Group Therapy for Mood Disorders
Unipolar Depressive Disorders – An Overview of Effectiveness
• Evidence for group as primary treatment for Major Depressive
Disorder (MDD) is “promising to good,” an improvement on “mixed to
untested” in 2004 (2 meta-analytic studies included 65 studies and 17
new studies since 2004). A major review of the evidence for mood
disorders can be found in Burlingame, Strauss & Joyce (2013).
• Group Cognitive Behavior Therapy (GCBT) is the primary modality
studied, with other groups focusing on behavioral activation or
• Effect sizes (which in this case measured the impact of the treatment)
range from 1.0-1.1 for depression remission. These are in the large range.
• Meta-analyses (McDermut, Miller & Brown, 2001; Oei & Dingle, 2008)
produced 14 studies that compared individual and group therapy. These
studies showed, on aggregate, equivalence in treatment outcomes.
• “Sudden gains” predict better outcomes. That is, when group
treatments deliver strong results early in their life (sessions 1-5), they
tend to predict stronger outcomes at the end. This suggests that groups
structured for early success may be more potent, which may be a result of
the common factors in all group therapy rather than the specific
components of an individual treatment. Third generation group CBT
focuses on the addition of physical regulation and context in addition to
addressing the typical cognition-affect link (e.g., Acceptance and
Commitment Therapy; Crosby, 2012).
• Approaches to treating depression in a group format that are on
NREPP’s (National Registry of Evidence-Based Programs and Practices) list
of Evidence Based Practices include:
o Mindfulness based Cognitive Therapy (MBCT)
o Mindfulness Based Stress Reduction (MBSR)
o Acceptance and Commitment Therapy (ACT)
o Group Interpersonal Therapy (G-IPT), which has also shown some
early evidence suggesting effectiveness in treating depression.
o Short-term Interpretive Group Therapy for Complicated Grief
• Most, but not all, of these approaches tend to rely less on group
process and more on the teaching of skills in a group format.
• Meta-analytic research shows that interventions that are culturally
adapted have a moderately strong effect, suggesting that considerable
care should be paid to the role of culture. Moreover, targeting a specific
cultural group was found to be four times more effective than
interventions targeting a mixed multicultural group. Equally, if an
intervention was conducted in a client’s native language, it was found to
be twice as effective (Griner & Smith, 2006).
Group psychodynamic treatments have received little empirical attention due to the methodological challenges embedded within these inherently complex treatment modalities that, by definition, rely on group-level therapeutic processes (Green, 2012). Researchers (e.g., Bhar & Beck, 2009; Blackmore, Tantam, Parry & Chambers, 2012) report that it is impossible to say whether psychodynamic or analytic approaches are proven to be better or worse than other group modalities in ameliorating depression due to the following reasons: difficulty in defining terminology/ensuring fidelity/establishing treatment integrity, varying quality in the research studies, the low number of RCTs, and the variety of different outcome measures. Overall, manualized treatments with greater ability to control internal validity are proving more prevalent in the research literature. The evidence suggests that group approaches to impacting depression are effective and comparable to individual approaches in the aggregate (Burlingame, Strauss & Joyce, 2013).
Etiology-Specific or Population-based Group Treatments for Unipolar Depression
Depression caused by Grief
• Complicated grief: set of intensive and prolonged negative reactions to
the loss of significant others through death.
• Patients with complicated grief constitute approximately one-third of
all psychiatric out-patients.
• The efficacy of short-term interpretive group therapy with CG patients
has been demonstrated through controlled clinical trials.
• Statistical and clinical significance have been demonstrated.
• Positive findings have been consistently maintained over a six month
Complicated grief (CG) is defined as a set of negative reactions to the loss of significant others through death. To qualify as complicated grief these negative reactions must be of high intensity and persist over a prolonged period of time. Studies of psychiatric out-patients indicated that as many as one-third of the patients met criteria for CG (Piper et al., 2001; Zisook & Lyons, 1989-90 ). Since 1986, Piper and colleagues have conducted several controlled outpatient clinical trials to study the efficacy of short-term interpretive group therapy with CG patients (Piper, Ogrodniczuk, Joyce, & Weideman, 2011). Treated patients, in comparison to control patients, demonstrated both statistical and clinical significant improvements in a variety of symptoms and behaviours (Piper et al, 2011). These findings were maintained over a 6 month follow up period. This research is included as an efficacious form of treatment for patients with complicated grief in the National Registry of Evidence-based Programs and Practices (NREPP).
In addition to demonstrating RCT-evidence for the efficacy of short-term interpretive group therapy, Piper et al. have investigated the relationship between the personality variable known as “Quality of Object Relations (QOR),” its interaction with different forms of therapy, and the composition of therapy groups. QOR refers to the life-long pattern of interpersonal behavior and ranges on a dimension from primitive to mature. In the former case, QOR was directly related to success in interpretive group therapy and inversely related to success in other forms of therapy (Piper et al., 2001). In the latter case, where composition was defined as the average QOR score across patients, the greater the group level of QOR the greater the success (Piper et al., 2007).
In summary, these results demonstrated the opportunity to investigate a variety of topics that go beyond the classical randomized clinical trial. In so doing, an understanding of the factors affecting success in interpretive group therapy has been increased.
• Post-partum depression is the incidence of depression following child-
birth. It is the focus of increasing attention due to its prevalence.
• Two recent studies (Pesssagno & Hunker, 2013; Reay et al., 2012)
found empirical support for group Interpersonal Therapy IPT for post-
partum depression (Weissman, Klerman & Markowitz, 2007).
• Treatment of depression in adolescents has its own body of literature.
• Group treatment approaches range from skill-building approaches
such as CBT and DBT that are designed to promote resiliency, to Multi-
Family Pyschoeducational Psychotherapy that integrates work to
strengthen and support the family in a group format.
• NREPP recommended group treatments for adolescent mood disorders
o Cultural Adaptation of Cognitive Behavioral Therapy (CBT) for
Puerto Rican Youth (Rosselló, & Bernal, 2007).
o Multi-family Psychoeducational Psychotherapy (MF-PEP) (Fristad, &
o Adolescent coping with depression (CWD-A) (Clarke, Lewinsohn,
Hops, & Grossen, 1990).
o CAST: Coping and Support Training curriculum (CAST: Coping And
Support Training Curriculum, 2007)
o Dialectic Behavior Therapy (DBT-A) for adolescent depression
(Goldstein et al, 2014)
• Unlike treatment of adolescent depression, which has received
considerable empirical attention and has proven efficacious,
group depression treatments for the geriatric population remain mixed to
• In a meta-analysis, Krishna et al. (2013) found that for the sub-clinical
geriatric population, GCBT’s initial gains failed to be maintained at follow up.
However, this may have been impacted by the poor quality of studies and
sub-optimal power issues.
There have been several recent studies exploring the effectiveness of
treating bipolar disorder with group therapies.
• The role of psycho-education and building coping skills (including
interpersonal skills) to manage this disorder seems to be a common
feature of the approaches that have received empirical validation.
• Psychoeducation (PEG) for bipolar disorder has had the strongest
evidence base, with two RCT designs:
o PEG by Colom et al. (2003) showed reduced hospitalizations and
maintenance of gains after 5 years, although patients with a longer
history of episodes did not achieve the same gains.
o PEG by Simon et al. (2005) showed fewer episodes of mania,
greater medication compliance and reduction in symptom intensity.
• Other recent approaches to group treatment of bipolar disorder that
have shown early promise, but require further study include:
o Group Interpersonal Social Rhythm Therapy (GIPSRT; Bouwkamp,
et al., 2013)
o Dialectic Behavior Therapy (DBT; Van Dijk & Katz, 2013)
o Dialectic Behavior Therapy for adolescents with bipolar disorder
(Goldstein, et al., 2014)
Overall, the evidence for the efficacy of different group psychotherapy treatments for the treatment of depression is highly promising, with some approaches, such as GCBT, now well studied and researched. Treatment for several sub-populations (e.g., adolescent depression) and etiologies (e.g., grief) are well supported by evidence, although some sub-population (e.g. geriatric depression) group treatments have shown mixed findings. Other approaches remain promising, with group treatments for bipolar disorder receiving increasing empirical attention. Overall, there is a continued need for a range of high-quality studies, with Randomized Clinical Trials providing the most direct route to designation as Evidence Based Practice. However, there is also a significant need for high quality mixed-methods and process-outcome studies to better understand the mechanisms of change involved in group therapies.
Bhar, S. S., & Beck, A. T. (2009). Treatment Integrity of Studies That Compare Short-Term Psychodynamic Psychotherapy with Cognitive-Behavior Therapy. Clinical Psychology: Science & Practice, 16(3), 370-378. DOI:10.1111/j.1468-2850.2009.01176.x
Blackmore, C., Tantam, D., Parry, G., & Chambers, E. (2012). Report on a Systematic Review of the Efficacy and Analytic/Dynamic Group Psychotherapy. Group Analysis. 45(1): 46-49. DOI: 10.1177/0533316411424356
Burlingame, G., Strauss, B. & Joyce, A (2013). Change mechanisms and effectiveness of small group treatments, In M. J. Lambert (Ed.), Bergin & Garfield’s Handbook of psychotherapy and behavior change, 6th Ed. New York: Wiley & Sons. (pp. 640-689)
CAST: Coping And Support Training curriculum. (2007). Redmond WA: Reconnecting Youth Publications, a division of RY, Inc.
Clarke, G., Lewinsohn, P., Hops, H., & Grossen, B. (1990). Leader's manual for adolescent groups: Adolescent Coping With Depression course. Retrieved from http://www.kpchr.org/public/acwd/CWDA_manual.pdf
Ekers, D., Webster, L., Van Straten, A., Cuijpers, P., Richards, D., & Gilbody, S. (2014). Behavioural Activation for Depression; An Update of Meta-Analysis of Effectiveness and Sub Group Analysis. Plos ONE, 9(6), 1-11. DOI:10.1371/journal.pone.0100100.
Fristad, M.A. & Danner, S. (2011). Multi-Family Psychoeducational Psychotherapy (MF-PEP) therapist workbook: Children’s Groups. Columbus, Ohio: Child and Family Psychological Services, Inc.
Greene, L. R. (2012, July 9). Group Therapist as Social Scientist, With Special Reference to the Psychodynamically Oriented Psychotherapist. American Psychologist, 67(6), 477–489. DOI: 10.1037/a0029147
Goldstein, T.R., Fersch-Podrat, R.K., Rivera, M., Axelson, D.A., Merranko, J., Yu, H., Bren, D, & Birmaher B. (2014 Jul 10). [Epub ahead of print]. Dialectical Behavior Therapy (DBT) for Adolescents with Bipolar Disorder: Results from a Pilot Randomized Trial. Journal of Child and Adolescent Psychopharmacology.
Griner, D. & Smith, T.B. (2006). Culturally adapted mental health intervention: A meta-analytic review. Psychotherapy: Theory, Research, Practice, Training, 43(4), 531-548. DOI: 10.1037/0033-318.104.22.1681
Hoberg, A. A., Ponto, J., Nelson, P. J., & Frye, M. A. (2013). Group Interpersonal and Social Rhythm Therapy for Bipolar Depression. Perspectives In Psychiatric Care, 49(4), 226-234. DOI:10.1111/ppc.12008
Krishna, M., Honagodu, A., Rajendra, R., Sundarachar, R., Lane, S., & Lepping, P. (2013). A systematic review and meta-analysis of group psychotherapy for sub-clinical depression in older adults. International Journal Of Geriatric Psychiatry, 28(9), 881-888. DOI:10.1002/gps.3905
Jensen, H., Mortensen, E., & Lotz, M. (2010). Effectiveness of short-term psychodynamic group therapy in a public outpatient psychotherapy unit. Nordic Journal Of Psychiatry, 64(2), 106-114. DOI:10.1027/1901-2276/a000021
Linehan, M. (1993). Skills training manual for treating borderline personality disorder. New York: Guilford.
Luoma, J., Hayes, S. C., & Walser, R. (2007). Learning ACT: An Acceptance & Commitment Therapy skills-training manual for therapists. Oakland, CA: New Harbinger Publications.
Oei, T., & Dingle, G. (2008). The effectiveness of group cognitive behavior therapy for unipolar depressive disorders. Journal of Affective Disorders, 107(1-3), 5-21.
Okumura, Y., & Ichikura, K. (2014). Efficacy and acceptability of group cognitive behavioral therapy for depression: A systematic review and meta-analysis. Journal of Affective Disorders, 164. 155-164. DOI: 10.1016/j.jad.2014.04.023
McDermut, W., Miller, I., & Brown, R. (2001).The efficacy of group psychotherapy for depression. Clinical Psychology: Science and Practice, 8(1), 98-116. DOI:10.1016/j.jad.2007.07.018
Pessagno, R. A., & Hunker, D. (2013). Using Short-Term Group Psychotherapy as an Evidence-Based Intervention for First-Time Mothers at Risk for Postpartum Depression. Perspectives In Psychiatric Care, 49(3), 202-209. DOI:10.1111/j.1744-6163.2012.00350.x
Piper, W.E., McCallum, M., Joyce, A.S., Rosie, J.S., & Ogrodniczuk, J.S. (2001). Patient personality and time- limited group psychotherapy for complicated grief. International Journal of Group Psychotherapy, 51, 525-552.
Piper, W.E., Ogrodniczuk, J.S., Azim, H.F.A. & Weideman, R. (2001). Prevalence of loss and complicated grief among psychiatric outpatients. Psychiatric Services, 52, 1069-1074.
Piper, W.E., Ogrodniczuk, J.S., Joyce, A.S., Weideman, R., & Rosie, J.S. (2007). Group composition and group therapy for complicated grief. Journal of Consulting and Clinical Psychology, 75, 116-125.
Piper, W.E., Ogrodniczuk, J.S., Joyce, A.S. & Weideman, R. (2011). Short-Term Group Therapies for Complicated Grief: Two Research-Based Models. Washington, DC: American Psychological Association.
Reay, R., Owen, C., Shadbolt, B., Raphael, B., Mulcahy, R., & Wilkinson, R. (2012). Trajectories of long-term outcomes for postnatally depressed mothers treated with group interpersonal psychotherapy. Archives of Women's Mental Health, 15(3), 217-228. DOI:10.1007/s00737-012-0280-4
Rosselló, J., & Bernal, G. (2007). Treatment manual for cognitive behavioral therapy for depression: Group format (therapist's manual)--Adaptation for Puerto Rican adolescents. San Juan: University Center for Psychological Services and Research, University of Puerto Rico, Río Piedras.
Santorelli, S.F. &Kabat-Zinn, J. (Eds.). (2011). Mindfulness-Based Stress Reduction (MBSR) professional education and training: MBSR Curriculum and supporting materials. Worcester, MA: Center for Mindfulness in Medicine, Health Care and Society, University of Massachusetts Medical School.
Shedler, J. (2010). The Efficacy of Psychodynamic psychotherapy. American Psychologist, 63(2),98-109. DOI: 10.1037/a0018378
Weissman, M. M, Markowitz, J. C., & Klerman, G. L. (2007). Clinician's quick guide to interpersonal psychotherapy. New York: Oxford University Press.
Segal, Z., Teasdale, J., & Williams, M. (2002). Mindfulness-Based Cognitive Therapy for depression: A new approach to preventing relapse. New York, NY: Guilford Press.
Zisook, S. & Lyons, L. (1989-90). Bereavement and unresolved grief in psychiatric outpatients. Omega:Journal of Death and Dying, 20, 307-322.