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

  1. Bursztajn HJ, Brodsky A. Captive patients, captive doctors: clinical dilemmas and interventions in caring for patients in managed health care. Gen Hosp Psychiatry 1999;21:239-48.
  2. Meissner WW. The therapeutic alliance. New Haven: Yale University Press, 1996.
  3. Illingworth P. Bluffing, puffing and spinning in managed care organizations. J Med Philos 2000;25:62-76.
  4. Bursztajn HJ. Efficacy research and psychodynamic psychiatry [letter]. Am J Psychiatry 1991;148:817-18.