Der Nervenarzt

, Volume 80, Issue 5, pp 540–555 | Cite as

Depressive Störungen

Stellenwert psychotherapeutischer Verfahren
Leitthema

Zusammenfassung

Der Einsatz psychotherapeutischer Verfahren bei der Behandlung depressiver Störungen gilt heutzutage als unverzichtbar. Psychotherapien erwiesen sich bei leichten bis mittelschweren Depressionen als mindestens gleichwertig effektiv wie eine Pharmakotherapie, bei schweren und chronischen Depressionen gilt die Kombination beider Therapieformen als leitlinienempfohlene Standardbehandlung. Psychotherapeutische Ansätze weisen zwar eine längere Wirklatenz auf als Antidepressiva, wirken jedoch nachhaltiger. Da hinsichtlich der Effektivität von den im Handel befindlichen sowie in der Entwicklung stehenden Antidepressiva eher ernüchternde Ergebnisse publiziert wurden, gilt der Weiterentwicklung psychologischer Behandlungsansätze derzeit besondere Aufmerksamkeit.

Die kognitive Verhaltenstherapie und die interpersonelle Psychotherapie können die höchste Evidenzstufe nachweisen, bei psychodynamischen Verfahren ist die Studienlage noch begrenzt. Bei chronischer Depression gewinnt eine neuere störungsspezifische Psychotherapie – das „cognitive behavioral analysis system of psychotherapy“ – zunehmend an Bedeutung.

Insgesamt geht der Trend zu einer zunehmenden Spezifizierung der Therapie für umschriebene Zielgruppen. Herausforderungen für die Zukunft bestehen in der Steigerung der Effizienz, der weiteren Erforschung von Wirkmechanismen und Prädiktoren für eine differenzielle Indikation und schließlich darin, die wirksamen Psychotherapiemethoden für Patienten allgemein zugänglich zu machen.

Schlüsselwörter

Depressive Störungen Psychotherapie Kognitive Verhaltenstherapie Interpersonelle Psychotherapie Cognitive behavioral analysis system of psychotherapy 

Affective disorders

The significance of psychotherapeutic approaches

Summary

The use of psychotherapeutic strategies is essential in the treatment of affective disorders. Psychotherapy proved to be at least equivalent to antidepressant medication in the treatment of mild to moderate depression. In severe cases, the combination of both treatments is considered by guidelines to be the standard treatment. Psychotherapeutic approaches show a longer latency than antidepressants; however, the effects are longer lasting. Regarding the effectiveness of pharmacotherapy sobering results have been published recently. Therefore, the further development of psychotherapy deserves special attention.

Cognitive behavioral therapy and interpersonal therapy provide the highest evidence. The empirical basis for psychodynamic psychotherapies is still limited. In the treatment of chronic depression a new approach – cognitive behavioral analysis system of psychotherapy – is gaining importance.

There is a trend towards an increasing specification of psychotherapy for distinct subgroups of depressed patients. Challenges for the future include increasing treatment efficacy, investigating mechanisms of efficacy and predictors for a differential indication, and making effective approaches generally available to all patients.

Keywords

Affective disorders Psychotherapy Cognitive behavioral therapy Interpersonal psychotherapy Cognitive behavioral analysis system of psychotherapy 

Notes

Interessenkonflikt

Der korrespondierende Autor gibt an, dass kein Interessenkonflikt besteht.

Literatur

  1. 1.
    DeRubeis RJ, Siegle GJ, Hollon SD (2008) Cognitive therapy versus medication for depression: treatment outcomes and neuronal mechanisms. Nat Rev Neurosci 9(10):788–796PubMedCrossRefGoogle Scholar
  2. 2.
    Wampold BE (2007) Psychotherapy: the humanistic (and effective) treatment. Am Psychol 62(8):855–873PubMedCrossRefGoogle Scholar
  3. 3.
    De Maat SM, Dekker J, Schoevers RA, de Jonghe F (2007) Relative efficacy of psychotherapy and combined therapy in the treatment of depression: a meta-analysis. Eur Psychiatry 22(1):1–8Google Scholar
  4. 4.
    Imel ZE, Malterer MB, McKay KM, Wampold BE (2008) A meta-analysis of psychotherapy and medication in unipolar depression and dysthymia. J Affect Disord 110(3):197–206PubMedCrossRefGoogle Scholar
  5. 5.
    Vittengl JR, Clark LA, Dunn TW, Jarrett RB (2007) Reducing relapse and recurrence in unipolar depression: a comparative meta-analysis of cognitive-behavioral therapy’s effects. J Consult Clin Psychol 75(3):475–488PubMedCrossRefGoogle Scholar
  6. 6.
    Cuipers P, van Straten A, Andersson G, van Oppen P (2008) Psychotherapy for depression in adults: a meta-analysis of comparative outcome studies. J Consult Clin Psychol 76(6):909–922CrossRefGoogle Scholar
  7. 7.
    Casacalenda N, Perry JC, Looper K (2002) Remission in major depressive disorder: a comparison of pharmacotherapy, psychotherapy, and control conditions. Am J Psychiatry 159(8):1354–1360PubMedCrossRefGoogle Scholar
  8. 8.
    Khan A, Warner HA, Brown WA (2000) Symptom reduction and suicide risk in patients treated with placebo in antidepressant clinical trials: an analysis of the Food and Drug Administration database. Arch Gen Psychiatry 57(4):311–317PubMedCrossRefGoogle Scholar
  9. 9.
    Westen D, Morrison K (2001) A multidimensional meta-analysis of treatments for depression, panic, and generalized anxiety disorder: an empirical examination of the status of empirically supported therapies. J Consult Clin Psychol 69(6):875–899PubMedCrossRefGoogle Scholar
  10. 10.
    Hollon SD, DeRubeis RJ, Shelton RC et al (2005) Prevention of relapse following cognitive therapy vs medications in moderate to severe depression. Arch Gen Psychiatry 62:417–422PubMedCrossRefGoogle Scholar
  11. 11.
    Rush AJ, Trivedi MH, Wisniewski SR et al (2006) Acute and longer-term outcomes in depressed outpatients requiring one or several treatment steps: a STAR*D report. Am J Psychiatry 163(11):1905–1917PubMedCrossRefGoogle Scholar
  12. 12.
    Hirschfeld RM, Dunner DL, Keitner G et al (2002) Does psychosocial functioning improve independent of depressive symptoms? A comparison of nefazodone, psychotherapy and their combination. Biol Psychiatry 51(2):123–133PubMedCrossRefGoogle Scholar
  13. 13.
    Judd LL, Akiskal HS, Maser JD et al (1998) Major depressive disorder: a prospective study of residual subthreshold depressive symptoms as predictor of rapid relapse. J Affect Disord 50(2–3):97–108Google Scholar
  14. 14.
    Insel TR (2006) Beyond efficacy: the STAR*D trial. Am J Psychiatry 163(1):5–7PubMedCrossRefGoogle Scholar
  15. 15.
    Trivedi MH, Fava M, Wisniewski SR (2006) Medication augmentation after the failure of SSRIs for depression. N Engl J Med 354:1243–1252PubMedCrossRefGoogle Scholar
  16. 16.
    Schatzberg AF, Krämer HC (2000) Use of placebo control groups in evaluating efficacy of treatment of unipolar major depression. Biol Psychiatry 47(8):736–744PubMedCrossRefGoogle Scholar
  17. 17.
    Barlow DH, Gorman JM, Shear MK, Woods SW (2000) Cognitive-behavioral therapy, imipramine, or their combination for panic disorder: A randomized controlled trial. JAMA 283(19):2529–2536PubMedCrossRefGoogle Scholar
  18. 18.
    Etkin A, Pittenger C, Polan HJ, Kandel ER (2005) Toward a neurobiology of psychotherapy: basic science and clinical applications. J Neuropsychiatry Clin Neurosci 17(2):145–158PubMedGoogle Scholar
  19. 19.
    Thase ME, Friedman ES (1999) Is psychotherapy an effective treatment for melancholia and other severe depressive states? J Affect Disord 54(1–2):1–19Google Scholar
  20. 20.
    Elkin I, Shea T, Watkins JTet al (1989) National institute of mental health treatment of depression collaborative research program general effectiveness of treatments. Arch Gen Psychiatry 46(11):971–982PubMedGoogle Scholar
  21. 21.
    Thase ME, Greenhouse JB, Frank E et al (1997) Treatment of major depression with psychotherapy or psychotherapy-pharmacotherapy combinations. Arch Gen Psychiatry 54(11):1009–1015PubMedGoogle Scholar
  22. 22.
    DeRubeis RJ, Gelfand LA, Tang TZ, Simons AD (1999) Medications versus cognitive behavior therapy for severely depressed outpatients: mega-analysis of four randomized comparisons. Am J Psychiatry 156(7):1007–1013PubMedGoogle Scholar
  23. 23.
    Friedman MA, Detweiler-Bedell JB, Leventhal HW et al (2004) Combined psychotherapy and pharmacotherapy for the treatment of major depressive disorder. Clin Psychol Sci Practice 11:47–68CrossRefGoogle Scholar
  24. 24.
    Jindal RD, Thase ME (2003) Integrating psychotherapy and pharmacotherapy to improve outcomes among patients with mood disorders. Psychiatr Serv 54(11):1484–1490PubMedCrossRefGoogle Scholar
  25. 25.
    Bockting CLH, Schene AH, Spinhoven P et al (2005) Preventing relapse/recurrence in recurrent depression with cognitive therapy: a randomized controlled trial. J Consult Clin Psychol 73(4):647–657PubMedCrossRefGoogle Scholar
  26. 26.
    Reynolds CF 3rd, Frank E, Perel JM, Imber SD et al (1999) Nortriptyline and interpersonal psychotherapy as maintenance therapies for recurrent major depression: a randomized controlled trial in patients older than 59 years. JAMA 281(1):39–45PubMedCrossRefGoogle Scholar
  27. 27.
    National Institute for Health and Clinical Excellence (2007) Clinical Guideline 23 (amended): Depression: management of depression in primary and secondary care. http://www.nice.org.uk/CG023NICEguidelineGoogle Scholar
  28. 28.
    DGPPN (2009) S-III-Leitlinien der Deutsche Gesellschaft für Psychiatrie, Psychotherapie und NervenheilkundGoogle Scholar
  29. 29.
    Pampallona S, Bollini P, Tibaldi G et al (2004) Combined pharmacotherapy and psychological treatment for depression: a systematic review. Arch Gen Psychiatry 61(7):714–719PubMedCrossRefGoogle Scholar
  30. 30.
    Orlinsky DE, Grawe K, Parks B (1994) Process and outcome in psychotherapy. In: Bergin AE, Garfield SL (Hrsg) Handbook of psychotherapy and behavior change. John Wiley & Sons, New York, S 270–376Google Scholar
  31. 31.
    Orlinsky DE, Roennestadt MH, Willutzki U (2004) Fifty years of psychotherapy process-outcome research: Continuity and change. In: Lambert MJ (Hrsg) Bergin and Garfield ́s Handbook of Psychotherapy and Behavior Change. Wiley, New York, S 307–390Google Scholar
  32. 32.
    Beck AT, Rush AJ, Shaw BF, Emery G (1979) Cognitive Therapy of Depression. Guilford Press, New YorkGoogle Scholar
  33. 33.
    Lewinsohn PM (1974) A behavioral approach to depression. In: Friedman RJ, Katz MM (eds) The psychology of depression. Wiley & Sons, New YorkGoogle Scholar
  34. 34.
    Klerman GL, Weissman M, Rounsaville BJ, Chevron ES (1984) Interpersonal Psychotherapy of Depression. Basic Books, New YorkGoogle Scholar
  35. 35.
    Mentzos S (1995) Depression und Manie; Psychodynamik und Psychotherapie affektiver Störungen. Vandenhoeck & Ruprecht, Göttingen ZürichGoogle Scholar
  36. 36.
    Finke J (2004) Gesprächspsychotherapie. Grundlagen und spezifische Anwendungen. 3. Aufl. Thieme, Stuttgart New YorkGoogle Scholar
  37. 37.
    Conte HR, Plutchik R, Wild KV, Karasu TB (1986) Combined psychotherapy and pharmacotherapy for depression. A systematic analysis of the evidence. Arch Gen Psychiatry 43(5):471–479PubMedGoogle Scholar
  38. 38.
    Gloaguen V, Cottraux J, Cucherat M, Blackburn I (1998) A meta-analysis of the effects of cognitive therapy in depressed patients. J Affect Disord 49(1):59–72PubMedCrossRefGoogle Scholar
  39. 39.
    de Mello MF, de Jesus Mari J, Bacaltuchuk J et al (2005) A systematic review of research findings on the efficacy of interpersonal therapy for depressive disorders. Eur Arch Psychiatry Clin Neurosci 255(2):75–82CrossRefGoogle Scholar
  40. 40.
    de Jong-Meyer R, Hautzinger M, Kühner C, Schramm E (2007) Evidenzbasierte Leitlinie zur Psychotherapie Affektiver Störungen. Im Auftrag der Fachgruppe Klinische Psychologie und Psychotherapie in der Deutschen Gesellschaft für Psychologie. Hogrefe, GöttingenGoogle Scholar
  41. 41.
    Crits-Christoph P (1992) The efficacy of brief dynamic psychotherapy: a meta-analysis. Am J Psychiatry 149(2):151–158PubMedGoogle Scholar
  42. 42.
    Leichsenring F (2001) Comparative effects of short-term psychodynamic psychotherapy and cognitive-behavioural therapy in depression. Clin Psychol Rev 21:401–419PubMedCrossRefGoogle Scholar
  43. 43.
    Leichsenring F, Rabung S, Leibing E (2004) The efficacy of short-term Psychodynamic Psychotherapy in specific psychiatric disorders. A meta-analysis. Arch Gen Psychiatry 61:1208–1216PubMedCrossRefGoogle Scholar
  44. 44.
    Shapiro DA, Barkham M, Rees A et al (1994) Effects on treatment duration and severity of depression on the effectiveness of cognitive-behavioral and psychodynamic-interpersonal psychotherapy. J Consult Clin Psychol 62:522–534PubMedCrossRefGoogle Scholar
  45. 45.
    De Jonghe F, Hendriksen M, van Aalst G et al (2004) Psychotherapy alone and combined with pharmacotherapy in the treatment of depression. Br J Psychiatry 185:37–45CrossRefGoogle Scholar
  46. 46.
    Leichsenring F, Rabung S (2008) Effectiveness of long-term psychodynamic psychotherapy. A meta-analysis. JAMA 300(13):1551–1565PubMedCrossRefGoogle Scholar
  47. 47.
    Watson JC, Gordon LB, Stermac L et al (2003) Comparing the effectiveness of process-experiential with cognitive-behavioral psychotherapy in the treatment of depression. J Consult Psychol 71(4):773–781CrossRefGoogle Scholar
  48. 48.
    Hautzinger M (2008) Depression (2. Aufl). Fortschritte der Psychotherapie. Hogrefe, GöttingenGoogle Scholar
  49. 49.
    DeRubeis RJ, Gelfand LA, Tang TZ, Simons AD (1999) Medications versus cognitive behavior therapy for severely depressed outpatients: mega-analysis of four randomized comparisons. Am J Psychiatry 156(7):1007–1013PubMedGoogle Scholar
  50. 50.
    Jorgensen BM, Dam H, Bolwig TG (1998) The efficacy of psychotherapy in non-bipolar depression. A review. Actas Psychiatr Scand 98:1–13CrossRefGoogle Scholar
  51. 51.
    Schramm E (1998) Interpersonelle Psychotherapie. Schattauer, StuttgartGoogle Scholar
  52. 52.
    Schramm E, van Calker D, Dykierek P et al (2007) An intensive treatment program of Interpersonal Psychotherapy plus pharmacotherapy for depressed inpatients: acute and long-term results. Am J Psychiatry 164:768–777PubMedCrossRefGoogle Scholar
  53. 53.
    Dunner DL (2001) Acute and maintenance treatment of chronic depression. J Clin Psychiatry 62:10–16PubMedGoogle Scholar
  54. 54.
    Pincus HA, Pettit AR (2001) The societal costs of chronic major depression. J Clin Psychiatry 62(6):5–9PubMedGoogle Scholar
  55. 55.
    McCullough JP (2000) Treatment for chronic depression. Cognitive behavioral analysis system of psychotherapy. Guilford Press, New YorkGoogle Scholar
  56. 56.
    Schramm E, Schweiger U, Hohagen F, Berger M (2006) Dtsch Übersetzung und Bearbeitung von: McCullough JP (2000) Treatment for chronic depression. Cognitive Behavioral Analysis System of Psychotherapy. Elsevier, MünchenGoogle Scholar
  57. 57.
    Keller MB, McCullough JP, Klein DN et al (2000) A comparison of nefazodone, the cognitive behavioral-analysis system of psychotherapy, and their combination for the treatment of chronic depression. N Engl J Med 342(20):1462–1470PubMedCrossRefGoogle Scholar
  58. 58.
    Nemeroff CB, Heim CM, Thase ME et al (2003) Differential responses to psychotherapy versus pharmacotherapy in patients with chronic forms of major depression and childhood trauma. Proc Natl Acad Sci USA 100:14293–14296PubMedCrossRefGoogle Scholar
  59. 59.
    Schramm E (2008) Psychotherapeutische Behandlung der chronischen und therapieresistenten Depression (Vortrag im Symposium: Chronische und therapieresistente Depressionen, Chair: M. Bauer & E. Schramm). Kongress der Deutschen Gesellschaft für Psychiatrie, Psychotherapie und Neurologie (DGPPN), BerlinGoogle Scholar
  60. 60.
    Ost LG (2008) Efficacy of the third wave of behavioral therapies: a systematic review and meta-analysis. Behav Res Ther 46(3):269–321CrossRefGoogle Scholar
  61. 61.
    Browne G, Steiner M, Roberts J et al (2002) Sertraline and/or interpersonal psychotherapy for patients with dysthymic disorder in primary care: 6-month comparison with longitudinal 2-year follow-up of effectiveness and costs. J Affect Disord 68(2–3):317–330Google Scholar
  62. 62.
    Schulberg HC, Block MR, Madonia MJ et al (1996) Treating major depression in primary care practice. Eight month clinical outcomes. Arch Gen Psychiatry 53(10):913–919PubMedGoogle Scholar
  63. 63.
    Longmore RJ, Worrell M (2007) Do we need to challenge thought in cognitive behavior therapy? Clin Psychol Rev 27:173–187PubMedCrossRefGoogle Scholar
  64. 64.
    Hautzinger M, de Jong-Meyer R (1996) Depression. Ergebnisse von zwei multizentrischen Vergleichsstudien bei unipolarer Depression. Z Klin Psychol 26:80–160Google Scholar
  65. 65.
    Frank E, Kupfer DJ, Perel JM et al (1990) Three-year outcomes for maintenance therapies in recurrent depression. Arch Gen Psychiatry 47(12):1093–1099PubMedGoogle Scholar
  66. 66.
    Frank E, Kupfer DJ, Wagner EF et al (1991) Efficacy of interpersonal psychotherapy as a maintenance treatment of recurrent depression. Contributing factors. Arch Gen Psychiatry 48(12):1053–1059PubMedGoogle Scholar
  67. 67.
    Frank E, Kupfer DJ, Buysse DJ et al (2007) Randomized trial of weekly, twice-monthly, and monthly Interpersonal Psychotherapy as maintenance treatment for woman with recurrent depression. Am J Psychiatry 164:761–767PubMedCrossRefGoogle Scholar
  68. 68.
    Teasdale JD, Segal ZV, Williams JM et al (2000) Prevention of relapse/recurrence in major depression by mindfulness-based cognitive therapy. J Consult Clin Psychol 68(4):615–623PubMedCrossRefGoogle Scholar
  69. 69.
    Ma SH, Teasdale JD (2004) Mindfulness-based cognitive therapy for depression: replication and exploration of differential relapse prevention effects. J Consult Clin Psychol 72(1):31–40PubMedCrossRefGoogle Scholar
  70. 70.
    Klein DN, Santiago NJ, Vivian D et al (2004) Cognitive-behavioral analysis system of psychotherapy as a maintenance treatment for chronic depression. J Consult Clin Psychol 72:681–688PubMedCrossRefGoogle Scholar

Copyright information

© Springer Medizin Verlag 2009

Authors and Affiliations

  • M. Berger
    • 1
  • E.L. Brakemeier
    • 1
  • C. Klesse
    • 1
  • E. Schramm
    • 1
  1. 1.Abteilung für Psychiatrie und PsychotherapieUniversitätsklinikumFreiburgDeutschland

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