The treatment of nonmelancholic depression: when antidepressants fail, does psychotherapy work?

OBJECTIVE

Treatment-resistant depression (TRD) is used as a descriptive or diagnostic term and has generated many management guidelines weighting antidepressant (AD) therapy, but which may be an inappropriate paradigm for the nonmelancholic disorders where psychotherapy may be a more salient modality. This study sought to evaluate the effectiveness of psychological therapy in patients whose nonmelancholic depressive condition had been resistant to at least 2 ADs.

METHOD

Principal analyses compared 32 patients, diagnosed with a nonmelancholic depression who received 12 weeks of psychological therapy, with a small control group. Comparative analyses failed to find a distinct therapeutic effect, leading to an extension study pursuing candidate explanatory factors for this lack of response, including psychosocial factors.

RESULTS

While our sample showed a 41% response and 22% remission rate to psychotherapy, their improvement pattern was similar to the control group, thus arguing against any specific therapeutic benefit. Explanatory factors nominated by the treating psychologist weighted personality issues for 35% of the patients, distal stressors for 22%, and comorbid anxiety conditions for 18%. When sample members were compared with an age- and sex-matched sample of patients with nonmelancholic depression who improved distinctly during a similar 12-week period, rates of such putative personality, stress, and anxiety risk factors did not differ, arguing against the likelihood of these factors compromising improvement.

CONCLUSIONS

Patients with nonmelancholic TRD also failed to demonstrate a clear response to a psychotherapeutic approach, while our pursuit of clinically explanatory variables was not supported empirically.