Treatment Pharmacotherapy Psychotherapy

Inform patients of treatment options for anxiety disorders and the expected benefits of each (e.g., pharmacotherapy, psychotherapy, and combination treatment). 

In general, patients who seek treatment acutely after a trauma and are in intense distress should receive therapy based on their presenting symptoms (e.g., a nonbenzodiazepine hypnotic for difficulty sleeping). Short courses of cognitive behavioral therapy (CBT) can be helpful. If symptoms (e.g., hyperarousal, avoidance, dissociation, sleep difficulties, or depressed mood) persist for 3 to 4 weeks and the patient experiences marked social, occupational, and/or interpersonal impairment, they should be treated with pharmacotherapy, psychotherapy, or both. Many patients with PTSD will improve substantially with pharmacotherapy but retain some symptoms. Treatment regimens usually combine psychoeducation, psychosocial support and/or treatment, and pharmacotherapy."... 

In research and clinical treatment of substance use disorders, pharmacotherapy and psychotherapy are frequently combined. Medication is often used as a maintenance drug, to reduce cravings or intoxication, or to produce aversion to a substance, while the focus of psychotherapy may be to encourage abstinence, teach the patient new coping skills, or improve motivation to address drug or alcohol problems. 

In some pharmacotherapy studies, psychotherapy exposure has been minimized, on the basis of concern that psychotherapy may produce a ceiling effect on improvement in drug or alcohol use, making medication effects difficult to detect. However, a recent meta-analysis revealed that psychosocial interventions, in fact, may enhance pharmacotherapeutic effects (Hopkins et al. 2002). In this review we have also noted instances where psychosocial and medication treatments have had beneficial additive effects. Minimization of psychotherapy in pharmacotherapy trials may be counterproductive, because psychosocial therapies that encourage the patient to remain engaged in treatment may positively affect patients adherence to the medication regimen, a factor that has an effect on alcohol treatment outcomes (Chick et al. 2000 Volpicelli et al. 1997). 

Various forms of psychotherapy are regarded as effective interventions in mild to moderate depression, but studies comparing the economics of psychotherapy and pharmacotherapy are few (Rosenbaum and Hylan, 1999). One study found that the total health-care costs for patients who received psychotherapy were no different from those for patients who received an antidepressant. However, no efficacy measure was used (Edgell and Hylan, 1997). A randomized, prospective study which evaluated the treatment of depression with nortriptyline, interpersonal therapy or treatment as usual, with outcomes expressed in quality-adjusted life years, found that nortriptyline but not interpersonal therapy was a cost-effective alternative to treatment as usual (Lave et al, 1998). 

Interpersonal therapy and cognitive behavioral therapy are types of psychotherapy that have well-documented efficacy for the treatment of MDD. Psychotherapy alone is an initial treatment option for mild to moderate cases of depression, and it may be useful when combined with pharmacotherapy in the treatment of more severe cases of depression. In fact, the combination of psychotherapy and pharmacotherapy can be more effective than either treatment modality alone in cases of severe or recurrent MDD. Psychotherapy can be especially helpful for patients with significant psychosocial stressors, interpersonal difficulties, or comorbid personality disorders.16... 

Educate patients about their disease state and appropriate lifestyle modifications, as well as psychotherapy and pharmacotherapy for effective treatment. 

Patients with GAD may be managed with psychotherapy, pharmacotherapy, or both. The treatment plan should be individualized based on the patients symptom severity, comordid illnesses, medical status, age, and preference. Patients with severe symptoms resulting in functional impairment should receive antianxiety medication. 

Treatment options include medication, psychotherapy (e.g., CBT preferred), or a combination of both. In some cases, pharmacotherapy will follow psychotherapy treatments when full response is not realized. Patients with panic symptoms without agoraphobia may respond to pharmacotherapy alone. Agoraphobic symptoms generally take longer to respond than panic symptoms. The acute phase of PD treatment lasts about 12 weeks and should result in marked reduction in panic attacks, ideally total elimination, and minimal anticipatory anxiety and phobic avoidance. Treatment should be continued to prevent relapse for an additional 12 to 18 months before attempting discontinuation. 6 49 Patients who relapse following discontinuation of medication should have therapy resumed.49... 

Friedman, Michael A., Jerusha B. Detweiler-Bedell, Howard E. Leventhal, Rob Horne, Gabor I. Keitner and Ivan W. Miller, Combined Psychotherapy and Pharmacotherapy for the Treatment of Major Depressive Disorder , Clinical Psychology Science andPractice 11, no. 1 (2004) 47-68... 

Sotsky, Stuart M., D. R. Glass, M. Tracie Shea, Paul A. Pilkonis, J. F. Collins, Irene Elkin, John T. Watkins, S. D. Imber, W. R. Leber and J. Moyer, Patient Predictors of Response to Psychotherapy and Pharmacotherapy Findings in the NIMH Treatment of Depression Collaborative Research Program , American Journal of Psychiatry 148 (1991) 997-1008... 

For years, psychiatric and drug abuse disorders were not even treated together. Now we know they commonly co-occur, which means for many years clients were getting only partial treatment. Even today we are still not sure how to treat these co-occurring conditions simultaneously in a consistently effective way with both psychotherapy and pharmacotherapy (see Chapter 5). The next century is likely to see many advances in both pharmacotherapy and psychotherapy to treat co-occurring conditions. There are effective methods to treat drug abuse and to treat other co-occurring psychiatric disorders. The next frontier in research is to learn how to combine these approaches in a way that can treat multiple disorders at once ... 

When is medication indicated in the treatment of psychiatric illness There is no short answer to this question. At one end of the continuum, patients with schizophrenia and other psychotic disorders, bipolar disorder, and severe major depressive disorder should always be considered candidates for pharmacotherapy, and neglecting to use medication, or at least discuss the use of medication with these patients, fails to adhere to the current standard of mental health care. Less severe depressive disorders, many anxiety disorders, and binge eating disorders can respond to psychotherapy and/or pharmacotherapy, and different therapies can target distinct symptom complexes in these situations. Finally, at the opposite end of the spectrum, adjustment disorders, specific phobias, or grief reactions should generally be treated with psychotherapy alone. 

Eriedman MA, Detweiler-Bedell JB, Leventhal HE, et al. Combined psychotherapy and pharmacotherapy for the treatment of major depressive disorder. Clin Psychol Sci Pract 2004 11(1) 47-68. 

It is important to recognize the fact that the cornerstone of treatment for BPD is psychotherapy. All patients should ideally be treated with a combination of psychotherapy and pharmacotherapy. 

Our purpose with this book is to provide a background into the what, why, how, and when questions of psychotropic medications. Recognizing that this conversation cannot exist in a vacuum, we also review diagnostic issues, treatment goals, and ways to integrate psychotherapy with pharmacotherapy and then intersperse this information with clinical examples. It is this combination, the bio witli the psychosocial that optimizes care for so many of the people we treat. 

It is important to note that specific psychotherapies (CBT or IPT) (Brent et ah, 1997 Mufson et ah, 1999) are also reasonable initial choices for the acute treatment of a youth with the first noncomplicated episode of major depression. Nevertheless, if patients are treated with psychotherapy alone, pharmacotherapy... 

Comorbid anxiety has been associated with differential treatment response. This association predicts at times a better response to CBT and TCAs (Hughes et ah, 1990 Brent et ah, 1998). Treatment of comorbid anxiety, which most often precedes depression, is essential because the treatment contributes to improvement and may prevent future depressive episodes (Ko-vacs et ah, 1989 Hayward et ah, 2000). Fortunately, pharmacotherapy and psychotherapy treatments found useful for the treatment of MDD have also been found to be beneficial for treatment of youths with anxiety disorders (Kendall, 1994 RUPP Anxiety Group, 2001). 

The treatment of EOS requires a coordinated team approach and is based upon several components that have to be individually tailored to meet the needs of the patient and family. The treatment components comprise pharmacotherapy, individual psychotherapy, family oriented measures as well as specific measures of rehabilitation, described in several recent reviews (AACAP 2000 2001 Remschmidt et ah, 1996 2001 Lambert, 2001)... 

The duration of pharmacotherapy for generalized anxiety disorder is controversial. Psychotherapy is recommended for most patients with this disorder, and it may facilitate the tapering of doses of medication. However, generalized anxiety is often a chronic condition, and some patients require long-term pharmacotherapy. As in other anxiety disorders, the need for ongoing treatment should be reassessed every 6-12 months. 

An attempt has been made to discuss the position of drug therapy of various types of mental disorders within a wider perspective, and especially to clarify the relationship between drug therapy and non-drug treatments. It was necessary to deal separately with the various classes of psychopharmaceuticals and the disorders treated with them, and for our purposes it was also sensible to refer as far as possible to controlled, i.e. comparative, studies. The drawback of this evidence-based approach is obvious comparative studies of therapeutic procedures almost necessarily favor one of the compared treatments because they can never be carried out with completely identical preconditions for all treatments (Elkin et studies comparing psychotherapy with pharmacotherapy were scrutinized and discovered to include studies that were not entirely blind, random, controlled or of high quality, leading to inaccurate conclusions. Thus, meta-analyses based on flawed studies are clearly inadequate for the establishment of treatment guidelines (Klein, 2000). On the other hand, the value of an admittedly incomplete summary such as presented here is that results obtained in different places by different authors with different preconditions can be critically compared and related one to the other. 

Bellack, A.S., Hersen, M. Himmelhoch, J. Social skills training compared with pharmacotherapy and psychotherapy in the treatment of unipolar depression. Am. J. Psychiatry 138, 1562-1567, 1981. 

In addition to adequate pharmacotherapy, specific forms of psychotherapy may also be indicated. These may include cognitive or interpersonal psychotherapy or various behavior desensitization and biofeedback techniques. Some patients may benefit from insight-oriented psychotherapy group, family, or marital counseling or both. Finally, in more chronic disorders, patients often benefit from vocational rehabilitation. A knowledgeable clinician realizes that these disorders do not occur in a vacuum, and, regardless of diagnosis, each patient requires an individualized treatment plan to optimize outcome. 

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