'Sequential' Approach to Combo TX Can Work: Augmenting Medication with Psychotherapy 'Ties in with the Growing Emphasis on Remission.'

Article excerpt

It has become clear in recent years that pharmacotherapy and psychotherapy are not just either/or alternatives. Many patients, such as those with severe or treatment-resistant depression, appear to do better with both treatments than with either alone.

Situations in which the addition of psychotherapy to medication is worth considering in fact arise regularly. Boon or bane? Combined therapy is a usually productive but sometimes volatile mixture, and its success depends in large part on how skillfully it's handled.

Although depression is the most common context, "these issues come up everywhere," said Dr. Richard Gottlieb of Albert Einstein College of Medicine, New York, and the New York Psychoanalytic Society and Institute.

Medication and psychotherapy complement each other, and in the case of depression, psychotherapy "may enhance psychosocial functioning more than antidepressant treatment itself," said Timothy J. Petersen, Ph.D., research psychologist in the mood disorders program at Brown University, Providence, R.I.

An increasing body of neuroimaging research suggests that the modalities complement each other biologically as well. "Antidepressants may work from the bottom up, through the limbic system; CBT, [cognitive-behavioral therapy] from the top down, through the frontal cortex," he said.

"One treatment may make the other more available or simply possible," said Dr. Adele Tutter of Columbia University and Cornell University, New York. Psychotherapy can help patients understand conflicts and issues concerning medication that interfere with their ability to accept it, or the psychological factors that contribute to medication intolerance. "It can help with the stigma of taking drugs--the shame and poor self-esteem that medication can magnify," she said.

Adherence difficulties and treatment resistance are not the only indications for adjunctive psychotherapy. Indeed, it may be considered at the outset, Dr. Petersen said, when it appears that psychosocial stressors contribute to the psychiatric difficulty.

Such issues, however, may emerge only when symptoms of the primary disorder have abated with pharmacotherapy, Dr. Tutter added. "If the depression has been treated, but significant problems related to the family or workplace persist, [the patient] may be suitable for psychotherapy."

"It's helpful to realize which problems are addressable by medication and which aren't," she said. "Irritability, for example, can be caused by depression, or it can be part of a personality problem--the narcissist who is sensitive to criticism."

Dr. Petersen sees a particular role for evidence-based psychotherapy in treating residual symptoms of depression, such as irritability and anxiety: "There are adapted forms of [cognitive-behavioral therapy] that focus on these symptoms, as well as approaches that enhance relapse prevention efforts."

This "sequential" approach seems a particularly efficient form of combined therapy, and it "ties in with the growing emphasis on remission, rather than treatment response," he said.

The acceptability of psychotherapy to a patient treated with medication "depends on the way the clinician presents it," Dr. Tutter said. "If you believe the patient will see it as punishing or stigmatizing, the patient will get that. The more it's presented in an enthusiastic, positive way, the more he or she can accept it. …

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