When should psychotherapy be the treatment of choice for major depressive disorder?

Clinicians should think carefully before deciding on the initial treatment for a patient with major depressive disorder. The author argues that this does not happen often enough, and that psychotherapy may be overlooked too often as a first treatment option. Based on the research literature and the American Psychiatric Association Practice Guidelines, this article reviews potential cautions and relative indications for initiating treatment with evidence-based psychotherapies for major depressive disorder. Potential indications include 1) patient preference; 2) symptom severity; 3) relative contraindications to pharmacotherapy; 4) prior treatment history; 5) nature of symptoms; 6) psychosocial context, including a life crisis or complicated bereavement; 7) control and credit; and 8) new and enduring skills.