The Role of Psychotherapy in the Treatment of Depression

We review two recent practice guidelines' assessments of the role of psychotherapy in the treatment of major depression in adults. We examine the practice guideline published by the American Psychiatric Association (APA) and that published by the Depression Guideline Panel of the Agency for Health Care Policy and Research. We focus on the guidelines' evaluations of psychotherapies, their statements about the role of psychotherapy in first-line treatment of depression, and the procedures they recommend for choosing among psychotherapies. We argue that the APA guideline understates the value of cognitive, behavioral, brief psychodynamic, and group therapies. Both guidelines understate the value of psychotherapy alone in the treatment of more severely depressed outpatients. The APA guideline overvalues the role of combined psychotherapy-pharmacotherapy regimens, particularly in view of the greater cost of this strategy. The APA guideline also makes recommendations about choosing among psychotherapies that are not well supported by empirical evidence. We conclude with some guidelines for guideline development.