Adding psychotherapy to pharmacotherapy: data, benefits, and guidelines for integration.

"A man's body and his mind with the utmost reverence to both . . . are exactly like a jacket, and a jacket's linings-rumple the one-you rumple the other." L Sterne, (1759-67). The quotation above suggests that it has long been appreciated that brain and behavior are complexly interrelated. Thoughts and behaviors controlled by a disordered brain have brought patients to the attention of mental health-care providers, who have attempted to change the dysfunctional behavior by using either medications and/or psychotherapeutic intervention. What is relatively new in psychiatric practice is that most patients with Axis I disorders are receiving combined treatment, rather than either medication alone or psychotherapy alone (1, 2). But as Lenfant has discussed in other areas of medicine than psychiatry, "enormous amounts of new knowledge are barreling down the information highway, but they are not arriving at the doorsteps of our patients" (3). The problem has been that the potential for integration has generally not been fulfilled, in part because guidelines are lacking and in part because of financial disincentives to provide the psychotherapy component (4). As a result, the treatment is usually delivered by two mental health professionals rather than integrated (5). Since the economics of delivery of mental health services almost always mandate medication as a first choice intervention, the essential question is, "what does the psychotherapy part of the equation contribute to outcome?" Klerman (6), was in the vanguard of attempting to facilitate the integration of psychotherapy and pharmacotherapy, when he reviewed their theoretical basis and described possible "outcomes." He observed that drugs and psychotherapy derive from different theoretical realms and are therefore theoretically neutral, but ideologically competitive. At around the same time, Beitman and Klerman (7) edited a volume of papers dealing with specific types of combined interventions for a variety of disorders, but there was still very little controlled data supporting the efficacy or effectiveness of combined treatments. Glick et al. (8) reviewed the combining of medication and (specifically) family therapy in 1993. Today the field seems less competitive than in the early 1990s, and there is far greater acceptance of using combinations of medication and psychotherapy (2). In fact, a recent paper made a strong case for combining treatment using an integrative model rather than a collaborative treatment model (5).* (One bit of confusion is that the term "combined treatment" sometimes is used to mean two different providers-a psychopharmacologist and a psychotherapist, while integrated usually means using both in an integrated fashion. A psychiatrist can do combined treatment by talking about medication in parts of the session and psychotherapy in the other). Our aim is to build on that report focusing on providing guidelines of how to integrate these modalities and summarizing the data supporting the efficacy of adding psychotherapy to medication. A major problem in clinical practice is that "even in the absence of compelling evidence for the additive benefits of combined treatments" (9) it is being used. A second issue is that in the treatment guidelines for each disorder, there is almost no literature on specifics of how to do the combined treatment. Since science moves more slowly than practice, we agree there may be wisdom in the practice of using combined treatment even in advance of supporting data, but there is a strong need for more specific recommendations for the practicing psychiatrist when and how to combine treatments over the lifetime of these disorders. The range of tested interventions is now so broad-medication, family therapies, individual psychotherapies as well as consumer-support-group interventions (10)-that if psychiatrists are to lead this multimodal and multidisciplinary therapeutic effort, they must have a reasonable knowledge of when, and how, to integrate treatment approaches, enlist the family in the therapeutic strategy, and refer the patient and family to an appropriate support group. …