Conceptualizing and treating chronic depression: A naturalistic study of psychotherapy and combination treatment

Categories: Research project completed

Nyhetsartikkel publisert 30/01/24

Fog in the mysterious rainforest, sun rays are shining through high dark trees, tropical woods, dangerous travel concept

Psychotherapy and antidepressant medication (ADM) are very different treatments that presumably work through different mechanisms of change. Still, research indicates they are both effective treatments and work equally well to treat chronic depression. An explanation for this may be that depression consists of different subgroups of affective, cognitive and somatic symptoms and that psychotherapy are effective for some of these, while ADMs are effective for others. Thus, these treatments may be hypothesized to treat limited and different parts of the symptoms that make up the total distress of patients with chronic depression. This is further supported by research findings indicating a combination of psychotherapy and ADM provides better outcomes compared to either monotherapy.  However, the nature of the specific symptoms of depression and the mechanisms through which various treatments – alone or in combination – may affect them, remain largely unknown. Establishing how treatments may act differently on specific symptom groupings could assist therapists in assigning patients to treatments that better fit their needs, and thus improve remission rates.

Andreas Høstmælingen is a clinical psychologist specialized in clinical psychology for adults. Andreas’ areas of interest include psychotherapy, depressive disorders, intersection between research and practice, development of intervention and child and youth psychology.

About the Project

The empirical analyses in this thesis were based on naturalistic data from the Depression Unit  at Modum Bad hospital, in which 437 patients with chronic depression underwent a 12-week inpatient treatment program.


The overarching aim of this thesis was to explore how different treatment conditions might affect specific symptoms of chronic depression and discuss possible mechanisms underlying these effects. To address this the group conducted three studies. The first aim was to explore the assumption that combination treatment provides an accumulated effect resulting in better outcomes than either monotherapy. This was done by comparing outcomes of patients using antidepressant medication while in psychotherapy to patients only receiving psychotherapy. The second aim was to explore whether it was possible to identify specific symptoms that constituted meaningful subgroups within chronic depression. The third aim was to examine whether patients in the two treatment conditions had different outcomes on these symptoms.


Impact of Antidepressant Medication (ADM) Discontinuation (Papers 1 and 3):

  • No significant difference in outcomes between those who continued or discontinued ADM (Paper 1).
  • No significant difference in outcomes between patients using ADM and unmedicated patients throughout psychotherapy (Paper 3).
  • Lack of accumulated effects suggested psychotherapy alone could be a viable alternative.

Structure of Depressive Symptoms in Chronic Depression (Paper 2):

  • Bi-factor model identified:
  • One global depression factor.
  • Two sub-factors: Self-critical cognitions and somatic symptoms (sleep, appetite, fatigue).
  • Affective symptoms loaded on the general factor but did not form a separate independent factor.
  • Chronic depression characterized by negative emotionality influencing all symptoms, with specific sub-factors as treatment targets.

Differences in Treatment Outcomes Between ADM Users and Non-Medicated Patients (Paper 3):

  • ADM-users did not show better outcomes on “self-criticism” sub-factor compared to non-medicated patients.
  • No difference between groups on the somatic symptoms sub-factor.
  • Use of ADM in addition to psychotherapy may have a negative effect on self-critical schemas.


  • The results challenge the assertion that combination treatment is superior to monotherapy for chronic depression. Oppositional tolerance to ADM and potential negative effects on psychotherapeutic interventions targeting self-criticism suggest psychotherapy alone may be a viable alternative in some cases.


The project is a doctoral research project that began in 2018 and finished up in 2022. The project used data from the Unit for Depressive Disorders at Modum Bad. The department offers affect-oriented therapy with persistent eating and trauma disorders. The treatment is inpatient and lasts approximately 10 weeks.


The project was funded by University of Oslo.


Contact Information

Project Manager: Pål Ulvenes, PhD, Clinical Psychologist Specialist and senior reseracher

Project contact: Andreas Høstmælingen, head of  The Norwegian Center for Child Behavioral Development (NUBU)

You can also reach us through the Modum Bad telephone service: 32 74 97 00.

Project participants

Bruce Wampold, Ph.D., University of Wisconsin 

Pål G Ulvenes, Clinical Psychologist, PhD, Head of Department, Modum Bad, Supervisor 

Helene Nissen-Lie, professor University of Oslo


Høstmælingen, A., Ulvenes, P., Nissen-Lie, H. A., Eielsen, M., & Wampold, B. E. (2022). Trajectories of change in chronic depression: Differences in self-criticism and somatic symptoms between users of antidepressants and nonmedicated patients. Journal of Counseling Psychology69(1), 85. (

Høstmælingen, A., Ulvenes, P., Nissen‐Lie, H. A., Eielsen, M., & Wampold, B. E. (2021). Comparing outcomes in chronic depression following inpatient psychotherapy for patients continuing versus discontinuing antidepressant medication. Clinical Psychology & Psychotherapy28(5), 1111-1127. (

 Høstmælingen, A., Ulvenes, P., Nissen-Lie, H. A., Eielsen, M., & Wampold, B. E. (2021). Do self-criticism and somatic symptoms play a key role in chronic depression? Exploring the factor structure of Beck depression inventory-II in a sample of chronically depressed inpatients. Journal of affective disorders283, 317-324. (

Share Button
Print Friendly and PDF