Trends in the United States

As developers of a psychotherapy for depression, we bring a point of view to the topic of the future of antidepressant psychotherapies. Let us state this view up front and emphasize it reflects that most of our experience has been in the United States. Our guiding principles are: • Psychotherapies, like any treatments, should be evidenced based. Evidence is best derived from randomized controlled clinical trials like those used in testing medications. • The effects of psychotherapies need assessment using a broad range of outcome variables, including symptoms, social functioning, costs, etc., since psychotherapy may have targets and consequences that differ from psychotropic medications. • Psychotherapies need to be specified in manuals that describe procedures and their sequences with case illustrations. These manuals form the basis for training therapists and allow standardization of treatment. • Effectiveness studies, which have broad diagnostic entry criteria and test treatments in real practice outside research settings, are useful, but few actually exist for psychotherapies. Although the virtues of these studies have been detailed, problems in their conduct and interpretation have not. • Once the efficacy of a psychotherapy has been established, research on the active ingredients in the treatment process and factors mediating outcome deserve exploration. Any discussion of the future is a wish list based on problems and gaps in past and present research. As a context for forecasting the future, we must first describe where we now stand in the psychotherapy of mood disorders. We shall describe trends in psychotherapy use over the past decade; the status of evidence-based psychotherapy (EBP); the expansion of psychotherapy to developing countries; the gap between research and training in EBPs; the need for more psychotherapy development and testing and for new methods of delivery; and finally, what we see as the future.