Combining Psychotherapy and Medication to Improve Outcomes in Patients With Axis I Disorders

During a session at the 2017 Neuroscience Education Institute Congress, Ira D. Glick, MD, professor emeritus, Department of Psychiatry and Behavioral Sciences, Stanford School of Medicine, emphasized the importance of combining psychological and psychopharmacologic strategies for patients with Axis I disorders and provided guidelines for administering the combination. According to the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), Axis I represents acute symptoms that need treatment. These disorders include major depressive disorder (MDD), schizophrenia, and anxiety disorders.

“You’ve got to talk to your patients as well as prescribe them medicine,” said Glick.

Glick first outlined the rational for combining medication and therapy:

• Patients value psychotherapy
• Patients may not be on medication
• Etiology: although biological, “stress” may precipitate episodes
• Pathogenesis: illness has effects on the family
• Treatment: to improve adherence
• It may work better than 1 modality (medication or therapy)

Psychotherapy is important because some conditions have no effective pharmacotherapy treatment available, medication can be contraindicated, and the patient may not want to take medication. Most importantly, most patients have social and interpersonal problems accompanying Axis I disorders either as the source of or the consequence of the illness, said Glick.

However, there are several reasons why combined therapy is not delivered, said Glick. Many providers deliver one or the other, most insurers pay for non-integrated treatment, many professionals are trained in one or the other, and there is still a presence of provider bias.

Psychotherapy has shown to improve outcomes over medication alone in bipolar disorder, childhood attention-deficit/hyperactivity disorder, MDD, schizophrenia, posttraumatic stress disorder, sleep disorders, and bulimia nervosa, said Glick.

Glick then provided the audience with guidelines for administering combined therapy for their patients:

1. Diagnosis

• Make a DSM-5 diagnosis.
• Make a family systems diagnosis.
• Make an individual dynamic diagnosis.
• Formulate a case.

2. Goals

• Select appropriate modalities and their combination.
• Develop specific goals for each modality.
• Decide about sequencing.
• Be aware of, and enquire about, side effects of each modality as well as their interactive effects.

3. Sequencing of combined treatments

• Establish an alliance.
• For psychotic disorders, start medication early.
• Add individual intervention as patient is able to participate.
• Add family intervention early. Start with psychoeducation and referral to appropriate consumer group depending on DSM-5 diagnosis.
• Add family dynamic and systematic interventions as the patient stabilizes.
• Rehabilitation in maintenance phase.
• Do not add another modality if the first intervention is adequate for efficacy.

Glick ended the session by describing the advantages and disadvantages of combined therapy. For patients who are biologically-oriented, psychotherapy promotes a sense of increased collaboration and targets intrapsychic and interpersonal problems. For patients who are psychologically oriented, medication response relieves hopelessness associated with the lack of improvement in psychotherapy, as well as targeting the primary symptoms of the illness. In addition, it provides a faster response than either modality alone. Lastly, family and individual therapy can increase medication compliance, and medication can increase psychotherapy compliance.

However, there are several disadvantages. With medication, there is an increased risk for side effects and early termination of all therapies, and with psychotherapy the perceived need for medication decreases, Glick explained.