British Journal of Psychiatry (1994), 165 (suppl. 26), 42-50 Psychotherapy In the Maintenance Treatment of Depression MYRNA M. WEISSMAN A review of epidemiologic and clinical data on depression suggests that psychotherapy is both an important alternative as well as a supplement to medication for the maintenance treatment of depression. Psychotherapy is an alternative for patients during periods when medication may not be suitable or feasible (e.g. pregnancy, nursing, before or during major surgery, or in the elderly). Psychotherapy also has a role in maintenance treatment in dealing with the social and interpersonal consequences or triggers of recurrent depression. Although the number of continuation or maintenance treatment trials that include psychotherapy is quite limited, the efficacy of maintenance treatment in the delay of recurrence and enhancement of social functioning is best established for interpersonal psychotherapy. There are also some results concerning cognitive and behavioural therapies for maintenance treatment of depression. Major depression may require long-term treatment because it is a debilitating and recurrent disorder (Klerman & Weissman, 1989). Efficacious alter- natives to medication, including psychotherapy, are necessary, especially for patients requiring treatment when medication may not be suitable or possible, such as during pregnancy or major surgery, for the elderly, for those who may not tolerate or respond to medication, and for patients who refuse to take medication. Approximately 10-15070 of patients with depression discontinue or cannot tolerate the initial medication received, another 15- 25070 respond only modestly, and 5-1 0070 refuse to take medication (Klerman, 1990). Major depression has a serious impact on social functioning, and is associated with absenteeism and impaired work performance, marital discord, and parent-child problems (Klerman & Weissman, 1992; Mintz et ai, 1992). It is unclear whether these problems are consequences or causes of depression; regardless, these problems do not disappear when the symptoms of depression resolve (Keller et ai, 1992; Warner et ai, 1992).Furthermore, for patients with recurrent depression, the social and inter- personal problems associated with depression may not resolve between episodes or may trigger recurrences (Keller et ai, 1992).The onset of episodes of major depression is often associated with an increase in life events, particularly after the loss or disruption of interpersonal relationships through discord, separation, divorce, or death. Thus, psychotherapy may have a role in maintenance therapy as the sole treatment or in combination with medication to help the patient manage the social and interpersonal consequences or triggers of recurrent depression. 42 Over the past 20 years, major achievements have been made in specification and testing of psychotherapy. These include the use of clinical trials with random assignment and control groups, and the testing of psychotherapy for specific diagnoses (e.g. depression, panic disorder, anorexia). Most importantly, training programmes and descriptive manuals have been developed presenting the strategies and techniques, therapist characteristics and time limitation of the psychotherapy. The most significant progress has been made with psychotherapies designed specifically for major depression, which have usually undergone testing for acute treatment. These psychotherapies include interpersonal psychotherapy (Klerman et ai, 1984), cognitive therapy (Beck et ai, 1979), and behaviour therapy. There have been numerous clinical trials demonstrating the efficacy of psychotherapy in reducing acute symptoms of depression, with the greatest efficacy in the more mildly ill patients (Smith & Glass, 1977; Hollon & Beck, 1978; Weissman, 1979; Smith et ai, 1980; Conte et ai, 1986; Weissman et ai, 1987; Klerman, 1988). In contrast to drug treatment of depression, psychotherapy is associated with a longer lag time for response. Psychotherapy has not been extensivelyevaluated for the long-term treatment of depression; however, several studies suggest that it may be a promising alternative during long-term maintenance therapy. The concept of maintenance therapy Several terms have been used to define maintenance treatment, including 'continuation', 'maintenance', or 'prophylactic' treatment.