What types of psychological treatments can be used in depression?

In Germany, statutory health insurers cover the costs of the following types of psychological therapy for the outpatient treatment of depression:

• Cognitive behavioral therapy: This therapy approach aims to change behaviors and attitudes, work on current problems, and find concrete solutions.
• Analytical psychotherapy: Analytical therapy focuses more on past experiences. The aim is to find possible causes of the person's psychological problems and, for example, work through problematic relationship experiences.
• Depth psychotherapy: This is similar to analytical therapy, but it focuses more on current conflicts and usually doesn't last as long.
• Systemic therapy: Systemic therapy is based on the assumption that relationships between people, especially those within the family, play an important role in the development and treatment of depression. The therapy is intended to help family members communicate better and give each other more support.

All four approaches are offered by psychotherapists with a background in psychology or medicine. There are more types of treatment recognized by the psychological community, but they are not currently covered by statutory health insurers in Germany or they may only be available in inpatient facilities. These include interpersonal psychotherapy and person-centered therapy. Sometimes elements of different approaches are combined.

Person-centered therapy and interpersonal psychotherapy are similar to systemic therapy and cognitive behavioral therapy in that they focus more on finding solutions concerning current problems and experiences.

How effective is psychological treatment?

Many studies have shown that people with depression benefit from psychological treatment. It's not possible to tell for sure which of the approaches is most effective in different situations, though.

Psychological treatment can help to relieve the symptoms of depression and lower the risk of becoming depressed again – for instance, by helping you to deal with negative thoughts or challenges better. It can also be a relief to have a better understanding of what is causing the symptoms.

How well psychological treatment works will depend on the approach used, the type and severity of depression, how long the patient has had depression, and whether he or she has other psychological problems too. Also, not everyone responds to psychological treatment in the same way: Some people are helped by just a few sessions, while others need longer treatment. Further factors that play a role include the sometimes very diverse symptoms, and the patient’s personality, life experiences, and current circumstances.

The relationship between the patient and therapist is also a crucial factor. It is important for the therapist to be attentive, respectful, open-minded and empathetic – and the "chemistry" has to be right. The patient's expectations of therapy have to be realistic.

When is psychotherapy an option?

Psychological treatment can relieve acute depression effectively, just as medication can. It is usually recommended for moderate to severe depression. Experts typically only recommend psychotherapy if other approaches have not been effective enough or there is a risk that the symptoms might get worse. These other approaches might include psychological counseling, sports or certified digital health applications (apps).

Severe depression is often treated with a combination of psychological treatment and medication. This combination can help more than just antidepressants or psychological treatment on their own. Some people don't start psychological treatment until they have had acute treatment with medication. Psychological treatment aims to offer long-term stability and stop the depression from returning. Chronic and recurrent depression are also often treated with both antidepressants and psychological therapy.

Can psychological treatment have side effects?

Like antidepressant medication, psychological treatment can have side effects and other repercussions. The difference is that antidepressants are more likely to have physical side effects than psychological ones. As a result, treatment with antidepressants is stopped more often than psychological treatment is. But there's a general lack of research on the side effects of psychological treatment.

Psychological treatment also involves dealing with topics that may be unpleasant and upsetting. That can sometimes be too much for the patient, making them feel even less stable and possibly worse for a while. But facing these issues can also be an important step towards getting better.

Psychological treatment can affect partnerships, friendships and other relationships, including ones at work, for example. It usually helps people to deal with conflicts. If someone changes their usual behavior as a result of psychotherapy, it may lead to tension with others too, though. The patient might also become dependent on their therapist, or conflicts between the patient and therapist may arise.

Before starting therapy, it's important to openly discuss what you expect from treatment and what is actually possible. If the therapist warns you about how the treatment might affect you, you may be better prepared, helping you to handle more difficult phases of treatment. Should you think the treatment isn't going well, it's always good to let your therapist know that you feel that way.

How can you get a regular appointment for psychological treatment?

Your family doctor can often recommend a therapist. But you can also contact the private practices of psychotherapists or psychiatrists directly. In Germany, the Association of Statutory Health Insurance Physicians (“Kassenärztliche Vereinigung”) can help you to get an appointment.

You can also go directly to a special initial consultations (“psychotherapeutische Sprechstunde”). These are offered by outpatient psychotherapy practices. Adults can have up to six of these 25-minute consultations without having to wait a long time to get an appointment, and children and teenagers can have up to ten of them (together with their parents if needed). These sessions can be used to assess the symptoms and to see what further treatments and forms of help are possible. The special initial psychotherapy sessions described above may help people find a suitable therapy for more long-term treatment.

People who would like to have long-term outpatient psychological treatment may have to wait several weeks or months before it starts, depending on what part of Germany they are in. In urgent cases you can contact a practice that offers out-of-hours services, the outpatient services for psychotherapy or a psychosomatic medicine clinic. Call the emergency services (112 in Germany and many other countries, 911 in the U.S.) if someone is thinking of killing themselves.

How do I find the right therapist?

For outpatient psychotherapy to work, it's very important to find a psychotherapist who you can trust and feel comfortable with. On top of that, the therapist and health insurance company have to check whether psychological treatment is a suitable and promising approach in each individual case.

In Germany, the first three to five psychotherapy sessions in an outpatient setting are considered to be trial sessions, to see whether the chemistry between the client and therapist is right and whether the client is happy with the therapist’s treatment approach. Statutory health insurers cover the costs of these trial sessions, even if the therapy isn’t continued afterwards.

It is possible to have new trial sessions if you switch therapists. It can sometimes take a while to find the right therapist. Even if someone has been going to a therapist for a while and then starts to feel like things aren’t quite working out, they can still try out another therapist. The insurer will determine whether a new application for therapy needs to be submitted.

What can help to start psychological treatment?

Some people find it hard to take the necessary steps to start psychological treatment. If that’s the case, it can help to

• talk to other people who have had similar therapy in the past.
• call a psychotherapy practice anonymously and find out what the therapy they offer typically involves.
• look for a psychotherapy practice in a different area, further away from your home.
• walk past the practice and take a look at it from the outside.
• ask a friend or family member to go to the first appointment with you.

Depression is a disease, not a sign of weakness. Even so, people still don’t like to talk about it. They often don’t admit how bad they're feeling – perhaps because they feel ashamed or guilty, or doubt that anyone can help them.

But many people say that they feel better after getting treatment and wish they had sought help earlier. It is important to know that there are plenty of places you can turn to for support and understanding.

What can be done if the psychotherapy doesn't help enough?

If psychotherapy doesn't improve your symptoms enough, it is important to find out the reasons why. The possible causes include

• The symptoms are too severe.
• Other illnesses or stressful life circumstances are affecting the treatment.
• The type of therapy is not suitable or is not being administered professionally.
• The diagnosis is wrong.
• You don't have a good relationship with the therapist.
• One of the two parties is not motivated enough or has the wrong expectations.
• The therapy leads to side effects like more severe symptoms or conflicts with others.

Discussions are used to find causes and solutions together. Sometimes therapists also seek support from their peers, in the form of "supervision," which can be used to talk through tricky situations or reflect on the therapist's own actions.

One solution might be to change the type of therapy or have more sessions per week. Sometimes it's also worth trying antidepressants in addition to therapy.

Sources

• Bundesärztekammer, Kassenärztliche Bundesvereinigung (KBV), Arbeitsgemeinschaft der wissenschaftlichen medizinischen Fachgesellschaften (AWMF). Nationale Versorgungsleitlinie Unipolare Depression. AWMF-Registernr.: nvl-005. 2022.
• Clarke K, Mayo-Wilson E, Kenny J et al. Can non-pharmacological interventions prevent relapse in adults who have recovered from depression? A systematic review and meta-analysis of randomised controlled trials. Clin Psychol Rev 2015; 39: 58-70. [PubMed: 25939032]
• Cuijpers P, Berking M, Andersson G et al. A meta-analysis of cognitive-behavioural therapy for adult depression, alone and in comparison with other treatments. Can J Psychiatry 2013; 58(7): 376-385. [PubMed: 23870719]
• Gartlehner G, Gaynes BN, Amick HR et al. Nonpharmacological Versus Pharmacological Treatments for Adult Patients With Major Depressive Disorder. 2015.
• Ijaz S, Davies P, Williams CJ et al. Psychological therapies for treatment-resistant depression in adults. Cochrane Database Syst Rev 2018; (5): CD010558. [PMC free article: PMC6494651] [PubMed: 29761488]
• Institute for Quality and Efficiency in Health Care (IQWiG, Germany). Systemic therapy in adults as a psychotherapeutic approach: Final report; Commission N14-02. 2017.
• Karyotaki E, Smit Y, Cuijpers P et al. The long-term efficacy of psychotherapy, alone or in combination with antidepressants, in the treatment of adult major depression (KCE Reports Good Clinical Practice). 2014.
• Linde K, Sigterman K, Kriston L et al. Effectiveness of psychological treatments for depressive disorders in primary care: systematic review and meta-analysis. Ann Fam Med 2015; 13(1): 56-68. [PMC free article: PMC4291267] [PubMed: 25583894]

• IQWiG health information is written with the aim of helping people understand the advantages and disadvantages of the main treatment options and health care services.

  Because IQWiG is a German institute, some of the information provided here is specific to the German health care system. The suitability of any of the described options in an individual case can be determined by talking to a doctor. informedhealth.org can provide support for talks with doctors and other medical professionals, but cannot replace them. We do not offer individual consultations.

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