combining pharmacotherapy with psychotherapeutic management for the treatment of psychiatric...

Combining Pharmacotherapy with Psychotherapeutic

Management for the Treatment of Psychiatric

DisordersIra D. Glick, M.D.

Stanford University School of Medicine

PretestPretest

1.1. Modalities necessary for adequate treatment Modalities necessary for adequate treatment of most Axis I disorders over the long-run of most Axis I disorders over the long-run include:include:

a.a. individual psychotherapyindividual psychotherapy

b.b. medicationmedication

c.c. rehabilitationrehabilitation

d.d. family interventionfamily intervention

e.e. all of the aboveall of the above

2

PretestPretest

2.2. A basic rationale underlying combined therapy A basic rationale underlying combined therapy includes:includes:

a.a. correct the presumed biochemical deficitcorrect the presumed biochemical deficit

b.b. use the “window of opportunity” provided use the “window of opportunity” provided by the suppression of symptoms to remold by the suppression of symptoms to remold both cognition and behaviorboth cognition and behavior

c.c. When using family intervention, have the When using family intervention, have the patient actually change behavior before patient actually change behavior before getting “insight”getting “insight”

d.d. All of the aboveAll of the above

3

PretestPretest

3.3. All of the following, except one, have All of the following, except one, have controlled data suggesting the adding controlled data suggesting the adding psychotherapy improves outcome above what psychotherapy improves outcome above what medication alone provides:medication alone provides:

a.a. SchizophreniaSchizophrenia

b.b. Pervasive Developmental DisorderPervasive Developmental Disorder

c.c. Bipolar DisorderBipolar Disorder

d.d. Major Depressive DisorderMajor Depressive Disorder

e.e. Bulimia NervosaBulimia Nervosa

4

PretestPretest

4.4. Advantages of combined therapy include all of the Advantages of combined therapy include all of the following except one::following except one::

a.a. Increased cost in the short runIncreased cost in the short run

b.b. For those patients biologically-oriented, For those patients biologically-oriented, psychotherapy promotes a sense of increased psychotherapy promotes a sense of increased collaboration and targets intrapsychic and collaboration and targets intrapsychic and interpersonal problemsinterpersonal problems

c.c. Medication can improve psychotherapy Medication can improve psychotherapy compliancecompliance

d.d. Family therapy can improve increase medication Family therapy can improve increase medication compliancecompliance

5

PretestPretest

5.5. Disadvantages of combined therapy include all of the Disadvantages of combined therapy include all of the following except:following except:

a.a. With medication, increased risk for side effects and With medication, increased risk for side effects and early termination of all therapiesearly termination of all therapies

b.b. Faster response than either modality aloneFaster response than either modality alone

c.c. With psychotherapy, perceived need for medication With psychotherapy, perceived need for medication decreased (“I can solve this on my own”)decreased (“I can solve this on my own”)

d.d. Increased cost of treatmentIncreased cost of treatment

e.e. Slower response than either aloneSlower response than either alone

6

Teaching Teaching PointsPoints

• To improve To improve ““outcomesoutcomes”” for most for most psychiatric disorders, one must combine psychiatric disorders, one must combine psychotherapeutic/rehabilitation psychotherapeutic/rehabilitation strategies with medication strategies.strategies with medication strategies.

• To effectively deliver combined To effectively deliver combined medication and psychotherapeutic medication and psychotherapeutic treatments, this lecture provides treatments, this lecture provides guidelines on how to integrate the guidelines on how to integrate the therapies (including sequencing, therapies (including sequencing, structure of sessions, goals, etc.).structure of sessions, goals, etc.).

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Teaching PointsTeaching Points (cont’d)(cont’d)

• Because this is a psychopharmacology course, and Because this is a psychopharmacology course, and because this is designed as a one hour lecture, because this is designed as a one hour lecture, broad guidelines for “how” to combine are presented broad guidelines for “how” to combine are presented with psychotic disorders as a focus. The student may with psychotic disorders as a focus. The student may be referred to the large existing literature on be referred to the large existing literature on which type of psychotherapy (for example CBT) for which type of psychotherapy (for example CBT) for which disorder (for example, mood disorders, anxiety which disorder (for example, mood disorders, anxiety disorders or OCD). See references at end of lecture.disorders or OCD). See references at end of lecture.

• The RRC requires competency in combining The RRC requires competency in combining psychotherapy and psychopharmacologypsychotherapy and psychopharmacology

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Characteristics of Characteristics of Psychotherapy Received in Psychotherapy Received in

U.S.U.S.

Olfson, 2002Olfson, 2002

19871987 19971997

Psychotherapy >20 visitsPsychotherapy >20 visits 16%16% 10%10% P< .004P< .004

Any psychotropic Any psychotropic medication receivedmedication received

32%32% 62%62% P< .0001P< .0001

9

IssueIssue

What does psychotherapy add above What does psychotherapy add above what medication alone provides?:what medication alone provides?:

• in what conditions?in what conditions?

• for which patients?for which patients?• at what phase?at what phase?

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Outline

• Introduction• Rationale• Theoretical Outcomes

• Results

• Guidelines

• Summary and Clinical Implications

11

Rationale for Combined TherapyRationale for Combined Therapy

• Patients value psychotherapyPatients value psychotherapy• Patient may not be on medicationPatient may not be on medication• EtiologyEtiology

• Although biological, “stress” may precipitate Although biological, “stress” may precipitate episodeepisode

• PathogenesisPathogenesis• Illness has effects on the familyIllness has effects on the family

• TreatmentTreatment• To increase complianceTo increase compliance

• Increased efficacy of combined therapy when Increased efficacy of combined therapy when compared to pharmacotherapy or psychotherapy alonecompared to pharmacotherapy or psychotherapy alone

13

Reasons Why Psychotherapy is Important and HELPS

• Some conditions have no effective treatment

• Medication may be contraindicated

• Patient may not want to take medication (numerous reasons)

• Most patients have social and interpersonal problem accompanying Axis I disorders either as the source of or are the consequence of the illness

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• Positive effects

• Negative effects

• No effect

Theoretical Outcomes of Combined Treatment

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Combined Treatment Outcome No Additive Therapeutic Effect

0

5

10

15

20

25

Imp

rove

men

t

Control Psycho-therapy

Drug therapy Combinedtreatment

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Combined Treatment Outcome Positive Effect — Additive

0

5

10

15

20

25

30

35

Imp

rove

men

t



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Combined Treatment Outcome Positive Effect — Synergistic

0

5

10

15

20

25

30

Imp

rove

men

t


Drug therapy Combinedtreatment 18

Combined Treatment Outcome Positive Effect — Facilitative

0

5

10

15

20

25

30

35

Imp

rove

men

t



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Medications Facilitate Accessibility to Psychotherapy

Psy

cho

ther

apy

Acc

essi

bil

ity

High

Moderate

Low

Low High

Symptomatic Distress

Drug effectPeak or optimum

range

Inaccessibility due to

excessive distress

Threshold range

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Outline


• Results

• Guidelines


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ResultsResults

• Controlled Research - examples TSSControlled Research - examples TSS• Guidelines and AlgorithmsGuidelines and Algorithms

• For schizophrenia - <50% received For schizophrenia - <50% received adequate treatment (Lehman et al, adequate treatment (Lehman et al, 1998)1998)

• For depression - consistent For depression - consistent undertreatment undertreatment

(Keller et al, 1997)(Keller et al, 1997)

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Disorder/Syndrome

Treatments Standard of Proof

Bulimia Nervosa (BN)

• A large number of Type 1 and Type 2 TCTs, utilizing placebo as comparison.• A very substantial number of Type 1 and Type 2 TCTs

Table 1. Summary of Disorders in Which Psychotherapy Improves Outcome Over Medication Alone (cont’d)

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Outline


• Results

• Guidelines


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Combining Pharmacologic and Psychosocial Intervention

Psychosocial treatment

Pharmacologic treatment

Functional outcomes:

Work

Education

Social functioning

Quality of life

Psychosocialtreatment andrehabilitation

Positive symptomsNegative symptomsMoodNeurocognitive impairmentsTreatment adherenceSubjective responseSubstance abuse

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Table 1 - General Table 1 - General Guidelines for Combined Guidelines for Combined

Therapy:Therapy:

I - DiagnosisI - Diagnosis

• Make a DSM-IV diagnosisMake a DSM-IV diagnosis• Make a family systems Make a family systems diagnosisdiagnosis

• Make an individual dynamic Make an individual dynamic diagnosisdiagnosis

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Therapy:Therapy:

II - GoalsII - Goals

• Develop specific goals for each Develop specific goals for each

modalitymodality

• Be aware of, and enquire about, Be aware of, and enquire about,

side effects of each modality as side effects of each modality as

well as their interactive effectswell as their interactive effects

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Hierarchy of Treatment Hierarchy of Treatment Goals in Medical Goals in Medical Psychotherapy of Psychotherapy of SchizophreniaSchizophrenia

• Acute Phase Acute Phase Medical/neuropsychiatric assessmentMedical/neuropsychiatric assessment Rapid symptom reductionRapid symptom reduction Reduce impact of episode on Reduce impact of episode on

friends, friends, family, family, housing, activitieshousing, activities• Convalescent PhaseConvalescent Phase

Gain trust/alliance with family/caregiversGain trust/alliance with family/caregivers Assess and mobilize social supportAssess and mobilize social support Ensure human service needs are met (food, Ensure human service needs are met (food,

clothingclothing housing)housing)

Ensure safety and predictability of environmentEnsure safety and predictability of environment

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Therapy:Therapy:III - Sequencing of Combined TreatmentsIII - Sequencing of Combined Treatments

• Step 1 - Establish an allianceStep 1 - Establish an alliance• Step 2 - For psychotic disorders, start Step 2 - For psychotic disorders, start medication earlymedication early

• Step 3 - Add individual intervention as Step 3 - Add individual intervention as patient is able to participatepatient is able to participate

• Step 4 - Add family intervention early. Step 4 - Add family intervention early. Start with psychoeducation and referral to Start with psychoeducation and referral to appropriate group depending on DSM-IV appropriate group depending on DSM-IV diagnosis.diagnosis.

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Therapy:Therapy:

III - Sequencing of Combined TreatmentsIII - Sequencing of Combined Treatments

• Step 5 - Add family dynamic and Step 5 - Add family dynamic and systemic intervention as patient systemic intervention as patient stabilizesstabilizes

• Step 6 - Rehabilitation in maintenance Step 6 - Rehabilitation in maintenance phasephase

• Step 7 - Do not add a modality, if Step 7 - Do not add a modality, if first intervention (vs second) adequate first intervention (vs second) adequate for efficacyfor efficacy..

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Table 4 - Guidelines forTable 4 - Guidelines forStructure of Session Structure of Session

• Assumption: Minimum 15 minutes, maximum 60 Assumption: Minimum 15 minutes, maximum 60 minutes - mean 30 minutesminutes - mean 30 minutes

• Divide session in three parts:Divide session in three parts:• Part I - 5 minutesPart I - 5 minutes::

• ask global questionsask global questions• then ask about side effects and target then ask about side effects and target symptoms (compared to baseline)symptoms (compared to baseline)

• do psychoeducationdo psychoeducation• adjust medicationadjust medication

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• Part 2 - 20 minutesPart 2 - 20 minutes::

•explore life eventsexplore life events

•explore issues of transference explore issues of transference

to “pill” and to psychotherapyto “pill” and to psychotherapy

•explore issues of explore issues of

countertransferencecountertransference

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• Part 3 - 5 minutes, integration ofPart 3 - 5 minutes, integration of::

•patient issuespatient issues

•family issuesfamily issues

•provide final prescription of provide final prescription of medication and summarize medication and summarize therapy, discussed in therapy, discussed in psychotherapypsychotherapy

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Table 5 - General Guidelines forPsychotherapy

• Which type in which phase

– family intervention early if patient cognitively impaired

– individual intervention as patient able to participate

– combine both with family session as needed in maintenance phases

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Table 5 - General Guidelines forPsychotherapy. Which type in which phase, cont’d

• Which model in which phase - provide psychoeducation early then

psychodynamic or CBT, and/or family systemic intervention, as patient

and family can utilize it

• Psychotherapeutic alliance characterized by receptive and “open

stance”

• Duration - varied but can be intermittent as needed over lifetime of

illness

• Approach - patient and family viewed as partners on “treatment team”

47

Table 6 - Guidelines for Effective Family Intervention in Psychotic Disorder

1) A positive approach and genuine working relationship between the therapist and family.

2) The provision of family therapy in a table, structured format with the availability of additional contacts with therapists if necessary.

3) A focus on improving stress and coping in the “here and how,” rather than dwelling on the past

48

Table 6 - Guidelines for Effective Family Intervention in Psychotic Disorder

4) Encouragement of respect for interpersonal boundaries within the family

5) The provision of information about the biological nature of schizophrenia in order to reduce blaming of the patient and family guilt

6) Use of behavioral techniques, such as breaking down goals into manageable steps.

7) Improving communication among family members

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Summary of Effects of Family Intervention and Pharmacological Intervention

Including Rehabilitation

• Family Intervention

• Education

• Communication Skills

• Problem Solving Skills

• Resolution of Dynamic and Systems Issues

• Pharmacological Intervention

• Normalize Illness

• Suppress Symptoms 50

Table 7 - Guidelines for Table 7 - Guidelines for Effective Individual Effective Individual

Intervention in Intervention in Psychotic DisorderPsychotic Disorder

• First - make an alliance with patient and First - make an alliance with patient and familyfamily

• Help patient maintain self-esteem Help patient maintain self-esteem regardless of illnessregardless of illness

• Focus on improving adherenceFocus on improving adherence

• Distinguish among and manage among:Distinguish among and manage among:• Objective psychopathologyObjective psychopathology

• Psychodynamic issuesPsychodynamic issues

• Personality conflicts/deficits from patient’s Personality conflicts/deficits from patient’s life historylife history

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Psychoeducation for Psychoeducation for Combined TreatmentCombined Treatment

• Provide systematic information Provide systematic information (repetitively) to both patient and to (repetitively) to both patient and to family aboutfamily about

• signs and symptomssigns and symptoms• diagnosisdiagnosis• treatment - both medication and psychotherapytreatment - both medication and psychotherapy• prognosis with and without treatmentprognosis with and without treatment

• Aim for behavioral change in both patient Aim for behavioral change in both patient and family - don’t just provide and family - don’t just provide informationinformation

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Combined TherapyCombined TherapyAdvantagesAdvantages

1)1) For those patients biologically-oriented, psychotherapy For those patients biologically-oriented, psychotherapy promotes a sense of increased collaboration and targets promotes a sense of increased collaboration and targets intrapsychic and interpersonal problems.intrapsychic and interpersonal problems.

2)2) For those patients psychologically-oriented, medication For those patients psychologically-oriented, medication response relieves hopelessness associated with lack of response relieves hopelessness associated with lack of improvement in psychotherapy as well as targeting primary improvement in psychotherapy as well as targeting primary Sx of illness.Sx of illness.

3)3) Faster response than either modality aloneFaster response than either modality alone

4)4) Family therapy can Family therapy can medication compliance medication compliance

5)5) Individual therapy can Individual therapy can medication compliance medication compliance

6)6) Medication can Medication can psychotherapy compliance psychotherapy compliance

7)7) Matching of patient predictors and meds, plus therapist Matching of patient predictors and meds, plus therapist skills can be maximizedskills can be maximized

• Often faster onset of actionOften faster onset of action

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Combined TherapyDisadvantages

1) With medication, risk for side effects and

early termination of all therapies

2) With psychotherapy, perceived need for

medication decreased (“I can solve this on

my own”)

56

Outline


• Results

• Guidelines


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Nature via NurtureNature via Nurture

A revolution is sweeping the field of biology that holds A revolution is sweeping the field of biology that holds that the influences of nature and nurture are so that the influences of nature and nurture are so inextricably linked that it is difficult to speak of inextricably linked that it is difficult to speak of them as distinct forces that shape who we are. We now them as distinct forces that shape who we are. We now know that our environment can change us only if we are know that our environment can change us only if we are genetically predisposed to change and that our genes are genetically predisposed to change and that our genes are powerless if they are not primed by the environment. powerless if they are not primed by the environment. When it comes to understanding our fate, we can no When it comes to understanding our fate, we can no longer study the effect of genes of the environment longer study the effect of genes of the environment without considering the interaction between them.without considering the interaction between them.

C.T. Gross, 2004C.T. Gross, 2004

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Quality Family Individual Consumer

Treatment = Medication + Intervention + Intervention + Group

Support

Quality Treatment Equation

MedicationFamily

InterventionIndividual

InterventionCustomer

GroupSupport

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What We KnowWhat We Know

•Psychotherapy added to medication Psychotherapy added to medication can improve outcome more than can improve outcome more than medication alone . . . . medication alone . . . .

•For For somesome disorders, for disorders, for somesome patients at patients at somesome phases of their phases of their illnessillness

•Especially to insulate against Especially to insulate against relapserelapse

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What We Don’t KnowWhat We Don’t Know

•Which type of Which type of psychotherapeutic psychotherapeutic intervention?intervention?

•In what dose? What In what dose? What duration?duration?

•Delivered by whom?Delivered by whom?

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Post-testPost-test

1.1. Modalities necessary for adequate treatment Modalities necessary for adequate treatment of most Axis I disorders over the long-run of most Axis I disorders over the long-run include:include:

a.a. individual psychotherapyindividual psychotherapy

b.b. medicationmedication

c.c. rehabilitationrehabilitation

d.d. family interventionfamily intervention

e.e. all of the aboveall of the above

65

Post-testPost-test

2.2. A basic rationale underlying combined therapy A basic rationale underlying combined therapy includes:includes:

a.a. correct the presumed biochemical deficitcorrect the presumed biochemical deficit

b.b. use the “window of opportunity” provided use the “window of opportunity” provided by the suppression of symptoms to remold by the suppression of symptoms to remold both cognition and behaviorboth cognition and behavior

c.c. When using family intervention, have the When using family intervention, have the patient actually change behavior before patient actually change behavior before getting “insight”getting “insight”

d.d. All of the aboveAll of the above

66

Post-testPost-test

3.3. All of the following, except one, have All of the following, except one, have controlled data suggesting the adding controlled data suggesting the adding psychotherapy improves outcome above what psychotherapy improves outcome above what medication alone provides:medication alone provides:

a.a. SchizophreniaSchizophrenia

b.b. Pervasive Developmental DisorderPervasive Developmental Disorder

c.c. Bipolar DisorderBipolar Disorder

d.d. Major Depressive DisorderMajor Depressive Disorder

e.e. Bulimia NervosaBulimia Nervosa

67

PretestPretest

4.4. Advantages of combined therapy include all of the Advantages of combined therapy include all of the following except one::following except one::

a.a. Increased cost in the short runIncreased cost in the short run

b.b. For those patients biologically-oriented, For those patients biologically-oriented, psychotherapy promotes a sense of increased psychotherapy promotes a sense of increased collaboration and targets intrapsychic and collaboration and targets intrapsychic and interpersonal problemsinterpersonal problems

c.c. Medication can improve psychotherapy Medication can improve psychotherapy compliancecompliance

d.d. Family therapy can improve increase medication Family therapy can improve increase medication compliancecompliance

68

Post-testPost-test

5.5. Disadvantages of combined therapy include all of the Disadvantages of combined therapy include all of the following except:following except:

a.a. With medication, increased risk for side effects and With medication, increased risk for side effects and early termination of all therapiesearly termination of all therapies

b.b. Faster response than either modality aloneFaster response than either modality alone

c.c. With psychotherapy, perceived need for medication With psychotherapy, perceived need for medication decreased (“I can solve this on my own”)decreased (“I can solve this on my own”)

d.d. Increased cost of treatmentIncreased cost of treatment

e.e. Slower response than either aloneSlower response than either alone

69

Pre- and Post-Test Pre- and Post-Test Answer KeyAnswer Key

1.1. EE

2.2. DD

3.3. BB

4.4. AA

5.5. EE

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