COMBINING PSYCHOTHERAPY AND PSYCHOPHARMACOLOGY: RATIONALE, APPLICATION, AND OUTCOMES
Learning Objectives •Describe the neuroscientific benefit of combining therapy and medication management •Understand best practices in regard to clinical application •Be aware of the evidence-base for outcomes for combined treatment
Should we combine therapy and medication management in one visit? •Why do we need both modalities? • Certain patients do not respond to either modality • Certain patients refuse certain modalities • Certain patients have increased expectations for certain modalities Cooper AA, Conklin LR. Clin Psychol Rev. 2015;40:57-65; Keyloun KR et al. CNS Drugs. 2017;31(5):421-432; Salanti G et al. Int J Epidemiol. 2018;47(5):1454-1464.
Should we combine therapy and medication management in one visit? •What is the drop out rate between the modalities? • Meta-analysis of 80 psychotherapies = 19.9% • Rx Dropouts? • 44-88% in naturalistic settings • 16-48% in clinical trials Cooper AA, Conklin LR. Clin Psychol Rev. 2015;40:57-65; Keyloun KR et al. CNS Drugs. 2017;31(5):421-432; Salanti G et al. Int J Epidemiol. 2018;47(5):1454-1464.
Take Home Point: “The More Weapons In Your Arsenal” • Make an accurate diagnosis, • Use treatment guidelines, • Know which medications and which therapies have the best outcomes, • Clinicians have the ability to deploy either, or both, in calculated fashion • This should allow for better outcomes
Does Psychotherapy Work Within the Context of a Medication Management Visit? • It depends… - Motivation - Empathy - Openness - Collaboration - Warmth - Positive • We assume that during a 10-30 min medication Regard- Sincerity - session that the - Corrective Experience – Catharsis prescriber conducts and - Established Goals exhibits gold standard skills - Establish Time Frame • May improve compliance - Establish Patient Effort Needed with visits, adherence with meds, placebo VERSUS effects and lower nocebo effects Weekly CBT, IPT, Psychodynamics Etc. Oliveira IR et al. Integrating Psychotherapy and Psychopharmacology, A Handbook for Clinicians. Routledge; 2013.
If a patient wants to do Integrated Treatment, can they receive an appointment with a single provider? • Integrated suggests one clinician provides therapy plus medications in one visit. • Many places use a triage worker model, to gain access to a prescriber • This model often assumes all providers are interchangeable • Also assumes the triage worker is knowledgeable about • What symptoms require medications or not • Which symptoms respond to specific psychotherapy modalities Riba MB, Balon R. Competency in Combining Pharmacotherapy and Psychotherapy, Integrated and Split Treatment. Amer Psychiatric Pub Incorporated; 2005.
Are Clinicians Competent to Provide Integrated Care? • Competencies to provide pharmaco + psychotherapy should include: • Understanding of the triage system in place • Ability to take a full psychiatric history/MSE to delineate whether a patient would benefit from medication, therapy or combination, or split vs. integrated care • Ability to establish rapport quickly and elaborate a biopsychosocial formulation • Understanding of which medications and therapies have best outcomes based on diagnoses and target symptoms Riba MB, Balon R. Competency in Combining Pharmacotherapy and Psychotherapy, Integrated and Split Treatment. Amer Psychiatric Pub Incorporated; 2005.
Key Elements to Consider When Choosing • Diagnosis, comorbidity • Guidelines and evidence-based data available • Dangerousness (treatment time to onset differences) • Patient beliefs, expectations, level of functioning • Personality traits/disorder, trauma? • History of non-adherence • Cost, insurance, availability of treatment options Riba MB, Balon R. Competency in Combining Pharmacotherapy and Psychotherapy, Integrated and Split Treatment. Amer Psychiatric Pub Incorporated; 2005.
Does it make sense for a prescriber to refer to a therapist to provide psychotherapy (split-model)? • Personal preference • Income • Should prescriber refer for eclectic vs. specialized psychotherapy? • Depending on DSM diagnosis? • Depending on availability of therapist?
Is it cost-effective to use the split-model approach instead of integrated model? • Brief psychotherapy by a social worker is least expensive treatment •If both therapy and medication needed, •combined treatment by a psychiatrist costs about the same or less than split treatment with a social worker •Is often less expensive than split treatment with a psychologist •What about noncompliance with visiting multiple providers? •What about cost of time visiting multiple providers? •What about outcomes? Dewan M. Am J Psychiatry. 1999;156(2):324-6; Goldman W et al. Psychiatr Serv. 1998;49(4):477-82.
Outcomes via Quality Adjusted Life Years • Price to ‘buy more healthy years by way of participating in treatment’ • Therapy = $30,000, combining with meds = $50,000 • In US, costs between $50,000-120,000 suggest good cost-benefit ratio • In Canada, combination saves $2300 per major depressive episode (MDE) Shapiro Y et al. J Psychiatr Pract. 2016;22(4):321-32.
Rationale of Combining Modalities • 1980s of biological vs psychological psychiatry is likely over given the advances in genetics and neuroimaging • Would also counter that medication provision has clear psychological implications as well Shapiro Y et al. J Psychiatr Pract. 2016;22(4):321-32.
Predicting Antidepressant Response Biologically Harmer CJ et al. Curr Behav Neurosci. 2014;1:125–133.
Most Commonly Studied Therapies Dunlop BW et al. Focus. 2016;14(2):156-173.
What about psychotherapy? •Response to medication versus therapy for MDD associated with divergent pattern of ACC response • Increased ACC response to negative stimuli predicts better outcome with medication •Right Anterior Insula best discriminated treatment outcome • hypometabolism predicts remission via CBT • hypermetabolism via escitalopram Roiser JP et al. Neuropsychopharmacology. 2012;37(1):117-36; Thompson DG et al. Am J Geriatr Psychiatry. 2015;23(1):13-22; McGrath CL et al. JAMA Psychiatr. 2013;70:821–9.
What is the effect of supportive or eclectic psychotherapy? • Unclear as these approaches are usually tagged as ‘treatment as usual’ • Do all therapies provide core skills? • Do all therapies provide new, safer learning environments? • Perhaps improving attachment helps regardless? • Research shows that insecure styles are associated with impaired prefrontal-cortico-limbic and right hemispheric connectivity… Shapiro Y et al. J Psychiatr Pract. 2016;22(4):321-32.
Hidden Forms of Psychotherapy •Dosing of psychotherapy •20 weekly sessions seems to be adequate •Placebo effect is real •Prescriber effect is real •Rapport and core skills increase compliance and adherence •All therapies use learning, memory, and adaption •All of which use similar LTP and CNS processes Shapiro Y et al. J Psychiatr Pract. 2016;22(4):321-32.
The question at an initial evaluation should not be whether the patient needs medications or therapy?, but rather … What medication and what therapy are specifically designed, can be specifically delivered in order to obtain specific outcomes for the patient?
Psychotherapy Creates Lasting Brain Changes •With CBT and psychodynamic approaches •Caudate metabolism normalizes with CBT as does the cortical-striatal-thalamic circuitry in OCD •In MDD, DLPFC activity increases •Insula and ACC activity increases as limbic activity lowers •Psychodynamics increases 5-HT1A density •Psychotherapy recruits inhibitory cortical neurons to help contain limbic hyperarousal •CBT/DBT increase neuroplasticity and BDNF activity Shapiro Y et al. J Psychiatr Pract. 2016;22(4):321-32; Perroud N et al. Transl Psychiatry. 2013;3:e207.
Specific Outcomes for Combining Treatment Modalities • Caveats •There are over 500 types of psychotherapy studied •Few are studied to the point of showing clear validity in specific disorders •Medications studied and approved for specific DSM disorders are less •Though we often seem to provide off-label medications and psychotherapies often… •There are likely less than 50 trials of varying stringency looking at combination treatment Shapiro Y et al. J Psychiatr Pract. 2016;22(4):321-32.
Major Depressive Disorder (as an example) • Most trials use a combination-initiation treatment (CIT) approach and have shown mixed results • Initial trials of CBT and TCA showed remarkable CIT effects • Medication alone allows faster response but predicts greater relapse/recurrence over time Dunlop BW et al. Am J Psychiatry. 2017;174(6):533-545.
Major Depressive Disorder (as an example) •CBASP (cognitive behavioral analysis system of psychotherapy) Vs nefazodone revealed combination superior •CT and SSRI found combination 10% more effective •Psychodynamically informed supportive therapy has two CIT positive trials •Remission rates in MDD+ personality disorder substantially higher with combination treatment (47% vs. 19%, respectively) •IPT has 10 trials and meta-analysis suggested no clear benefit from CIT •Some niche trials were more positive (ex. Inpatient depressives) Dunlop BW et al. Am J Psychiatry. 2017;174(6):533-545.
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