I enjoyed David Taylor's spirited defence of the use of dynamic therapies in depression but feel that his clear model allegiance may have led to the neglect of other practical considerations (Reference TaylorTaylor 2008).

The popular use of cognitive–behavioural therapy (CBT) in depression and other disorders is not solely due to ‘a homoeopathic fantasy that brief psychological treatments are highly potent’. In comparing any National Health Service treatment, efficacy is only one consideration. Cost-effectiveness and flexibility in delivery are other issues to take into account. I believe that CBT may be superior to dynamic therapy in these regards. The recent and compelling Layard economic argument for the cost-effectiveness of CBT in adult depression has prompted the government's Improved Access to Psychological Therapies (IAPT) initiative. It is difficult to see how psychodynamic therapies could be delivered in such a responsive way, consistent with a stepped-care model. A relative advantage of CBT is that single threads of therapy at different levels of intensity can be titrated to patient need, rather than a blanket execution of the full CBT model in every case (Reference Lovell and RichardsLovell 2000). This is supported by the finding of Reference Jacobson, Dobson and TrauxJacobson et al (1996) that many patients with depression improve with behavioural activation alone. What single threads of psychodynamic therapy could be similarly utilised, independent of the complex frame that dynamic therapy usually demands?

Reference Lovell and RichardsLovell & Richards (2000) argue that the traditional focus on ‘high intensity multiple-thread interventions’ to a select few disenfranchises the remainder of people who would benefit from, but cannot access, briefer and simpler interventions. The current delivery of traditional psychodynamic therapy in traditional settings with traditionally long waiting lists is particularly vulnerable to this criticism. Reference WhyteWhyte (1996) reports that a wider range of patients might be able to access dynamic therapy if their psychiatrists were not so deterred by the waiting lists. The coherence of CBT also lends itself more readily to training and the increased dispersion of less intensive treatments to patients directly through guided self-help materials (including computerised CBT) or indirectly through the multidisciplinary team and the new models of brief training such as the SPIRIT (Structured Psychosocial InteRventions In Teams) course (Reference Whitfield and WilliamsWhitfield 2003).

David Taylor makes a convincing case that dynamic therapy may be as effective as CBT in depression but he does not suggest how dynamic therapy can be as coherent, cost-effective and deliverable in busy clinical settings. His argument fuels the polarised argument of CBT v. dynamic therapy and ignores more integrative therapies such as Ryle's cognitive analytic therapy. Reference BatemanBateman (1997) argues that ‘a creative and constructive partnership between different psychotherapies needs to develop if psychotherapeutic psychiatry is to flourish’. He goes on to suggest that the greatest threat to this ‘is the partisan approach of the psychotherapies themselves’.