Chapter 24. Depression-Focused Psychotherapies

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Edward S. Friedman, Michael E. Thase: Chapter 24. Depression-Focused Psychotherapies, in Gabbard’s Treatments of

DOI: 10.1176/appi.books.9781585622986.256315. Printed 5/10/2009 from www.psychiatryonline.com

Gabbard’s Treatments of Psychiatric Disorders > Part V. Mood Disorders >

Chapter 24. Depression-Focused Psychotherapies

INTRODUCTION

The term depression-focused psychotherapy is used herein to describe the time-limited

psychosocial treatments that have been tested and found to be effective treatments of major

depressive disorder. In this chapter we will review the most influential of these forms of therapy:

interpersonal psychotherapy (IPT) (Klerman et al. 1984) and the cognitive-behavioral models of

therapy, including cognitive therapy (CT) (Beck et al. 1979) and cognitive-behavioral analysis

system of psychotherapy (CBASP) (McCullough 2000). Each of these models of psychotherapy

emphasizes the use of model-specific formulations, psychoeducation, and procedurally guided

interventions to help patients learn to cope with and, it is hoped, recover from depression. Another

feature in common is that each of these psychotherapies has been subjected to empirical study

using randomized clinical trials. In this chapter we describe the conceptual and pragmatic

underpinnings for the major forms of depression-focused psychotherapy and summarize evidence

concerning their efficacy in the treatment of major depressive disorder in the adult population,

building on the comprehensive review published by the Agency for Health Care Policy and Research

(Depression Guideline Panel 1993) and the “Practice Guideline for the Treatment of Patients With

Major Depressive Disorder” published by the American Psychiatric Association (2000). The

interested reader might also wish to consult the earlier version of this chapter for a more detailed

review of the older literature (Thase 2001).

This research was supported in part by grants MH-71799, MH-61587, NIMH-98-05-0001, and MH-30915 (MHIRC) from

the National Institute of Mental Health.

SHARED FEATURES OF DEPRESSION-FOCUSED PSYCHOTHERAPIES

The depression-focused psychotherapies are nontraditional in that they do not posit that depression

is the result of core unconscious or neurotic conflicts, nor do they consider the therapeutic

relationship to be the central vehicle for clarification and resolution of such conflicts (e.g., Beck et

1979; Klerman et al. 1984; Lewinsohn et al. 1984). Nevertheless, it would be incorrect to

surmise that these therapies discount the importance of the working alliance between patient and

therapist. Rather, a therapeutic alliance based on mutual respect, genuineness, and empathy is

understood as the foundation on which the specific tasks and methods of the therapy are based

(e.g., Beck et al. 1979; Klerman et al. 1984). Furthermore, McCullough (2000) has incorporated a

focus on interpersonal interactions, including those with the therapist, in his treatment for patients

with chronic depression.

The depression-focused psychotherapies share a number of other features (Table 24–1). First, each

model of treatment was initially developed as a short-term therapy, generally delivered over 2–4

months. The time-limited nature of therapy has been emphasized explicitly in terms of the goal to

achieve relief of depressive symptoms as rapidly as possible—that is, in order to be cost-effective in

comparison with pharmacotherapy. Furthermore, by emphasizing short-term goals, these therapies

capitalize on the acute nature of many episodes of depression.

Table 24–1. Shared elements of depression-focused psychotherapies developed for treatment of

major depression

Time-limited format
Acute-phase treatment (i.e., 8–16 weeks)Print: Chapter 24. Depression-Focused Psychotherapies http://www.psychiatryonline.com/popup.aspx?aID=256319&print=yes…

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Modifications for continuation- or maintenance-phase therapies
Coherent theoretical model
Behavioral
Extinction of reinforcement
Decreased self-efficacy

iii. Decreased problem solving

Deficient social skills
Cognitive
Dysfunctional automatic thoughts
Distorted information processing

iii. Pathological basic assumptions or schemas

Interpersonal
Pathological grief
Interpersonal disputes

iii. Social role transitions

Interpersonal deficits
Procedurally specified methods of treatment
Treatment manuals
Theoretically guided types of interventions
Reframing of symptoms of depression syndrome within the theoretical context of the specific model
Feasibility of assessments of fidelity and adherence
Suitability for nondoctoral therapists
Specified and measurable outcomes
Symptom reduction
Improved global adjustment and enhanced quality of life
Model-specific outcomes
Behavioral (e.g., enhanced problem solving)
Cognitive (e.g., decreased severity of dysfunctional thoughts)

iii. Interpersonal (e.g., improved social adjustment)

Modules and provisions for training
Compatibility with concurrent antidepressant medication

Other shared features of the depression-focused psychotherapies include their specific linkage of a

theoretical model of phenomenology with strategies for symptom reduction, with specification of

methods to facilitate training and enhance fidelity (Dobson and Shaw 1993; Luborsky and DeRubeis

1984), and with acceptance of the need to identify observable and measurable goals and outcomes.

The latter two qualities are crucial advantages for empirical studies because the type of therapy

(the independent variable) and symptom change (the dependent variable) can be readily defined to

ensure internal validity. The particular theoretical orientation of each model of treatment also

yields predictions about specific outcomes, such as the effects of CT on measures of dysfunctionalPrint: Chapter 24. Depression-Focused Psychotherapies http://www.psychiatryonline.com/popup.aspx?aID=256319&print=yes…

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attitudes (e.g., Whisman et al. 1991) or IPT on measures of social adjustment (e.g., Weissman et

1981). Finally, these therapies share several pragmatic features, including their compatibility for

use in combination with pharmacotherapy and their suitability for use by therapists with a range of

backgrounds and training, after—of course—appropriate training.

INTERPERSONAL PSYCHOTHERAPY

At the most basic level, IPT aims to relieve depression by helping the patient to improve the quality

of his or her interpersonal world. Klerman et al. (1984) emphasized that depression occurs within

an interpersonal context regardless of its severity, phenomenology, or presumed etiology. The

authors further proposed that helping patients to improve their understanding of and ability to

modify the interpersonal context associated with depression facilitates the recovery process.

Additional long-term benefits were predicted to include improved social function and prophylaxis

against relapse. The original work using IPT also drew heavily on the methods and findings of social

casework. As a result, the therapy was always intended to be feasible for social workers and other

master’s degree–prepared mental health workers, as well as psychologists and psychiatrists.

The social milieu of the depressed person is central to the interpersonal therapist’s case

formulation. Of particular importance are the high rates of life stressors temporally associated with

the onset of unipolar depression, especially both acute and chronic marital difficulties.

Consequently, IPT often focuses on the relationship between attachment bonds and vulnerability to

depression. The apparent protective or “neutralizing” role of social support conversely may be

enhanced by helping the patient strengthen his or her intimate relationships. Another important

aspect of the depressed person’s social milieu is his or her performance in the workplace, with

friends and peer groups, and in neighborhood or community. Attention to social role performance

thus includes the individual’s current and long-term patterns of functioning in diverse situations, as

well as more recent or still-evolving role transitions (Klerman et al. 1984).

IPT also is a psychoeducational intervention because, in addition to the strong social emphasis,

therapists teach patients about depression and its treatment. This includes providing practical

advice or recommendations to help patients better tolerate the symptoms of depression (Klerman

et al. 1984). Although less structured than CT, IPT similarly aims to help patients improve

management of the symptoms and impairments associated with the depressive state. These efforts

also serve to help lessen the demoralization and hopelessness experienced by most depressed

individuals. The therapy may be quite active in this regard, including providing assistance to

patients through the use of problem-solving strategies.

A course of IPT typically consists of weekly sessions for 12–16 weeks. Therapy begins with

psychoeducation, including an explanation of the diagnosis and the goals and methods of therapy.

Concurrently, the therapist establishes a working alliance and performs an assessment of current

interpersonal relationships. In fact, competent interpersonal therapy is highly correlated with the

therapist’s ability to be empathic and genuine (Klerman et al. 1984).

Next, the interpersonal therapist helps the patient to identify interpersonal problems that are

associated with the depressive episode. An interpersonal inventory is obtained to help guide

treatment for one or two key problem areas. Four common theme areas generally serve as the

focus for IPT: unresolved grief, role disputes, role transitions, and interpersonal deficits. The latter

category incorporates areas such as the maladaptive interpersonal patterns associated with

personality disorders, deterioration in the patient’s social role performance (the “sick” role), or

social isolation.

The manual of Klerman et al. (1984) guides therapeutic interventions. In cases of unresolved grief,

the patient is encouraged to mourn the lost loved one and begin to develop new relationships.

When IPT centers on social role disputes, the patient is encouraged to explore whether the

difficulties might be resolved by renegotiation (as when the conflict appears to be at an impasse) or

dissolution (as when options might include separation or divorce). In states of role transition, the

therapy centers on recognition of the transition’s impact and assistance in developing solutions toPrint: Chapter 24. Depression-Focused Psychotherapies http://www.psychiatryonline.com/popup.aspx?aID=256319&print=yes…

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problems. When interpersonal deficits are paramount, overcoming social isolation and lack of

fulfillment is often emphasized.

Regardless of the key theme area, IPT also takes into account the role of personality patterns in the

genesis and maintenance of the problem. For example, the therapist may encourage the patient to

“try out” a different way of interacting and to compare the outcome with his or her more habitual

response (Klerman et al. 1984). Patients who are unable to maintain a strong therapeutic alliance

often have a harder time with IPT and, in turn, may elicit less competent interventions from

otherwise well-trained therapists (Barber and Muenz 1996).

Some evidence suggests that IPT may be perceived as more acceptable than either

pharmacotherapy or CT, at least by younger patients (Banken and Wilson 1992). It also has been

suggested that traditionally trained therapists may master IPT faster than CT (Thase 1994).

COGNITIVE THERAPY

The cognitive model of depression and the resulting therapy are largely the result of the seminal

work of Aaron T. Beck (Beck 1967, 1976). Beck posited that three types of problems in cognition

are associated with depression. The first is that depressed persons spend too much time thinking

unrealistically negative thoughts about themselves, the world, and their future (the cognitive

triad). Cognitions that are particularly relevant are those that occur almost instantaneously with

the worsening of dysphoric affect, which are referred to as automatic negative thoughts. These

negative cognitions provide the gateway for the cognitive therapist to understand the depressed

patient’s phenomenological world. The second type of cognitive dysfunction involves errors in

information processing, including overgeneralization, excessive personalization, selective

abstraction, emotional reasoning, and all-or-none thinking (for an expanded description, see Burns

1980). Such cognitive errors are characteristically state-dependent—that is, only apparent during

the depressive episode (Robins and Hayes 1993)—and may be heuristically understood as serving

to clarify and intensify the depressed person’s guiding beliefs (Thase and Beck 1993). Thus,

automatic negative thoughts dominate the depressed person’s state of mind and are reinforced by

mistaken conclusions resulting from errors in information processing. The third type of cognitive

dysfunction involves “deeper” levels of cognition, such as dysfunctional attitudes and

depressogenic schemas (Segal 1988; Young and Lindemann 1992). Schemas are basic organizing

cognitive structures. Although attitudes and schemas are unconscious, they can be accessed

through questioning, as illustrated by Beck’s (1976) use of the Socratic method or guided

discovery. The personal meaning revealed in a series of automatic thoughts is used to deduce the

patients’ beliefs and schemas. Dysfunctional attitudes are associated with more extreme or intense

reactions to life stress and may confer a greater risk of encountering new adversities (Simons et al.

1993).

These depressogenic structures are presumed to result from adverse early experiences (Beck 1976;

Segal 1988). In persons prone to depression, schemas representing excessive interpersonal

dependence or perfectionistic demands are theorized to be “silent” during times of a stable

romantic relationship or a high vocational attainment (Persons and Miranda 1992). However, they

are “activated” in response to specific matching adversities (e.g., Segal et al. 1992). The activation

of a pathological schema is hypothesized to induce mood-dependent changes in memory,

information processing, and automatic negative thoughts (Persons and Miranda 1992; Thase and

Beck 1993). Stress–diathesis interactions may explain why only some individuals become

depressed after a stressor such as divorce or unemployment.

Like IPT, CT was developed as a short-term model of treatment (Beck et al. 1979). Refinements in

the original manual have been made in case formulation (Persons 1989) and in treatment of

personality pathology (Beck et al. 1990; Young and Lindemann 1992) and more severe depression

(Wright et al. 1993). The technical fidelity and quality of CT sessions can be measured reliably with

the Cognitive Therapy Scale (Vallis et al. 1986).

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scheduling and graded task assignments, guided practice, and individualized homework

assignments. Explicit stepwise strategies are used to improve recognition of problem areas and

effect changes in thoughts, behaviors, and feelings. As with other types of therapy, therapists

employ core therapeutic skills, based on empathy, genuineness, and a strong therapeutic alliance to

facilitate a milieu conducive to learning and the mastery of targeted therapeutic tasks.

CT differs from most forms of behavior therapy with respect to its more elaborate theoretical

orientation and the detail of its guidelines for working with depressed patients (e.g., Beck et al.

1979; Thase and Wright 1991). These guidelines include a unique approach to the therapeutic

relationship, termed collaborative empiricism, which directs the therapist to assume the role of a

coach or teacher in addition to his or her provision of the more traditional nonspecific elements of

understanding and support. Through this model of interaction, the therapist and patient develop

stepwise goals to reduce symptoms, improve management of pressing day-to-day problems, and

increase morale. Collaboration is explicitly fostered via the liberal use of feedback and questioning

to ensure that the patient understands the material being covered. Compared with the process of

more traditional dynamic therapies, CT requires greater therapist activity (Jones and Pulos 1993),

which may foster a stronger working alliance (Raue et al. 1993). Paradoxically, an excessive focus

on correcting cognitive errors may strain the therapeutic alliance (Hayes et al. 1996).

The therapist introduces each new technique or intervention as a hypothesized means to help bring

about therapeutic change. Formal homework assignments and in-session demonstration of methods

and techniques are employed to facilitate the patient’s participation. Each session utilizes a

coherent structure in which an agenda is set, homework is reviewed, attention is given to one or

two key problem areas, and feedback is obtained. Some evidence indicates that the therapist’s

ability to structure and pace sessions and to consistently integrate homework assignments is

predictive of better outcomes (e.g., Bryant et al. 1999). Early in the course of therapy, particularly

with more severely depressed patients, there is typically a greater emphasis on behavioral

techniques. For example, daily monitoring of moods and activities is used to increase participation

in rewarding behaviors and to establish functional relationships between moods and automatic

thoughts. Similarly, stepwise graded task assignments are used to address problems that are

perceived as overwhelming. Slowly, and at a pace appropriate to the patient’s ability to use

abstract thought, the therapy moves toward eliciting and testing the accuracy of automatic

thoughts and developing rational alternatives. Therapeutic strategies, such as the use of written

responses to stereotypic automatic negative thoughts (“coping cards”) and a printed five-column

form known as the Daily Record of Dysfunctional Thoughts, are used to teach patients to begin to

challenge their negative cognitions. Patients are also encouraged to keep their thought records as

part of a journal or notebook so that a coherent summary of the course of therapy is readily

available. Each session ends with a new homework assignment that builds logically on the material

just covered. It is important to distinguish more simplistic models of cognitive intervention, such as

verbal persuasion, from the actual process of CT.

In contrast to persuasion, in which the “expert” advocates the “correct” position, CT emphasizes

guided discovery of logical errors and alternative interpretations. The fact that more positive

alternative conclusions can typically be identified and validated is at the heart of CT. Another

misconception about CT is that it minimizes affect and negates the personal significance of serious

setbacks, recommending Pollyanna-like optimism in the face of adversity. Rather, when CT is

conducted skillfully, the patient’s emotional reaction to a significant event is respectfully and

empathically understood in relation to his or her thoughts about self, world, and future (Thase and

Beck 1993). Through guided discovery, the therapist helps the patient elicit the chain of associated

thoughts in order to clarify a more realistic conclusion. CT thus differs from dynamic or experiential

therapies in that affect is specifically used to identify a cognitive process by which depressed

patients learn to solve problems and gain greater control over dysphoric moods (see, e.g., Jones

and Pulos 1993).

It is also believed to be incumbent on the cognitive therapist to help patients identify patterns and

themes associated with depressive vulnerability before terminating treatment. In this regard, thePrint: Chapter 24. Depression-Focused Psychotherapies http://www.psychiatryonline.com/popup.aspx?aID=256319&print=yes…

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final sessions are devoted to “diagnosing” pathological schemas and specific skills deficits and

developing longer-range self-help plans to address these problems, which is proposed to convey a

more enduring prophylactic effect (Beck et al. 1979; Persons 1993; Thase 1993). It remains

controversial whether such decreased vulnerability is better understood as the result of

development of a compensatory set of skills (i.e., to offset a persistently pathological schema) or

the actual revision of schemas (Barber and DeRubeis 1989; Persons 1993).

TREATMENT EFFICACY

A large number of randomized clinical trials have compared the depression-focused

psychotherapies with both psychosocial and pharmacological control conditions. The published

literature through 2000 has been reviewed extensively elsewhere (Dobson 1989; Robinson et al.

1990; Thase 2000); updated summaries of published controlled trials are summarized in Tables

24–2 and 24–3.

Table 24–2. Randomized clinical trials comparing depression-focused psychotherapies and

nonpharmacological control conditions as acute-phase treatments of major depressive disorder

Treatment Study

Duration

(weeks)

Comparison of efficacy

Interpersonal

Weissman et al. 1979 96 16 IPT > nonscheduled treatment

Elkin et al. 1989 239 16 IPT placebo + CMA; IPT = CT

O’Hara et al. 2000 120 12

IPT > waiting listf

Cognitive

Shaw 1977 32 4 CT (group) > attentional control; CT (group) >

waiting list; CT (group) = BT (group)

Fleming and Thornton

1980

35 4

CT (group)b BT (group); CT (group)b = dynamic

psychotherapy (group)

Comas-Diaz 1981 26 4

CT (group)b > waiting list assessment

Gallagher and Thompson

1982 (geriatric patients)

37 12 CT = BT; CT dynamic psychotherapy

Wilson et al. 1983 25 8

CTb > waiting list; CTb = BT

Steuer et al. 1984

(geriatric patients)

33 36 CT (group) dynamic therapy (group)

Ross and Scott 1985 51 12 CT > waiting list; CT (group) = CT (individual)

Rude 1986 48 5

CTb > waiting list; CTb = BT

Beutler et al. 1987 56 20 CT (group) + placebo > supportive care + placebo

Covi and Lipman 1987 70 14 CT (group) > “traditional” process group

Thompson et al. 1987

(geriatric patients)

91 16 CT > waiting list; CT = dynamic psychotherapy;

CT = BT

Hogg and Deffenbacher

1988 (college students)

37 8

CT (group)b = waiting listc ; CT (group)b =

dynamic psychotherapy (group)

Elkin et al. 1989 239 16

CT placebo + clinical managementa ; CT =

interpersonal

J. Scott and Stradling

1990, Study 1: primary

care setting

67 12 CT > waiting list;

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Treatment Study

Duration

(weeks)

Comparison of efficacy

J. Scott and Stradling

1990, Study 2: employee

assistance setting

36 12 CT (group) = CT (individual)

Selmi et al. 1990 36 6 CT = computerized CT; CT > waiting list

Jacobson et al. 1991 72 16

CTd BT (marital)

Beach and O’Leary 1992 45 15 CT > waiting list; CT = BT (marital)

Propst et al. 1992e

(devoutly religious

patients)

59 12 CT (“conventional”) > waiting list;

CT (“conventional”) = pastoral counseling;

CT (religious) > pastoral counseling;

CT (religious) CT (nonreligious)

Shapiro et al. 1994 117 16 CT psychodynamic interpersonal

Jacobson et al. 1996 149 16 CT = AT = BA

Note. IPT = interpersonal psychotherapy; AT = automatic thoughts; BA = behavioral activation; BT =

behavior therapy; CMA = clinical management; CT = cognitive therapy; “>” indicates more efficacy; ” “

indicates at least as much efficacy and sometimes more; “=” indicates equal efficacy.

aGeneral pattern of results favored active treatments over control, especially for IPT (relative to placebo) in

more severely depressed patients.

bCT condition is not fully representative of Beck’s (1976) model of treatment.

cWaiting-list group was not randomly assigned. Waiting-list subjects’ treatment was delayed by the Christmas

holiday break in classes.

dCT was more effective in couples whose marriages were not distressed.

e This included two forms of CT: “conventional” and a specially modified form integrating religious beliefs and

metaphors.

fAll patients in this study were women diagnosed with postpartum depression.

Source. Adapted and updated from Thase 1995.

Table 24–3. Randomized controlled clinical trials comparing depression-focused psychotherapies

and pharmacotherapy as acute-phase treatments of major depressive disorder

Treatment Study

Duration

(weeks)

Comparison of efficacy

Interpersonal

Weissman et al. 1979 96 16 Combined > IPT = amitriptyline

Schneider et al. 1986 26 16 IPT = nortriptyline

Elkin et al. 1989 239 16

IPT > imipraminea

Schulberg et al. 1996 276 32 IPT = nortriptyline > TAU

Reynolds et al. 1999b 80 16 Nortriptyline > IPT = placebo

Cognitive

Rush et al. 1977 41 12 CT > imipramine

Rush and Watkins

1981

39 12

Combined (tricyclic)b CT

Blackburn et al. 1981 64 12

Combined = CT > tricyclicb (general practice

clinic setting)

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Treatment Study

Duration

(weeks)

Comparison of efficacy

Teasdale et al. 1984 34 15

CT + TAU >TAUd

Murphy et al. 1984 70 12 Combined = CT = nortriptyline

Beck et al. 1985 33 12 Combined (amitriptyline) = CT

Beutler et al. 1987 56 20 CT (group) + alprazolam > alprazolam alone

Covi and Lipman 1987 70 14 Combined (imipramine) = CT (group)

Elkin et al. 1989 239 16

CT imipraminea

Hollon et al. 1992 106 12

Combinedc CT = imipramine

McKnight et al. 1992 43 8

CT = amitriptylinee

Murphy et al. 1995 37 16 CT = RT > desipramine

Blackburn and Moore

1997

75 16

CT = antidepressantsb

Jarrett et al. 1999 108 10 CT = phenelzine > placebo

B. Keller et al. 2000

DeRubeis et al. 2005

681

240

Combined > CT = nefazodone; CT =

antidepressant

Note. IPT = interpersonal psychotherapy; CT = cognitive therapy; TAU = treatment as usual; PST =

problem-solving therapy; “>” indicates more efficacy; ” ” indicates at least as much efficacy and sometimes

more; “=” indicates equal efficacy.

a Imipramine was more rapidly effective than either form of psychotherapy. Also, imipramine was more

effective than cognitive therapy in patients with Hamilton Rating Scale for Depression (Hamilton 1960) scores

> 20.

bThis indicates doctor’s choice of medication.

cAdvantage of combined treatment was limited to selected measures.

d Treatment as usual (TAU) was provided by primary care physician.

eMelancholic and hypercortisolemic patients in both cells had significantly poorer outcomes.

Source. Adapted and updated from Thase 1995.

Interpersonal Psychotherapy

Controlled Studies of Major Depressive Disorder

Acute-Phase Studies

An early study demonstrated that IPT was superior to a nonscheduled supportive contact and

comparable to acute-phase treatment with amitriptyline (DiMascio et al. 1979; Weissman et al.

1979).

In the second major study, the multicenter National Institute of Mental Health Treatment of

Depression Collaborative Research Program (TDCRP) (Elkin et al. 1989), IPT was compared with

CT, active imipramine plus clinical management, and inert placebo plus clinical management. The

efficacy of IPT was found to be comparable to that of both imipramine and CT by the end of a

16-week acute-phase protocol, although imipramine was more rapidly effective (Gibbons et al.

1993; J. T. Watkins et al. 1993). Unlike imipramine, IPT was as effective for patients with atypical

depression as for those with more classic neurovegetative profiles (Stewart et al. 1998). Within the

IPT group, patients with less pronounced interpersonal problems did better (Sotsky et al. 1991)

and patients with personality disorders did worse (Shea et al. 1990). Barber and Muenz (1996)

further examined specific personality traits and found that IPT—as compared with

cognitive-behavioral therapy (CBT)—was significantly more effective for patients withPrint: Chapter 24. Depression-Focused Psychotherapies http://www.psychiatryonline.com/popup.aspx?aID=256319&print=yes…

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obsessive-compulsive traits and significantly less effective for those with avoidant traits. Two other

groups have subsequently reported an association between anxiety symptoms and poorer IPT

response (Brown et al. 1996; Feske et al. 1998).

Schulberg et al. (1996) tested IPT against both a standardized pharmacotherapy protocol

(nortriptyline, titrated against plasma levels) and an unstructured treatment-as-usual condition

among patients treated in four urban primary care clinics. Results indicated that nortriptyline was

significantly more rapidly effective but that IPT “caught up” during the latter half of the 8-month

trial; both interventions were significantly more effective than the treatment-as-usual control

condition (Figure 24–1). A subsequent analysis suggested that standardized pharmacotherapy with

nortriptyline was more cost-effective (Lave et al. 1998).

Figure 24–1. Course of depressive severity from baseline (M0) to month 8 (M8) among

intent-to-treat primary care cohorts randomized to interpersonal psychotherapy (IPT),

nortriptyline hydrochloride (NT), or usual care (UC).

HAM-D = 17-item Hamilton Rating Scale for Depression (Hamilton 1960).

Source. Reprinted from Schulberg HC, Block MR, Madonia M, et al.: “Treating Major Depression in Primary

Care Practice: Eight-Month Clinical Outcomes.” Archives of General Psychiatry 53:913–919, 1996. Copyright

Used with permission.

IPT also is being studied in depression associated with pregnancy. For example, O’Hara et al.

(2000) compared women with postpartum depression who were being treated with IPT or a

wait-list condition. Compared with the control group, women receiving IPT showed significantly

reduced depressive symptoms and improved social adjustment.

Although the general equivalence of IPT and pharmacotherapy in elderly outpatients was reported

in an early study (Schneider et al. 1986; Sloane et al. 1985), a more recent study by Reynolds et al.

(1999b) found that IPT plus pill placebo was significantly less effective than pharmacotherapy with

nortriptyline and no more effective than pill placebo alone. This study was unique in that all

patients had bereavement-related depressive syndromes.

In a very intriguing recent study of bereavement-related depression, Shear et al. (2005) compared

conventional IPT with a targeted complicated grief treatment (CGT) that included CT techniques to

treat traumatic symptoms of disbelief, intrusive images, and avoidance behaviors. ThesePrint: Chapter 24. Depression-Focused Psychotherapies http://www.psychiatryonline.com/popup.aspx?aID=256319&print=yes…

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researchers found that although both treatments produced improvement in complicated grief

symptoms, the response rate was greater for CGT versus IPT (51% vs. 28%), and time to response

was faster for CGT (number needed to treat was 4.3). This study supports the notion that the

treatment of bereavement requires specific interventions beyond those typically employed in IPT.

Relapse Prevention and Prophylactic Treatment Studies

Klerman et al. (1974) assigned patients who responded to pharmacotherapy to 8 months of

treatment in one of four conditions that included weekly sessions with either a prototypical form of

IPT (with or without active amitriptyline) or supportive management (with or without active

amitriptyline). IPT did not have a significant preventive effect after the withdrawal of amitriptyline;

however, after 1 year of follow-up, IPT resulted in a significant improvement in social adjustment

for those who did not relapse (Weissman et al. 1974).

Subsequently, Frank et al. (1990) studied the manualized form of IPT in patients with highly

recurrent major depressive disorder in a maintenance-phase trial. Among 225 patients who began

therapy, 128 achieved and maintained a clinically significant remission for at least 4 months on

combined treatment and entered the 3-year experimental phase of this protocol. Patients were

randomized to one of five maintenance conditions: continued monthly IPT in combination with

active imipramine, monthly IPT in combination with placebo, monthly IPT alone, imipramine with

supportive management, and placebo with supportive management. Monthly sessions of

maintenance IPT produced a significant prolongation of well time compared with the placebo with

supportive care condition. However, outcome was superior in both conditions in which patients

received active maintenance pharmacotherapy. Beyond a nonsignificant trend during the first 9

months of maintenance therapy, there was no prophylactic advantage for patients receiving the

combination of IPT and maintenance pharmacotherapy compared with patients receiving treatment

with medication alone.

Subsequent analyses revealed two interesting correlates of longer-term IPT response. Patients

were found to have a more favorable outcome with maintenance IPT if their sleep profile showed a

more normal pattern of slow-wave sleep. An assessment of the quality of IPT also showed a large

effect on treatment outcome (Frank et al. 1991). Patients who participated in above-average

therapist-patient dyads showed a substantially lower risk of recurrent depression than did those

who participated in below-average dyads. In fact, the below-average IPT dyads showed a rate of

recurrence after discontinuance of medication that was almost identical to the rate of recurrence in

the placebo and clinical management group. Spanier et al. (1996) subsequently evaluated the

potential interaction of these two response modifiers. They found that the best outcomes were in

the patients with normal slow-wave sleep who participated in higher-quality therapy dyads, and the

worst outcomes were in the group characterized by decreased slow-wave sleep and membership in

a below-average therapy dyad (Figure 24–2). Thus, higher-quality therapy partly offset the

increased vulnerability associated with diminished slow-wave sleep.

Figure 24–2. Relationship of treatment specificity and delta ratio to time to recurrence.Print: Chapter 24. Depression-Focused Psychotherapies http://www.psychiatryonline.com/popup.aspx?aID=256319&print=yes…

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Note. High delta ratio/high focus, n = 13; low delta ratio/high focus, n = 8; high delta ratio/low focus, n =

13; and low delta ratio/low focus, n = 7.

Source. Reprinted from Spanier C, Frank E, McEachran AB, et al.: “The Prophylaxis of Depressive Episodes in

Recurrent Depression Following Discontinuation of Drug Therapy: Integrating Psychological and Biological

Reynolds et al. (1999a) completed a parallel study of preventive therapy with IPT and

pharmacotherapy in elderly patients with recurrent major depression. Patients were first stabilized

on the combination of IPT and pharmacotherapy; after 4 months of sustained remission, 107

patients were randomized to one of four maintenance treatment conditions: nortriptyline and

clinical management, combination therapy, IPT alone, and placebo and clinical management. Both

groups receiving IPT attended monthly therapy sessions. Results indicated that the combined

condition had the best preventive effect, with both of the monotherapies being superior to the

placebo plus clinical management condition (Figure 24–3). The advantage of the combined

condition over the monotherapies was particularly evident in the patients age 70 years and older.

In comparison with the midlife study of Frank et al. (1990), older patients showed a relatively

poorer protective effect with antidepressant monotherapy and hence a relatively greater long-term

benefit from the addition of IPT.

Figure 24–3. Survival function of four treatment groups stratified by age at current major

depressive episode.Print: Chapter 24. Depression-Focused Psychotherapies http://www.psychiatryonline.com/popup.aspx?aID=256319&print=yes…

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Note. Kaplan-Meier tests of survival function were significant for subjects ages 60–69 years (log rank = 25.9;

df = 3; P = 0.001) and subjects 70 years or older (log rank = 9.05; df = 3; P = 0.03). Pairwise contrasts

within each age stratum were not performed due to small sample sizes. IPT = interpersonal psychotherapy.

Source. Reprinted from Reynolds CF III, Frank E, Perel JM, et al.: “Nortriptyline and Interpersonal

Psychotherapy as Maintenance Therapies for Recurrent Major Depression: A Randomized Controlled Trial in

In summary, there is now reasonably broad empirical support for the utility of IPT for treatment of

major depressive disorder. Overall, these effects are similar in magnitude to acute-phase

antidepressant pharmacotherapy, although the time course of symptom reduction appears to bePrint: Chapter 24. Depression-Focused Psychotherapies http://www.psychiatryonline.com/popup.aspx?aID=256319&print=yes…

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slower and IPT may be less effective for patients with prominent anxiety. Such patients may do

better if they are treated with the combination of IPT and pharmacotherapy. The combination of

IPT and pharmacotherapy is an effective longer-term treatment for prevention of recurrent

depression. For both midlife and late-life patients, monthly sessions of IPT have some preventive

value after withdrawal of antidepressants, particularly for those in higher-quality therapy dyads.

The value of longer-term therapy for patients who respond to IPT alone during the acute phase has

not been established.

Cognitive Therapy

CT is the best-studied psychological treatment of major depression (Clark et al. 1999; Friedman et

2003; Gloaguen et al. 1998). CT has been extensively studied in comparison with both wait-list

control conditions and other forms of psychotherapy (see Table 24–2), as well as pharmacotherapy

(see Table 24–3). However, despite such intensive study, only three published trials of CBT have

included a placebo plus clinical management condition (DeRubeis et al. 2005; Elkin et al. 1989;

Jarrett et al. 1999).

Studies Comparing Cognitive-Behavioral Therapy With Wait-List or Placebo

Conditions

There is no doubt about the efficacy of CBT as an acute-phase treatment compared with wait-list

control conditions (Beach and O’Leary 1992; Depression Guideline Panel 1993; Neimeyer et al.

1989; Propst et al. 1992; Ross and Scott 1985; Rude 1986; M. J. Scott and Stradling 1990; Selmi et

1990; Thompson et al. 1987).

Studies Comparing Cognitive Therapy, Placebo, and Antidepressants

Two of the three placebo-controlled trials of CT unequivocally yielded positive results (DeRubeis et

2005; Jarrett et al. 1999). In the third study, the TDCRP (Elkin et al. 1989), CT surpassed

placebo only on some secondary analyses and was less effective than pharmacotherapy in some

analyses of more severely depressed subsets of patients. Jarrett et al. (1999) found CBT to be equal

to phenelzine and superior to pill placebo in a well-controlled 10-week double-blind study of 108

patients with atypical depression (58% intent-to-treat response rates, compared with 28% in the

pill placebo group) (Figure 24–4). The most recent study (DeRubeis et al. 2005) reports on a

16-week placebo-controlled trial comparing the efficacy of CT and clinical management with either

paroxetine or placebo in moderate to severely ill depressed outpatients. The trial is unique in that

the placebo group only received 8 weeks of double-blind therapy, and nonresponders in the

paroxetine group could receive augmentation with desipramine or lithium at week 8. They found

response rates of 50% for pharmacotherapy, 43% for CT, and 25% for the placebo plus clinical

management group. Using continuous score analysis, both active treatments pairwise contrasts

show a significant advantage for medication treatment compared with placebo plus clinical

management (P = 0.006) and a nonsignificant trend in favor of CT compared with placebo plus

clinical management (P = 0.09). Interpretation of these findings is complicated by a significant

site-by-treatment interaction. Specifically, an advantage for pharmacotherapy was evident at the

Vanderbilt site, whereas CT tended to be more effective at the Philadelphia site.

Figure 24–4. Symptomatic responses to cognitive therapy and phenelzine sulfate

pharmacotherapy were not significantly different, and both treatments were superior to

administration of placebo.Print: Chapter 24. Depression-Focused Psychotherapies http://www.psychiatryonline.com/popup.aspx?aID=256319&print=yes…

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HAM-D = Hamilton Rating Scale for Depression (Hamilton 1960).

Source. Reprinted from Jarrett RB, Schaffer M, McIntire D, et al.: “Treatment of Atypical Depression With

Cognitive Therapy or Phenelzine: A Double-Blind, Placebo-Controlled Trial.” Archives of General Psychiatry

In comparisons with pharmacotherapy conducted in primary care clinics, results of five trials

indicated that CT, either alone (Blackburn et al. 1981) or in combination with treatment as usual

(Ross and Scott 1985; C. Scott et al. 1997; M. J. Scott and Stradling 1990; Teasdale et al. 1984),

was significantly more effective than control conditions. Like the findings of DeRubeis et al.

(2005)—and unlike those of the TDCRP (Elkin et al. 1989)—most studies conducted in psychiatric

outpatient settings have documented parity between CT and pharmacotherapy (see Thase (2000). A

mega-analysis that focused on more severely ill patients in four of the earlier studies showed no

benefit of pharmacotherapy over CT (DeRubeis et al. 1999). Results from studies utilizing more

rigorous pharmacotherapy conditions (the psychiatric clinic settings of Blackburn and Moore 1997;

Blackburn et al. 1981; Elkin et al. 1989; Hollon et al. 1992; Jarrett et al. 1999; McKnight et al. 1992;

and Murphy et al. 1984 have yielded more consistent evidence of parity (see Table 24–3).

Exceptions to such parity include an initial study by Beck’s group, in which results favored CT over

imipramine hydrochloride (Rush et al. 1977); Murphy et al.’s (1995) small study of depressed

outpatients, in which both CT and relaxation training were significantly more effective than

desipramine; Markowitz et al.’s (1998) study of mildly depressed HIV-seropositive men, in which

imipramine was more effective than CT; and, as noted earlier, the TDCRP (Elkin et al. 1989). Some

have questioned the quality of CT in the TDCRP (Jacobson and Hollon 1996a), the role of site effects

on outcomes in multisite study designs (DeRubeis et al. 2005), and whether CBT and IPT as

performed in this study were truly separate and distinct treatments (Ablon and Jones 2002).

Studies Comparing Cognitive Therapy With Other PsychotherapiesPrint: Chapter 24. Depression-Focused Psychotherapies http://www.psychiatryonline.com/popup.aspx?aID=256319&print=yes…

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CT has generally been found to have an efficacy comparable to that of other active psychotherapies,

including behavioral marital therapy, behavior therapy, IPT, brief dynamic therapy, pastoral

counseling, and nondirective group therapy (see Table 24–2). Published comparative studies have

similarly documented a slight advantage for individual CT compared with group CT (see Table

24–2). In fact, Ravindran et al. (1999) found that group CT added little symptomatic benefit when

combined with sertraline in a study of 97 patients with primary dysthymic disorder.

Inpatient Applications of Cognitive Therapy

CT is the only form of individual psychological treatment to be specifically modified for treatment of

hospitalized depressed patients (Stuart and Thase 1994; Wright et al. 1993). Poorer outcomes have

been observed among inpatients with significant comorbidity (Thase 1994) and/or a history of

nonresponse to antidepressant medication (Thase and Howland 1994). In two controlled studies of

combined treatment (Bowers 1990; Miller et al. 1989), CT plus antidepressants was generally more

effective than antidepressants alone, although the studies were small and the observed advantages

were not always statistically significant.

Cognitive-Behavioral Analysis System of Psychotherapy Modifications

As noted earlier, McCullough (2000) adapted CT to deal with common problems that he found to

arise in the treatment of people with more long-standing depressive disorders, including dysthymia

and the so-called double depression. McCullough had been impressed by chronically depressed

patients’ relative passivity and ineffective approaches to social problem solving and their

difficulties in developing and maintaining a productive therapeutic relationship. To address these

problems, CBASP includes a greater focus on the patients’ interactions with significant others

(including the therapist) and systematic use of a stepwise situational analysis of interpersonal

interchanges to help patients better clarify their goals and develop more effective methods of

obtaining their goals.

To date, only the study of M. B. Keller et al. (2000) has systematically evaluated CBASP. This large

multicenter trial compared CBASP and the antidepressant nefazodone, singly and in combination, in

more than 600 patients with chronic forms of major depression. The two monotherapies were

comparably effective at week 12, although nefazodone was more rapidly effective. The combination

of CBT and pharmacotherapy was markedly more effective than both of the monotherapies (e.g.,

intent-to-treat response rates: CBT alone, 48%; nefazodone alone, 48%; in combination, 73%).

Analyses of the rates of change in symptom measures suggested that the combined condition

benefited by having both the early symptom effects of nefazodone and the later emerging symptom

effects of psychotherapy. Subsequent analyses indicated that combined therapy was particularly

helpful for insomnia and anxiety (compared with CBASP alone), whereas CBASP was particularly

helpful (compared to nefazodone alone) among patients with a history of early trauma (i.e., sexual

or physical abuse or neglect) (Nemeroff et al. 2003; Ninan et al. 2002; Thase et al. 2002).

Follow-Up Studies of Cognitive Therapy and Related Therapies

During naturalistic follow-up, patients treated with CT generally fared better over 1- or 2-year

follow-ups than patients who were treated with treatment-as-usual interventions (Hensley et al.

2004; Ross and Scott 1985; M. J. Scott and Stradling 1990) or those who were withdrawn from

antidepressant pharmacotherapy (Blackburn et al. 1986; Evans et al. 1992; Hollon et al. 2005;

Kovacs et al. 1981; Simons et al. 1986). However, in the TDCRP study (Elkin et al. 1989), no

appreciable difference in relapse rates was found among patients who responded to CT compared

with those who were treated with imipramine or placebo (Shea et al. 1992). Given that CT was not

particularly effective in this study, this finding is not too surprising. Comparability in survival rates

among several forms of active psychotherapy has been observed in four follow-up studies

(Gallagher and Thompson 1982; Gallagher-Thompson et al. 1990; Jacobson et al. 1993; Shea et al.

1992).

In the naturalistic studies of Blackburn et al. (1986) and Simons et al. (1986), relapse after CT or

pharmacotherapy was heralded by high levels of residual symptoms and/or high residual scores onPrint: Chapter 24. Depression-Focused Psychotherapies http://www.psychiatryonline.com/popup.aspx?aID=256319&print=yes…

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a measure of dysfunctional attitudes. These findings were replicated by Thase et al. (1992) during a

controlled 1-year follow-up of CT responders. In this latter study, the relapse rate at 1-year

follow-up was only 10% among patients who terminated 16 weeks of individual CT after having

achieved at least 2 months of symptom remission. By contrast, patients without a sustained

remission had a relapse rate of more than 50%. Recently, Hollon et al. (2005) reported on a

12-month naturalistic follow-up of patients who responded to either CT or medication (paroxetine

plus or minus adjuncts) in a randomized controlled trial (DeRubeis et al. 2005). One-half of the

medication responders were randomized to receive continuation-phase pharmacotherapy; the

remainder were withdrawn from the antidepressant. Patients withdrawn from CT during

continuation were less likely to relapse than patients withdrawn from medication, and the relapse

rate following CT was about the same as the relapse rate of those patients who continued

medication. Several early studies evaluating CT as a continuation- or maintenance-phase therapy

(Baker and Wilson 1985; Blackburn et al. 1986; Kavanaugh and Wilson 1989) were equivocal. On

the other hand, Jarrett and Kraft (1997) observed that an 8-month course of continuation-phase CT

(10 sessions) reduced relapse rates by about 50% compared with a historical control group that

received only acute-phase therapy. In the first randomized trial comparing CT with and without a

continuation phase in responders to CT, Jarrett et al. (2001) found that a continuation phase plus

CT significantly reduced relapse. This was especially true for those subjects with early onset of

depression and those with unstable remission after acute-phase treatment.

Fava et al. (1994) developed a form of CBT for patients with residual depressive symptoms despite

adequate pharmacotherapy. In the initial trial, they randomized 40 incompletely remitted patients

to either 10 sessions of CBT (in addition to ongoing pharmacotherapy) or continued

pharmacotherapy alone. CBT had a significant effect in reducing residual symptoms (Fava et al.

1994), and across 4 years of follow-up, the risk of relapse/recurrence and the likelihood of being

able to be withdrawn from antidepressants were significantly improved in comparison with the

group that did not receive medication (Fava et al. 1996, 1998).

This approach has been independently replicated in a larger group of incompletely remitted patients

receiving ongoing pharmacotherapy (Paykel et al. 1999). Subsequent analyses indicated that this

model of CBT reduced relapse via modification of dysfunctional information processing (Teasdale et

2002), was cost-effective (J. Scott et al. 2003), and conveyed protection against relapse for

more than 1 year after therapy was terminated (Paykel et al. 1999).

Fava et al. (1998) also studied the utility of their model of CBT as an alternative to extended

pharmacotherapy for patients with highly recurrent depression. They conducted a pilot study of 40

patients who had been in remission for at least 10 weeks on antidepressants. Half were randomly

assigned to receive 10 sessions of CBT and half received standard clinical management; all were

withdrawn from antidepressants. They observed that CBT had highly significant effects, offering a

level of protection against recurrent depressive episodes that is comparable to maintenance

antidepressant therapy (Figure 24–5).

Figure 24–5. Recurrence rates after antidepressant discontinuation among patients who received

either cognitive-behavioral therapy (CBT) or clinical management.Print: Chapter 24. Depression-Focused Psychotherapies http://www.psychiatryonline.com/popup.aspx?aID=256319&print=yes…

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Note.The difference between groups was highly significant (log rank 2 = 11.98, P < 0.001).

Source. Reprinted from Fava GA, Rafanelli C, Grandi S, et al.: “Prevention of Recurrent Depression With

Cognitive Behavioral Therapy: Preliminary Findings.” Archives of General Psychiatry 53:816–820, 1998.

Correlates of Cognitive-Behavioral Therapy Response

One advantage of the relatively large number of studies of CT is that evidence about correlates or

predictors of response has emerged (see Whisman 1993 for a detailed review of earlier studies).

Specifically, single or unmarried status, high pretreatment levels of dysfunctional attitudes,

chronicity, increased initial symptom severity, and higher rates of comorbid Axis I disorders have

been associated with poorer outcomes after 10–16 weeks of treatment with CBT (Barber and Muenz

1996; DeRubeis et al. 2005; Jarrett et al. 1991a, 1991b; K. Keller 1983; McKnight et al. 1992; Rush

et al. 1978; Simons et al. 1995; Sotsky et al. 1991; Stewart et al. 1993; Thase 1993; Thase et al.

1991, 1992, 1994a, 1994b, 1996). Men and women appear to be equally responsive to CT

(DeRubeis et al. 2005; Jarrett et al. 1991a; Thase et al. 1994a), although more severely depressed

women may have somewhat poorer outcomes (Thase et al. 1994a). Patients with certain comorbid

personality disorders appear to respond as well to CT as do patients with no personality disorders

(Shea et al. 1990; Stuart et al. 1992), although Barber and Muenz (1996) found that those with

obsessive-compulsive traits were less responsive to CT than to IPT. It should be noted that

research trials of major depressive disorder typically have excluded patients with more severe Axis

II psychopathology, such as those with antisocial and/or borderline personality disorders. It is

noteworthy that several groups have found that comorbid personality disorders do not predict

poorer response to CT (Persons et al. 1988).

Positive correlates of CT outcome may include high pretreatment levels of learned resourcefulness

(Burns et al. 1994; Simons et al. 1985), self-efficacy (Kavanaugh and Wilson 1989), optimism

(Seligman et al. 1988), motivation (Fennell et al. 1987; Marmar et al. 1989), and homework

compliance (Bryant et al. 1999; Burns and Nolen-Hoeksema 1991; Neimeyer and Feixas 1990;

Persons et al. 1988; Primakoff et al. 1986). The relationship between learned resourcefulness andPrint: Chapter 24. Depression-Focused Psychotherapies http://www.psychiatryonline.com/popup.aspx?aID=256319&print=yes…

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CT outcome has not been replicated by all groups (Beckham 1989; Jarrett et al. 1991b) and may be

relevant to only more severely depressed patients (Burns et al. 1994). High levels of therapist core

skills have been associated with favorable outcomes in some (Burns and Nolen-Hoeksema 1992;

DeRubeis et al. 2005) but not in others (DeRubeis and Feeley 1990; Schmaling et al. 1986). Years

of therapeutic experience (Burns and Nolen-Hoeksema 1992) and technical competence in

structuring therapy (Bryant et al. 1999; DeRubeis et al. 1990) have also been associated with

better outcomes. Nevertheless, this line of research warrants further attention, particularly in

trying to understand the results of studies such as the TDCRP (Elkin et al. 1989) and DeRubeis et al.

(2005), in which the performance of CT varied across sites (DeRubeis et al. 2005; Jacobson and

Hollon 1996b; Thase 1994).

DEPRESSION-FOCUSED PSYCHOTHERAPIES FOR BIPOLAR DISORDER

Psychotherapies based on IPT and CT have been adapted to the treatment of bipolar disorder. All of

these psychotherapies have several characteristics in common. First, they are designed to be

adjunctive to optimal pharmacotherapy. They incorporate an educational component to teach

patients (and their families) about bipolar illness. Furthermore, the promotion of medication

compliance and treatment adherence is recognized to be a central goal of the psychotherapy. In

summary, all these therapies attempt to reduce symptoms, enhance functioning, prevent relapse,

and decrease the risk of recurrence.

Basco and Rush (1996) formulated a CBT approach to bipolar disorder that focused on intervening

in the mutually reinforcing cycle of symptomatic relapse, impairment of cognition, worsening

psychosocial function, and increasing level of stress. CBT adherents attempt to target the cognitive,

behavioral, and affective changes in depression and mania, helping patients to effectively manage

bipolar illness by stopping the progression of episodes (Basco et al. 2004). CBT begins with

psychoeducation about the disorder and pharmacological treatments and the ways in which lifestyle

and interpersonal interactions affect the patient’s cognitions and behaviors. A second goal of

treatment is relapse prevention, which includes learning to identify and monitor symptoms for signs

of relapse. The third goal of treatment is to improve adherence to pharmacotherapy and to

introduce lifestyle modifications, such as sleep and exercise hygiene. The fourth goal of treatment

examines the cognitive and behavioral strategies for symptom control. The final goal of CBT

treatment focuses on the reduction of psychosocial stressors (e.g., relationships, financial

problems, vocational and occupational problems) (Basco et al. 2004).

There have been only a few studies examining the efficacy of CBT for patients with bipolar disorder.

Cochran (1984) studied a 6-week intervention targeting bipolar patients’ thoughts and beliefs that

interfered with lithium compliance. The CBT group was found to be significantly more compliant

with medication regimen than the control patients at the end of treatment and at 6-month (but not

at 3-month) follow-up. The CBT patients were less likely to terminate treatment against medical

advice and had fewer hospitalizations and fewer noncompliance-associated relapses. Lam et al.

(2003) compared a CBT intervention consisting of 12–20 sessions focused on symptom

identification and symptom management with a treatment-as-usual condition consisting of

standard outpatient maintenance treatment. The CBT-treated patients demonstrated a reduction in

the rate of relapse, improved medication adherence, improved psychosocial functioning, fewer days

in a bipolar episode, and fewer hospital admissions. These benefits have persisted after 2 years of

follow-up (Lam et al. 2005). These results support the more preliminary findings of J. Scott et al.

(2001), who—using a mirror image design—found a benefit for CBT in relapse prevention.

Zaretsky et al. (1999) have specifically studied CBT as an adjunctive treatment for the depressed

phase of bipolar illness. They compared bipolar patients taking mood stabilizers and receiving CBT

to a group of unipolar depressed patients receiving only CBT. All patients were moderately

depressed and reported histories of recurrent depressive episodes. Despite similar significant

reductions in depressive symptoms over the course of 20 sessions of treatment, the bipolar group

did not demonstrate significant reduction in underlying negative beliefs as was seen in the unipolar

patients.Print: Chapter 24. Depression-Focused Psychotherapies http://www.psychiatryonline.com/popup.aspx?aID=256319&print=yes…

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Although these studies are limited by the lack of control groups and small sample size, they support

the notion that CBT may be a useful adjunct treatment for patients with bipolar disorder.

Frank et al. (1994) have expanded on their work on unipolar depression by modifying IPT for

patients with bipolar disorder by increasing the attention paid to the stabilization of biological and

social rhythms. They hypothesize that stressful life events alter the stability of social and biological

rhythms, which leads to somatic disturbances, symptom exacerbation, and affective illness (Ehlers

et al. 1988). Key elements of interpersonal and social rhythm therapy (IPSRT) include 1) social

rhythm therapy to regularize daily routines and 2) IPT to educate patients to link their moods to life

events and to address interpersonal problem areas (grief, role transition, role dispute,

interpersonal skills deficit). Frank et al. (2005) randomly assigned acutely ill bipolar I patients to

one of four treatment strategies: acute and maintenance IPSRT, acute IPSRT and maintenance

intensive clinical management (ICM), acute ICM and maintenance IPSRT, or acute ICM followed by

maintenance IPSRT. All participants received pharmacotherapy according to a guideline-based

protocol. The investigators used survival analysis and found that patients assigned to acute IPSRT

survived significantly longer without a new mood episode. Subjects entering the study in a mixed

state suffered a recurrence more quickly, and those with a high medical comorbidity burden and

those with lifetime anxiety disorders survived longer in the ICM condition. The authors conclude

that the ICM sessions may have provided increased attention to somatic concerns, which would be

beneficial in patients with high medical comorbidity, anxiety, and greater illness burden, whereas

subjects in good health did better if they received acute IPSRT. Frank and colleagues conclude that

optimal care for those suffering from bipolar I disorder will require individualized treatment plans

that take into account the biological, psychosocial, and health needs of patients to successfully

treat this complex illness.

CONCLUSION

The depression-focused psychotherapies, as exemplified by IPT and CT, are practical and effective

outpatient treatments of mild to moderately severe major depressive disorder. From differing

vantage points, each therapy assesses the depressed patients’ current state and problem areas,

provides psychoeducation, explicitly instills hope, and guides the selection of model-specific

strategies to help patients “work out” of the depressive episode. No one form of psychotherapy has

emerged as superior to the others; interest, aptitude, and opportunities for supervised training may

have more to do with a therapist’s choice of a model than empirical evidence. In fact, some have

argued that the distinctions between the leading depression-focused therapies may not be valid.

Ablon and Jones (2002) examined IPT and CT sessions from the TDCRP (Elkin et al. 1989) and

found that the compared interventions were similar in treatment process. It remains to be seen if

an eclectic model of psychotherapy for depression will emerge, one that fuses the more clinically

germane aspects of IPT, behavior therapy, and CT (e.g., Karasu 1990). Caution should be exercised

before automatically adopting such integrated therapies, however, because several studies have

established that combinations of various behavioral, marital, and cognitive strategies are not more

effective than single models of treatment (e.g., Jacobson et al. 1991, 1996).

The depression-focused psychotherapies probably do best alone, without concomitant

pharmacotherapy, for more acutely depressed patients with higher levels of premorbid functioning

and adequate social support (e.g., Safran et al. 1993). This indication should not be trivialized as a

nonspecific response, because these psychotherapies have been consistently shown to be superior

to wait-list or low-contact control conditions.

The depression-focused psychotherapies should be conducted by appropriately trained clinicians

and, ideally, should be preferentially recommended for patients who are motivated to participate in

a psychosocial treatment. When these therapies are used as the primary treatment of major

depressive disorder, clinicians would be wise to follow the Agency for Health Care Policy and

Research (Depression Guideline Panel 1993) suggestion to reevaluate the need for

pharmacotherapy after several months of therapy. For example, our group found that more than

70% of IPT nonresponders responded to a sequential trial of imipramine or fluoxetine (Thase et al.Print: Chapter 24. Depression-Focused Psychotherapies http://www.psychiatryonline.com/popup.aspx?aID=256319&print=yes…

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1997).

The depression-focused psychotherapies remain relatively underused treatments within the

mainstream of American psychiatry. Greater emphasis on the training of psychiatric residents and

current practitioners and further research to help better define the boundaries of efficacy will lead

to a fuller capitalization of the benefits of these useful treatments.

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Course Content

Introduction to Depression Therapy: Understanding Key Concepts

Understanding Depression: Symptoms and Diagnosis
Theories and Models of Depression
Introduction to Psychotherapeutic Approaches
Quiz: Key Concepts in Depression
The Role of the Therapist in Depression Treatment

Core Psychotherapeutic Techniques: Foundations and Applications

Advanced Cognitive-Behavioral Strategies for Depression

Integrating Mindfulness and Acceptance in Therapeutic Practice

Course Conclusion: Synthesizing Techniques for Effective Depression Treatment

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Chapter 24. Depression-Focused Psychotherapies

About Course

Course Content

Introduction to Depression Therapy: Understanding Key Concepts

Understanding Depression: Symptoms and Diagnosis

Theories and Models of Depression

Introduction to Psychotherapeutic Approaches

Quiz: Key Concepts in Depression

The Role of the Therapist in Depression Treatment

Core Psychotherapeutic Techniques: Foundations and Applications

Introduction to Core Psychotherapeutic Techniques

Cognitive Behavioral Therapy: Concepts and Applications

Mindfulness-Based Cognitive Therapy: Integrating Mindfulness into Practice

Quiz on Core Psychotherapeutic Techniques

Interpersonal Therapy for Depression: Enhancing Relationships

Advanced Cognitive-Behavioral Strategies for Depression

In-depth Exploration of Cognitive-Behavioral Therapy (CBT)

Advanced Techniques in Cognitive Restructuring

Behavioral Activation Strategies

Quiz on Advanced CBT Techniques

Case Studies in CBT for Depression

Integrating Mindfulness and Acceptance in Therapeutic Practice

Understanding Mindfulness in Therapy

Acceptance and Commitment Therapy (ACT) Fundamentals

Combining Mindfulness and Acceptance Techniques

Mindfulness and Acceptance Knowledge Check

Case Studies: Mindfulness and Acceptance in Action

Course Conclusion: Synthesizing Techniques for Effective Depression Treatment

Integrating Therapeutic Modalities

Case Studies: Real-World Application

Comprehensive Assessment Quiz

Ethical Considerations in Depression Therapy

Future Directions in Depression Therapy

Earn a certificate