[Psychotherapy of depressive disorders: on theoretical background and practice relevance]

In the psychotherapy of depression a knowledge of causative factors is essential for both practical aspects of interventions and the design of refined outcome studies. Outcome studies, which should go beyond simple pre-post comparisons, require such detailed hypotheses about the underlying pathogenetic mechanism which is addressed by a therapeutic technique. Thus, for this purpose psychopathological classification has to be supplemented by a pathogenetic classification. In the first section of this paper the most influential conceptual models of depression are discussed, including loss and grief, inhibited and reversed aggression, disturbed attachment, narcissistic crisis, the disturbed "prolepsis", structural dynamic restriction, learned helplessness, the social role model and Brown's sociological 3-factor model. In the second part, a reduction to three models is suggested and elucidated--the melancholic type, the narcissistic structure and depressive structure--in order to achieve a selection of specific intervention strategies. These are explained by a number of case vignettes. This pathogenetic structural diagnosis should be worked out in addition to the cross-sectional psychotherapeutic work. An additional "staging" of the long-term course provides more precision to the pathogenetic focus and accordingly to the selection of an adequate intervention strategy. In the third section the empirical literature is reviewed of those studies which have adopted objective assessment methods. No consensus has yet been found regarding appropriate methods and results are still rather inconsistent. We emphasize the necessity for a pathogenetic focus agreed upon by both patient and therapist and the consideration of the psychotherapeutic impact of biological treatment components with regard to self-image, allocation of heteronomy, and the patient's disease concept.