Where Next in Psychotherapy for Depression?

Did you know that depression is now the leading source of disability worldwide? It is a surprising fact when one considers the range of other physical and mental health conditions that have a disabling effect on human wellbeing. According to World Health Organization estimates, more than 300 million people are now living with depression, an increase of more than 18 per cent between 2005 and 2015 (WHO, 2017). Why the 18 per cent increase? There are numerous potential reasons, but today we need to ask a different question: whatever the causes, what can psychotherapists do about it?  

There are many possible answers, but here I suggest just one: we should focus more of our energies on complex cases that are difficult-to-treat and prone to therapeutic failure. To my mind, this is not too controversial a suggestion, but it does not sit comfortably with all. If a therapy has a 60 per cent response rate, we could turn more attention to the 40 per cent, to find out what stopped them from benefiting. If the therapy has a 20 per cent rate of drop out, we could research what stopped those clients following through the whole process. If the therapy has a 30 per cent relapse rate, in the first year, and that rises to 50 per cent over two years: we could we try to learn something new about the processes that led those clients back into depression.

In fact, these are the approximate clinical outcomes of Cognitive-Behavioural Therapy (CBT) for major depression, as reflected in recent meta-analyses of several Randomized Controlled Trials (RCTs) (Cuipers et al, 2014). Whatever your therapeutic orientation – mine is CBT – please don’t make the mistake of rejecting an approach you have not directly experienced or, worse still, scoff from the side-lines as if your therapy’s outcomes are clearly better than this. They’re not.  The above outcomes are at least as good as any other bona fide therapy for major depression. Perhaps you’re just remembering your successes, or maintaining your beliefs about your preferred approach.

What might be jarring (or refreshing?) here is the lack of usual concerns about marketing. For any therapy to compete in the healthcare marketplace it has to put its best foot forward: keep the focus on the majority who benefit, keep repeating the strapline that ‘therapy A is effective for problem B’ – but that can so easily maintain the illusion that all clients benefit. These marketplace influences have unintended, unfortunate and somewhat insidious effects on the minds of all, including psychotherapists.  

It is human: our attention sits more comfortably on our successes. Their fate snugs neatly into the claims of the therapy; they make us feel good; they help us to keep our hopes up for the next client, maintain our preferred self-identity, and so on. Whereas our therapy failures can make us feel bad, doubt whether we provided the therapy well-enough, in the right way, or with enough skill. So a rather unholy alliance can form between therapy proponents and jobbing therapists: neither is too keen to
talk about their treatment failures. And there lies the rub.  

The most successful industry worldwide – in terms of safety, reliability, quality, and so on – is the aviation industry. The reason is this: it has statutory procedures to research all failures (i.e. crashes) with rapid global dissemination and update mechanisms for all safety and other procedures (Syed, 2015). The whole industry learns rapidly from any failure, wherever and however it occurs. So, perhaps unsurprisingly, the aviation failure rate continues to decrease and its success rate continues to increase. The industry always learns – it never looks the other way. I’m suggesting we could and should apply the same reasoning to psychotherapy failures, and let’s be honest there are plenty of them.  

But the extant culture in developing psychotherapies is the futile search for the holy grail: a fast, cheap intervention that is easy to train and deliver; it will be marketable to cash-strapped healthcare organisations and effective for all. This strategy will not create more effective therapies: at best it will produce faster recoveries for clients with straightforward problems, the same people who benefit from current therapies. That, in itself, is not a bad thing: but we shouldn’t be surprised when the resulting therapies are no more potent for difficult-to-treat or complex clients. And those clients aren’t going away.

Cuijpers, P., Karyotaki, E., Weitz, E., Andersson, G., Hollon, S.D. & Straten, A. (2014). The effects of psychotherapies for major depression in adults on remission, recovery and improvement: A meta-analysis. Journal of Affective Disorders. 159: 118–126

Syed, M. (2015). Black Box Thinking: Marginal Gains and the Secrets of High Performance. John Murray

World Health Organisation (2017). Depression and Other Common Mental Disorders: Global Health Estimates. WHO/MSD/MER/2017.2

CBT for Depression: An Integrated Approach, by Stephen Barton and Peter Armstrong, is published by Sage.