integrated treatment of psychiatric disorders

Integrated or combined treatment is the simultaneous use ofpsychotherapy and pharmacotherapy in the treatment of pa-tients with mental disorders.. Studies of integrated and collaborative

Integrated Treatment of Psychiatric Disorders

Review of Psychiatry Series

John M Oldham, M.D.Michelle B Riba, M.D., M.S

Series Editors

No 2

Washington, DC London, England

Integrated Treatment of Psychiatric Disorders

EDITED BY

Jerald Kay, M.D.

Note: The authors have worked to ensure that all information in this book concerning drug dosages, schedules, and routes of administration is accurate as

of the time of publication and consistent with standards set by the U.S Food and Drug Administration and the general medical community As medical research and practice advance, however, therapeutic standards may change For this reason, and because human and mechanical errors sometimes occur, we recommend that readers follow the advice of a physician who is directly involved

in their care or the care of a member of their family A product’s current package insert should be consulted for full prescribing and safety information.

Books published by American Psychiatric Publishing, Inc., represent the views and opinions of the individual authors and do not necessarily represent the policies and opinions of APPI or the American Psychiatric Association Copyright © 2001 American Psychiatric Publishing, Inc.

04 03 02 01 4 3 2 1

ALL RIGHTS RESERVED

Manufactured in the United States of America on acid-free paper

The correct citation for this book is

Kay J (editor): Integrated Treatment of Psychiatric Disorders (Review of Psychiatry

Series, Volume 20, Number 2; Oldham JM and Riba MB, series editors) Washington, DC, American Psychiatric Publishing, 2001

Library of Congress Cataloging-in-Publication Data

Integrated treatment of psychiatric disorders / edited by Jerald Kay.

p ; cm — (Review of psychiatry ; v 20, no 2)

Includes bibliographical references and index

ISBN 1-58562-027-0 (alk paper)

1 Psychopharmacology 2 Psychotherapy 3 Mental illness—Treatment

I Kay, Jerald II Review of psychiatry series ; v 20, 2.

[DNLM: 1 Mental Disorders—therapy 2 Combined Modality Therapy.

3 Psychotherapy 4 Psychotropic Drugs—therapeutic use WM 400 I61 2001] RC480.5.I556 2001

616.89′1—dc21

00-067397

British Library Cataloguing in Publication Data

A CIP record is available from the British Library.

Cover illustration: Copyright © 2001 Jac Depczyk/The Image Bank.

Contributors ix Introduction to the Review of Psychiatry Series xi

John M Oldham, M.D., and

Michelle B Riba, M.D., M.S., Series Editors

Psychodynamic Therapy and Medication:

Can Treatments in Conflict Be Integrated? 31

Steven P Roose, M.D.

Is an Integrated Model Possible? 42

Chapter 3

Integrated Treatment Planning for

Borderline Personality Disorder 51

John M Oldham, M.D.

Developing a Biopsychosocial Treatment Plan 61

Chapter 4

Integrated Treatment of Alcohol,

Douglas Ziedonis, M.D., M.P.H.

Jonathan Krejci, Ph.D.

Sylvia Atdjian, M.D.

Goals of Psychotherapy for

Specific Psychotherapies for

Timing and Role of Medications for

Combined Treatment Studies For Opioid,

Alcohol, Cocaine, and Alcohol Use Disorders 91

Specifying the Causes of Noncompliance 125Behavioral Techniques to Increase Compliance 126Cognitive Techniques to Increase Compliance 127Examining Advantages and Disadvantages 129

Eliciting and Responding to

Cognitive Restructuring of Core Beliefs 139

Afterword 165

Jerald Kay, M.D.

Professor of Psychiatry, Department of Psychiatry and Behavioral

Neurosciences, Wayne State University School of Medicine, Detroit, Michigan

John M Oldham, M.D

Dollard Professor and Acting Chairman, Department of Psychiatry, Columbia University College of Physicians and Surgeons, New York, New York

Michelle B Riba, M.D., M.S.

Associate Chair for Education and Academic Affairs, Department of Psychiatry, University of Michigan Medical School, Ann Arbor, Michigan

Steven P Roose, M.D.

Professor of Clinical Psychiatry, College of Physicians and Surgeons, Columbia University, New York, New York

Douglas Ziedonis, M.D., M.P.H.

Associate Professor and Director, Division of Addiction Psychiatry, University of Medicine and Dentistry of New Jersey, Robert Wood Johnson Medical School, Piscataway, New Jersey

Introduction to the Review

of Psychiatry Series

John M Oldham, M.D., and

Michelle B Riba, M.D., M.S., Series Editors

2001 R EVIEW OF P SYCHIATRY S ERIES T ITLES

• PTSD in Children and Adolescents

EDITED BY SPENCER ETH, M.D

• Integrated Treatment of Psychiatric Disorders

EDITED BY JERALD KAY, M.D

• Somatoform and Factitious Disorders

EDITED BY KATHARINE A PHILLIPS, M.D

• Treatment of Recurrent Depression

EDITED BY JOHN F GREDEN, M.D

• Advances in Brain Imaging

EDITED BY JOHN M MORIHISA, M.D

In today’s rapidly changing world, the dissemination of mation is one of its rapidly changing elements Information vir-tually assaults us, and proclaimed experts abound Witness, forexample, the 2000 presidential election in the United States, dur-ing which instant opinions were plentiful about the previouslyobscure science of voting machines, the electoral college, and themeaning of the words of the highest court in the land For medi-cine the situation is the same: the World Wide Web virtually bulg-

infor-es with health advice, treatment recommendations, and stridentwarnings about the dangers of this approach or that Authorita-tive and reliable guides to help the consumer differentiate be-tween sound advice and unsubstantiated opinion are hard to

come by, and our patients and their families may be misled bybad information without even knowing it.

At no time has it been more important, then, for psychiatristsand other clinicians to be well informed, armed with the very lat-est findings, and well versed in evidence-based medicine Wehave designed Volume 20 of the Review of Psychiatry Series withthese trends in mind—to be, if you will, a how-to manual: how toaccurately identify illnesses, how to understand where they comefrom and what is going wrong in specific conditions, how to mea-sure the extent of the problem, and how to design the best treat-ment, especially for the particularly difficult-to-treat disorders.The central importance of stress as a pathogen in major mentalillness throughout the life cycle is increasingly clear One form of

stress is trauma Extreme trauma can lead to illness at any age, but

its potential to set the stage badly for life when severe trauma

oc-curs during early childhood is increasingly recognized In PTSD

in Children and Adolescents, Spencer Eth and colleagues review the

evidence from animal and human studies of the aberrations, bothpsychological and biological, that can persist throughout adult-hood as a result of trauma experienced during childhood Newertechnologies have led to new knowledge of the profound nature

of some of these changes, from persistently altered stress mones to gene expression and altered protein formation In turn,hypersensitivities result from this early stress-induced biologicalprogramming, so that cognitive and emotional symptom patternsemerge rapidly in reaction to specific environmental stimuli.Nowhere in the field of medicine is technology advancingmore rapidly than in brain imaging, generating a level of excite-ment that surely surpasses the historical moment when the dis-covery of the X ray first allowed us to noninvasively see into theliving human body The new imaging methods, fortunately, donot involve the risk of radiation exposure, and the capacity of thenewest imaging machines to reveal brain structure and function

hor-in great detail is remarkable Yet hor-in many ways these techniquesstill elude clinical application, since they are expensive and in-creasingly complex to administer and interpret John Morihisahas gathered a group of our best experts to discuss the latest de-

velopments in Advances in Brain Imaging, and the shift toward

greater clinical utility is clear in their descriptions of these ods Perhaps most intriguing is the promise that through thesemethods we can identify, before the onset of symptoms, thosemost at risk of developing psychiatric disorders, as discussed byDaniel Pine regarding childhood disorders and by Harold Sack-eim regarding late-life depression.

meth-Certain conditions, such as the somatoform and factitious orders, can baffle even our most experienced clinicians As

dis-Katharine Phillips points out in her foreword to Somatoform and Factitious Disorders, these disorders frequently go unrecognized

or are misdiagnosed, and patients with these conditions may beseen more often in the offices of nonpsychiatric physicians than

in those of psychiatrists Although these conditions have been ported throughout the recorded history of medicine, patientswith these disorders either are fully convinced that their prob-lems are “physical” instead of “mental” or choose to present theirproblems that way In this book, experienced clinicians provideguidelines to help identify the presence of the somatoform andfactitious disorders, as well as recommendations about theirtreatment

re-Treatment of all psychiatric disorders is always evolving,based on new findings and clinical experience; at times, the fieldhas become polarized, with advocates of one approach vyingwith advocates of another (e.g., psychotherapy versus pharma-cotherapy) Patients, however, have the right to receive the besttreatment available, and most of the time the best treatment in-

cludes psychotherapy and pharmacotherapy, as detailed in grated Treatment of Psychiatric Disorders Jerald Kay and colleagues propose the term integrated treatment for this approach, a recom-

Inte-mended fundamental of treatment planning Psychotherapyalone, of course, may be the best treatment for some patients, just

as pharmacotherapy may be the mainstay of treatment for others,but in all cases there should be thoughtful consideration of acombination of these approaches

Finally, despite tremendous progress in the treatment of mostpsychiatric disorders, there are some conditions that are stub-bornly persistent in spite of the best efforts of our experts John

Greden takes up one such area in Treatment of Recurrent

Depres-sion, referring to recurrent depression as one of the most

dis-abling disorders of all, so that, in his opinion, “a call to arms” isneeded Experienced clinicians and researchers review optimaltreatment approaches for this clinical population As well, newstrategies, such as vagus nerve stimulation and minimally inva-sive brain stimulation, are reviewed, indicating the need to go be-yond our currently available treatments for these seriously illpatients

All in all, we believe that Volume 20 admirably succeeds in vising us how to do the best job that can be done at this point todiagnose, understand, measure, and treat some of the most chal-lenging conditions that prompt patients to seek psychiatric help

Jerald Kay, M.D.

Integrated or combined treatment is the simultaneous use ofpsychotherapy and pharmacotherapy in the treatment of pa-tients with mental disorders This approach is relevant to patientsacross a continuum of psychiatric disorders, from the mostchronic and disabling to those with more circumscribed and lessdisruptive symptomatology Integrated treatment is usually pro-vided by a psychiatrist; however, managed behavioral healthcare, with its emphasis on cost containment, frequently favors acombined treatment model called split or collaborative treat-

ment Most often split treatment refers to an arrangement whereby

a psychiatrist is responsible for medication management whilepsychotherapy is provided by another mental health profession-

al such as a psychologist, social worker, nurse specialist, or selor Although there is little scientific support for the efficacy orcost effectiveness of the split-treatment relationship, it is never-theless commonplace There are preliminary studies, however,that demonstrate cost savings when the psychiatrist is providingintegrated treatment

coun-Given the ubiquity of integrated treatment, it is odd that themajor scientific and clinical questions about this treatment mo-dality have been attended to only recently This effort is muchneeded because integrated treatment, more than any other pro-fessional psychiatric activity, defines the field of psychiatry anddistinguishes it from other mental health disciplines and othermedical specialties In this volume we not only apprise the reader

of the most recent research on this subject but discuss the clinicalindications, challenges, helpful approaches, and interventions in-volved in providing this type of treatment

In Chapter 1, I provide an introduction to integrated treatmentand review the benefits of this type of care I emphasize that allpatients attribute some meaning to the medications they are pre-scribed Given the significant problems associated with noncom-pliant behavior, it behooves the clinician to explore this meaningthoroughly in any treatment Invariably, this exploration alsoprovides useful information about the psychotherapeutic pro-cess and an enhanced appreciation of characterological issues.The literature on integrated and collaborative treatment is re-viewed, with a particular emphasis on randomized controlledtrials demonstrating positive findings, and recommendations aremade for the further study of specific clinical questions Last, thereader is offered some suggestions and guidance about the effec-tive use of combined treatment.

Since the majority of psychiatrists who provide integratedtreatment do so from a psychodynamic perspective, Chapter 2,

by Steven Roose, addresses the important question of theoreticalsupport for this type of treatment The combined use of psycho-dynamic psychotherapy and medication inherits a legacy of the-oretical conflict Appreciating the neurobiological aspects ofpsychotherapy will move the field away from dualistic thinkingand undoubtedly improve patient care Roose also explores theconcept of sequential treatment, a topic that has only recentlybeen addressed in the scientific literature

In Chapter 3, John Oldham builds upon the material introduced

by Roose, with particular attention to one of the most challenging(yet rather common) psychiatric disorders, borderline personalitydisorder (BPD) His chapter is especially timely given the forth-coming American Psychiatric Association Practice Guideline

on the treatment of this disorder, early drafts of which clearly vocate for integrated treatment Oldham makes the point thatBPD is a heterogeneous group of conditions that can be best ap-proached through examination of the patient’s most prominentsymptoms This concept appeals greatly to clinicians who havebeen troubled by a purely phenomenological approach to diagno-sis, which has been at times confusingly overinclusive A step-by-step process for the comprehensive treatment of patients withBPD is presented here that should be helpful to all psychiatrists

ad-Chapter 4 also addresses integrated and collaborative ment of specific disorders Douglas Ziedonis, Jonathan Krejci,and Sylvia Atdjian review the integrated treatment of substanceabuse disorders, which has been marked historically by intensecontroversy between physicians and nonmedical addiction ther-apists over the appropriate role of medications The authors re-view three of the leading psychotherapies currently in use in thetreatment of patients with substance abuse disorders: 12-stepfacilitation, motivational enhancement therapy, and relapseprevention They discuss 11 important goals of the use of psycho-therapy for addiction Studies of integrated and collaborativetreatment in opioid and nicotine dependence as well as in alcoholand cocaine use disorders are reviewed, highlighting the benefits

treat-of adopting a comprehensive treatment approach

In Chapter 5, Judith Beck writes about an issue central in

near-ly every medical specialty She points out that more than 50% ofpatients prescribed medication fail to follow the instructions pro-vided by their physician She describes a creative and thoroughcognitive therapy approach to dealing with medication compli-ance problems Her model for addressing the components of non-adherence is valuable to any psychiatrist using pharmacotherapy.Her chapter should be required reading for all psychiatry resi-dents, since she provides such clear techniques for effective inter-vention with patients ambivalent about medication

Last, in Chapter 6, Michelle Riba and Richard Balon considerthe virtues and challenges of split treatment They provide highlyrelevant direction for the psychiatrist who collaborates with non-physician mental health professionals Riba and Balon breakdown the stages of effective split treatment into their elements,and they present detailed clinical advice relevant to the begin-ning, middle, and end phases of treatment Moreover, throughnumerous clinical vignettes they describe practical and effectiveinterventions

Integrated or combined treatment is the simultaneous prescription

of psychotherapy and pharmacotherapy in the treatment of a tient’s mental illness Despite the ubiquity of this practice, rela-tively little research has been conducted on it until recently Theonly information regarding the use of integrated treatment inclinical practice has been provided by the American PsychiatricAssociation Practice Research Network (PRN) The 1997 PRNsurvey indicated that approximately 55% of patients receivedboth medication and psychotherapy from either a psychiatrist orother mental health professionals (Pincus et al 1999) Althoughunpublished as yet, further data analyses from this same studyshowed that 59.4% of adult patients with mood disorder receivedintegrated treatment (both psychotherapy and pharmacothera-py) from psychiatrists Combined or split treatment was associ-ated with a number of important factors, including younger age

pa-of psychiatrists and the presence pa-of utilization management niques Preliminary findings from the most recent PRN survey(Figure 1–1), of 1,500 randomly selected psychiatrists, indicatedthat of the patients treated by almost 900 psychiatrists, only one-third did not receive some type of psychotherapy (American Psy-chiatric Institute for Research and Education 2000) However,caution must be exercised in interpreting the PRN data because

tech-of an overly inclusive definition tech-of psychotherapy.

Other studies have indicated that for many patients the sion of both psychotherapy and psychopharmacology by psychi-

provi-atrists (as opposed to delegation of psychotherapy to other mentalhealth professionals) may be cost saving (Dewan 1999; Goldman1998) Another study compared treatment of depression by pri-mary care practitioners to treatment by mental health specialistsand found that, although the latter was slightly more costly, it re-sulted in much better patient outcomes (Sturm and Wells 1995).Despite the very small number of studies, the provision of bothpsychotherapy and medications by the psychiatrist appears to be

an important intervention in our therapeutic armamentarium

Integrated Treatment and the

Definition of Psychiatry

Although most psychiatrists advocate a biopsychosocial proach to patient care (Engel 1980), it has never been clear that

ap-Figure 1–1. Psychotherapy by psychiatrists: findings from the 1998

National Survey of Psychiatric Practice (N = 896).

Source Reprinted with permission from American Psychiatric Institute for

Re-search and Education: "Are Psychiatrists Commonly Providing Psychotherapy

to Their Patients?" PRN Update, Spring 2000, p 2 Copyright 2000, American

Psychiatric Institute for Research and Education.

this conceptual framework has provided hoped-for direction

to the field Psychiatry remains in practice divided betweenthose who conceptualize treatment from a biological point ofview and those who favor a psychosocial view The mind-bodysplit has not been healed The practice of combined treatment,recently supported by promising research, thus offers an op-portunity to unify our therapeutic approach to our patientsand simultaneously reduce distracting tension in our field.Furthermore, psychiatrists’ use of both medication and psy-chotherapy in treatment creates the clearest possible profes-sional distinction between psychiatrists and other physiciansand mental health professionals, a distinction critical for theidentity and economic future of the field for practitioners andtrainees

Exciting findings from neuroscience have demonstrated thepresence of neuronal plasticity within the human central nervoussystem The hippocampus, for example, which is vital to learningand memory, produces new cells daily (Eriksson et al 1998) Psy-chotherapy itself is a learning process whereby patients acquirenew resources to enhance coping skills; the neurobiologicalstudy of psychotherapy is thus becoming a reality (Liggan andKay 1999) Brain function and structure change with effectivepsychotherapy (Baxter et al 1992; Schwartz et al 1996; Thase et

al 1998; Viinamaki et al 1998)

With this explosion of knowledge about the neurobiologicalcorrelates of psychotherapy and with the demonstrated efficacyand effectiveness of psychotherapeutic treatments such as cogni-tive-behavioral, interpersonal, psychodynamic, and dialecticalbehavioral therapies, it would not be prudent to jettison psycho-therapy as a core clinical skill in psychiatry Although there is noscientific support, there are financial incentives in managed be-havioral health care for split treatment, in which the psychiatristmanages a patient’s medication and another mental health pro-fessional provides psychotherapy However, the field should notabandon the provision of psychotherapy by psychiatrists Rather,psychotherapy should remain a substantial component of psy-chiatry residency training programs

Historical Resistance to Integrated Treatment

The introduction of psychotropic medication in the last centurywas accompanied by resistance in some quarters (Karasu 1982;Klerman 1991) Claims were made that medication irreparablyaltered the therapeutic relationship and submerged patients’symptoms and their associated distress, thus decreasing theirmotivation for understanding their problems With regard to thetherapeutic relationship, it was argued that the introduction ofmedication encouraged a passive, dependent stance on the pa-tient’s part as well as magical thinking of the sort often character-istic of nonpsychiatric doctor-patient relationships Some criticsexpressed concerns that medication prematurely weakened de-fenses and increased the likelihood of symptom substitution(Seitz 1953; Weiss 1965) Introducing medication also raised thepossibility that patients’ self-esteem would be lowered becausethey would view themselves as being more ill and needing to rely

on something external to function Still other critics worried thatthe introduction of medication made patients feel they were lessinteresting to the psychiatrist

On the other hand, those psychiatrists advocating a purely ological approach to psychiatric disorders were concerned thatproviding psychotherapy frequently led to symptom exacerba-tion, which could complicate and prolong treatment From a re-ductionistic etiological point of view, psychotherapy is irrelevant

bi-to the treatment plan because medication alone is sufficient forimprovement

Potential Beneficial Effects of

Integrated Treatment

Opposed to criticisms of integrated treatment are a number ofpotential beneficial effects, above and beyond the purely medicalindications for medication (Klerman 1991) These include the fol-lowing:

• Medications can reduce some symptoms, which may result inenhancing the patient’s self-esteem

• Pharmacology may permit a patient greater cognitive and bal access to psychotherapy.

ver-• Medications may improve a patient’s autonomous ego tions, such as memory, thought, attention, concentration, andmotoric capacities, thereby permitting the ego to marshalgreater resources for the psychotherapy

func-• Medications may increase the safety within the therapeutic lationship, allowing greater expression of emotion and feeling

re-• Pharmacotherapy may promote patient abreaction and allowloosening of defenses, which may make the psychotherapymore effective

• Pharmacotherapy may be accompanied by a positive placeboeffect that reduces the stigma of being treated by a psychiatrist,allowing the formation of a more productive therapeutic alli-ance

• The patient’s and therapist’s feelings about medication and itsside effects may provide important insights into the patient’scharacter and emotional state and into the countertransferenceabout the patient, as is often the case with the resistant or non-compliant patient

• Improvement from medications may illustrate the patient’sconflicts about success and accomplishment in the treatment,which are often long-standing and self-defeating

• During interruptions of psychotherapeutic treatment, tion may provide an enduring connection to the treatment re-lationship

medica-Two clinical cases are described below which indicate the

val-ue of examining a patient’s feelings about medication

Clinical Case

Mr A, a 28-year-old accountant, was referred by his nologist for evaluation of depression He was placed on fluox- etine and began psychoanalytically oriented psychotherapy because of some rather pronounced characterological issues His depressive symptoms rapidly improved Six weeks into the treatment, he was asked by the psychiatrist whether there was need for a refill Mr A responded that he had run out of medi- cation 6 days earlier because his wife had failed to refill the

pulmo-prescription Apparently, it had become her responsibility to monitor his medication Exploration of this unusual assign- ment of responsibility by the patient to his wife revealed the fantasy that he had established a test of her caring for him His wife had disappointed him by failing to observe that he had run out of medication, and he demonstrated this disappoint- ment by discontinuing the medication despite his excellent re- sponse to it Examination of this behavior was remarkably productive in the psychotherapy, delineating the patient’s pas- sivity in his marriage, his consistent need for reassurance, and his inability to express his hostility and disappointment about his marriage directly to his wife He was also able to resume pharmacotherapy.

Clinical Case

Ms B, 53 years old, was referred to a psychiatrist for therapy and medication She had recently been discharged from a day-hospital program after experiencing a rather dra- matic and disabling major depression She was an exceptional-

psycho-ly accomplished woman whose illness was precipitated by an unusual work-related event: a need arose to terminate a num- ber of workers because of budgetary problems This act left her conflicted and guilt-ridden Like Mr A, this patient had an ex- cellent response to the antidepressant medication but became erratic about taking it Exploration of this noncompliance re- vealed that the patient’s family was averse to psychotropic medication and saw her need for pharmacotherapy as a weak- ness of character Moreover, it became clear that the patient’s continuance on medication brought back many memories of her mother, who was incapacitated by bipolar illness Ms B re- sented her mother’s unavailability throughout most of her for- mative years and decided as a teenager that she would never in any fashion identify with her mother Examination of the adherence issue permitted the patient to reexperience her long- denied resentment of her mother and to develop new ap- proaches to medication with her family members Subsequently she was able to take her medication as prescribed.

As these cases illustrate, psychotherapy—be it

psychodynam-ic, cognitive-behavioral, or interpersonal—can support cological treatment Improved adherence to medication andcompliance with the treatment approach are significant issues inany therapeutic relationship In general, psychiatrists agree that

pharma-psychotherapy and medications work synergistically However,the literature has been somewhat inconsistent on this point andvaries by diagnosis (Klerman et al 1994).

The following case demonstrates that medication can be ful in promoting a more comprehensive treatment experienceeven in the most complicated of situations and that an effectivepharmacotherapeutic alliance is critical to outcome

help-Clinical Case

Mr C was a 28-year-old married father who had undergone

liv-er transplantation Eight months postopliv-eratively he began to ject his new liver, was hospitalized, and became severely depressed His depression was marked by crying spells, anhe- donia, sleeplessness, suicidal ideation, and pervasive hopeless- ness At the transplant surgeon’s request, the psychiatrist visited the patient in the hospital and found him to be despon- dent, tearful, and hopeless He was difficult to engage, spoke very softly, and avoided nearly all eye contact His surgeon had informed him that he would undoubtedly require a second transplant, but the patient adamantly refused another opera- tion Given his difficulty in speaking to the psychiatrist, it was decided (with the patient’s consent) first to initiate antidepres- sant therapy, then to explore the basis of his refusal of further surgery Within 2 weeks Mr C’s depression began to lift; how- ever, his surgeon was becoming increasingly irritated with him because of his continued refusal to undergo retransplantation

re-In an attempt obtain a better understanding of the patient’s position, the psychiatrist saw the patient daily Although the patient denied any fear of dying under surgery, he was able to recall a highly traumatic incident that occurred when he was

16, at which time he nearly drowned while swimming in a rock quarry When the psychiatrist asked what was the most fright- ening aspect of the event, the patient described intense panic when he had swallowed large amounts of water and was un- able to breathe When questioned about the possible relation- ship between this event and his position on retransplantation,

Mr C shared that the most terrifying aspect of the first plant operation had been his inability to breathe postoperative-

trans-ly because of the numerous tubes in his mouth and nose Psychoanalytically oriented focal psychotherapy allowed the patient to understand his resistance and to agree to a second operation—providing that his surgeon was aware of and sensi- tive to his concern.

Are Integrated Treatment and

Combined Treatment Effective?

It should be noted that studies of combined treatment for manydisorders have not uniformly demonstrated superiority overmedication or psychotherapy alone However, studies acrossvarious patient populations have demonstrated the efficacy ofcombined treatment A meta-analysis of psychotherapy studiescomparing psychodynamic psychotherapy with other therapies,including medication, demonstrated no difference in response;combined treatment, however, was clearly more effective thanany monotherapy (Luborsky et al 1993) In the following sec-tions, the literature on combined treatment for specific disorders

is reviewed The reader should keep in mind, however, that though the discussion focuses on randomized controlled trials,there is much controversy about the usefulness and applicability

al-of this type al-of study to clinical practice, since study populationsoften differ in many respects from patients treated in a naturalis-tic setting

Mood Disorders

Combined treatment has been studied closely with patients ing unipolar depression A recent randomized controlled studydemonstrated that patients with recurrent nonpsychotic majordepression were helped most by combining psychotherapy andmedication (Reynolds et al 1999) In this study of nearly 200 eld-erly patients, the combination of a tricyclic antidepressant andinterpersonal psychotherapy (IPT) was more effective in prevent-ing recurrences (for the 107 patients who improved) than eithermedication or psychotherapy alone Those treated with nortrip-tyline and psychotherapy had only a 20% recurrence rate, com-pared to a 43% rate for those receiving only an antidepressant in

hav-a medichav-ation clinic setting The recurrence rhav-ate for those trehav-atedwith IPT and placebo was 64% and was 90% for patients receiv-ing only a placebo

The largest meta-analysis to date of patients with nonpsychoticunipolar depression (including nearly 600 patients) has demon-strated that for severe depression the combination of medication

and psychotherapy is clearly superior to psychotherapeutic ments alone, as judged by time to recovery and by outcome(Thase et al 1997) This meta-analysis examined six standardizedtreatment protocols from one university Following these protocols,patients were treated for 16 weeks with either IPT or cognitive-behavioral therapy (CBT) The results were compared with those

treat-of studies where patients were treated with both IPT and cation In patients with less severe depression, psychotherapywas as effective as combined treatment; for severe depression,collaborative treatment was more effective

medi-Results from the largest randomized controlled study of thetreatment of chronic depression with medication, psychotherapy,

or both demonstrate conclusively that combination is the mosteffective option (Keller et al 2000) This study of 681 patientsfrom multiple locations compared treatment with nefazadone to

a behavioral psychotherapy called the behavioral analysis system of psychotherapy (CBASP) Patientsreceiving both medication and psychotherapy had an 85% re-sponse rate The response rate of patients receiving nefazadonealone was 55%, and that of patients receiving psychotherapyalone was 52%

cognitive-Swiss researchers studied the cost effectiveness of combinedtreatment for patients referred to outpatient treatment with acutemajor depression, a group about which there are few studies Pa-tients receiving both medication and psychodynamic psycho-therapy had fewer inpatient days by the end of treatment and at1-year follow-up (Andreoli et al 2000) Combined treatment wasalso associated with lower direct costs and indirect costs (i.e., sickleave)

In an important study of what treatment strategy to use withrecurrent unipolar depression, Frank et al (2000) found thatwomen who did not respond to IPT alone did improve when im-ipramine was added Seventy-nine percent of patients responded

to this sequential strategy, compared to 66% of patients receivingboth psychotherapy and medication from the outset While thiswas not a randomized controlled study of a single patient popu-lation (patient groups included women treated in an earlierstudy under similar treatment conditions), it nevertheless raises

a number of issues First, studies have demonstrated that if tients are treated successfully for an acute episode of their recur-rent depression, they are more likely to stay in remission withmaintenance treatment (Kupfer et al 1992; Frank et al 1993) Sec-ond, Frank and colleagues noted that this treatment approachmay be particularly appealing to women of child-bearing agewho have strong feelings against using medication during preg-nancy and lactation.

pa-In an inconclusive study of combined treatment for thymia, group CBT by itself was no better than placebo and wasless effective in reducing symptoms than was medication alone.However, in conjunction with an antidepressant (sertraline), itwas associated with increased functioning for a subset of patients(Ravindran et al 1999) An investigation of combined treatmentfor 26 inpatients with double depression indicated that CBT andmedication improved short-term, but not long-term, outcome fordouble depression (Miller et al 1999)

dys-With respect to the treatment of bipolar disorder, a small randomized controlled study of 10 patients with schizoaffectivedisorder and 20 with bipolar disorder found that after 3 years,patients receiving systemic family therapy with medication hadfewer relapses and hospitalizations than those treated withoutpsychotherapy (Retzer et al 1991) Moreover, after treatmentfamily members were less likely to view their loved ones as help-less in the face of their illness In bipolar disorder as in the treat-ment of schizophrenia, psychotherapy is aimed at adherence tomedication and at appreciation for the nature of the illness.Any balanced discussion must note that the superior efficacy

non-of combined treatment for major depression is by no meansproved In the case of CBT, for example, randomized controlledstudies have supported the equivalence of medication alone,psychotherapy alone, and combined treatment (Hollon et al.1992) In all likelihood, for each study supporting combinedtreatment there is a study failing to demonstrate any advantageover psychotherapy or medication alone In particular, three ad-ditional meta-analyses assessed the benefits of combining medi-cation and psychotherapy and were unable to demonstrate anyadvantage over treatment with psychotherapy alone (Antonuc-

cio 1995; Manning et al 1992; Wexler and Chicchetti 1992) search design and associated differential attrition are otherproblems in demonstrating differences in combined studies.Studies have also failed to demonstrate the superiority of com-bined medication and psychosocial interventions in primary care(Mynor-Wallis et al 2000) Studies of combined treatment of af-fective disorders as well as in other diagnostic categories are in-fluenced by ideological differences, professional turf issues,pharmaceutical industry support, and the manner in which men-tal health services are now delivered under managed care (Eells1999) Concern has been expressed that nearly all studies of com-bined treatment have relied on tricyclic antidepressants and thatwith newer-generation antidepressants there may be greater re-sponses to medication alone in chronically depressed patients(Thase et al 2000).

Re-Schizophrenia

Despite the severity of this illness, the literature is positive aboutintegrated treatment for schizophrenia Patients who live withfamilies characterized as having high expressed emotion are atgreater risk for relapse after discharge from the hospital Thesefamilies tend to be intense, intrusive, and critical of their affectedfamily member Improved outcome has been demonstrated forpatients and their families who receive family therapy that ad-dresses this expressed intensity This improvement includes ill-ness course and adherence to medication (Falloon et al 1982;Hogarty et al 1991; Leff et al 1985) An 18-month randomizedcontrolled trial of family intervention with medication for first-episode patients showed that only 10% of patients receiving suchtreatment required readmission to the hospital (Zhang et al.1994) This was in marked contrast to the readmission rate for pa-tients treated with neither medication nor family therapy—ap-proximately 75%

Individual psychotherapy has also been shown to be effective

in patients with schizophrenia A 36-month randomized trolled trial found medication with personal psychotherapy to besuperior to medication with family and supportive psychothera-pies in preventing relapse in those patients who lived with their

con-families (Hogarty et al 1997a, 1997b) This type of individualpsychotherapy did not rely on interpretation of unconscious con-flicts or feelings; rather, the patient’s characteristic responses tostress were examined Additionally, personal therapy providededucation about the illness and about effective strategies for dealingwith stress and social interaction Compared to more supportivemeasures, personal therapy provided persistent improvement insocial adjustment for the duration of the study.

Cognitive-behavioral therapy over a 9-month period has beenshown to aid patients whose symptoms have not respondedcompletely to medication (Sensky et al 2000) Medication withrational discussion of delusions and hallucinations was associat-

ed with a 50% reduction of symptomatology in this British study

of 90 patients Moreover, these gains persisted after formal apy was completed, whereas the symptoms of patients receivingmedication and a nonspecific befriending relationship did not.Another randomized controlled trial comparing medication with

ther-20 individual CBT sessions to medication alone and medicationwith supportive care found that 3 months after treatment the firstgroup showed significant improvement in symptom severity,whereas the other two had not made substantial gains (Tarrier et

Despite the severity of this illness, the clinician should ber that patients with schizophrenia and their families tend tovalue psychotherapy as a very helpful intervention (Coursey et

remem-al 1995; Hatfield et remem-al 1996) and that the addition of apy to medication treatments shows great promise for bettersymptom alleviation

psychother-Anxiety Disorders

Compared to the number of studies using both medication andpsychotherapy in the treatment of patients with depression orschizophrenia, the number using this treatment for anxiety disor-ders is small Panic disorder has been studied the most; in thetreatment of other anxiety disorders, the clinician usually relies

on the consensus view as expressed in treatment guidelines.Most psychiatrists use both psychotherapy and medication withmany anxiety disorders

Panic Disorder

There is some evidence that using both medication and therapy in the treatment of panic disorder is more advantageousthan using monotherapies A recent randomized controlled trialwith more than 300 participants compared patients with panicdisorder who received CBT and imipramine with those who re-ceived only medication or only psychotherapy The combinedtreatment was superior to either monotherapy as measured at theend of the maintenance stage of treatment (Barlow 2000)

There are few rigorous studies of psychodynamic therapy alone or in combination with medication This is unfor-tunate, as the majority of psychiatrists treating patientsprobably do so from a dynamic point of view However, the ef-fectiveness of dynamic psychotherapy without medication inthe treatment of panic disorder is currently being investigated,and preliminary reports support its usefulness (Milrod et al.2000) Moreover, a study of brief dynamic psychotherapy withmedication concluded that a combination of psychotherapyand clomipramine was more effective than medication alone(Wiborg and Dahl 1996) One group of patients received medi-cation only; a second group received medication and was also

psycho-seen for 15 weekly dynamic psychotherapy sessions Panicsymptoms disappeared in all patients in both treatment groupswithin approximately 6 months However, after discontinua-tion of medication at 9 months, the relapse rate for patients whohad received both psychotherapy and medication was signifi-cantly lower than those who had received only clomipramine.The lower relapse rate was attributed to accomplishments

in psychotherapy that allowed patients to function at higherlevels

Earlier studies of the treatment of panic disorder and bia supported the use of tricyclic antidepressants with behavioraltherapy over either monotherapy Many of these investigationshave been summarized by Mavissakalian (1993)

agorapho-In general, studies have demonstrated that combined ment with antidepressants is more effective in reducing specificand social phobia as well as functional impairment but appears

treat-to be no more effective than psychotherapy or medication alone

in reducing the number of panic attacks (Gabbard 2000)

The use of benzodiazepines and behavioral treatment inpatients with panic disorder and agoraphobia has also been stud-ied However, studies have been inconclusive about the ad-vantage of combined treatment with benzodiazepines andbehavioral and cognitive-behavioral therapies Although there is

no question about the efficacy of these medications in the ment of panic disorder with or without agoraphobia (Roth andFonagy 1996), there has been speculation that benzodiazepinesmay in some way be responsible for increased relapse rates afterthe completion of combined treatment as compared with psycho-therapy alone (Marks et al 1993)

treat-Generalized Anxiety Disorder

The literature on combined medication and psychotherapy in thetreatment of generalized anxiety disorder (GAD) is very limited.Antidepressants and benzodiazepines are used to treat patientswith this disorder With benzodiazepines, patients with GAD re-spond rapidly; however, a combined CBT and medication ap-proach achieves a more lasting recovery than medication alone(Power et al 1990)

Obsessive-Compulsive Disorder

There is general consensus that obsessive-compulsive disorder(OCD) is best treated through an integrated approach using sero-

tonergic antidepressants with exposure and response prevention, a

type of behavioral therapy (Cottraux et al 1990; Greist 1995).However there are few controlled studies evaluating the benefits

of combined treatment over psychotherapy or medication alone.Behavioral treatment has been repeatedly shown to result in alower relapse rate than medication There may also be a role forpsychoanalytic psychotherapy in the integrated treatment ofOCD when there are psychological conflicts about some symp-toms (Kay 1996)

Eating Disorders

A randomized controlled study of 120 women with bulimia vosa has demonstrated the superiority of antidepressants withCBT in patients with this disorder (Walsh et al 1997) This studyaddressed the following questions:

ner-1 Is supportive dynamic psychotherapy superior to CBT?

2 Is a two-step pharmacological intervention employing a cyclic antidepressant followed by a selective serotonin re-uptake inhibitor (SSRI) (if the first medication is poorlytolerated or ineffective) beneficial with psychotherapy?

tri-3 Was combined treatment with either psychotherapy morehelpful than medication alone?

The conclusions of this study were as follows:

1 CBT was more effective than supportive dynamic therapy inreducing vomiting and binge eating

2 Patients treated with medication and either psychologicaltreatment had less depression and binge eating than patientsreceiving psychological treatment and placebo

3 CBT with an antidepressant was more effective than CBTalone

4 Supportive psychotherapy with medication was not

superi-or to medication alone

5 Two-step antidepressant therapy added modestly to the fectiveness of either psychotherapy.

to one of three groups The first group received medication alone,the second medication and counseling, and the third a broadrange of services including access to a psychiatrist, an employ-ment counselor, and a family therapist Those in the last groupwho received psychotherapy had lower hospitalization rates andbetter job histories and received less public assistance compared

to those in the last group who did not receive psychotherapy.McLellan and colleagues noted the cost effectiveness of addingthe additional services (See Chapter 4 for a comprehensive re-view of the integrated treatment of addictions.)

up of these patients, who had received intensive psychotherapyand medication in the context of a partial hospital program of ayear and a half, not only maintained their improvement in func-tioning but demonstrated increased gains in a number of signifi-cant areas while receiving ongoing psychoanalytic grouppsychotherapy twice weekly These gains included decreased fre-quency of suicide attempts, self-mutilating behavior, numberand duration of inpatient admissions, and use of other psychiat-ric services In addition, continued symptomatic improvement indepression, anxiety, and general symptom distress were evident,

as well as gains in social adjustment and interpersonal tioning

func-General consensus—as represented by the most recent draft ofthe American Psychiatric Association Practice Guideline for Bor-derline Personality Disorder (American Psychiatric Association,

in press)—supports a role for combined treatment in addressing

a host of symptoms in many patients with personality disorders

In borderline personality disorder, for example, medicationshave been associated with a reduced treatment dropout rate andfewer psychotic regressions and feelings of aloneness, an impor-tant concern for many of these patients (Koenigsberg 1994) Theuse of medications in this group of patients is complex, given itsfrequent problems with compliance and adherence Other symp-toms commonly treated with combined medication and psycho-therapy include affective instability, behavioral dyscontrol,hostility or aggression, and interpersonal sensitivity, to name just

a few Nearly every class of psychotropic medication has beenfound in noncontrolled studies and clinical reports to be effec-tive; see Table 1-1

Clinical Case

Mr D, a 32-year-old lawyer, sought treatment for his standing depression Although he clearly met criteria for a ma- jor depression, chief among his concerns was his inability to commit to a relationship with a woman Despite being excep- tionally handsome he experienced himself as repugnant and ugly; each relationship he entered he terminated, for unclear reasons His work was uniformly admired in his law firm, yet

long-he still felt incompetent and a fraud Of importance in his

ily history was his relationship with his father, whom he ized but who was also the object of his intense anger The patient described his father as having superior intellect, out- standing career accomplishments, and strong opinions about every conceivable subject This man was admired by all and gave freely of himself to his colleagues and to many organiza- tions However, Mr D had many unsettling memories of times when he wished his father was as devoted to him as to his em- ployees The patient recalled having many arguments with his father as a teenager and noted that his father had won them all.

ideal-At the conclusion of the first diagnostic interview, the atrist shared his preliminary assessment with the patient and rec-ommended initiation of an antidepressant because of Mr D’sconsiderable psychological discomfort Mr D thanked the psy-chiatrist politely for this suggestion but stated that medicationwas not an option for him The patient felt that to take an antide-pressant would destroy him The psychiatrist was puzzled butlistened to the patient for more than 10 minutes He was empath-

psychi-ic with the patient’s quandary and explored it but explained thatthe matter could be revisited at some time in the future

The patient felt immediate intense relief and became tearful

He had been worried that his refusal of medication would angerthe physician and that he would be told to either comply or forgotreatment Only some weeks later did it become clear that to havefollowed the psychiatrist’s recommendation of medicationwould have felt, to Mr D, too much as if the psychiatrist were in

a position like that of Mr D’s father More specifically, it becameclear that the patient feared that the psychiatrist would maintainthat there was only one way to proceed in treatment, recalling

Mr D’s father’s absolute conviction of being right on every ter Once this issue was clarified, the patient agreed to the medi-cation Understanding his initial refusal had deepened thepsychotherapy significantly

mat-This case illustrates a number of central issues about how tients may attribute meanings to the prescribing of medicationand about medication’s usefulness in the treatment relationship

pa-As noted earlier, prescribing medications may provide a windowinto the patient’s beliefs, fantasies, fears, and his or her responses

to the doctor-patient relationship at any given moment in thetreatment.

Mr D’s response to the offer of medication was dramatic andintense and provided the psychiatrist with an early and invalu-able shared experience First, the patient’s response demonstrat-

ed that transference is a ubiquitous phenomenon and is notlimited to psychodynamically oriented treatments Second, thespecificity of the patient’s reaction to medication permitted aclear glimpse of an important earlier conflict with his father thatundoubtedly had relevance to the patient’s current world andday-to-day relationships Third, this case has much to teachabout the potential countertransferential responses of the physi-cian While it did not occur in this situation, the physician couldhave become irritated or angry with the patient for refusing hisadvice; this could have impacted negatively on the treatment al-liance if the both parties had become locked in a struggle over au-thority Fourth, the patient’s refusal to accept medicationforeshadowed the patient’s mixed feelings about getting better.That is, it became clear in the treatment that the patient did not

feel he deserved to improve, much as he felt undeserving in his

re-lationships with women and in his law firm Fifth, it became vious later in the treatment that Mr D’s refusal of medicationillustrated intense feelings of anger about his competitive rela-tionship with his father It ultimately became clear that the pa-tient was frightened of outperforming his father because he wasconvinced that if this should indeed happen his father wouldwant nothing more to do with him and would end the father-sonrelationship in anger

ob-Medications may have many other meanings to patients; some

of these are highlighted in Table 1-2

Integrated Treatment: Unanswered

Scientific Questions

Despite the rigorous scientific studies of the last decade on laborative treatment, a number of issues central to the use of in-tegrated treatment must still be addressed These issues includebut are not limited to the following:

col-• Under what conditions is integrated treatment by a trist superior to split treatment?

psychia-• For what disorders should psychotherapy precede tion?

medica-• For what disorders should both medication and

psychothera-py be instituted from the outset of treatment?

• Are some psychiatrists more effective in using integrated ment? If so, why?

treat-• For which disorders is integrated treatment cost effective?

• What factors are critical in the success of split treatment?

• What are the benefits of brief integrated therapies of 12–16sessions compared with longer treatments for some disor-ders?

Table 1–2. Patients’ feelings about the psychiatrist and about medication

Feelings about the psychiatrist

Positive Negative

Genuine acknowledgment of pain Discomfort with patient’s plight Interest in patient’s feelings Lack of interest in patient’s feelings Support and safety Physician’s control of patient

Hopefulness about symptom relief Minimization of patient’s problems Appreciation of clinician's skills Fear of limited skills of clinician Comfort with consistency of

prescribing

Anger over clinician’s refusal to prescribe what patient desires or feels is needed

Feelings about medication

Recommendations for the Clinician

There are a number of principles that will assist the psychiatrist

in using integrated treatment

1 The clinician should not assume that making the correct agnosis and providing the most scientifically supportedmedication guarantees the establishment of a solid ther-apeutic alliance No treatment will succeed without a safe,noncritical, and empathic working relationship betweendoctor and patient Medication adherence problems areubiquitous, prevent the relief of much discomfort in patients,their families, and important relationships, and add greatly

di-to direct and indirect health care costs

2 The psychiatrist should adopt a system to routinely and cifically address medications in combined treatment For ex-ample, the clinician may discuss medication issues at thebeginning or at the end of a session There are virtues to eachmethod With the former, the entire session may provide im-portant material about the therapeutic relationship Howev-

spe-er, some clinicians are concerned that opening the sessionwith questions about medication will influence the contentand process of the entire visit Others argue that by leavingthe medication inquiry to the end, important dialogue may beclosed prematurely Still others hold that it is best to addressmedication issues whenever they arise in the session’s mate-rial (if they do arise) Regardless of the chosen approach, it iscrucial to establish a routine that will provide consistency andpredictability to meetings Deviations from this process willalert the clinician to the possibility of countertransferencephenomena Asking specific questions about the likelihood of

a patient’s taking medication, permitting sufficient time to plore fears and fantasies about this component of the treat-ment, and providing comprehensive information aboutindications, side effects, and advantages of taking medicationare vital in the provision of effective integrated treatment

ex-3 Attention must be paid to patient’s questions about side effects,

to changes in medication type and dosage, and to the tinuation of medication, all of which often provide additional