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Book Forum: Theory and Treatment of Depression   |    
Active Treatment of Depression
DAVID L. DUNNER, M.D.
Am J Psychiatry 2002;159:169-a-170. doi:10.1176/appi.ajp.159.1.169-a
View Author and Article Information
Seattle, Wash.

By Richard O’Connor. New York, W.W. Norton & Co., 2001, 272 pp., $35.00.

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This is a rather provocative book written by a psychotherapist and apparently intended for psychotherapists. I am not certain I am the right person to review it because the message clearly is less intended for me than for other clinicians. In the introduction, Dr. O’Connor states, "This is a book for mental health professionals who treat patients with depression. I am a therapist who suffers from depression myself."

The tone of this book is quite critical toward the usual treatment that therapists provide for depressed patients. The initial three chapters, "What Is Depression?" "The Disease That Causes Itself," and "The Functional Symptoms/Skills of Depression," set the stage for the remaining 11 chapters, which deal with assessment and treatment of patients with depression. Each chapter has some case material in it to help make the point of the particular chapter.

The first three chapters review the current status of diagnosis and treatment of depression in the United States. The review is, in my mind, a bit too critical. Dr. O’Connor sees the glass as half empty. I would prefer to see it as half full. I agree with him that more research needs to be done to determine the effectiveness of treatment in patients. I also agree with a major point that he makes that manualized therapies restrict the therapist to perform within the confines of a particular approach.

However, the alternative is to have no way of being able to assess whether a therapy is useful for patients, since therapies would then be individually grounded on the basis of the technique of the individual therapist. This indeed was the situation before the National Institute of Mental Health (NIMH) organized research into therapies such as cognitive behavior therapy and interpersonal psychotherapy for the treatment of depression. These therapies are not perfect, but adherence to the principles and guidelines from the treatment manuals will provide at least something of a standardized treatment. If that therapy is effective, at least we know how to approach relapse or recurrence. If that therapy is less effective we know what was delivered so we can treat the patient in an alternate way.

I like to think of psychotherapy as being like branded medications. When one is treated with a medication one gets a standard pill with research behind it to indicate its clinical utility, likely efficacy, and likely side effects. In my view, the same should hold true for other treatments, including psychotherapy. Having taken histories from a number of patients and asked what kind of psychotherapy they received, for the most part what they seem to be getting is supportive therapy. There are absolutely no data about the efficacy of this therapy for depression, nor is there any standardization of this type of therapy. Why pay money for a treatment if the treatment is not standardized and not shown to be effective?

Dr. O’Connor’s position is that therapists need to break loose from analytic traditions and be more inventive in their treatment. This may be fine for him, but I don’t know that his therapy is otherwise defined so that I could suggest to a patient of mine that whatever type of therapy Dr. O’Connor espouses is apt to be effective or indeed reproducible. Here again, I disagree very strongly with his major point: although I agree that therapy needs to be individualized, to some extent this is more like adjusting the dose of medication than providing a different therapeutic stance for every depressed patient who comes through the door.

Furthermore, I think Dr. O’Connor dismisses too quickly the research that has been done into therapies for depression, not only with cognitive behavior therapy and interpersonal psychotherapy but also with the cognitive behavioral analysis system of psychotherapy. He also seems to be unaware of current initiatives to expand psychotherapy research into the "component parts" of cognitive behavior therapy. For example, we are currently conducting a study of "behavioral activation," a therapy developed by the late Neal Jacobson. This study is funded by NIMH.

Some of the points Dr. O’Connor makes are well-taken and I think will be useful to people who are involved in the treatment of depressed patients. The tone of the book, to me, is quite negative and surprisingly jarring. However, because it was jarring it caused me to think about the role of people who treat individuals with depression and how we approach our patients. The provocative nature of Dr. O’Connor’s book makes it useful for individuals involved in the treatment of depressed patients to read. I doubt this book would be helpful for others, such as medical students or patients.

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