Approaches to Depression and Anxiety

The Diagnostic and Statistical Manual of Mental Disorders (DSM 5-TR, 2022) defines mental health including depression and anxiety in terms of pathology, or a deviation from normal, that is reliably exhibited in observable behaviors. It describes genetics and risk factors, differences in gender, and considers cultural perspectives. Limitations of the DSM diagnostic criteria are acknowledged and recognize that human experience, or interaction between genetics and environment, cannot be captured completely. The underlying neurobiology of depression has long been the subject of concentrated study in the medical field. Current understanding suggests that it reflects complex interconnection in brain circuits rather than the simple derangement of a neurotransmitter such as serotonin (Nemeroff, 2020). This makes sense considering that the contributions of interaction between an individual and their environment is too complex to be delineated in the strictly descriptive approach of the DSM. This furthermore suggests the intricate nuances with which treatment must grapple in effectively addressing symptoms of depression with a shift in focus from simple biological derangement to a more intricate interpersonal etiology.

In his paper originally published in 2010 and later updated, Shedler delineates substantial evidence in support of psychotherapy for the treatment of depression. He compares medication to various psychotherapeutic approaches looking at outcomes and describes important differences in approach contributing to improvements in depression and anxiety. While the DSM provides a comprehensive description for mental disorders, the Psychodynamic Diagnostic Manuel (PDM) focuses on interpersonal contributions to personality and to the ways in which people suffer, tackling the underpinnings of what it means to be human. Additionally it provides a looking glass into the workings of the psychotherapy relationship, which evidence supports as having more durable impacts on both depression and anxiety.

The structuring of personality and characteristic coping styles and defenses against anxiety have been more the purview of infant research and the psychodynamic framework originating with Freud's work from the 1880s as a neurologist. While the DSM focuses exclusively on describing characteristics of a disorder, a developmental approach seeks to understand where deviation from normal originates and what purpose it may have served. This is an important shift because it both removes stigma (I had to cope with difficult circumstances versus there is something inherently wrong with me) and provides avenues for purposeful engagement. This has the potential to empower the depressed or anxious individual who feels helpless or hopeless.

Recommendations for the treatment of depression consider the severity of illness and patient preference and resources. Psychotherapy is recommended for mild depression, psychotherapy or medication for moderate depression, and a combination of psychotherapy and medication for severe depression (American College of Physicians, 2023). Inpatient versus outpatient care is a consideration for severe depression. When choosing an approach, it is important to understand that medication can improve vegetative symptoms (sleep, appetite, energy level) to facilitate the unearthing of underlying contributors to the development of depression. It can also be a sole treatment for anyone not able or willing to undertake the considerable work of psychotherapy.

Medication continues to support ameliorative change, as long as it is continued, with significant relapse rates otherwise. By contrast psychotherapy aims, in part, to inform a reliable sense of identity that is not negatively skewed, change underlying expectations and assumptions, and facilitate a realistic acceptance of and informed ability to navigate challenges in life, ultimately leading to favorable change in the underlying structure and functionality of the brain (Nohesara, Alfonso, 2025). This seems a lot to attribute to work done in a therapeutic relationship, but it makes sense in considering the crucible in which the brain develops, beginning in infancy. Without attentive others, babies fail to thrive and die despite having adequate food and shelter. Babies become who they are as individuals with a concept of self, recognition of feelings, and a blueprint for unwritten rules of relationship, all facilitated by their primary caregivers. While the impacts of psychotherapy on changes in the brain have already been demonstrated by studies, there is increasing data to suggest that effective psychotherapy also leads to change in our DNA and epigenetics, important underpinnings of the durable impacts of trauma and aging. This is an exciting development potentially attributable to the healthy adaptations in relationship with our environment that can result from the work of psychotherapy.

American College of Physicians Guidelines https://doi.org/10.7326/ANNALS-25-02711

American Psychiatric Association. (2022). Diagnostic and statistical manual of mental disorders (5th ed., text rev.). https://doi.org/10.1176/appi.books.9780890425787

Lingiardi V., McWilliams N. (2015). The psychodynamic diagnostic manual- 2nd edition (PDM-2). World Psychiatry, https://doi.org/10.1002/wps.20233

Nemeroff, C. B. (2020). The State of Our Understanding of the Pathophysiology and Optimal Treatment for Depression: Glass Half Full or Half Empty? Am. Journal of Psychiatry (177.8). https://doi.org/10.1176/appi.ajp.2020.20060845

Nohesara, S., Alfonso, C.A. (2025). Trauma, Epigenetic Alterations, and Psychotherapy. Journal of Psychodynamic Psychiatry (53, 2), The Guilford Press. PMID: 40454823

• DOI: 10.1521/pdps.2025.53.2.143

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