Staging Models Are Crucial in Planning Psychotherapeutic Interventions in Depression

My colleagues and I recently reviewed the role of staging in planning a psychotherapeutic intervention for patients with depressive disorders. Clinical psychology and psychiatry had, for a long time, neglected staging as a model to classify the development of mental disorders. Staging defines not only the extent of progression of a disorder at a particular point in time but also where a person currently is along the continuum of the course of illness. In addition, staging encourages clinicians to select treatments relevant to the stages of the disorder, thus improving the logic and timing of interventions. In the past decade, developments on staging in psychiatry have been made, and several efforts have also been made to develop methods to stage the degree of treatment resistance.

Fava and his colleagues developed and updated a staging model of unipolar depression. It ranges from the prodrome to the residual and chronic phases of the illness, considers the longitudinal history of the patient’s disease, can be applied to patients at risk for depressive relapse, and may pave the way for more effective modalities of treatment selection and relapse prevention.

The prodromal phase (stage 1) is characterized by either (1) mild functional change despite the absence of depressive symptoms or (2) the presence of subsyndromal symptoms, including tension and vague feelings of anxiety, irritability, impaired work and initiative, trouble concentrating, fatigue, sleep and eating disturbances, diminished sexual drive, somatic complaints, and feelings of worthlessness. The clinical advantages of early detection and treatment in recurrent depression have been outlined.

For a major depressive episode (stage 2), pharmacotherapy and/or psychotherapy may be pursued. Solid evidence exists for the efficacy of 2 psychotherapeutic approaches for the treatment of an acute episode of depression: cognitive-behavioral therapy (CBT) and interpersonal psychotherapy. The joint use of psychotherapy and pharmacotherapy in treating the acute phase of depression was found to yield some benefit in relapse prevention compared with antidepressant drug treatment alone.

Stage 3 (the residual phase) is more complex, since it includes various scenarios: persistence of residual symptoms despite apparent remission or recovery; failure to achieve remission; and the occurrence of relapse that may lead to recurrent episodes. Social and interpersonal maladjustments appear to be common in the residual phase of depressive illness. Clinical evidence suggests that the sequential administration of pharmacotherapy and psychotherapy according to the stages of the disorder (ie, antidepressant drugs in the acute phase, followed by psychotherapy in the residual phase) is a viable strategy for preventing relapse and recurrence in major depressive disorder. Discontinuation of antidepressants is feasible when psychotherapy is provided, yielding enduring results. Modifications of CBT (eg, mindfulness-based cognitive therapy, CBT of residual symptoms, and well-being therapy) appear to be uniquely suited for addressing the residual phase of depression.

When incomplete recovery from the first lifetime major depressive episode contributes to a recurrent (stage 4) or chronic (stage 5) course of the depressive illness, the cognitive-behavioral analysis system of psychotherapy (CBASP) appears to be indicated.

This critical review by my colleagues and I suggests the importance of applying psychotherapy to depression according to an individualized treatment plan encompassing treatment history, staging of the disorder, clinical judgment, and the patient’s preferences.

Financial disclosure:Dr Guidi has no relevant personal financial relationships to report.