Are all psychotherapies equally effective for the treatment of depression? Or do cognitive behavioral techniques clearly rise above the pack, as implied by the amount of media coverage they receive? In this article, we’ll take a hard-nosed look at the evidence.
Cognitive therapy (CT). Teaching patients to examine the evidence for their underlying negative thoughts such as “I am a loser,” or “I always fail,” is key to cognitive therapy, as depression often includes unrealistic negative beliefs. When something goes awry, such patients tend to blame themselves (technically termed “internal negative beliefs”), believe that their flaw is permanent (“stable negative beliefs”), and believe the flaw covers a large swath of their personality (“global negative beliefs”—for example, “I’m a failure,” as opposed to, “I made a small mistake”). In therapy, you help your patient to identify negative thoughts and to seek evidence about whether they are true. Homework assignments help patients identify and transform these thoughts in real time as they live their lives.
Behavioral activation therapy (BT). Depressed patients, often driven by their negative thoughts, sometimes call in sick to work, stop attending college classes or engaging in hobbies, and avoid social events. If they felt better, they would engage in these important life functions, but because they are depressed, they just don’t feel up to it. The behavioral activation approach says essentially: “Don’t wait until you feel better—rather, you’ll feel better once you become more active.”
Avoiding work, school, and social situations leads to guilt and withdrawal of positive reinforcement. While most people don’t love their jobs, they have a certain sense of accomplishment from getting tasks completed on the job. Also, going to work or spending time with friends and family often provides some positive social reinforcement. So by avoiding these important life tasks, depressed people are limiting their chances to improve their moods. If patients change avoidance behavior to allow for more reinforcement from the environment, mood should improve. This is often a gradual process—depressed patients aren’t expected to change all of their behavior at once. In a meta-analytic comparison of 11 trials that directly compared behavioral activation therapy to a full package of CBT (both cognitive and behavioral interventions), both treatments yield similar benefits (Cuijpers P et al., J Consult Clin Psychol 2008;76:909–922).
Cognitive-Behavioral Therapy. Cognitive-behavioral therapy has earned its reputation as a strongly supported treatment for depression. Dozens of clinical trials clearly show that cognitive and behavioral interventions, alone or in combination, are more effective than no treatment or psychological placebo (Gloaguen V et al., J Aff Disord 1998;49(1):59–72; Wampold BE et al., J Aff Disord 2002;68:159–165).
Cognitive and behavioral techniques often go hand-in-hand. You might teach a depressed patient to challenge her negative thoughts and also change her depressive behavior. CBT can be seen as fighting depression on two fronts, though there is actually not much data to suggest that a twopronged approach works much better than using either cognitive or behavioral tactics alone.
In comparisons with antidepressant medication, CBT fares about as well in the short-term but offers better long-term results after treatment discontinuation. One meta-analysis of six comparisons found that relapse rates at 1 to 2 year follow-up after successful treatment were significantly lower with psychotherapy (27%) than with medication (57%). Nearly all patients described in this report received CBT, so it is tempting to conclude that CBT has demonstrated convincing long-term efficacy relative to medication, but major caveats are in order (de Maat S et al., Psychother Res 2006;16:562–572). These comparisons were based on fewer than 300 patients, and the medication arms typically used MAOI or tricyclic medication, so we would need larger studies using modern antidepressants to draw firmer conclusions. Nonetheless, this evidence base provides preliminary support to bolster CBT’s case as a very impressive long-term antidepressant.
Interpersonal Therapy (IPT). IPT emphasizes the importance of relationships in depression. In the IPT model, you take a thorough history of your patient’s past and present relationships. Depending on your patient’s issues, IPT may offer one or more of the following four therapeutic interventions: 1) Helping your patient mourn the loss of somebody; 2) Teaching conflict management skills; 3) Helping patients understand how to navigate shifting roles (eg, from one job to another, or from being married to getting divorced); and 4) Providing social skills training. IPT is designed to be a short-term intervention of 12 to 16 weekly sessions that yields longterm benefits. A meta-analysis of five randomized trials comparing IPT to CBT found that both techniques were effective, with no significant differences between the two in depression outcomes (Cuijpers P et al., J Consult Clin Psychol 2008;76:909– 922).
Psychodynamic therapy (PT). PT was adapted from traditional Freudian psychoanalysis, a procedure often associated with patients lying on couches, silent analysts, and a relative lack of empirical validation. However, several variants of PT are designed as brief interventions and have solid scientific support. The underlying theory is that all people develop relationship templates (ideas of how relationships tend to work), based upon their experiences. Early relationships with parents may be particularly powerful in shaping these templates. Patients often transfer their experiences with others onto their relationship with the therapist. For example, a patient who had cold, disapproving parents may interpret neutral behavior on the part of the therapist as harsh or rejecting. The psychodynamic therapist discusses transference with the patient, helping the patient to develop insight into what drives his behavior and views of the world. The therapist is finely attuned to behaviors indicating “resistance”—such as frequently showing up late or missing appointments, avoiding discussion of important issues, or ignoring the therapist’s suggestions. These generally signal some reluctance to change and should be examined, though the therapist should be tactful and caring when discussing these issues. A very understandable description of many key aspects of PT can be found at: http://bit.ly/bkiS4s.
While PT has not been studied as much as other techniques for the treatment of depression, a recent meta-analysis of four trials found that PT worked significantly better than waiting-list control groups in relieving depressive symptoms with a moderate to large effect size. But in a meta-analysis comparing PT to other interventions, nearly all of which were variants of CBT, PT was less effective by a small but statistically significant margin across 13 studies (Driessen E et al., Clin Psychol Rev 2010;30:25–36). This paper had a shortcoming, however: some of the included studies failed to use random assignment to treatment groups. Another meta-analysis that included only randomized comparisons found no statistically significant difference between PT and CBT across seven trials (Cuijpers P et al., J Consult Clin Psychol 2008;76:909–922).
Supportive Therapy (ST): Supportive therapy is defined in different ways by various practitioners. Most often, ST has been described by what it does not do: it is not psychodynamic, behavioral, or cognitive. What is left is a general focus on reflective listening, encouraging emotional expression, and developing a strong therapeutic relationship. The patient is typically left in charge of directing the topics of treatment sessions. Surprisingly, in a meta-analysis of 18 randomized comparisons between ST and CBT, the two treatments were equally effective (Cuijpers P et al., J Consult Clin Psychol 2008;76:909 –922).
Bottom Line: In many clinical trials comparing psychotherapies to each other for the treatment of depression, the only clear trend is for legitimate therapies to perform about as well as each other and for bona fide therapies to outperform psychological placebo treatments (eg, prerecorded relaxation instructions, group therapy without clear psychological rationale, etc.). Though CBT is the brand of therapy with the reputation of having the most empirical support, it appears that all legitimate therapies perform about the same in treating depression. CBT has shown better long-term results than medication, but this is quite tentative and sorely in need of more investigation (de Maat S et al., Psychother Res 2006;16:562–572). Therapies other than CBT may compare equally well to meds, but the relevant studies have yet to be published.
TCPR VERDICT: For depression, all psychotherapies probably yield about the same results, though CBT is unique in that in some studies it led to a lower rate of relapse than antidepressant medication.