Letters to the Editor
In Reply
We thank our correspondents for their comments on our summary of the national disease management guideline on unipolar depression.
David Zilles-Wegner and Alexander Sartorius express criticism that electroconvulsive therapy was not adequately represented. This was mainly because of the maximum length of the article, which meant that our focus was on the guideline’s innovations; we did not have the scope to explain unchanged or modified recommendations. In actual fact the guideline group formulated four clinically highly relevant recommendations for ECT, which relate to its use in treatment-resistant depressive episodes, especially at an older age or when psychotic symptoms are present, in acute suicidality in addition to psychotherapeutic crisis interventions and in emergency situations (depressive stupor, vital threat in psychotic depression). These situations constitute relevant areas of use for this tried and tested and safe treatment method.
Compared with repetitive transcranial magnetic stimulation (rTMS) and intranasal esketamine, notably longer clinical experience exists for ECT, but no direct comparisons exist between those options. Methodologically, the evidence for ECT is weaker than for other interventions because for ethical reasons it cannot be studied using a blinded design. Furthermore, the required anesthesia is associated with a greater practical healthcare effort. For this reason the guideline emphasizes joint decision making after all options have been explored, including the evidence and the respective risks and benefits.
Wilfried Hammacher’s criticism is that group psychotherapies were not considered. The guideline does point out options for individual and group treatment. Outpatient psychotherapy can take place in different settings (individual therapy, group therapy, therapeutic settings including several persons). Furthermore it describes how—thanks to the 2020 German psychotherapy directive—short term psychotherapy exists as a therapeutic option without the need for an notification or application procedure. Among the healthcare services providing medical rehabilitation, group therapies are of major importance; in psychiatric hospitals or hospitals for psychosomatic medicine, individual sessions are combined with group sessions and the psychotherapeutic treatment intensity is greater than in the outpatient setting. We pointed out in the 2nd edition of the national disease management guideline that the recommendations are based on meta-analyses of individual psychotherapeutic approaches and cross disciplinary meta-analyses and review articles on group therapy.
At the same time we share the sentiment that the provision of group therapies in outpatient settings should be expanded and may result in a more efficient use of the psychotherapy resource. The reasons for the sparse implementation of group therapeutic treatments are manifold and should continue to be raised to problem status at different levels. We will discuss the topic of group therapy and its implementation in healthcare settings explicitly in the guideline group and check whether specific recommendations for group therapies should be formulated for the next revision.
DOI: 10.3238/arztebl.m2023.0211
On behalf of the authors
Prof. Dr. Dr. Martin Härter
Institut und Poliklinik für Medizinische Psychologie,
Universitätsklinikum Hamburg-Eppendorf und Ärztliches
Zentrum für Qualität in der Medizin, Berlin
m.haerter@uke.de
Conflict of interest statement
MH has received payment for one lecture each from the TK health insurance fund (Techniker Krankenkasse) and Münsterlingen Psychiatric Hospital (Switzerland) and for the compilation of two brochures for patients from the Confederation of Occupational Health Insurance Funds (BKK Dachverband). He receives an expense allowance for his activity as chair of the Scientific Advisory Board and Scientific Director of the Agency for Quality in Medicine (AZQ).
| 1. | Härter M, Prien P, on behalf of the NVL Guideline Group: Clinical practice guideline: The diagnosis and treatment of unipolar depression—National Disease Management Guideline. Dtsch Arztebl Int 2023; 120: 355–61 VOLLTEXT |
