Overview

The combination of psychotherapy plus biological therapies (i.e., pharmacotherapy, device-based therapies) is frequently used to treat psychiatric disorders. In support, various studies (e.g., neurophysiological, neuroendocrine, neuroimaging) report similar actions with each approach and possibly additive or synergistic actions with combined medication and psychotherapy.¹ Further, Hollen and Fawcett² note that combining these treatments increases the magnitude and probability of a response, enhances the breadth of response, and improves patients’ acceptance. Therefore, their careful integration is often required to achieve an optimal outcome. In this context, several combination or sequencing strategies can be considered, including:

Adding medication to psychotherapy to enable the therapeutic process to proceed optimally (e.g., enhance concentration, reduce distorted thinking, reduce anxiety)
Adding psychotherapy to medication to enable the therapeutic process to proceed optimally (e.g., improve patients’ understanding, acceptance, and management of their illness)
Combining both from the outset in disorders clearly benefited by such an approach (e.g., use psychotherapy to manage psychosocial stressors not addressed by pharmacotherapy alone)
Transitioning from one approach to another in the face of issues such as poor tolerability or patient preference
Transitioning from combined treatment to a single approach for maintenance therapy after acute symptoms are controlled
Utilizing psychotherapy to enhance medication adherence and to prevent relapse

It should also be noted that there is the potential risk for negative consequences when combining treatments (e.g., benzodiazepines causing dependency or interfering with learning and memory, psychotherapy producing higher stress in patients with schizophrenia).

Although major depressive disorder (MDD), obsessive compulsive disorder (OCD), various anxiety-related (e.g., panic disorder and posttraumatic stress disorder) and sleep-related problems are the best studied conditions in the context of combining therapies, there is a growing literature to support an integrated approach in such diverse conditions as schizophrenia, bipolar disorder, and borderline personality. While there are also data and clinical experience with combined treatments for conditions such as social phobia, the specific disorders covered in this book were chosen because they clearly illustrate the benefits of integrated therapy.

Considering all these issues, we will develop a series of treatment strategies to highlight the discussion of combined treatment approaches for specific diagnoses. The three underlying assumptions guiding these strategies are the best available evidence (primarily from adequately controlled trials), the breadth of clinical experience with various approaches, and the relative risk-benefit ratio. The following chapters cover those conditions, which we believe are best served by combination therapy based on the existing research and clinical experience: