopped, found no difference at 1-year followup between interpersonal psychotherapy, amitriptyline, the combination of interpersonal psychotherapy and amitriptyline, and nonscheduled treatment in reducing relapse/recurrence (Weissman, Klerman, Prusoff, et al., 1981). Interpersonal psychotherapy did significantly improve social functioning. A more recent report also failed to find a lower relapse rate in interpersonal psychotherapy responders than in responders to the other three acute treatments in an 18-month followup (Shea, Elkin, Imber, et al., 1992).
One of several treatment paradigms that involve patients’ significant others (Jacobson, Holtzworth-Munroe, Schmaling, 1989), marital therapy is believed to be indicated in the treatment of some patients with major depressive disorder because:
The only randomized controlled trial of behavioral marital therapy (BMT) for depression reported that BMT reduced depressive symptoms significantly more than did a wait-list control and as well as did cognitive therapy in women with major depressive disorder or dysthymia (O’Leary and Beach, 1990). Both BMT and cognitive therapy reduced depressive symptoms significantly more than did wait-list, but only BMT increased marital satisfaction. Meta-analysis was not feasible, because outcome was not reported categorically.
In a preliminary report of a randomized trial of depressed married women assigned to marital therapy alone, cognitive therapy alone, or individual cognitive therapy with conjoint marital therapy, individual treatments effectively reduced depressive symptoms in those without marital discord (Jacobson, Schmaling, Salusky, et al., 1987). However, for those with marital discord, marital therapy was more effective than was cognitive therapy in alleviating depressive symptoms.
Four other studies, while ineligible for meta-analysis, indicated that marital or couples therapy addresses broader domains of outcome than does medication. Friedman (1975) randomly assigned married depressed patients in a mixed sample of “neurotic” (80 percent), bipolar, and psychotic (DSM-II) depressed outpatients to four treatment groups (amitriptyline and marital therapy, amitriptyline and minimal contact, placebo and marital therapy, and placebo and minimal contact). The study found that amitriptyline produced significantly greater relief from depressive symptoms than marital therapy or placebo. Marital therapy was more effective than placebo plus minimal supportive contact in reducing depressive symptoms and improving family functioning. McLean, Ogston, and Grauer (1973) found that couples behavioral therapy reduced selfreported depressive symptoms and decreased negative verbal interactions and actions toward the significant other more than did a nonspecific comparison condition. Corney (1987) assigned 80 depressed women who were seeing their general practitioners either to treatment with the general practitioner alone or to this treatment plus social work intervention. Social work intervention reduced depressive symptoms in the sample overall and was specifically beneficial to patients with marital problems. Sher, Baucom, and Larus (1990) treated couples with marital distress by BMT alone, BMT plus cognitive restructuring, BMT plus emotional expressiveness training, BMT plus cognitive restructuring plus emotional expressiveness, or wait-list. All treatment conditions improved marital satisfaction more than did wait-list.
The goal of brief dynamic psychotherapy is to resolve core conflicts based on personality and situational variables, thereby, in theory, resolving depressive symptoms in depressed patients. Neither the theory nor the technique was designed specifically for depression. Several brief dynamic psychotherapy approaches have been described (Malan, 1976, 1979; Mann, 1973; Wolberg, 1967). Treatment manuals are available (Luborsky, 1984; Strupp and Binder, 1984).
The acute effects of brief dynamic psychotherapy were investigated in seven randomized controlled trials (Covi and Lipman, 1987; Gallagher and Thompson, 1982; Hersen, Bellack, Himmelhoch, et al., 1984; Kornblith, Rehm, O’Hara, et al., 1983; McLean and Hakstian, 1979; Steuer, Mintz, Hammen, et al., 1984; Thompson, Gallagher, and Breckenridge, 1987), of which six could be meta-analyzed. No studies have compared brief dynamic psychotherapy to a pill placebo.
The overall efficacy of brief dynamic psychotherapy in these six studies was 34.8 percent. Compared to other therapies, brief dynamic psychotherapy may be slightly less effective. Compared to medication, it was 8.4 percent more effective. No placebo-controlled comparisons are available. Only one study contrasted brief dynamic psychotherapy to a wait-list control, but the response rate for those in the wait-list group was not reported categorically (Thompson, Gallagher, and Breckenridge, 1987).
Of the therapies studied to date, brief dynamic psychotherapy may have a slightly weaker overall effect. While this finding may suggest that better effects can be obtained with more structured, directive, less exploratory therapies (such as cognitive therapy, behavioral therapy, and interpersonal psychotherapy) for those with major depressive disorder, present data have several key limitations; Five of the six studies used brief dynamic psychotherapy in the group format, while the individual format is ypical practice. Second, the investigators were aligned in nearly every case with other forms of psychotherapy, which may have lead to less than optimal implementatio nof brief dynamic psychotherapy. Third, it is conceivable that some patients respond to brief dynamic psychotherapy, while others respond to other forms of treatment. If so, comparisions across different forms of treatment will be dictated by the mix of such patients in any given sample.
All naturalistic studies of the prophylactic value of acute phase brief dynamic psychotherapy for major depression revealed no differences in depressive symptoms at followup between brief dynamic psychotherapy and nospecific treatment (McLean and Hakstian, 1990), cognitive therapy (Gallagher-Thompson, Hanley-Peterson, and Thompson, 1990; MacLean and Hakstian, 1990), or the use of of antidepressant medication (MacLean and Hakstian, 1990). However, these studies have methodological problems that prohibit firm conclusions.
Guideline: Because psychotherapy alone has produced equivocal results in patients with melancholic (endogenous) symptom features, medication is recommended as the first-line treatment in these patients; medications have clear evidence of efficacy in placebo-controlled trials. (Strength of Evidence = A.)
Melancholic (endogenous) symptom features, such as pervasive anhedonia, unreactive mood, psychomotor disturbances, severe terminal insomnia, and weight and appetite loss, have been suggested as predictive or a poor response to psychotherapy for the acute treatment of major depressive disorder, but the strength of this possible association is unclear. Gallager and Thompson (1982, 1983) found that elderly patients who had major depressive disorder without endogenous features responded more quickly to psychotherapy than did those who had the disorder with such features. Prusoff, Weissman, Klerman, and colleagues (1980) ascertained that patients with endogenous symptom features did not respond well to interpersonal psychotherapy alone, but this finding was not replicated (Sotsky, Glass, Shea, et al., 1991). Patients with situational depressions responded as well to amitriptyline as to interpersonal psychotherapy alone or to the combination (Prusoff, Weissman, Klerman, et al., 1980). On the other hand, two studies failed to find a relationship between response to cognitive therapy alone and the presence of endogenous symptom features in outpatients with major depressive disorder (Blackburn, Bishop, Glen, et al., 1981; Kovacs, Rush, Beck, et al., 1981). Finally, Persons, Burns, and Perloff (1988), in an open trial of cognitive therapy in routine practice, found that patients without endogenous symptoms and those with peronality disorders were more likely to discontinue therapy prematurely. However, those with endogenous symptoms who completed treatment fared less well than did those without endogenous symptoms.
The value of endogenous symptom features in predicting behavioral therapy response is unclear. Some found no difference in acute phase response to behavioral therapy between those with and those without endogenous symptoms (These, Hersen, Bellack, et al., 1983), but others did (Brown and Lewinsohn, 1984; Gallagher and Thompson, 1982; Kornblith, Rehm, O’Hara, et al., 1983; McLean and Hakstian, 1979; Nezu, 1986; Nezu and Perri, 1989; Rehm, Kornblith, O’Hara, et al., 1981; Robin and De Tissera, 1982; Roth, Bielski, Jones, et al., 1982; Rude, 1986; Steuer, Mintz, Hammen, et al., 1984; Thompson and Gallagher, 1984; Thompson, Gallagher, and Breckenridge, 1987; Usaf and Kavanagh, 1990). Outpatients with more severe pretreatment symptoms seem less likely to respond to behavioral therapy (Steinmetz, Lewinsohn, and Antonuccio, 1983; Teri and Lewinsohn, 1986) and more likely to drop out of treatment (Last, Thase, Hersen, et al., 1985).
By contrast, there is strong evidence in inpatients and some in outpatients that those with a disorder that has melancholic features will do especially well with medication alone (Rush and Weissenburger, in press). Given the positive findings for medication and the unresolved, conflicting findings for acute phase psychotherapy alone, logic dictates that medication ;hould be the first-line treatment for patients with melancholic symptoms.
The presence of personality disorders may reduce or slow the response to cognitive, interpersonal, and other time-limited, symptom-focused psychotherapies alone, as well as to medication (Thompson, Gallagher, and Czirr, 1988; Depression Guideline Panel, forthcoming). For example, higher levels of neuroticism and personality pathology have generally been associated with a poorer response to interpersonal psychotherapy (Frank, Kupfer, Jacob, et al., 1987; Prusoff, Weissman, Klerman, et al., 1980; Shea, Pilkonis, Beckham, et al., 1990; Zuckerman, Prusoff, Weissman, et al., 1980) or cognitive therapy (Persons, Burns, and Perloff, 1988). A better response has been found in those without personality pathology (Pilkonis and Frank, 1988). Similarly, the therapist’s judgment of emotional health and better pretreatment social adjustment may predict better outcome (Rounsaville, Weissman, and Prusoff, 1981).
Marital dissatisfaction may be associated with higher rates of relapse and recurrence following maintenance interpersonal psychotherapy (Rounsaville, Weissman, Prusoff, et al., 1979), which logically suggests that marital therapy may be indicated for patients who suffer from marital discord and depression. Thus, remediation of continued psychosocial difficulties by means of therapy may help in the long-term prognosis of some depressed patients.
Guideline: In most cases, therapies that target depressive symptoms (cognitive or behavioral therapy) or specific interpersonal or current psychosocial problems related to the depression (interpersonal psychotherapy) are more similar than different in efficacy. (Strength of Evidence = B.) Long-term therapies are not currently indicated as first-line the acute phase treatments for patients with major depressive disorder. (Strength of Evidence = C.)
The exception to this guideline may be brief dynamic psychotherapy, which seems to have a lower overall response rate (34.8 percent, based on meta-analyses) in outpatients with major depressive disorder. However, different individuals may differentially benefit from one or another treatment (Persons, 1991), which mitigates strong inferences from the available data.
The evidence upon which to select among the several psychotherapies with efficacy suggested by randomized trials for the acute treatment of major depressive disorder is sparse (Table 12). Few studies have directly compared one psychotherapy to another. Furthermore, studies to date have been conducted largely at sites closely associated with the development or administration of one of these methods. Whether the comparison therapy(ies) was (were) administered with equal skill and enthusiasm (which could potentially bias findings) is unclear.
When formal psychotherapy is selected as the sole treatment for less severe episodes of major depression, the following general principles may be useful:
Medication and formal, short-term therapies or the combination of both are effective treatments for major depression. Long-term therapies have not been studied in randomized controlled trials. Therefore, long-term therapies used alone are not recommended as acute phase treatments for major depressive disorder.
Some forms of short-term psychotherapy not specifically designed for treatment of depression (e.g., marital therapy) may contribute to symptom improvement if the psychosocial situation indicates that focused therapy would be helpful.
Only a few forms of therapy as solitary acute treatments for major depressive disorder have been studied. In these cases, the therapists were highly trained in the particular modality, followed a manual, and often received ongoing supervision. Therefore, the question of the effectiveness of these therapies in everyday practice has not yet been fully addressed.
Guideline: At least once-a-week visits on a regular basis are recommended for formal psychotherapy. (Strength of Evidence = B.)
There are no randomized controlled trials comparing different psychotherapy session schedules. In nearly all of the published trials of psychotherapy, sessions occur once (most often) or sometimes twice a week (for cognitive therapy) (see Beck, Rush, Shaw, et al., 1979). In primary care settings, therapy is likely to be provided by a consultant/therapist who sees the patient one to two times a week. This schedule facilitates the assessment of the severity of depressive symptoms, seems sufficient to promote the therapeutic alliance between therapist and patient, and allows frequent enough visits to ensure adherence. Based on the available randomized controlled trials, at least a partial response is often present by 6 weeks, and remission occurs in most patients by 12 weeks.
Guideline: If psychotherapy alone is chosen as the acute treatment and there is no improvement of depression after 6 weeks or only partial improvement after 12 weeks, a consultation, referral, change in, or augmentation of the treatment plan is advised. Medication may appropriately be started in those who do not respond at all. (Strength of Evidence = B.)
No crossover trials to either another form of psychotherapy or medication have been conducted on patients who have not fully responded to psychotherapy alone. A switch to or addition of antidepressant medications, which are thought to work by different mechanisms of action and have been well demonstrated to be effective in major depressive disorder, should be considered. Medication should be started in those who do not respond at all. Formal psychotherapy may be continued or discontinued.
As with medications, a significant number of patients (20 to 50 percent) may drop out of psychotherapy shortly after its initiation for various reasons (Persons, Burns, and Perloff, 1988:
Depression Guideline Panel, forthcoming). The primary care practitioner will find it helpful to provide the patient with the option of returning for consultation or alternative therapy if the patient remains depressed, even before the 6-week reassessment visit.
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