Integrating Psychotherapy and Psychopharmacology

A Handbook for Clinicians

Irismar Reis de Oliveira, Thomas Schwartz, Stephen M. Stahl, Irismar Reis de Oliveira, Thomas Schwartz, Stephen M. Stahl

• Publisher: Routledge
• Year: 2013
• Print ISBN: 9780415529976
• eBook ISBN: 9781136302817
• Topic: Psychology
• Subtopic: Mental Health in Psychology
• Index: Psychology

Integrating Psychotherapy and Psychopharmacology: A Handbook for Clinicians is a practical guide for the growing number of mental-health practitioners searching for information on treatments that combine psychopharmacology, psychotherapy, and psychosocial rehabilitation. Research shows that combined approaches are among the most effective ways to treat an increasing number of psychiatric disorders. However, though these combined treatments are becoming the everyday practice of psychiatrists, psychologists, and other mental-health professionals, identifying the right treatment plan can be notoriously difficult, and clinicians are often left scrambling to answer questions about how to design and customize their treatment strategies. In Integrating Psychotherapy and Psychopharmacology, readers will find these questions fully addressed and the answers explained, and they'll come away from the book with a toolbox full of strategies for helping their patients improve symptoms, achieve remission, and stay well using a combination of drug and psychological treatments.

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Integrating Psychotherapy and Psychopharmacology

Outcomes, Endophenotypes, and Theoretical Underpinnings Regarding Effectiveness

Thomas L. Schwartz and Shilpa Sachdeva

Introduction

This book strives to provide to the reader a compendium of information regarding specific psychiatric disorders and their amenability to be treated with integrated psychotherapy and psychopharmacology approaches. Evidence-based information will be provided, and in its absence, theoretical approaches and explanations will be given to explain why integration and simultaneous use of these two treatment modalities should make both biological and psychological sense to the practitioner and the patient. This introductory chapter will first review some typical integrative studies and their outcomes, where a specific psychotherapy technique and/or a specific psychopharmacological intervention were provided to patients with a defined psychiatric disorder. Clinical outcomes will be discussed briefly to set a tone for the following, psychiatric-disorder specific, chapters in this book where more in-depth analyses will be forthcoming. More important than reviewing initial hallmark outcomes, this chapter will briefly discuss endophenotypic neuroimaging findings regarding treatment integration and will finally attempt to theoretically explain why combining medications and psychotherapy makes sense from a neuroscience, or biological, perspective.

The chapters that follow will provide more in-depth information on key psychiatric disorders such as schizophrenia, depression, anxiety disorders, sleep, and substance use disorders. The final chapter will present itself as a foil to this introductory one, and the psychosocial aspects of prescribing psychopharmacological agents will be discussed and explained. In this way, the reader will have come full circle and will be able to appreciate the integrated treatment approach that this chapter will introduce called psychopharmacopsychotherapy (PPPT). PPPT should allow the prescribing clinician to engage in providing a greater amount of care, making intuitive sense, theoretical sense, and evidence-based sense from a biopsychosocial approach.

Outcome-Based Studies on Integrated Treatment

Regarding major depressive disorder (MDD), one of the most commonly diagnosed and treated psychiatric disorders, there is likely the largest evidence base of completed studies regarding psychotherapy, psychopharmacology, and integrated treatment (PPPT) available. In deciding the course and type of treatment, numerous factors must be taken into account by the clinician, including pivotally, the severity of the depression (Thase et al., 1997). The greater the severity of MDD likely warrants more antidepressant medication utilization. Mild to moderate symptoms could easily be treated by psychotherapy and/or psychopharmacology independently. In fact, United Kingdom guidelines clearly denote that mild MDD should be treated with psychotherapy only, but combining treatments may be considered as severity increases (National Institute for Health and Clinical Excellence [NICE], 2009).

Some authors suggest strongly that depressed patients with personality disorders often have a decreased response to psychopharmacology alone compared to those without any Axis II symptomatology (Reich & Vasile, 1993; Thase, 1996). Specifically, it has been shown that patients with cluster A or cluster B personality pathology appear to have less satisfactory results to medication management than those with cluster C symptoms (Wilberg et al., 1998; Peselow, Sanfilipo, Fieve, & Gulbenkian, 1994). It also appears that MDD patients who have suffered trauma or abuse in childhood will preferentially respond to psychotherapy plus an antidepressant, while those without a trauma history appear to do well on an antidepressant alone (Nemeroff et al., 2003). As it is often the norm that clinicians treat comorbidity rather than single disorders, these integrated, combined approaches make intuitive sense (Schwartz & Rashid, 2007).

It is important to delineate up front that a majority of the following studies were conducted in patients with clear Axis I disorders and often with a relative lack of Axis I and Axis II comorbidity. Levels of psychiatric symptoms were often noted to be at a moderate degree, as subjects with severe depression may not be competent or capable of receiving informed consent or completing full study participation, and subjects with mild MDD symptoms may not have been ill enough to enter an experimental drug study for MDD.

We begin our MDD review with a key example: Keller et al. (2000) observed that the combined and integrated treatment of nefazodone (a serotonin agonist-reuptake inhibitor approved antidepressant) and cognitive behavioral analysis (CBASP) was significantly more efficacious than either treatment when used alone. This study was conducted with a stringent design and statistical analysis (Keller et al., 2000). It should be considered a hallmark study where integrated, evidence-based psychotherapy and pharmacotherapy, or psychopharmacopsychotherapy (PPPT) for short, together yielded a superior outcome result for subjects. This makes factual sense given this study’s outcome and makes intuitive clinical sense that combining two active treatments should allow for better MDD response rates than one modality alone. Theoretically, understanding why PPPT works from a neuroscience and psychosocial point of view will be discussed later in this chapter and throughout the book.

To broaden the discussion regarding MDD, a trial by de Jonghe, Kool, van Aalst, Dekker, and Peen (2001) found that the combined PPPT (with psychodynamic supportive psychotherapy) was more effective than pharmacotherapy alone in their treatment. The psychotherapy here was short term, with sixteen 45-minute sessions, and the medication protocol included fluoxetine, amitriptyline, or moclobemide. At 24 weeks, the mean success rate in the pharmaco-therapy alone versus combined medication plus psychotherapy group was 40.7% and 59.2%, respectively. This particular study was limited in that it did not have a psychotherapy-only arm, and patients were allowed to choose not to be involved in the pharmacotherapy-only treatment arm. A second de Jonghe et al. (2004) study used short-term psychodynamic supportive therapy alone or in combination with venlafaxine (SNRI), a selective serotonin norepinephrine reuptake inhibitor (SNRI), nortriptyline (TCA), or nortriptyline plus lithium. It found no distinction between psychotherapy alone compared to when PPPT was utilized in regards to objective Hamilton Rating Scale data. However, subjective patient responses on the Symptom Check List were significant for greater symptom improvement in the combined treatment group. This particular study was limited in that it did not have a psychopharmacology-only arm, and patients were allowed to choose not to be involved in the combination treatment arm due to fear of medication side effects.

A study conducted by Kool, Dekker, Duijsens, de Jonghe, and Puite (2003) observed that for MDD, a PPPT approach was more effective than pharmacotherapy alone. They also concluded that the combined therapy was more effective with patients with coexisting personality disorders. Bellino, Zizza, Rinaldi, and Bogetto (2006) studied MDD with comorbid borderline personality disorder (BPD) subjects and compared the combination of fluoxetine and interpersonal psychotherapy (IPT) with fluoxetine alone. Neither group showed a significant difference in MDD remission rates, although combination therapy showed signifi-cant positive differences in depressive symptoms, relationship satisfaction, and quality of life.

Regarding data in adolescents, the Treatment for Adolescents with Depression Study (TADS) observed that response rates to cognitive behavioral therapy (CBT) and fluoxetine PPPT were higher than with CBT alone or pharmacotherapy alone (Emslie et al., 2006).

The STAR*D (Sequenced Treatment Alternatives to Relieve Depression) trial and others suggest that psychotherapy used as augmentation of pharmacotherapy (psychotherapy added sequentially after incomplete antidepressant response) had a better impact on clinical symptoms of MDD than medication alone (Harley, Sprich, Safren, Jacob, & Fava, 2008; Thase et al., 2007). Furthermore, the REVAMP (Research Evaluating the Value of Augmenting Medication With Psychotherapy) trial evaluated MDD patients with incomplete antidepressant responses and placed subjects into one of several groups: (a) continued pharmacotherapy plus augmentation with cognitive behavioral analysis system of psychotherapy (CBASP), (b) continued pharmacotherapy and augmentation with brief supportive psychotherapy (BSP), and (c) continued optimized pharmacotherapy (MEDS) alone, and determined that neither augmentation psychotherapy modality nor continued psychopharmacology alone significantly improved MDD outcomes from a superiority point of view (Kocsis et al., 2009).

This equivocal finding is a segue to a disclaimer that the evidence base in MDD, and in other psychiatric disorders, clearly has both positive and negative findings. Sometimes comparing trials has an “apples and oranges” effect. The REVAMP trial was attempting to determine whether a strictly manualized CBASP would outperform a treatment as usual supportive psychotherapy condition. Studies in previous paragraphs utilized CBASP as combination treatment effectively. Other studies revealed success with psychodynamic psychotherapy. Therefore, validation and evaluation of the stringency of these studies warrants attention. The positive studies above and throughout this chapter are discussed initially to set the stage for a more theoretical discussion later in this chapter regarding the concept that psychotherapy plus pharmacotherapy makes biological and neuroscientific sense.

In regards to bipolar disorder, there is certainly less data and evidence base for combination treatment, or PPPT. Treatment guidelines often do not support using monotherapy, unipolar antidepressants as front line treatment as they are utilized in MDD (American Psychiatric Association, 2012). Oftentimes, mood stabilizing agents are used to treat both mania and depression. Finally, psychotherapy as a treatment for mania, alone or combined with a pharmacotherapy, is often fraught with ineffectiveness, as manic patients tend to lack insight regarding their behavior or even experience any motivation to change, since mania is an illness of denial. A review by Hollon and Ponniah evaluated bipolar disorder, cognitive behavioral therapy (CBT), and family-focused psychotherapy and found that these psychotherapies were effective adjunctives to medications for depressed phases only, and possibly useful for preventing future bipolar episodes of either pole as well. Psychoeducation has also been found to be effective in the prevention of mania/hypomania and possibly depression when added to consistent mood stabilization with psychopharmacology approaches (Hollon & Ponniah, 2010).

Another group determined that, in regards to bipolar disorder, supportive psychoeducation given to the individual patient statistically lowered the chances of mania, mixed features, and depression. Furthermore, when this type of therapy was applied to the patient’s family and support system, it further reduced relapse into mania. Schmitz, Averill, Sayre, McCleary, Moeller, and Swann (2002) reviewed patients with bipolar disorder and comorbid substance misuse and randomly assigned 46 individuals to either 12 weeks medication monitoring alone or in combination with CBT, and found that the latter allowed for greater medication adherence based on patient self-report, as well as, consistent blood level maintenance of mood stabilizers. It is often assumed, and a well-noted clinical phenomenon, that when medication adherence increases, outcomes likely improve or are maintained longer. Lam et al. conducted studies with patients who were randomized to receive either “minimal psychiatric care” alone or with the addition of CBT for relapse prevention for 6 months. The patients in the experimental PPPT condition reported significantly greater compliance immediately after treatment and this extended to 18 and 24 months after CBT, although not at the 12-month assessment in longer-term assessments (Lam et al., 2003; Lam, Hayward, Watkins, Wright, & Sham, 2005). Many of these bipolar trials again focused on depression, not mania. Often-times, outcomes were measured in terms of medication adherence, which again, clinically should yield better maintenance of response and help in prophylaxis against relapse.

A more formal discussion regarding the treatment of anxiety disorder occurs later in this book and an in-depth review is well covered by Stahl and Moore (2013) in a separate publication. Here, as an introduction to integrated anxiety disorder treatment, panic disordered (PD) patients are the most often studied via CBT protocols, and it is considered a very effective standalone treatment. CBT can improve panic attacks, phobic avoidance, generalized anxiety, and anticipatory anxiety (Oei, Llamas, & Evans, 1997; Steketee & Shapiro, 1995). Oei et al. (1997) found that preexisting anxiety medication regimes did not affect long-term outcome of brief intensive group CBT in panic disorder (PD) with or without agoraphobia. Beurs, van Balkom, Lange, Koele, and van Dyke (1995) conducted a comparative outcome study and found that the PPPT fluvoxamine (SSRI) plus exposure in vivo demonstrated efficacy superior to that of any single modality treatment with double the effect size on self-reported agoraphobic avoidance.

There have been several other systematic evaluations by Sharp et al. (1996) and Marks et al. (1993) comparing CBT in combination with medications like fluvoxamine (SSRI) and alprazolam (benzodiazepine), and their findings suggest that both CBT and medications are effective individually, although the combination of both is more effective. SSRIs plus exposure and response prevention-based CBT are both established treatments for obsessive-compulsive disorder (OCD). CBT here may be an effective augmentation treatment strategy in treating OCD for patients who do not respond to SSRIs (Math & Janardhan, 2007). A small number of placebo-controlled trials have compared efficacy of medications and/or exposure and response prevention therapy (ERP), and it has been shown that ERP therapy combined with pharmacotherapy (a PPPT approach) to be superior to SSRIs alone in child and adult populations. In adults, Foa et al. (2005) conducted a randomized controlled trial to study clomipramine (TCA) alone, ERP alone, and their combination in 86 patients, and found that the PPPT approach was superior to clomipramine alone on all outcome measures. Simpson et al. (2008) conducted a randomized controlled trial in 108 patients to compare the effects of augmenting SSRIs with ERP or stress management training (another form of CBT) and found that ERP was superior to stress management training in reducing OCD symptoms and that augmentation to an SSRI with ERP was an effective strategy for reducing OCD symptoms. In the pediatric obsessive-compulsive disorder treatment study (POTS), sertraline (SSRI) was compared to ERP and combination PPPT. PPPT was superior at one of two sites (POTS team, 2004). Treatments for posttraumatic stress disorder (PTSD) broadly have been defined as biological or psychosocial in nature. Randomized clinical trials for adult PTSD have been conducted for various treatments, such as cognitive restructuring, imaginal exposure, in vivo exposure, and various combinations of these in a CBT context delivered in groups and individually (Bradley, Greene, Russ, Dutra, & Westen, 2005). The long-term effectiveness of medications in PTSD may be limited, as findings often suggest 30% complete remission after short-term treatment compared to 65%–79% with CBT (Foa et al., 1999). Rothbaum et al. (2006) studied whether a combination of sertraline (SSRI) with prolonged exposure therapy would result in greater improvement than continuation with sertraline alone in patients with chronic PTSD. They observed that sertraline itself led to a significant reduction in PTSD severity over 10 weeks of psychopharmacology-only treatment but was associated with no further reductions after 5 additional weeks of pharmacotherapy. In contrast, the other group who received combined modalities (PPPT) did exhibit further, continued reduction in PTSD symptom severity. Moreover, an augmentation effect was seen in patients with only partial medication response, allowing a greater chance of remission (Rothbaum et al., 2006).

Depressive and anxiety disorders seem amenable to combined psychotherapy plus pharmacotherapy, and there is clear evidence that an integrated approach often allows for more favorable outcomes in certain patient populations. Schizophrenia is one of the most chronic and debilitating psychiatric disorders, with typically less robust outcomes in regards to psychopharmacology or psychotherapy approaches. Long-term maintenance on antipsychotic medications has been considered to be the most important factor in preventing rehospitalization in these patients (Schooler et al., 1997). Mojtabai, Nicholson, and Carpenter (1998), in their comprehensive meta-analysis, found that psycho...

Table of contents

• Cover
• Title
• Copyright
• Contents
• List of Figures
• List of Tables
• List of Contributors
• Foreword
• Preface
• Series Editor Introduction
• 1 Integrating Psychotherapy and Psychopharmacology: Outcomes, Endophenotypes, and Theoretical Underpinnings Regarding Effectiveness
• 2 Trial-Based Cognitive Therapy (TBCT): A New Cognitive-Behavior Therapy Approach
• 3 Integrating Psychopharmacology and Psychotherapy in Mood Disorders: Major Depression
• 4 Integrating Psychopharmacology and Psychotherapy in Mood Disorders: Bipolar Disorder
• 5 Integrating Psychopharmacology and Cognitive Remediation to Treat Cognitive Dysfunction in the Psychotic Disorders
• 6 Integrating Psychopharmacology and Psychotherapy in Anxiety Disorders
• 7 Integrating Psychopharmacology and Psychotherapy in Eating Disorders
• 8 Integrating Psychopharmacology and Psychotherapy to Treat Children with ADHD
• 9 Integrating Psychopharmacology and Psychotherapy in Insomnia
• 10 Integrating Psychotherapy and Medication for Addicted Patients
• 11 Integrating Pharmacotherapy and Psychotherapy in Perinatal Distress
• 12 Integrating Psychotherapy and Psychopharmacology in Sexual Disorders
• 13 Integrating Psychopharmacology and Computer-Based Psychotherapy
• 14 A Delicate Balance: The Contribution of Psychosocial Factors to Biological Treatments of Mental Disorders
• Index