The Endowment for the Advancement of Psychotherapy

Depression Module

What is depression?

More than just feeling a little sad, clinical depression can be a severe mental illness with both biological and environmental underpinnings. Symptoms of depression can vary between individuals but often include diminished interest in activities, persistent low energy, difficulties with concentration, excessive or diminished sleep, changes in appetite, increased feelings of guilt or worthlessness, and in severe cases, thoughts of self-harm or of committing suicide.  The American Psychiatric Association has established criteria for the diagnosis of a major depressive episode which include five or more symptoms of depression, as described above, that are present for at least two weeks and impair one’s ability to function at work or maintain relationships. Not only can depression lead to suffering for those with the disorder, but it often extends to their loved ones through impaired interpersonal relationships, difficulties at work, and through tragedies such as suicide.

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Depression can impact people from all walks of life during practically the entire lifespan. Major depression affects approximatley 14.8 million American adults or about 6.7% of the U.S. population in a given year.1 Depression is also a cause of significant disability and is expected to be the second largest cause of disability in the United States by 2020.2  Not only does depression affect mental health, it has also been associated with poor outcomes in a number of medical illness including diabetes, coronary artery disease, and stroke.3-5 Those that experience one episode of depression have a 50% risk of experiencing another episode making the illness often chronic in nature. Despite there being effective treatments for depression including talk therapy and medications, stigma often prevents people suffering from seeking treatment. Those suffering from depression can feel optimistic that several approaches can be helpful in alleviating symptoms.

What is psychodynamic psychotherapy for depression?

There are many different types of treatments for depression including several types of psychotherapy and medications. Psychodynamic psychotherapy is unique in a number of ways from other types of psychotherapies in its approach and also in its efficacy. In psychodynamic psychotherapy, the client is encouraged to talk freely through the guidance of a psychotherapist. As the person continues to speak, there becomes an awareness of patterns in relationships, patterns in thought processes, and an understanding of unrecognized feelings that are often based in early experiences. There is also a focus on deepening the relationship with the therapist as a means of understanding prior patterns in interpersonal relationships. Often, psychological difficulties may stem from problems in the way people relate to others or view themselves and much of the work in psychodynamic psychotherapy involves understanding these parts of ourselves. As a person develops awareness into these parts of themselves, it is possible to resolve or cope with past difficulties and the past can gradually have less control over our lives.

Several different types of psychodynamic therapy are available with the most intensive being the client and therapist meeting multiple times per week. Sometimes the patient will lie on a couch with the psychotherapist or psychoanalyst sitting behind. A similar treatment involves weekly psychotherapy in which both the client and therapist are sitting face to face. Both types of therapy have advantages and disadvantages although both have been shown to be effective (see below). In most cases, the appointments will last forty-five or fifty minutes and will continue for months, or in some cases, years, depending on the needs of the client. Many people find that the experience of psychodynamic psychotherapy is rewarding in alleviating symptoms and improving their immediate relationships. Many find “the talking cure” has long lasting benefits in both their personal and professional lives.

Is psychodynamic psychotherapy effective in treating depression?

Contrary to the common belief that psychodynamic psychotherapy lacks scientific evidence, there is a growing body of research literature supporting this distinct type of therapy as effective in treating depression. Such evidence include a recent 2008 study that found even a short-term course of psychodynamic psychotherapy of four months was highly effective in treating depression with 57% of people achieving full resolution of symptoms.6 These results were further observed in a recent 2014 study that combined results from over 33 other studies involving more than 2,000 people. The results indicated that not only was a four month course of psychotherapy helpful, but the beneficial results of psychodynamic psychotherapy lasted 3-6 months after psychotherapy ended.7 Other research suggests that psychodynamic psychotherapy sets in motion psychological processes that lead to continued change. One such study found that after 40 hours of psychodynamic psychotherapy, not only did symptoms of depression improve, but 9 months after the treatment was completed symptom improvement continued.8 This suggests that unlike other types of treatment, psychodynamic psychotherapy works well in the long-term to prevent the re-emergence of depression.

One might also wonder how the efficacy of psychodynamic psychotherapy compares to other types of psychotherapy. When compared to other psychotherapies such as cognitive behavior therapy, it has been shown to be just as effective in the treatment of depression.9 There is also a growing body of evidence that psychodynamic psychotherapy is effective in specific populations with depression. Studies have shown that a psychodynamic approach reduces symptoms of depression in the elderly, those with postpartum depression, and even those with some types of cancer.10-12 Additionally, in patients who have been psychiatrically hospitalized for depression, psychodynamic psychotherapy has been shown to have significant efficacy in reducing symptoms.13 Of note, the treatment duration had a mean of 61.8 days in the hospital which is much higher than current typical inpatient psychiatric admissions and no control group was included in the study. This collection of studies help to confirm what many practitioners have observed, psychodynamic psychotherapy is an effective treatment for depression.

What are the other treatments for depression?

While psychodynamic psychotherapy has a large body of evidence for its benefits in the treatment of depression, there are other treatments that are also effective. Other forms of talk therapy including cognitive behavioral therapy (CBT), dialectic behavioral therapy (DBT), and interpersonal psychotherapy (IPT) have strong evidence bases. While often therapy can be helpful, some people may choose dual treatment, psychotherapy plus medication prescribed by their physician. Many people choose to have their medications for depression prescribed by the primary care physician, however when depression may be difficult to treat, referral to a psychiatrist is indicated. When thinking what treatments to pursue for depression, evidence suggested that medications with talk therapy are more effective than either treatment alone.14 In one such study, depression was successfully treated in 37.3% of clients in 16 weeks with both medication and psychodynamic psychotherapy while just 15.5% improved significantly with medications alone.15 It is also important to note that medications work best in cases of severe depression rather than mild to moderate cases of depression.16 Furthermore, although medications are effective treatments when they are continued, once stopped, depression frequently returns.17

Deciding on the type treatment for depression is an individual one and often is unique to one’s circumstances. Various factors should be considered including time available for treatment, available treaters in your area, willingness to take medications, and personal preference. When looking for a therapist, it is also important to ask what type of psychotherapy the treater uses as some may not have a background in psychodynamic psychotherapy.

In regards to medications, there are a number of advantages and disadvantages. In terms of advantages, many physicians are familiar with antidepressant medications as they are a common and accepted treatment. In terms of disadvantages, there are often a number of side effects with many medications and as discussed above, rates of recurrence of depression are high if treatment is discontinued. Another important factor is personal preference. Many people find that psychodynamic psychotherapy is an enriching experience where they learn much about themselves and their relationships. Some people find this experience to be rewarding while others may prefer a more limited scope in their treatment.

Citations:

  1. Kessler RC, Chiu WT, Demler O, Merikangas KR, Walters EE. Prevalence, severity, and comorbidity of 12-month DSM-IV disorders in the National Comorbidity Survey Replication. 2005; 62(6): 617-627.
  2. Murray CJ, Lopez AD. Evidence-based health policy – lessons learned from the Global Burden of Disease Study. Science. 1996. 14(9):569-580.
  3. Ford De, Mead LA, Chang PP, et al. Depression is a risk factor for coronary artery disease in men: the precursor study. Arch Int Med. 1998; 158(13): 1422-1426.
  4. Ciechanowski PS, Katon WJ, Russo JE. Depression and diabetes: impact of depressive symptoms on adherence, function, and costs. Arch Int Med. 2000; 160(12):3278-3285.
  5. Robinson RG, Bolduc PL, Price TR. Two-year longitudinal study of post stroke mood disorders: diagnosis and outcome at one and two years. Stroke. 1987; 18(5): 837-843.
  6. Salminen JK, Karisson H, Hietala J, Kajander J, Aalto S, Markkula J, Rasi-Hakala H, Toikka T. Short-term psychodynamic psychotherapy and fluoxetine in major depressive disorder: a randomized comparative study. Psych other Psychosom. 2008; 77(6): 351-7.
  7. Abbass AA, Kisely SR, TOwn JM, Leichsenring F, Driessen E, De Maat S, Gerber A, Dekker J, Rabung S, Rusalovksa S, Crowe E. Short-term psychodynamic psychotherapy for common mental disorders. 2014. Cochrane Database Syst Review.
  8. Abbass AA, Hancock JT, Henderson J, Kisely S. Short-term psychodynamic psychotherapy for common mental disorders. 2006. Cochrane Database Syst Review.
  9. Thase ME. Comparative effectiveness of psychodynamic psychotherapy and cognitive-behavioral therapy: It’s about time and what’s next. Am J Psychiatry. 2013; 170:953-5.
  10. Thompson LW, Gallagher D, Breckenridge JS. Comparative Effective of psychotherapies for depressed elders. J Consult Clin Psychol. 1987; 55: 385-390.
  11. Cooper PJ, Murray L, Wilson A, Romaniuk H. Controlled trial of short and long-term effect of psychological treatment of postpartum depression. Impact on maternal mood. Br J Psychiatry. 2003; 182: 412-419.
  12. Beutel ME, Weissflog G, Leuteritz K, Wiltinik J, Haselbacher A, Ruckes C, Kuhnt S, Barthel Y, Imruck BH, Zwerenz R, Brahler E. Efficacy of short-term psychodynamic psychotherapy (STPP) with depressed breast cancer patients: results of a randomized controlled multi-center trial. Ann Oncology. 2014; 25: 378-384.
  13. Franz M, Seidler D, Jenett D. Psychodynamically oriented inpatient psychotherapy of depressive disorders – First findings from a naturalistic, multicenter study. Z Psychosom Med Psychother. 2015; 61(1): 19-35.
  14. Burnand Y, Adreoli A, Kolatte E, Venturini A, Rosset N. Psychodynamic psychotherapy and clomipramine in the treatment of major depression. Psychiatric Services. 2002; 53:585-590.
  15. de Jonghe, Kool S, van Aalst G, Dekker J, Peen J. Combining psychotherapy and antidepressants in the treamtent of depression. Journal of Affective Disorders. 2001; 64:217-29.
  16. Fournier JC, DeRubeis RJ, Hollon S, Dimidjian S, Amsterdam J, Shelton R, Fawcett J. Antidepressant Drug Effects and Depression Severity. JAMA. 2010; 303(1): 47-53.
  17. American Psychiatric Association. Practice guideline for the treatment of clients with major depressive disorder (revision). Am J Psychiatry. 2000;157 (suppl 4): 1-45.

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