# Psychotherapy for Depression — APA 2023

## Overview

The APA Clinical Practice Guideline for the Treatment of Depression Across Three Age Cohorts recommends psychotherapy as a first-line treatment for depressive disorders. The guideline addresses major depressive disorder (MDD), persistent depressive disorder, and subsyndromal depressive symptoms across three developmental cohorts: children/adolescents, adults, and older adults (age 60 and over). Ten systematic reviews and meta-analyses served as the evidence base.

The panel found that effectiveness studies demonstrated **comparable effects across psychotherapies** for initial treatment of depression. As a result, the panel does not recommend a single specific monotherapy for initial treatment; instead, treatment selection should be individualized based on patient preference, clinical factors, and shared decision-making.

## Recommended Psychotherapies for Adults

For initial treatment of adult patients with MDD, the panel recommends that clinicians offer psychotherapy as a first-line treatment option (Strong Recommendation).

### Cognitive-Behavioral Therapy (CBT)

- CBT is one of the most extensively studied psychotherapies for depression, with the most robust evidence base across all three age cohorts
- Targets dysfunctional cognitions and maladaptive behaviors
- Typically delivered in 12-20 individual sessions
- Effective for acute-phase treatment, relapse prevention, and as an adjunct to pharmacotherapy
- **For combined treatment:** If psychotherapy and pharmacotherapy are combined, the panel recommends CBT or interpersonal psychotherapy (IPT) plus a second-generation antidepressant (Strong Recommendation)

### Behavioral Activation (BA)

- A guideline-recommended, evidence-based derivative of CBT for depression
- Focuses on increasing engagement in values-based activities that provide pleasure, connection, or achievement
- Efficacy is comparable to full CBT and other major psychotherapy modalities
- May be more accessible and easier to disseminate than full CBT protocols

### Interpersonal Psychotherapy (IPT)

- Focuses on resolving interpersonal difficulties (grief, role transitions, role disputes, interpersonal deficits) that trigger or maintain depressive episodes
- Typically delivered in 12-16 sessions
- Recommended for combined treatment with pharmacotherapy (Strong Recommendation)
- Effective for relapse prevention

### Psychodynamic Therapy

- Focuses on unconscious processes, past experiences, and interpersonal patterns contributing to depressive symptoms
- For adults who have not responded or only partially responded to initial antidepressant treatment, the panel suggests adding psychodynamic therapy as one option (Conditional Recommendation)
- Evidence supports its use as a second-line adjunctive treatment

### Mindfulness-Based Cognitive Therapy (MBCT)

- Integrates mindfulness meditation practices with cognitive therapy techniques
- Specifically recommended for **relapse prevention** in patients who have achieved remission
- Particularly suited for patients with recurrent MDD (two or more episodes)

## Recommended Psychotherapies for Children and Adolescents

- **CBT** is the most evidence-supported psychotherapy for adolescent depression
- The panel recommends CBT as a first-line treatment for adolescents with MDD
- Combined CBT plus fluoxetine showed the highest response rate in the TADS trial: **71%** (vs. 60.9% fluoxetine alone, 43.2% CBT alone, 35% placebo)
- The panel did not make treatment recommendations specific to children younger than adolescent age due to insufficient evidence

## Recommended Psychotherapies for Older Adults (Age 60+)

For initial treatment of older adult patients with depression, the panel recommends:

- **Group life-review therapy** or **group CBT** (either alone or added to usual care) over no treatment (Strong Recommendation)
- **Combined pharmacotherapy and IPT** over IPT alone (Strong Recommendation)
- **Behavioral activation therapy** (individual) and treatment as usual over treatment as usual alone for depressive symptoms in older adults with mild to moderate depression (Conditional Recommendation)
- **Problem-solving therapy** (individual) for older adults with MDD and executive dysfunction (Conditional Recommendation)
- **Problem-solving behavioral therapy** or **pleasant events behavioral therapy** (individual) for minor or major depressive disorder in older adults with dementia (Conditional Recommendation)

## Relapse Prevention with Psychotherapy

For adult patients with MDD who have achieved remission, the panel suggests offering psychotherapy to prevent relapse (Conditional Recommendation):

- **CBT**, **IPT**, or **MBCT** during remission can reduce the risk of relapse
- This recommendation applies particularly to patients with unstable remission or two or more prior episodes of MDD
- Continuing medications for at least 6 months after symptom remission reduces relapse by nearly one-third; psychotherapy-based relapse prevention offers an alternative or adjunctive strategy

## Inadequate Response to Initial Treatment

For adult patients who have not responded or only partially responded to initial antidepressant medication, the panel suggests one of the following (Conditional Recommendation):

- **Add psychotherapy** (IPT, CBT, or psychodynamic therapy) to the antidepressant medication
- **Augment** with another antidepressant medication
- There is insufficient evidence to determine differences in treatment effect between switching to another antidepressant, switching to cognitive therapy monotherapy, or augmenting with guided CBT self-help

## Shared Decision-Making

The guideline emphasizes **shared decision-making** as essential to treatment selection. The panel recommends that clinicians present the available evidence on benefits and harms of treatment options and collaborate with patients to select the treatment that best aligns with their values, preferences, and clinical circumstances.

## Limitations

- The guideline acknowledges that most psychotherapy research is based on **efficacy trials** (controlled settings) rather than effectiveness trials (real-world settings), which may limit generalizability
- Evidence for specific psychotherapy modalities in **children** (as distinct from adolescents) remains insufficient for the panel to make specific treatment recommendations
- Comparative effectiveness data directly comparing different psychotherapies head-to-head are limited; the panel found comparable overall effects across modalities
- Access to evidence-based psychotherapy remains a significant barrier in many clinical settings
- The guideline notes that therapist training, competence, and treatment fidelity are important moderators of psychotherapy outcomes that are difficult to standardize
