Psychotherapy of the Affective Psychoses

Until recently, the remarkable advances in chemotherapy of affective disorders have tended to obscure innovations in psychotherapeutic methods for these conditions. Further, an overreliance on psychological theory has resulted at times in persistent application, rather than modifications, of routine treatment techniques. Finally, psychotherapy researchers have only recently employed careful diagnostic methods to identify patients with affective disorders.

Within the last few years, a number of comparative outcome studies have suggested that psychological treatments have a place in treatment of at least some outpatients with mild to moderate depressions.1 However, no comparative outcome studies have evaluated psychotherapeutic methods with psychotic depressions.

This paper is based on available research, clinical reports, and our own experiences in psychotherapy on psychotic depressions. It will focus on cognitive conceptualizations and techniques that may be particularly useful with severe depressions. A cognitive perspective often facilitates reconceptualization of specific obstacles found in the treatment of these patients. This reconceptualization can lead to specific techniques to reduce these obstacles. Case examples will illustrate several of these techniques.

For this discussion, “depression” refers to a syndrome according to the criteria for major depressive disorder in the Diagnostic and Statistical Manual of Mental Disorders-Ill.2 The depressive syndrome may result from various medical disorders (e.g. endocrinopathies, degenerative brain disease, etc.). Excluding these disorders, psychotic depression refers to patients with hallucinations and/or delusions in association with the depressive syndrome, while severe depression refers to inability to function in routine daily activities, or to maintain personal hygiene, without hallucinations or delusions. Medication and/or electroconvulsive therapies (ECT) continue to be modal treatments for psychotic and severe