Major depression is a serious, commonly occurring disorder associated with decreased functioning, including low educational attainment, low work performance, and low marital quality.  Depression is also related to an elevated risk of various chronic physical disorders (Kessler, 2012). The World Health Organization (WHO) ranked depression as the fourth leading cause of disability worldwide (Murray & Lopez, 1996).

Despite these adverse outcomes, there are effective treatments for depression, including psychotherapy. Because behavioral health referrals can be difficult to obtain, psychotherapy may be administered in the primary care setting (Goldberg, 1995). When psychological interventions for depression were applied in primary care, they were linked to clinical improvement, showing greater effectiveness over usual primary care in both the short term and long term (Bortolotti, Menchetti, Bellini, Montaguti, & Berardi, 2008). 

Different types of psychotherapy for depression are generally considered to be equally efficacious (Cuijpers, Van Straten, Andersson, & Van Oppen, 2008). Commonly used psychotherapies to treat depression are:

•    Psychodynamic therapy: enhances the awareness and insight regarding the impact of unresolved conflicts on behavior and mood. Psychodynamic therapy may include exploration of childhood experiences, past unresolved conflicts, and the relationship between the therapist and patient.
•    Behavioral activation: gradually builds motivation and energy through pleasure from new behaviors and mastery of behaviors.
•    Cognitive behavioral therapy (CBT): focuses on evaluating, challenging, and modifying dysfunctional beliefs. These cognitive interventions may be provided in combination with other components such as behavioral activation or coping skills.
•    Acceptance and commitment therapy (ACT): changes patients’ relationship with their thoughts, feelings, memories, and bodily reactions, so they do not entangle in maladaptive patterns. ACT emphasizes being open, flexible, mindful, and actively pursuing values.
•    Interpersonal psychotherapy (IPT): time-limited psychotherapy that focuses on interpersonal issues as a key component of psychological distress. IPT provides relief by reducing symptoms, improving interpersonal functioning, and increasing social supports.  

As noted above, psychotherapy offered by behavioral health providers within the primary care setting can be valuable in driving improved outcomes. However, for practices without embedded behavioral health providers, the provision of psychotherapy within primary care may be out of scope for the physician, particularly when considering practical elements of visits. Actionable therapeutic strategies may be useful for primary care providers for the management of symptoms, in conjunction with and/or while awaiting connection with a behavioral health provider. They may also be offered as an option to patients who are not certain about connecting with behavioral health care. Offered in this context, psychotherapeutic techniques may provide the physician with resources to support treatment in primary care, and/or provide the patient with exposure to what they can expect from care with a specialist.

Refer to these resources for actionable therapeutic strategies

1.    Behavioral activation/therapist aid
2.    CBT worksheets / APA publishing
3.    ACT clinical resources / Association for contextual behavioral science 
4.    Key IPT strategies / International society of interpersonal psychotherapy

References: 

Bortolotti, B., Menchetti, M., Bellini, F., Montaguti, M. B., & Berardi, D. (2008). Psychological interventions for major depression in primary care: a meta-analytic review of randomized controlled trials. General hospital psychiatry, 30(4), 293-302.

Cuijpers, P., Van Straten, A., Andersson, G., & Van Oppen, P. (2008). Psychotherapy for depression in adults: a meta-analysis of comparative outcome studies. Journal of consulting and clinical psychology, 76(6), 909.

Cuijpers, P., van Straten, A., Bohlmeijer, E., Hollon, S. D., & Andersson, G. (2010). The effects of psychotherapy for adult depression are overestimated: a meta-analysis of study quality and effect size. In Database of Abstracts of Reviews of Effects (DARE): Quality-assessed Reviews. Centre for Reviews and Dissemination (UK).

Goldberg, D. P. (1995). Form and frequency of mental disorders across centres. Mental illness in general health care: An international study.

Hasin, D. S., Sarvet, A. L., Meyers, J. L., Saha, T. D., Ruan, W. J., Stohl, M., & Grant, B. F. (2018). Epidemiology of adult DSM-5 major depressive disorder and its specifiers in the United States. JAMA psychiatry, 75(4), 336-346.

Kessler, R. C. (2012). The costs of depression. Psychiatric Clinics, 35(1), 1-14.

Murray, C. J., & Lopez, A. D. (1996). Evidence-based health policy--lessons from the Global Burden of Disease Study. Science, 274(5288), 740-743.

Wang, P. S., Aguilar-Gaxiola, S., Alonso, J., Angermeyer, M. C., Borges, G., Bromet, E. J., ... & Wells, J. E. (2007). Use of mental health services for anxiety, mood, and substance disorders in 17 countries in the WHO world mental health surveys. The Lancet, 370(9590), 841-850.
 

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