Tomes have been written about various psychodynamic approaches to psychotherapy and the authors are unable to comment authoritatively on them. A structured and problem-oriented approach to psychotherapy using “cognitive-behavioral” and “interpersonal” strategies has gained considerable popularity since its introduction in the 1970s by Beck. It draws to a limited extent on psychoanalytic and other psychodynamic theories and has been used in patients with depression and in those with anxiety, chronic pain, and other disorders. According to Blenkiron, cognitive-behavioral therapy is most effective in patients with mild to moderate (not chronic) depression, generalized anxiety and panic disorder, and obsessive-compulsive and phobic disorders. Essentially, in the short term, the therapist provides the patient with information on the nature of the illness, its common symptoms, and the active interventions that are to be undertaken by the patient with the aid of the therapist to alter the specific misperceptions and the dysfunctional behaviors that spring from them. In difficult chronic forms of depression, Keller and colleagues compared an antidepression drug (nefazodone), cognitive-behavioral therapy, or the combination, and found remissions in approximately 50 percent of each of the first 2 groups and in 85 percent of the combined treatment cohort by 12 weeks. This stands as one of the better demonstrations of the value of modern, result-oriented psychotherapy. One popular derivative approach is “Acceptance and Commitment Therapy” (ACT), which aids in accepting the difficulties of life. The interested reader can find discussion of this subject in the current edition of Kaplan and Sadock’s Comprehensive Textbook of Psychiatry (Sadock and Sadock). Noteworthy is the opinion of Gabbard that behavioral-cognitive psychotherapy has been shown to be no better or worse than other forms of psychotherapy, but it has the virtues of relative brevity, uniformity of application, and straightforwardness that avoids blaming the patient, family, environment, or other external forces.
Some 30,000 suicides are recorded annually in the United States, and attempted suicides exceed this number by approximately 10 times. All psychiatrists agree that these are conservative figures. Suicide is the eighth leading cause of death among adults in the United States and the second leading cause among persons between the ages of 15 and 24 years, figures that emphasize the importance of recognizing depression that has a high potential for self-destruction. Every physician should be familiar with the few clues we possess to identify those patients who intend to end their lives. Some of the questions that may be broached in the interview regarding depression were listed earlier, but particularly, “Do you think of hurting yourself or taking your own life?” and the follow-through query, “Do you have a plan?” Physicians should also be aware that the majority of suicides are accomplished by taking an overdose of prescribed medications, for which reason caution needs to be exercised in their distribution and administration in depressed patients.