The Role of Psychotherapy

in the Treatment of Depression

Review of Two Practice Guidelines
Jacqueline B. Persons, PhD; Michael E. Thase, MD; Paul Crits-Christoph, PhD

We
review two recent practice guidelines' assessments of the role of psycho-
therapy in the treatment of major depression in adults. We examine the practice
guideline published by the American Psychiatric Association (APA) and that pub-
lished 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 recom-
mend 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, particu-
larly 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 con-
clude with some guidelines for guideline development.
(Arch Gen Psychiatry. 1996;53:283-290)
Practice guidelines have enormous poten¬ Both guidelines have many strengths.
tial. They are expected to directly affect the However, we argue that the APA guideline
behavior of practicing clinicians. They are undervalues the efficacy of cognitive therapy
likely to be adopted by managed care and (CT), behavior therapy (BT), brief psycho-
insurance companies and may be used in dynamic psychotherapy, and group thera¬
malpractice lawsuits and other litigation pies. To support our thesis, we review both
to establish standards of care. Therefore, guidelines' assessments of these psycho¬
it is essential that practice guidelines pro¬ therapies. We also examine both guidelines'
vide a balanced, up-to-date review of what statements about the role of psychotherapy
is known about effective treatment. in the first-line treatment of depression. We
In 1993, practice guidelines for the argue that both guidelines understate the
treatment of depression were published by value of psychotherapy alone in the treat¬
the American Psychiatric Association ment of more severely depressed outpa¬
(APA)1 and by the Depression Guideline tients. In addition, the APA guideline over¬
Panel of the Agency for Health Care Policy values the use ofcombined psychotherapy-
and Research (AHCPR).2 The APA guide¬ pharmacotherapy regimens. Finally, we
line addressed the treatment of depres¬ argue that the APA guideline makes recom¬
sion by psychiatrists, and the AHCPR mendations about choosing among pyscho-
guideline addressed the treatment of de¬ therapies that are not well supported by the
pression in primary care. available empirical evidence. We preface
our discussion with an examination of the

From the Department of Psychiatry, University of California at San Francisco, and methods of evaluation used to write the two
Center for Cognitive Therapy, Oakland, Calif (Dr Persons); Western Psychiatric guidelines, and we conclude with a brief dis¬
Institute and Clinic, Department of Psychiatry, University of Pittsburgh School of cussion of the limitations of controlled tri¬
Medicine, Pa (Dr Thase); and Department of Psychiatry, University of Pennsylvania, als and some guidelines for future guide¬
Philadelphia (Dr Crits-Christoph). line development.

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 METHODS OF EVALUATION
The AHCPR Clinical Practice Guide¬
line was written by the Depression
Guideline Panel, a 12-member mul-
tidisciplinary group chaired by A.
John Rush, MD. Each section of the
guideline was informed by a report
prepared by an expert in the field. One
of us (M.E.T.) wrote two reviews for
the AHCPR document: on mono¬
amine oxidase inhibitor therapy and
on depression.
treatment-resistant
Each report provided a comprehen¬
sive literature review and, when pos¬
sible, a quantitative meta-analysis of
the relevant treatment outcome lit¬
erature.To assist with the literature
reviews and meta-analyses, the De¬
pression Guideline Panel provided
computerized literature searches and
biostatistical consultation.
See also pages 291,
298, 301, and 303
The APA document was writ¬
ten by a work group of six psychia¬
trists chaired by T. Byram Karasu,
MD. Most members of the work
group were experts in at least one
area pertaining to mood disorders,
and Dr Karasu is a prominent fig¬
ure in the area of psychotherapy. The
work group conducted a literature
search covering the period 1971
through 1991 but did not conduct
meta-analyses. The work group also
sought input from over 140 psychia¬
trists and from two nonpsychiatrist
experts in psychotherapy research
(Irene Elkin, PhD, and Myrna Weiss¬
man, PhD). Comments were also so¬
licited from over 36 mental health
organizations.
EVALUATIONS OF THE
PSYCHOTHERAPIES
Cognitive Therapy
The AHCPR panel examined 22
acute-phase randomized con¬
trolled trials of CT in adult or geri¬
atric patients and conducted a meta-
analysis to estimate the effects of
each treatment. When CT was com¬
pared with other acute-phase treat¬
ments, the panel concluded that
Overall, cognitive therapy was similar in
efficacy to all other psychotherapies
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taken together
cation alone, cognitive therapy had
. . .
slight advantage.2(p 76)
In contrast, the APA guideline states,
There is some evidence that
therapy reduces depressive symptoms
during the acute phase of less severe,
nonmelancholic forms of major depres¬
sion,131 but not significantly differently
from pill placebo coupled with clinical
'4| 5)
management. 1(p
(The references cited within quotes
from both the AHCPR and APA
guidelines are those that appear in the
guidelines' reference lists; they are
bracketed here and renumbered to
follow the sequence of references in
our article.)
When compared with the
AHCPR guideline's meta-analytic
evaluation, the APA guideline's re¬
view underestimates the efficacy of
CT. The APA guideline's statement
that "there is some
cognitive therapy reduces depres¬
sive symptoms
cantly differently . .
bo does not, in our view, re¬
"
flect a balanced assessment of the
...
available empirical evidence. The
statement that CT does not differ sig¬
nificantly from pill placebo coupled
with clinical management is based
on results from a single, albeit quite
important, study (the Treatment of
Depression Collaborative Research
Program [TDCRP]4) and ignores the
results of a number of other stud¬
ies. For example, controlled stud¬
ies have found CT's efficacy to be
comparable or superior to pharma¬
cotherapy (as conducted by psychia¬
trists),3'8 interpersonal therapy
(IPT),4 BT,911 behavioral marital
therapy,1213 and short-term psycho-
dynamic psychotherapy.9·10 (The
study by Hollon et al6 had not been
published at the time the APA guide¬
line was written, and it was appar¬
ently not included in the AHCPR re¬
view either, even though results from
the follow-up phase of this study
were cited in both practice guide¬
lines.) In addition, four of five stud¬
ies conducted in the United King¬
dom showed that CT was statistically
significantly more
treatment-as-usual or protocol phar¬
macotherapy provided by general
practitioners.14"17 Two meta-
analyses have documented CT's ef-
Compared to medi¬ ficacy when compared with waiting-
a list, alternate psychotherapeutic or
pharmacotherapy control condi¬
tions.1819 The APA guideline's state¬
ment that CT "reduces depressive
cognitive symptoms" does not convey clearly
that empirical studies consistently
document remission rates follow¬
ing CT that are comparable to those
following pharmacotherapy.
Behavior Therapy
The AHCPR guideline states,
In the panel's analysis, the overall effi¬
cacy of behavioral therapy was 55.3 per¬
cent. Compared to wait-list, behavioral
therapy was 17.1 percent more effec¬
tive; compared to all other forms of psy¬
chotherapy, behavioral therapy was 9.1
percent more effective. Compared to
medication alone, it was 23.9 percent
more effective. [This figure measures the
proportion of patients assigned to the
treatment who stayed in treatment and
evidence that
improved. ]2(p78)
, but not signifi¬ The APA guideline states,
.
from pill place¬ Behavior therapy has been reported to
be effective in the acute treatment of pa¬
tients with mild to moderately severe de¬
pressions, especially when combined
with pharmacotherapy.19·20"2311*5)
The APA guideline states that BT is
most effective when combined with
medications. However, the re¬
search cited in the guideline does not
support this assertion: none of the
studies cited even included a com¬
bined BT and pharmacotherapy con¬
dition! We are aware of only three
empirical studies that do examine
this question directly.24"26 Two25·26 of
the three trials did report more rapid
improvement for patients receiving
combined treatment, but there were
no statistically significant differ¬
ences between BT and combined
treatment at posttreatment in any of
the studies.
Brief Psychodynamic
Psychotherapy
The AHCPR guideline states,
The acute effects of brief dynamic psy¬
chotherapy were investigated in seven
randomized controlled trials19·10·20·24·27"291
effective than of which six could be metaalyzed.. The
overall efficacy of brief dynamic psy¬ .
chotherapy in these six studies was 34.8
percent. Compared to other therapies,
brief dynamic psychotherapy may be
 slightly less effective. Compared to medi¬
cation, it was 8.4 percent more effec¬
tive 2<p81)
The APA guideline states,
Brief psychodynamic psychotherapy may
be used in the acute-phase treatment of
depression, especially as an adjunct to
pharmacologie treatment. The efficacy
of brief psychodynamic psychotherapy
as a single modality in the treatment of
major depression has not been conclu¬
sively demonstrated by controlled stud¬
ies; although it has been shown to be
more effective than a waiting list con¬
trol,'91 the latter is considered a less than
satisfactory control condition. Its effec¬
tiveness in comparison to other psycho-
therapeutic approaches requires fur¬
ther research. Research on combined
pharmacotherapy and brief psychody¬
namic psychotherapy130·311 is equally
5)
sparse and inconclusive.1<p
We concur with the AHCPR guide¬
line'sstatement that brief dynamic
therapy may have a slightly weaker
overall effect than other therapies
and with the AHCPR's outline of the
limitations of available studies of
brief psychodynamic psycho¬
therapy that may have weakened its
effects in the research trials. These
limitations include the fact that most
studies were of group, not indi¬
vidual, treatment; therapy gener¬
ally was not procedurally specified;
and most of the investigators were
aligned with another mode of psy¬
chotherapy.
We agree with the APA guide¬
line's statement that the efficacy of
brief psychodynamic psycho¬
therapy has not been "conclusively
demonstrated." Nevertheless, the
APA guideline does not, in our view,
present a full and balanced review
of the evidence of the efficacy of brief
psychodynamic psychotherapy. The
APA guideline's evaluation of brief
dynamic therapy is incomplete in its
assessment of the efficacy data, and
its recommendation that the therapy
is best used in conjunction with
medication is not supported by any
empirical evidence.
The APA guideline cites the
study9 of depressed elders as show¬
ing that brief dynamic therapy is su¬
perior to a waiting-list control, but
it fails to mention that, in this study,
brief dynamic therapy did not dif¬
fer significantly from cognitive and
behavioral treatments for depres-
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sion, two modalities that have re¬
ceived more extensive empirical sup¬
port. Additional evidence supporting
the efficacy of brief psychody¬
namic therapy is available from a
study by Hersen et al,24 in which brief
dynamic therapy practiced by expe¬
rienced clinicians (without the ben¬
efit of a treatment manual) pro¬
duced significant improvements in
the depressive symptoms of unipo¬
lar depression in women. In fact,
outcome of brief dynamic therapy
was not statistically significantly dif¬
ferent from amitriptyline hydrochlo¬
ride treatment, social skills train¬
ing, or social skills training plus
amitriptyline treatment. This study
also included a 6-month continua¬
tion phase and showed that monthly
sessions of dynamic therapy
achieved the same outcome as con¬
tinuation therapy with amitripty¬
line. Inferences from the study by
Hersen et al are limited by the fact
that patients in the dynamic therapy
and social skills training condi¬
tions also received a pill placebo.
The statement in the APA
guideline that brief dynamic therapy
is especially useful as an adjunct to
medication is not supported by any
empirical evidence. Neither of the
studies cited by the APA guideline
(Daneman30 and Covi et al31) found
evidence of a significant additive ef¬
fect for the combination of brief dy¬
namic therapy and pharmaco¬
therapy on reduction of depressive
symptoms or remission rates.
Group Therapy
The AHCPR guideline did not spe¬
cifically review group therapy. How¬
ever, it did compare the efficacy of
group and individual forms of BT
and CT using meta-analysis and
found that group and individual BT
did not differ in effectiveness,
whereas individual CT was slightly
superior to group CT.
The APA guideline states,
The role of group therapy in the treat¬
ment of depression is based on clinical
experience rather than on systematic
controlled studies.1<p 6)
This statement by the APA guide¬
line ignores a very large body of pub¬
lished outcome studies of various
forms of group therapy. Perhaps the
APA guideline's conceptualization of
group therapy was restricted to tra¬
ditional "process"-oriented groups,
which have not been studied exten¬
sively. If cognitive, behavioral, and
other newer approaches to group
therapy are included in the review,
a large number of published empiri¬
cal studies are available. While it is
true that many are small studies of
restricted samples (eg, women only)
or use less rigorous methods (eg, pa¬
tients were not required to meet
DSM-IlP2 criteria for major depres¬
sion) the results of these studies are
,
nevertheless fairly consistent.
Group behavior therapy and
group CT have repeatedly been
shown to produce statistically sig¬
nificant changes in depressive symp¬
toms.15·17·23·27·29·33"39 In two stud¬
ies,1517 group CT was statistically
significantly more effective than
treatment as usual provided by gen¬
eral practitioners.
Other Psychotherapies
Although we are critical of the APA
guideline's reviews of cognitive, be¬
havioral, brief psychodynamic, and
group therapies, we find that more
balanced reviews are presented for
IPT and marital and/or family
therapy. The APA and AHCPR prac¬
tice guidelines' conclusions for IPT
and marital and/or family therapy are
essentially in agreement. In fact, when
compared with the APA guideline's
assessments of the other time-
limited therapies, APA's reviews of
IPT and marital and/or family therapy
are relatively positive. For example,
the failure of IPT to surpass the pla¬
cebo-clinical management condi¬
tion in the TDCRP is not mentioned
in the APA guideline. Similarly, the
APA guideline notes, on the basis of
a single study, that successful couples
therapy may reduce the risk of de¬
pressive relapse; in contrast, the much
more intensively studied long-term
effects of CT and BT are described as
inconclusive.
To their credit, both treatment
guidelines clearly state that no data
from controlled outcome studies sup¬
port the efficacy of long-term psy¬
chodynamic psychotherapy or psy¬
choanalysis in the treatment of
depression in adults. In view of the
fact that long-term psychodynamic
 theory was a dominant paradigm in
psychiatry for decades, these are
forthright and responsible state¬
ments. The AHCPR guideline ex¬
tends this statement to point out that
no data from controlled outcome
studies support the efficacy of any
form of long-term psychotherapy for
depression.
The guidelines' reviews of sup¬
portive psychotherapy, a widely used
modality, are unclear. The AHCPR
acknowledges (correctly) that sup¬
portive psychotherapy has not been
studied in randomized controlled tri¬
als but asserts that "a closely related
therapy, IPT, has been specifically de¬
signed for depressed patients and for¬
mally tested."1(p 87) We doubt that
most practitioners of interpersonal
therapy would consider it to be
"closely related" to supportive
therapy. The APA provides a rela¬
tively lengthy description of support¬
ive therapy but does not point out
that its efficacy has not been demon¬
strated in controlled studies.
ROLE OF PSYCHOTHERAPY
IN FIRST-LINE TREATMENT
FOR DEPRESSION
The recommendations about
first-line treatment made by both
guidelines raise two issues: the issue
of severity and the issue of combined
pharmacotherapy-psychotherapy regi¬
mens. We discuss each in turn.
Severity
The AHCPR guideline makes the fol¬
lowing recommendations about first-
line treatment:
Patients with moderate to severe major
depressive disorder are appropriately
treated with medication, whether or not
formal psychotherapy is also used.2(p 39)
and
Patients with mild to moderate major de¬
pression who prefer psychotherapy alone
as the initial acute treatment choice may
be treated with this option.2(p 40)
The APA guideline recommends,
Most patients are best treated with anti¬
depressant medication coupled with psy¬
cho therapeutic management or psycho¬
therapy [II]. Some patients with mild to
moderate degrees of impairment may be
treated with psychotherapeutic manage¬
ment or psychotherapy alone ..«PP19'20'
.
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[Roman numeral II codes recommen¬
dations based on "moderate clinical con-
fidence."Upl9)]
The two guidelines concur in the rec-
ommendation that severely de¬
pressed patients should receive phar-
macotherapy (with or without
psychotherapy) and that only some
mildly to moderately depressed pa¬
tients ought to receive psycho¬
therapy alone. Although some stud¬
ies support the recommendation that
only mildly to moderately de¬
pressed outpatients ought to receive
psychotherapy alone, others do not.
Thus, we believe that the empirical
evidence on this question is more
mixed than both practice guide¬
lines' recommendations indicate.
Certainly, there is voluminous
evidence that endogenously de¬
pressed outpatients or severely de¬
pressed inpatients benefit from phar¬
macotherapy.2 By contrast, there is
virtually no evidence that psycho¬
therapy is an effective, principal treat¬
ment of psychotic depression or de¬
pression in inpatients. In a recent
study of 30 unmedicated depressed
inpatients who were treated for up to
4 weeks with daily CT, Thase40 found
a significantly poorer outcome in pa¬
tients with Hamilton Rating Scale for
Depression (HAM-D) scores of 25 or
greater and/or patients with hyper-
cortisolemia.
However, when depressed out¬
patients are examined, the evidence
relating psychotherapy outcome to
severity of depression is not so clear-
cut. Some data support the guide¬
lines' assertions that more severely
depressed patients benefit less from
psychotherapy alone than do less se¬
verely depressed patients. In a re¬
cent analysis of the outcome of a large
series of depressed outpatients treated
with CT alone (n=129), IPT alone
(n=112), or IPT plus pharmaco¬
therapy (n=352), Thase et al41 found
a significant treatment type by sever¬
ity interaction. Among patients with
pretreatment HAM-D scores of 20 or
greater, psychotherapy alone and
combined IPT-pharmacotherapy
regimens were equally effective. By
contrast, in the more severe sub¬
group, combined IPT-pharmaco¬
therapy regimens were statistically
significantly more effective than CT
or IPT alone. In their meta-analytic
review, Robinson et al19 found a mod-
est, inverse relationship between pre¬
treatment severity and response to a
diverse group of time-limited psy¬
chotherapies.
However, other studies do not
support the notion that more se¬
verely depressed patients benefit less
from psychotherapy than do less se¬
verely depressed patients. Data from
the TDCRP on this question are
mixed. In the TDCRP,4 a pretreat¬
ment HAM-D score of 20 or greater
was used to identify a more severe
subgroup. Consistent with the
guidelines' recommendations, ac¬
tive drug treatment was statisti¬
cally significantly more effective than
both placebo plus clinical manage¬
ment and CT. However, contrary to
both guidelines' conclusions, more
severely depressed patients who re¬
ceived IPT did not differ in out¬
come from those who received ac¬
tive drug treatment.
Using the same definition of se¬
verity as the TDCRP, Hollon et al6
found that CT and pharmaco¬
therapy were equally effective treat¬
ments of severely depressed outpa¬
tients (this study was apparently
published too late for review by the
APA). McLean and Taylor42 also
failedto find a difference in re¬
sponse to BT or amitriptyline
treat¬
ment associated with severity
in a re-
analysis of the 1979 report by
McLean and Hakstian.20
The construct of endogeneity
overlaps significantly with symp¬
tomatic severity.43·44 Both practice
guidelines recommend that melan¬
cholic (endogenous) depressions
should be treated with pharmaco¬
therapy instead of, or in combina¬
tion with, psychotherapy.
Some studies support this rec¬
ommendation. Using the more inclu¬
sive Research Diagnostic Criteria
definition of endogenous depres¬
sion, Prusoff et al45 and Gallagher and
Thompson46 found poorer response
to psychotherapy (IPT and a pooled
grouping of dynamic, cognitive, and
behavioral treatments, respec¬
tively) in patients with endogenous
depression compared with patients
with nonendogenous cases. In a
reanalysis of the data from a clini¬
cal trial by Thase et al,47 amitripty¬
line (either alone or with BT) was sig¬
nificantly more effective than a
combined grouping of BT and
 dynamic therapy plus placebo.
Melancholic patients were also sig¬
nificantly more likely to drop out of
this study unless their treatment
included active pharmacotherapy.48
McKnight et al7 similarly reported
that melancholic patients had a poorer
response to CT than nonmelanchol-
ics. However, these investigators also
found poorer response to amitripty¬
line treatment in melancholies than
in nonmelancholics.
We are not aware of any pub¬
lished prospective studies using the
more restrictive diagnosis of melan¬
cholia that report a positive re¬
sponse to psychotherapy. How¬
ever, other studies using the broader
Research Diagnostic Criteria defini¬
tion have not found a relationship
between outcome and a clinical di¬
agnosis of endogenous depression in
studies of IPT,49 CT,5·6·49"52 or BT.53
In summary, while there is evi¬
dence in support of both practice
guidelines' recommendation to limit
use of psychotherapy alone to mild-
to-moderate episodes of depres¬
sion, empirical support for this rec¬
ommendation is hardly uniform. We
recommend that psychotherapy
alone be considered a treatment op¬
tion for more severely depressed out¬
patients who wish to pursue it and
who are able to work productively
in therapy. To restrict the use of CT,
BT, or IPT to only "some outpa¬
tients with mild-to-moderate" de¬
pressions appears to overstate the re¬
lationship between severity and
psychotherapy response. We fully
agree with the AHCPR recommen¬
dation to reconsider use of pharma¬
cotherapy if patients are not re¬
sponding after 6 to 12 weeks of
treatment with psychotherapy alone.
Combined Treatment
The APA guideline recommends
that,
Most patients are best treated with an¬
tidepressant medication coupled with
psychotherapeutic management or psy¬
chotherapy [II].1(pp 19"20)
In this statement, the APA guide¬
line seems to recommend com¬
bined pharmacotherapy-psycho-
therapy regimens for most patients.
We use the term seems because there
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is some ambiguity in the APA's rec¬
ommendation (this itself is a prob¬
lem). Perhaps when the APA rec¬
ommends coupling antidepressant
medication with "psychotherapeu-
tic management," it is referring to the
standard monitoring and educa¬
tion that accompany any compe¬
tently administered drug treat¬
ment. Our careful reading of the
document, however, suggests that
the APA is referring to a more in¬
tensive adjunct treatment. The term
psychotherapeutic management re¬
fers, the guideline states, to a type
of psychotherapy "sometimes re¬
ferred to as 'supportive psycho¬
4)
therapy.'"Up The detailed de¬
scription of the therapy indicates
that it is more extensive than
would ordinarily be provided by
psychopharmacologists.
In contrast, the AHCPR guide¬
line recommends combined phar-
macotherapy-psychotherapy regi¬
mens only for certain cases, stating,
Combined treatment may have an ad¬
vantage for patients with partial re¬
sponses to either treatment alone (if ad¬
equately administered) and for those
with a more chronic history or poor in-
terepisode recovery. However, com¬
bined treatment may provide no unique
advantage for patients with uncompli¬
cated, nonchronic major depressive dis¬
order.2*41'
When the two guidelines' recom¬
mendations about the use of com¬
bined treatment are compared, we
find the approach taken by the
AHCPR to have firmer empirical
support. In fact, the evidence com¬
paring combined treatment (phar¬
macotherapy plus psychotherapy) to
either modality alone provides little
support for the APA's recommen¬
dation that most patients need com¬
bined treatment.
Several published studies sup¬
port the APA guideline's assertion
that combined pharmacotherapy-
psychotherapy regimens are supe¬
rior to treatment with a single mo¬
dality. Blackburn et al5 found that
while CT and combined treatment
(CT plus antidepressant medica¬
tion) did not differ in efficacy for de¬
pressed patients treated in general
practice settings, the combined treat¬
ment was more effective than CT
alone in their more chronically ill
psychiatric clinic subsample. Inter-
pretation of this study is limited by
the inefficacy of pharmacotherapy in
the general practice setting. Weiss¬
man et al54 found combined treat¬
ment to be superior to both amitrip¬
tyline alone and IPT alone at
posttreatment. As reviewed earlier,
two reports25·26 found that de¬
pressed patients who received BT in
combination with antidepressants
improved more rapidly than those
receiving BT alone, but combined
treatment was not more effective by
the completion of the therapy pro¬
tocol. Finally, in a pooled analysis
of six studies in which patients were
treated with either psychotherapy
alone (CT or IPT) or combined treat¬
ment (antidepressants plus IPT),
Thase et al41 found a trend in favor
of the combined treatment condi¬
tion, with a significant advantage for
combined treatment in the more se¬
verely depressed subgroup of pa¬
tients.
However, an even larger num¬
ber of studies has found little or no
benefit for combined psychotherapy-
pharmacotherapy regimens compared
with single modalities''-8·24·27·30·31·52 For
example, Hollon et al6 found that CT
plus imipramine was statistically sig¬
nificantly superior to imipramine
alone on some measures (ie, the De¬
pression Subscale of the Minnesota
Multiphasic Personality Inventory
and Raskin) but not others (ie,
HAM-D or Beck Depression Inven¬
tory); CT plus imipramine was not
statistically significantly different from
cognitive behavior therapy alone on
any outcome measure. Two longer-
term studies also found no prophy¬
lactic advantage for the combination
of IPT and pharmacotherapy com¬
pared with pharmacotherapy alone
as either a continuation therapy55 or
maintenance-phase treatment.56
In meta-analyses, Conte et al57
and the AHCPR2 concluded that
combined psychotherapy-pharma-
cotherapy regimens were only
slightly superior to psychotherapy
alone or pharmacotherapy alone.
Hollon et al,58 Persons,59 and Man¬
ning and Frances60 drew similar con¬
clusions in qualitative reviews.
We conclude that although
some empirical evidence supports
the notion that combined treat¬
ment is more effective than single-
modality treatment, the evidence is
 not strong enough to warrant the
recommendation made by the APA
guideline, particularly in view of the
increased cost of this treatment strat¬
egy. The AHCPR came to essen¬
tially the same conclusion we did.
CHOOSING AMONG
PSYCHOTHERAPIES
When psychotherapy alone is used
as the first-line treatment, the
AHCPR offers a single guideline for
choosing among therapies:
Since it has not been established that all
forms of psychotherapy are equally ef¬
fective in major depressive disorder, if
one is chosen as the sole treatment, it
should have been studied in random¬
ized controlled trials.2* 84)
Extrapolating from this principle, the
AHCPR guideline states that
Long-term therapies are not currently in¬
dicated as first-line acute phase treat¬
ments for patients with major depres¬
sive disorder.2*84)
The APA guideline points out that
differential efficacy of the various
psychotherapies has not been estab¬
lished, and it offers a detailed state¬
ment about how the clinician might
choose among available psycho¬
therapies, stating,
The psychosocial therapeutic program
may range from psychotherapeutic man¬
agement [supportive psychotherapy] to
one of a number of forms of systematic
psychotherapy. The approach most con¬
gruent with the patient's needs should
be chosen. The differential efficacies of
and the indications for the various psy¬
chotherapies have not been fully estab¬
lished by formal studies. Interpersonal
therapy may be suited for individuals
who have experienced recent interper¬
sonal conflicts or difficult role transi¬
tions [II]. Cognitive therapy may be used
for those who desire and/or tolerate
structured guidance to correct their dis¬
torted concepts of themselves and oth¬
ers [II]. The psychodynamic approach
or psychoanalysis may be used in the
presence of chronic self-underestima¬
tion, excessive self-expectations, chronic
interpersonal conflicts, or unresolved
early losses or separations, if the pa¬
tient is inclined to be introspective, psy¬
chologically minded, and motivated and
has a stable environment [II]. Marital,
family, behavior, and group therapies
may also be used [II].1*
20)
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In these statements, the APA guide¬
line recommends with equal confi¬
dence therapies that have little or no
empirical evidence of efficacy (eg,
supportive psychotherapy and psy¬
choanalysis) and therapies that are
supported by significant amounts of
efficacy data (eg, BT, CT, and IPT).
The assertion by both guidelines that
one type of psychotherapy has gen¬
erally not been shown to be supe¬
rior to another is empirically justi¬
fied. However, psychotherapies differ
considerably in the degree to which
they are supported by empirical evi¬
dence, and it is disappointing that
those differences are not reflected in
the APA's recommendations about
selecting psychotherapies.
Instead, the APA guideline
seems to rely on what has been called
the matching hypothesis, the no¬
tion that the most effective therapy
for a patient is one that matches the
patient's areas of difficulty and the ar¬
eas of functioning emphasized by the
therapy. Thus, patients with dis¬
torted attitudes and beliefs are pro¬
posed to benefit most from CT, and
those with interpersonal difficulties
are presumed to benefit most from
IPT. However, little evidence sup¬
ports the matching hypothesis, and
several studies contradict it.33·49·61-67
For example, patients with high lev¬
els of distorted cognitions and/or dys¬
functional attitudes respond ¡ess fa¬
vorably to CT than dò patients with
lower levels of cognitive distor¬
tion!49·61·64"66 Similarly, patients with
marked interpersonal difficulties may
be less responsive to IPT.49
SUMMARY AND
CONCLUSIONS
The two practice guidelines re¬
viewed here are laudable first ef¬
forts. However, like others,68 we ar¬
gue that psychotherapy deserves
greater weight in the description of
treatment options for major depres¬
sion.
In the review of the two guide¬
lines presented here, we agree more
often with the AHCPR guideline
than with the APA guideline. We be¬
lieve that this is because the AHCPR
took a more empirical approach to
its task than did the APA. The
AHCPR explicitly stated its intent to
"focus on randomized controlled
clinical trials as the highest level of
credible evidence for treatment ef-
ficacy."2<p 8> It undertook a massive
literature review and, when fea¬
sible, conducted meta-analyses that
formed the basis for its recommen¬
dations. In fact, our major area of dis¬
agreement with the AHCPR guide¬
line, namely, its recommendations
about the use of psychotherapy in
more severe depressions, deals with
an issue for which a quantitative
meta-anlysis was not completed. The
APA also undertook a literature re¬
view but, as we argued above, did not
rely consistently on the empirical lit¬
erature in developing its guideline.
Limitations of Controlled
Clinical Trials
Although our critique of the AHCPR
and APA practice guidelines empha¬
sizes the importance of controlled
clinical trials, several limitations of
controlled trials deserve mention.
First, most clinical trials enroll only
a minority of the patients who are
screened for participation; patients
are typically excluded if they have
significant psychiatric or medical co¬
morbid conditions, as do many, if
not most, depressed patients. Clini¬
cal trials are limited, of course, to pa¬
tients who will accept random as¬
signment to treatment condition.
Differential attrition and the fidel¬
ity with which treatments are ad¬
ministered can influence the re¬
sults of a controlled trial. Even
powerful statistical techniques, such
as meta-analysis, can obscure the im¬
pact of systematic biases in patient
selection.
Second, epidemiologie data in¬
dicate that most depressed people do
not seek treatment in a psychiatric
setting. Thus, clinical trials con¬
ducted in psychiatric research cen¬
ters are skewed by their enrollment
of "convenience" samples. Third, the
findings of individual clinical trials
must be interpreted cautiously. Even
studies with 30 to 40 subjects per
condition lack the statistical power
to deter small, but clinically mean¬
ingful, differences between treat¬
ments, let alone interactions be¬
tween treatment and patient
characteristics, for example. De¬
spite these weaknesses (and others),
we view controlled clinical trials as
 the most objective means available
for assessing treatment efficacy.
Guidelines for Guideline
Development
Based on our review of the AHCPR
and APA practice guidelines for
treatment of depression, we offer
several recommendations for fu¬
ture guideline development.
First, as we have emphasized
throughout, we recommend that fu¬
ture practice guidelines give the
highest priority to controlled clini¬
cal trials. More concretely, we rec¬
ommend that the review of each
treatment alternative include a com¬
prehensive, quantitative review of
the available empirical outcome evi¬
dence or a clear statement that no
efficacy data are available.
Second, we recommend that
practice guidelines be written by
multidisciplinary panels. Input from
several disciplines will reduce bi¬
ases arising from intellectual or prac¬
tice traditions in any one disci¬
pline. This is particularly important
in view of the fact that most of the
clinical trials examining efficacy of
psychotherapy have been con¬
ducted by psychologists. The pro¬
cedure used by the APA (profession¬
als representing one discipline wrote
the draft guideline and then asked
for comments from reviewers from
other disciplines) did not, in our
view, adequately protect the guide¬
line from bias.
Third, we recommend that fu¬
ture practice guidelines include some
discussion of cost; an argument can
be made that treatment quality can¬
not be evaluated independently of its
cost.
Finally, we recommend that
practice guidelines be revised peri¬
odically so that new research find¬
ings can be incorporated in a timely
manner. The process of guideline de¬
velopment should be seen as con¬
tinuing past the point of publica¬
tion, so that comments, criticisms,
and suggestions for revision are wel¬
comed on an ongoing basis.
Accepted for publication August 25,
1995.
This work was supported in part
MH50367 (Dr Persons),
by grants
MH-30915 (Clinical Research Cen-
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ter), and MH-41884 (Dr Thase) from
the National Institute of Mental
Health, Rockville, Md, and grants DA-
07673 and DA-08541 from the Na¬
tional Institute on Drug Abuse, Rock¬
ville, Md (Dr Thase).
The authors thank Irene Elkin,
PhD, Ellen Frank, PhD, David f.
Kupfer, MD, Peter Lewinsohn, PhD,
and K. Daniel O'Leary, PhD, for their
helpful comments, and Andrew Ber-
tagnolli for his assistance with li¬
brary work.
Reprint requests to Center for
Cognitive Therapy, 5435 College Ave,
Suite 102, Oakland, CA 94618-
1502 (Dr Persons).
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