Psychotherapeutic Management of Depression

Psychotherapy may be a first line therapy choice for mild depression particularly when associated with psychosocial stress, interpersonal problems, or with concurrent developmental or personality disorders. Psychotherapy in mild to moderate depression is most effective in the acute phase, and in preventing relapse during continuation phase treatment. Psychotherapy is not appropriate alone for major depression, psychosis, and bipolar disorder. For more severe depression, psychotherapy may be appropriate in combination with the use of medications. The most effective forms of psychotherapy are those with structured and brief approaches such as cognitive behavioral therapy, interpersonal therapy, and certain problem solving therapies. Regardless of the psychotherapy initiated, “psychiatric management” must be integrated at the same time. Primary care physicians should be aware of the different psychotherapy approaches so that they can understand what their patients are undergoing and what goals they are trying to achieve.

Studies indicate that the use of cognitive therapy modalities is most effective (Rupke, 2006); Cognitive behavioral therapy (CBT) is most frequently cited in studies as highly effective in treating depression.  However, interpersonal psychotherapy and problem oriented psychotherapy have also been considered as desirable and cost effective when compared to more traditional models of psychotherapy.

Cognitive Behavioral Therapy (CBT)

CBT targets thoughts and behaviors that need to be changed. Based on the premise that behaviors have their roots in thoughts, this approach assumes that depression is rooted in pessimistic thoughts and excessive self-criticism.  The goal of the therapy is to recognize what triggers certain thoughts and behaviors and to alter your routines through direction and action. Learning to substitute healthy thoughts for negative thoughts will improve a person’s mood, self-concept, behavior and physical state. Behavior change is the primary goal with internal change as a byproduct. Initially, in treating depression, behavioral principles are used to overcome a patient’s inertia and to reinforce positive activities.  An important part of CBT for depression is scheduling pleasurable activities, especially with others, that usually give positive reinforcement.  Other CBT techniques include graded tasks and homework assignments as well as acting out difficult behavioral situations. Emphasis is on the present rather than on the past.  The combination of CBT and antidepressants has been shown to effectively manage severe or chronic depression and for adolescents with depression.  CBT has been shown to reduce relapse rates and effectively manage residual symptoms.

Interpersonal Therapy (IPT)

Based on the belief that depression is caused by problems in important interpersonal relationships, this approach focuses on teaching about the connection between interpersonal problems and depression.  Depression is viewed as arising out of conflict or loss in interpersonal relationships.  A key feature is the compiling of an interpersonal inventory that lists and examines all the patient’s relationships. In this approach the number of sessions is generally limited over a period of several months. Treatment is divided into three stages:  assessment, practice and termination, with emphasis on relapse prevention skills and techniques. Focus is on present events rather than past history and on learning ways to improve important relationships in the present and to have more positive interactions.  Patients are taught not only to identify but to deliberately tolerate feelings.  According to this model, as relationships improve, so should the patient’s mood. The model incorporates psychoeducation; is “medication friendly”; and agrees with a medical model of depression. Unlike CBT, IPT does not involve formal homework or rely on extensive paperwork, although patients are encouraged to develop skills and experiment between sessions. IPT is particularly useful for patients who find psychodynamic approaches mystifying, and has been modified for use with adolescents.

Problem Solving Therapy (PST)

Problem solving therapy is a brief, focused form of cognitive therapy that focuses on the problems a person is currently facing and on helping to find solutions to these problems.   Based on studies that have demonstrated links between poor problem solving abilities and the etiology and maintenance of psychological disorders, this approach is often used in the treatment of depression.  Problem focused methods involve changing the situation itself, whereas emotion-focused strategies involve changing one’s reaction to the situation.  Problem solving strategies work well in addressing and solving problems encountered in everyday situations where a change in behavior can have positive results. Individuals are taught to identify, discover and invent effective responses for specific problematic situations. The goal is to provide clients with a set of tools on how to effectively manage life’s stress in order to decrease distress, enhance sense of control, and improve quality of life.  Interventions include didactic explanations, training exercises, practice opportunities, and homework to practice between sessions. PST sessions are often conducted in groups as well as individual sessions. It is often less expensive than other forms of treatment and can easily be performed by health care professionals.  PST has been shown to be effective in treating depression in adults of all ages and is thought to be particularly effective in treatment of older adults.

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