Is psychotherapy an effective treatment for melancholia and other severe depressive states?

The treatment of severe depression with psychotherapy, alone, is controvers ial. In this paper, we review the historical, conceptual, and empirical con texts of this controversy. In addition to work by others, we review recent work from our institute which has examined the psychobiological substrates of response to treatment in depressive subtypes. We examine the traditional categories that describe severe depressions. The features and psychobiolog ical correlates of melancholia are discussed, as is the relationship betwee n melancholia and aging. Research on treatment of melancholia and other sev ere depressive states with psychotherapies such as cognitive behavior thera py (CBT) and interpersonal psychotherapy (IPT) is reviewed in detail. We co nclude that although some melancholic patients are responsive to IPT or CBT , there is not yet compelling evidence that melancholic patients respond to psychotherapy as well as they do to medications. The potentially mediating effects of hypercortisolism, alterations of sleep neurophysiology, and dis turbances of information processing and regional cerebral metabolism repres ent fertile grounds for future investigation. We discuss the practical impl ications of the literature reviewed. (C) 1999 Elsevier Science B.V. All rig hts reserved.