Commentary on: Cognitive behavioural therapy, systemic behavioural family
therapy, and non-directive supportive therapy had similar long term effectiveness
for major depressive disorder in adolescents
Birmaher et al's findings of the equivalence of 3 different forms of therapy
in adolescents' recovery from depression and recurrence during 2 years
of follow up need to be interpreted with caution as to ecological validity.
For example, the 12-fold reduction in rate of remission found in the
group recruited through advertising raises the question of how different
are patients and families who do not respond to advertising but go to
clinics for treatment or who seek help in the privacy of traditional,
non-institutional, private practice mental health settings. Unfortunately,
cautions about the study's ecological validity are likely to be lost
in a "keep psychotherapy cheap" climate where some managed
healthcare organisations take advantage of the stigma of mental illness
and popular prejudices that all therapy is the same. This study should
not be used to promote practices such as behavioural carveouts, which
limit both resources and choice, or to justify funnelling patients to
the cheapest "providers" rather than to the most highly trained
clinicians. A subtle but more valid inference from the study's most robust
finding is the importance of creating access to mental healthcare systems
and practices that promote choice and hope for potential patients. [1-3]
The finding that CBT is effective in the short term but not the long term
must be considered cautiously also, In private practice, achieving such
meaningful, yet hard to measure, long term mental health outcomes as
autonomy and authenticity are more likely to be clinical priorities.
[4] This study confirms clinical experience, which suggests that the
keys to effective treatment are attention to the therapeutic alliance
and open, non-transference distorted communication rather than simply
frequent booster sessions. This is, in effect, an informed consent process
rather than the pro forma informed consent of most study designs. [4]
Harold J Bursztajn, MD
Harvard Medical School
Cambridge, Massachusetts, USA
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