The most widely studied psychotherapy for MDD is cognitive therapy (Beck, Rush, Shaw, & Emery, 1979). This treatment is based on the model that the cognitions (conscious or readily accessible to consciousness) of depressed individuals are negatively biased. This negative bias is evident in negative beliefs about the self, the world, and the future. Such negative cognitions are one factor that plays a role in the initiation and maintenance of depressive symptoms. Cognitive therapy, typically consisting of 16 to 20 sessions over a period of 12 to 16 weeks, involves the application of both behavioral and cognitive techniques. The behavioral techniques serve to help patients engage in activities that give them pleasure, while cognitive techniques are used to help patients recognize negative cognitions and to evaluate the veracity of their beliefs.

Three meta-analyses of studies of cognitive therapy for MDD concluded that it is at least equal and often superior to other forms of treatment, including antidepressant medications (Dobson, 1989; Gaffan, Tsaousis, & Kemp-Wheeler, 1995; Agency for Health Care Policy Research, 1993). However, the comparison of cognitive therapy to medication continues to be controversial. While several studies have supported the finding that cognitive therapy and medication yield similar outcomes (Hollon et al., 1992; Murphy, Simons, Wetzel, & Lustman, 1984), another study (Elkin et al., 1989) failed to demonstrate that cognitive therapy is superior to pill placebo and yielded some evidence that, for more severely depressed patients, medication (imipramine) is superior to cognitive therapy (Elkin et al., 1995). Practice guidelines have recommended medication rather than psychotherapy for more severe depressions (American Psychiatric Association, 2000; Depression Guideline Panel, 1993). However, a direct examination of the comparative effects of cognitive therapy and medication across four studies revealed no evidence of a difference among those with moderate to severe depression (DeRubeis, Gelfand, Tang, & Simons, 1999).

Some further evidence on this issue has emerged from a two-site study by Hollon and DeRubeis (DeRubeis et al., in press) comparing standard cognitive therapy (N = 60), antidepressant medication (Paxil with augmentation by other agents if clinically indicated) N = 120; more patients were randomized to medication because of a subsequent continuation phase in which acute-phase medication responders were randomized to continuation medication or placebo), and placebo (N = 60) as acute treatments for moderate to severe MDD. At week 8, only

25% of placebo patients met criteria for clinical response, compared with 45% for cognitive therapy and 50% for medication (placebo treatment was ended at week 8 for ethical reasons). At week 16 (end of acute treatment), response rates for medication and cognitive therapy were identical (57%) and comparable to response rates from previous studies of cognitive therapy and medication in MDD.

Despite the lack of evidence that cognitive therapy is uniquely efficacious in the treatment of MDD, and some controversy over the comparative effects of medication and cognitive therapy in more severely depressed patients, the overall weight of the evidence is that cognitive therapy is an efficacious acute-phase treatment for MDD.

The predominant behavioral model of MDD treatment is Lewinsohn and MacPhillamy's (1974) approach. In this model, the primary goal is to increase the frequency of pleasant activities in the patient's life. Using a group format for therapy, Shaw (1977) found that behavior therapy was superior to a wait-list control at the end of treatment. The largest study of behavior therapy for MDD found it to be significantly better than psychotherapy (an unstandardized, insight-oriented approach), relaxation therapy, and medication (amitriptyline) (McLean & Hakstian, 1979). In another study of MDD, Jacobson et al. (1996) compared three treatments: behavior therapy (behavioral activation), cognitive therapy with behavioral activation techniques plus techniques designed to address automatic negative thoughts, and cognitive therapy with behavioral activation techniques and automatic thought modification plus the addition of techniques designed to address enduring maladaptive beliefs. At the end of acute-phase treatment, remission rates (Beck Depression Inventory [BDI] score <8, no major depressive disorder) ranged from 56% for the full cognitive therapy package to 46% for behavior therapy, but no significant differences were evident on any measure.

One version of behavior therapy has been developed specifically for couples in which at least one member has MDD. The outcome of behav ioral marital therapy for MDD was found to be not different from cognitive therapy when the couple was distressed, but inferior to cognitive therapy when the couple was not distressed (Jacobson, Dobson, Fruzzetti, Schmaling, & Salusky, 1991). Another study that included only distressed couples also found behavioral marital therapy to be equally effective to cognitive therapy, with both therapies being better than wait-list in the treatment of depression in the wife. The behavioral marital therapy, however, improved marital satisfaction more than cognitive therapy did.

As with cognitive therapy, there appears to be evidence that behavior therapy is an efficacious, but not uniquely effective, acute treatment for MDD.

Klerman & Weissman (1989) interpersonal psychotherapy (IPT) for depression assumes that although depression is caused by a number of factors (genetic, biological, social) interacting in complex ways, it is usually triggered by problems in four interpersonal domains: role transition, grief, interpersonal deficits, and interpersonal disputes. In IPT, the interpersonal problem that triggered the current depressive episode is addressed and the person is helped to build communication and interaction skills to resolve it. The acute phase of IPT typically lasts for 16–20 sessions.

Several studies have supported the efficacy of IPT for acute treatment of MDD in adults seeking treatment in psychiatric and primary care settings. In one study, the efficacy of IPT was similar to that of amitriptyline, and both were superior to a minimal contact control in outpatients (DiMascio et al., 1979). In the National Institute of Mental Health (NIMH) Treatment of Depression Collaborative Research Program, results with IPT were not different from those with either imipramine or cognitive therapy. However, among more severely depressed patients (with a Hamilton Depression Rating scale [HAM-D] >20), imipramine and IPT were superior to placebo whereas CBT was not (Elkin et al., 1989). In a primary care setting, IPT was found to be bet-ter than usual care, and results from IPT were

not different from those with nortriptyline at an 8-month assessment of depressed medical outpatients (Schulberg et al., 1996). Interpersonal therapy has also been tested with depressed HIV+ patients and was compared with imipramine, cognitive behavior therapy (CBT), and supportive psychotherapy. The IPT and imipramine showed similar efficacy and were both superior to CBT and to a lesser extent to supportive psychotherapy (Markowitz, Svartberg, & Swartz, 1998).

In the area of geriatric depression, IPT showed efficacy comparable to that of nortriptyline, but both failed to show significant difference from placebo in a 6-week trial (Schneider, Cooper, Staples, & Sloane, 1987). Interpersonal therapy has also been used to treat antepartum and postpartum depression. Treatment with IPT was superior to a parenting education program for women with antepartum depression in all measures of mood at termination (Spinelli & Endicott, 2003). Also, for symptomatic relief and social adjustment, IPT was superior to a wait-list control for women suffering from postpartum depression (O'Hara, Stuart, Gorman, & Wenzel, 2000). In a different study, IPT for postpartum depression was found to be as effective as a mother–infant therapy group and superior to a wait list control (Clark, Vittengl, Kraft, & Jarrett, 2003). Finally, in the only randomized, clinical trial of a Western psychotherapy adapted for Africa, group IPT was better than treatment as usual for depressed people in rural Uganda for depressive symptomatology and social functioning (Bolton et al., 2003).

Psychodynamic psychotherapy comes in many forms. Brief versions of this treatment typically have a clear interpersonal or intrapsychic focus and use therapist interpretations as the key intervention designed to increase self-understanding about interpersonal or intrapsychic issues that might be contributing to or maintaining depressive symptoms. Manual-based, brief psychodynamic psychotherapy has been evaluated in the treatment of MDD in several studies. In two studies, an interpersonally oriented psychodynamic therapy (somewhat similar to IPT) was found to yield comparable outcomes to those with CBT (Barkham, Hardy, & Startup, 1994; Shapiro et al., 1994). Similarly, in an elderly sample, brief psychodynamic therapy produced equal outcomes to those with behavioral and cognitive therapies (Thompson, Gallagher, & Breckenridge, 1987), although an earlier study using inexperienced therapists showed an advantage of CBT over psychodynamic therapy for depressed elders (Gallagher & Thompson, 1982). A study of clinically depressed elderly caregivers of frail, elderly relatives also found comparable efficacy for individual brief dynamic therapy and CBT (Gallagher-Thompson & Steffen, 1994). However, the duration of caregiving was an important factor, with brief dynamic therapy showing relatively better efficacy among the depressed elders who had been caregivers for a relatively briefer time period (≤3.5 years), whereas the CBT was relatively more efficacious with those that had been caregivers for longer than 3.5 years.

Although brief dynamic therapy appears to be a promising possibility for the acute treatment of MDD, more data on comparisons to credible control groups are needed.

Problem-solving therapy for MDD (Nezu, 1986) has been examined in several controlled studies. Nezu (1986) and Nezu and Perri (1989) found problem-solving treatment to be superior to a wait-list control group, using samples that were primarily female community volunteers. In each of these studies, the full version of problem-solving therapy was found to be better than a version that had some but not all of the key elements of the treatment. Problem-solving therapy has also been found to be as efficacious as routine medication treatment by general practitioners in one study (Catalan et al., 1991) and equal to amitriptyline but better than placebo in another (Mynors-Wallis, Gath, Lloyd-Thomas, & Tomlinson, 1995). In an elderly sample, Arean and colleagues (1993) found problem-solving therapy to yield roughly equivalent results to those with reminiscence therapy, but better results than those with wait-list.

Problem-solving therapy also appears to be

promising for the acute treatment of MDD. Additional larger studies are needed, as are comparisons to other standard psychotherapies for MDD, with samples recruited in psychiatric settings.

Studies that use naturalistic follow-up assessments of patients who have received a short-term course of treatment have suggested that cognitive therapy reduces relapse relative to discontinued medication (Blackburn, Eunson, & Bishop, 1986; Evans et al., 1992; Kovacs, Rush, Beck, & Hollon, 1981; Simons, Murphy, Levine, & Wetzel, 1986). In addition, for patients with residual depressive symptoms following pharmacotherapy, cognitive therapy has been found to reduce recurrence rates relative to maintenance medication only (Paykel et al., 1999) and treatment as usual (Teasdale et al., 2000). Several studies have examined continuation or maintenance psychotherapy for MDD patients who have achieved a clinical response or remission of symptoms following acute-phase treatment. In patients with recurrent MDD, continuation cognitive therapy has been found to reduce relapse relative to short-term cognitive therapy without continuation treatment (Jarrett et al., 2001). An earlier study found that both continuation-phase cognitive therapy alone or combined medication and continuation-phase cognitive therapy produced lower relapse rates than those with medication only (Blackburn et al., 1986). However, a subsequent study found that maintenance medication and maintenance cognitive therapy yielded similar prophylactic effects (Blackburn & Moore, 1997). Similarly, in patients treated to remission with fluoxetine (20 mg), Perlis et al. (2002) found that continuation treatment (28 weeks) with cognitive therapy plus fluoxetine (40 mg) yielded similar relapse rates to those with continuation treatment with fluoxetine (40 mg) alone.

Because residual symptoms of depression after successful treatment predicts the relapse or recurrence of MDD, research has examined the role of cognitive therapy in the treatment of such residual symptoms. Fava, Grandi, Zielezny, Rafanelli, and Canestrari, (1996) compared cog nitive therapy targeting residual symptoms with clinical management among patients who were successfully treated with antidepressant medications (in both treatments medications were gradually tapered and discontinued). Cognitive therapy resulted in substantially lower relapse rates than those after clinical management (Fava et al., 1996) over the course of a 4-year follow-up, and there were fewer depressive episodes at a 6-year follow-up assessment (Fava, Rafanelli, Grandi, Conti, & Belluardo, 1998).

In one large study of recurrent MDD maintenance, IPT (alone) was found to be inferior to medication and to medication plus IPT, but better than placebo (Frank et al., 1990). In a geriatric sample, MDD patients treated to remission with IPT plus nortrityline fared relatively poorer in maintenance IPT plus placebo treatment compared to IPT plus nortrityline (Reynolds et al., 1999). Maintenance IPT plus placebo, however, was superior to placebo in preventing recurrences of depressive episodes (Reynolds et al., 1999). Thus, overall, the evidence is stronger for cognitive therapy than for IPT as stand-alone continuation or maintenance treatment to prevent relapse or recurrences.

A relatively large and growing body of literature has substantiated the efficacy of targeted psychotherapies in the treatment of MDD in adults. Research evidence from controlled clinical trials in particular supports the efficacy of cognitive therapy, IPT, and behavioral therapy for MDD. Problem-solving therapy and certain forms of brief dynamic therapy appear promising, but further research is needed. Acute-phase cognitive therapy reduces the risk of relapse or recurrence of MDD, and continuation treatment reduces such risks further. Cognitive therapy and IPT generally have been found to be equally efficacious to medications, even with more severely depressed patients. However, a recent study suggests that chronic depression might best be treated with the combination of medication and psychotherapy.

Although many of the psychotherapeutic interventions studied in adults have been adapted to the treatment of adolescents, including IPT,

cognitive therapy, and behavioral therapy, the adult literature is characterized by a much broader set of studies than in the child and adolescent MDD treatment literature. Even with this relatively large number of MDD studies conducted to date, numerous questions remain about psychotherapy for MDD in adults. Despite the success of certain psychotherapies in the treatment of adult MDD, it may be risky to assume such treatments are likely to be the best psychosocial treatments for childhood and adolescent MDD. The biological, developmental, cognitive, and experiential differences between children and adolescents and adults raise the question of whether wholly different intervention strategies may be most effective with children and adolescents (Mueller & Orvaschel, 1997). For example, psychodynamic psychotherapy, especially variants that rely heavily on symbolic interpretations, may not be appropriate for younger individuals who lack the cognitive maturity to understand such interventions. Treatments that have been little studied in adults, such as family therapy, may have much greater relevance among children and adolescents. New treatments that incorporate developmental issues may be needed. Although it may be hazardous to export treatment modalities developed for adults to children and adolescents, research on children and adolescents can benefit greatly from the methodological developments in the treatment of MDD in adults, particularly the study of prevention of relapse or recurrence. Ongoing dialogue and interchange among investigators in the adult and child areas is likely to facilitate the more rapid development of literature on treatment of children with MDD.

In this section, we review controlled clinical trials of treating child and adolescent depressive disorders with CBT. The cognitive-behavioral approaches for youth depression focus on identifying and modifying negative thought patterns and improving disturbed behavioral self-and social-regulation skills thought to underlie the etiology of depression. In youth depression treatment, these foci have been addressed through the application of cognitive and behavioral techniques such as (1) mood monitoring; (2) cognitive restructuring; (3) behavioral activation, pleasant activity scheduling, and goal-setting strategies; (4) relaxation and stress management; (5) social skills and conflict resolution training; and (6) training in general problem-solving skills (Kaslow & Thompson, 1998; Kazdin & Weisz, 1998). Although the total number of youth depression treatment studies is relatively small, and different investigators have used varying combinations of these CBT techniques, preliminary evidence suggests that overall, CBT packages have beneficial effects on depression symptoms in youth. In two more recent meta-analyses of treatment of adolescent depression, mean effect sizes for comparisons of CBT to controls of CBT were estimated to be quite large, 1.02 and 1.27 post-treatment, respectively (Lewinsohn & Clarke, 1999; Reinecke, Ryan & DuBois, 1998).

To date, there have been 13 randomized studies of CBT with depressed youth—three in clinically referred samples, three in diagnosed community samples, and seven in symptomatic but not diagnosed community samples. Four studies were conducted in depressed children, and the remainder in adolescents. Most studies relied on samples of depressed youth recruited from school or community settings who may have mild to moderate symptoms of depression, as assessed by dimensional screening instruments; these studies are discussed only briefly here. Within the past 5 years, however, several inves