The past decade has also led to the development of more spe-cific depression-based treatment for MDD. These treatments have included supportive psychiatric management techniques during pharmacotherapy, interpersonal psychotherapy, cogni-tive–behavioral therapy, brief dynamic psychotherapy, and mari-tal and family therapy.
Psychiatric management and supportive psychotherapy is the standard in psychiatric office practice. The psychiatrist focuses on establishing a positive therapeutic relationship in the course of diagnosis and initiation of treatment of depression. The psy-chiatrist is attentive to all signs and symptoms of the disorder with particular attention to suicidality. The psychiatrist provides ongoing education, collaboration with the patient, and supportive feedback to the patient regarding ongoing response and progno-sis. The supportive psychotherapeutic management of depression facilitates the ongoing pharmacologic response. Brief supportive psychotherapy in individuals with mild to moderate depression is indicated to improve medication compliance, to facilitate re-duction of active depressive signs and symptoms, and to provide education regarding relapse and recurrence.
Interpersonal psychotherapy in outpatients with nonbipolar MDD has been demonstrated to be effective in acute treatment trials. Interpersonal psychotherapy of depression addresses four areas of current interpersonal difficulties:
· Interpersonal loss or grieving;
· Role transitions;
· Interpersonal disputes;
· Social deficits.
This type of treatment, like other psychotherapies for depres-sion, also involves education about the nature of MDD and the relationship between symptoms of depressive disorder and current interpersonal difficulties. Prior studies demonstrated efficacy of interpersonal psychotherapy for outpatients with depression. Interpersonal psychotherapy, cognitive–behavioral psychotherapy and medication treatment were comparable on several outcome measures and superior to placebo. Medication treatment was associated with the most rapid response and was superior to both interpersonal psychotherapy and cogni-tive–behavioral therapy in more severely depressed patients. Continuation studies with interpersonal psychotherapy of-fered monthly, as well as during maintenance treatment, have demonstrated response in prevention of recurrence, and was superior to placebo treatment. Those patients who received ongoing interpersonal psychotherapy and medication had the longest intervals without recurrence of depressive symptoms.
Cognitive–behavioral therapy for depression is a form of treat-ment aimed at symptom reduction through the identification and correction of cognitive distortions. These involve negative views of the self, one’s current world and the future. Several controlled studies have demonstrated the efficacy of cognitive therapy in res-olution of MDD in adults. Cognitive–behavioral therapy as well as interpersonal psychotherapy are somewhat less effective than medication treatment in moderate to severe MDD although some have suggested a relatively equal response to cognitive–behavioral therapy and medication in more severely depressed outpatients.
Brief dynamic psychotherapy addresses current conflicts as manifestations of difficulty in early attachment and disruption of early object relationships. Brief dynamic psychotherapy was not specifically designed for treatment of MDD and is currently the subject of ongoing studies as well as controlled clinical trials in comparison with medication treatment. The results of these tri-als will allow us to address the appropriate role of brief dynamic psychotherapy in outpatients with mild to moderate depression. In addition, it will be important to understand whether dynamic psychotherapy may address demoralization or response to trau-matic circumstances.
It has been difficult to assess the specific efficacy of marital or family therapy in individuals with MDD based on current studies to date. There is substantial evidence that marital distress is a ma-jor event associated with the development of a depressive episode. Marital discord will often persist after the remission of depression and subsequent relapses are frequently associated with disruptions of marital relationships. There has been no controlled clinical trial of marital therapy in relation to other treatments for promoting the resolution of depressive signs and symptoms. Both acute and con-tinuation phase treatment of MDD will require ongoing attention to marital and family issues to prevent recurrence of depression.