Moving beyond one-size-fits-all depression treatment

Clinical psychology researcher Lorenzo Lorenzo-Luaces, PhD, of the University of Indiana Bloomington, is best known for his work on what he refers to as the “heterogeneity of depression.” A central goal of this research is moving beyond one-size-fits-all approaches by identifying meaningful differences in symptoms, severity, prognosis, and treatment response.

“Depression is likely not a single, uniform condition. People experience it very differently, with different symptoms, levels of severity, and trajectories over time,” he says. “Historically, we haven’t been very good at linking that heterogeneity to treatment decisions, which could range from doing nothing to low-intensity treatments to talk therapy to electroconvulsive therapy or ketamine for treatment-resistant depression.”

Lorenzo-Luaces also studies low-intensity and stepped-care interventions, exploring how brief, scalable treatments can help many people recover without immediately turning to intensive therapy or medication. We asked him to break down his findings into the key takeaways for clinicians.

Many people don’t need long-term, intensive care to get better. A substantial number of individuals improve with very brief interventions—sometimes just a few therapy sessions, guided self-help, or structured materials like books or apps.

From a public health perspective, this is incredibly important. There are far more people who need help than there are therapists available. If we assume everyone needs weekly therapy for months, we create bottlenecks in care. Recognizing that some people can recover with lighter-touch interventions allows us to reserve more intensive resources for those who truly need them. For those that need it, care can be stepped up quickly.

One thing to keep in mind with self-guided care, though, is that when a human therapist is not involved, engagement can be a major challenge. People are more likely to benefit when there is at least some human support—brief check-ins, guidance, or words of encouragement. In our work, we’ve used very short, structured Zoom sessions that focus on emotional support and helping people understand how to use structured materials effectively.

One intervention I really like is called “Doing What Matters in Times of Stress,” developed by the World Health Organization for refugees who are coping with stressful situations, adversity, and the mental health aftermaths of being exposed to war. It’s based on mindfulness and acceptance principles, written for broad readability. We’ve found people like it and have large improvements. Doing it with a coach is better than doing it on your own, but both ways work compared to not doing anything.

There are also older digital programs like Beating the Blues and MoodGym, which both focus on depression and anxiety. Each module takes about an hour, and they’re both well-validated.

The patients who benefit most are often those who are motivated and have a high capacity for self-reflection and understanding of the motives behind the behaviors in oneself and others. However, we’ve found that certain risk factors, like chronicity, insomnia, unemployment, psychosis, significant substance use, a history of multiple depressive episodes, or high levels of hostility, might suggest that a person needs more than a digital app. People with the risk factors may need the flexibility and interpersonal corrective experiences that only a live therapist can provide. Some groups, including men, people with low literacy, or those who are unemployed, appear less likely to complete self-guided interventions. Age is less of a barrier than most therapists think. Older adults who start these programs often complete them at higher rates. It’s possible that older adults are less interested in starting those programs in the first place, but once they start, they are as or more likely to complete the programs.

The working alliance—the emotional bond between therapist and patient and their shared agreement on goals and tasks—is one of the most robust predictors of therapy outcomes. But research on this topic asks a hard question: Is a good alliance the cause of improvement, or is it a consequence of the patient getting better?

We’ve found that even in the case of digital intervention use with no therapist—and therefore no traditional alliance—people still get better. This suggests that the “active ingredients” of CBT, like cognitive restructuring and behavioral activation, are doing some of the heavy lifting. In some cases, the patient feels a great bond with the therapist because the symptoms are improving. For clinicians, this means we shouldn’t just focus on being “nice” or building rapport; we have to ensure we are actually delivering the skills that lead to symptom reduction, especially long-term skills.

While therapists often focus on the emotional connection, the part we have more control over is negotiating goals and tasks—making sure we’re aligned. If a therapist and patient fundamentally disagree about what they’re working toward or how therapy should proceed, it’s hard for treatment to be effective, no matter how warm the relationship feels. Misalignment can quietly undermine therapy week after week.

Most psychotherapists overestimate the burden on patients of reporting outcomes. In addition, there has been this idea that it takes five or six weeks to get better, but in reality, people start changing relatively early—even after one or two sessions. The earlier you change, the more likely you are to sustain change, no matter whether the intervention is high- or low-intensity. So, in my own practice, I have patients report before every session. Ideally, it should be every week. There’s evidence that collecting outcomes, especially when they’re trending downward (i.e., “not on track”), cues you that something’s wrong. If I’m seeing a patient with depression and by session five, they still have the same symptom level, I’d be concerned.

A big concern is misinformation about mental health treatment. On TikTok, there’s a lot of talk about ADHD and trauma with really expansive definitions. There’s potential for people self-diagnosing when they don’t actually meet the criteria for something. We also see therapists or coaches talking about practices like energy work that don’t have much research support, while also criticizing evidence-based practices.

On the other hand, social media can provide validation, support, and access to information for people who might otherwise feel completely alone. The challenge is learning how to distinguish helpful engagement from harmful exposure—and how clinicians can talk to patients about what they’re encountering online.

I believe the combination of scalable digital tools, better understanding of patient heterogeneity, and thoughtful human support will reshape mental health care. There’s also tremendous potential in the treatment of depression if we recognize both the promise and the limits of technology and keep people’s real needs at the center.