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Chapter 33. Combining Psychotherapy and Pharmacotherapy

Michelle B. Riba, M.D., M.S.; Richard Balon, M.D.
DOI: 10.1176/appi.books.9781585623402.339275

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The past 50 years of psychiatric practice have seen a burgeoning of new types and classes of psychotropic agents for major and minor psychiatric disorders (Olfson et al. 1999, 2002; West et al. 2003). Along with new pharmacological modalities, there is increased understanding to support and recommend that psychotherapy be provided along with pharmacological treatments for disorders including schizophrenia, bipolar disorder, and major depression (American Psychiatric Association 1994, 1997, 2000a). In addition, guidelines and position papers have been provided by the American Psychiatric Association to assist its members and mental health professionals in understanding the complexities of providing combined treatments in the form of both psychotherapy and pharmacotherapy (American Psychiatric Association 1980, 2002a).

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TABLE 33–1. Patient triaging issues associated with pharmacotherapy/psychotherapy decisions
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TABLE 33–2. Interaction of external and internal factors in positive and negative transference feelings experienced by the patient toward the psychiatrist and the medication early in treatment
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TABLE 33–3. Diagnostic possibilities to be considered in response to countertransference feelings
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TABLE 33–4. Some hypothesized interactions between pharmacotherapy and psychotherapy
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TABLE 33–5. Terms used to describe split and integrated treatment
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TABLE 33–6. Integrated versus split treatment: professionals involved
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TABLE 33–7. Conclusions from research in combined psychotherapy–pharmacotherapy
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TABLE 33–8. Questions to ask a patient in the initial telephone call for an appointment
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TABLE 33–9. Key ingredients of the first session of combined treatment
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TABLE 33–10. Medication issues to be addressed
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TABLE 33–11. Issues that need to be addressed at the beginning of split treatment
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TABLE 33–12. Factors affecting the prescribing of medication in split treatment
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TABLE 33–13. Suggested schedules for 15- to 30 minute medication visits
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TABLE 33–14. Steps in dealing with transference issues
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TABLE 33–15. Trials of combined treatment in unipolar depression
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Combined treatment involving the combination of pharmacotherapy and psychotherapy has become the most common approach to the treatment of mental disorders.

Numerous studies have demonstrated that combined treatment is frequently superior to pharmacotherapy or psychotherapy alone in the treatment of disorders such as major depression, anxiety, bipolar disorder, nicotine dependence, and others.

Compared with pharmacotherapy or psychotherapy alone, combination treatment does not uniformly provide additive benefits.

Combined treatment may be practiced in either an integrated or a split manner.

Integrated treatment (one-person model) is a treatment approach in which pharmacotherapy and psychotherapy are provided by a single provider—preferably a physician.

Split treatment (or two-person model) is a treatment approach in which pharmacotherapy and psychotherapy are divided up or shared by at least two different clinicians, psychiatrist and therapist.

The predominant belief that split treatment is more cost-effective than integrated treatment has been questioned by some studies.

Both integrated and split treatment involve complex clinical, ethical, legal, and managerial issues.

Both integrated and split treatment require proper training, skills, and knowledge.

Split treatment involves more complicated clinical, legal, ethical, and managerial issues.

Patients should be involved in the decision of which treatment approach will be used and how treatment will be conducted and terminated. Informed consent should be obtained regarding the choice of treatment and arrangements for its conduct.

Good communication between the prescribing physician and the therapist is the sine qua non for successful split treatment.

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According to Gabbard (2006), combining psychotherapy and psychopharmacology may offer all of the following benefits except
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The choice of integrated versus split treatment depends on a variety of factors. Which of the following statements is false?
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In combined psychotherapy and psychopharmacological treatment of a mood disorder, the psychiatrist should do all of the following except
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