The integration of psychotropics into a broader psychosocial therapeutic plan would seem more than justified by previous reviews of the benefits associated with such a multimodal approach to coordinated behavioral health treatment (Reis de Olivera, Schwartz, & Stahl, 2014). It is no longer enough to think along traditional lines of which is the best medication for a particular diagnosis, nor is it sufficient to adhere to one school of psychotherapy and apply it without much regard to diagnosis. Thus, CBT (cognitive-behavioral therapy) for CBT's sake, just as pharmacotherapy as a standalone, would appear to be paradigms with diminished futures. Evidence-based therapeutic strategies argue that treatments, or a combination of treatments, might best be selected according to their relative impact on a certain constellation of symptoms, together with accompanying psychosocial variables, not the least among these being subject variables. Such an approach advocates integrating different biopsychosocial approaches to optimize therapeutic result. In some instances it is a question of selecting one treatment over another, while in the majority of cases it is more a question of combining treatments, and often this means coordinating multimodal therapeutic interventions (Lazarus, 1981).
āEvidence-basedā is a lure that does not always provide us with clear-cut distinctions among multiple intervention strategies because, quite often, the evidence is not there. The evidence that is available, and it is substantial, is limited by its designs, which are driven by the interests of the investigators. Medications are largely tested against placebo, while CBT has rarely been pitted head-to-head against other psychosocial therapies, and where this has been done by resurrecting past studies in meta-analyses, the results are confoundingly ambiguous (Tolin, 2010), which is not a state to be cherished in science. Meta-analyses incorporate all of the shortcomings of the original randomized controlled trials (RCTs) that they attempt to digest (Kennedy-Martin, Curtis, Faries, Robinson, & Johnston, 2005; Walker, Hernandez, & Kattan, 2008). Oftentimes, meta-analyses find no difference between medication and psychotherapy, and no discernable advantage among various medications or among different psychotherapies. And, just as obfuscating is the fact that many studies are kept from public knowledge through selective publication, leading to a skewing of data toward a spurious impression of greater effectiveness than might otherwise be the case if all data were reported (Turner, Matthews, Linardatos, Tell, & Rosenthal, 2008). Still, one often finds that CBT is presented as having accumulated substantial data to support it as an efficacious therapy for the majority of psychiatric disorders (Butler, Chapman, Forman, & Beck, 2006), and this is certainly true because the number of studies completed with CBT as the independent variable far outweigh studies conducted on other psychotherapies. However, it is a stretch to say, based on the present data, that CBT is more efficacious than other psychotherapies. Hofmann, Asnaani, Imke, Sawyer, & Fang (2012), in a review of 269 meta-analyses concluded that CBT generally showed higher response rates than other psychosocial therapies, but the nature of the other therapies examined was often vague, and in several cases no superiority of CBT over the other psychosocial approaches was demonstrated, while in at least one case psychodynamic therapy was shown to be superior to CBT; indeed, when psychoanalysis is studied for effectiveness, it compares well with other therapies (de Maat et al., 2013), although the rigor of such studies leaves much to be desired.
What is the researcher, not to mention the clinician hoping to hang his shingle on tangible data, to derive from such a state of affairs? I submit that we have many wonderful meta-analyses that have given us a glimpse of where the truth lies, but we need to go back and design hard-hitting RCTs to fill in the blanks. Perhaps we have mined the data sufficiently at this point, and need more data. Well-designed RCTs that compare head-to-head the different psychosocial therapies are needed, just as are RCTs that pit different medications against psychosocial therapies, and not just placebo-controlled groups. And, the reciprocal influence among various therapiesāsuch as pharmacological agents with other psychotropics (so-called polypharmacy) as well as such agents with a multitude of psychosocial therapies (what analysis of variance calls āinteractionsā)āis where the hope for integration lies. Having said this, one is often struck by the commonalities of the various therapeutic approaches (Frank & Frank, 1991), be they pharmacologic or psychotherapeutic; and, until we are able to determine more precisely what components of a given approach endow it with an advantage over its brother, we are likely to run a lot of RCTs with equivocal results, since, in the end, the common response to therapeutic intervention, placebo included, is a global one in which patients tend to get better.
For years the movement toward integrating psychopharmacology with psychotherapy has moved forward on sound judgment alone: even with a paucity of substantiating research, a multimodal approach where pharmacotherapy is coordinated with psychological treatments has appeared to make sense at face value. Only recently has sufficient data accumulated to allow evidence-based pronouncements on the value of combining these two approaches, and the data available at this time have vindicated the theory to a large extent, while certain exceptions have also been found. The efficacy of combining pharmacotherapy and psychotherapy as a practice is borne out to a large extent by research; yet, as we shall see in the coming chapters, medication is sometimes contraindicated as an add-on to psychotherapy, and therapy is not always a benefit when added to medication management. As more investigations are completed in the area of biopsychosocial integration, it will become increasingly apparent that a multitude of variables are implicated in outcome, the patient population under consideration being one of the most important (Arnold, 1993).
We have elucidated here, as far as the evidence takes us to date, which combination of treatments is recommendable for each of the major psychiatric diagnoses. Never before has a single volume embarked upon coordinating psychopharmacological and psychotherapeutic treatments for the major psychiatric diagnoses from the evidence-based cognitive-behavioral perspective. Yet, diagnostic categorizations only take us so far, for it is, ultimately, the person whom we are treating, and the appreciation of the importance of patient variables is what distinguishes the astute practitioner from the mere technician.
There is a burgeoning movement in mental health to acknowledge the entire person's functioning across physical, psychological, and social spheres, and to integrate medical as well as psychological and social interventions in order to address the entire spectrum of the patient's life (McHugh & Slavney, 1998; McHugh, 2012a; McHugh, 2012b) presenting problems being, perhaps, the more important aspect of that life to the clinician. This book approaches the movement toward biopsychosocial integrative care from an evidence-based perspective, and goes beyond to offer a new way of conceiving of the interface between pharmacotherapy and psychotherapy by spelling out proven coordinated approaches for all of the major psychiatric diagnoses.
