Integrating Medications With Psychotherapy

If I need professional help, how do I know if I should take medications or look for a therapist? Dowd and Janicak’, a psychologist and psychiatrist, have recently published the book, “Integrating Psychological and Biological Therapies” (1), which addresses this question for the professional audience. But let’s cut through all the technical language and sift-out what consumers of medical and mental health services need to know, so that they too can make informed choices.

Based on the best scientific evidence, clinical experience as well as the risks and benefits, Dowd and Janicak suggest that carefully combining or integrating psychotherapy and medications “is often required to achieve an optimal outcome” for the patient. They say that combining medications and psychotherapy improves patient acceptance of treatment and improves treatment outcomes. They further point out that both medications and psychotherapy need to be accessible in urgent situations, affordable and acceptable to the patient.

The term “psychotherapy” needs to be defined. It is not just talking about your problems with a sympathetic listener. Psychotherapy is any one of several specific kinds of therapy with scientifically proven effectiveness, which produces a fundamental improvement in the individual’s life . When a mental health professional says that they are experienced treating a certain kind of problem, this does not necessarily mean that they are using procedures scientifically proven to be effective. So, before you commit yourself to working with a therapist, ask what kind of therapy they provide and what scientific evidence there is that the therapy will be effective for your kind of problem.

The authors describe how to combine medications and psychotherapy into Treatment Plans for nine frequent types of mental health disorders, including major depression, obsessive compulsive disorder, panic disorder, posttraumatic stress disorder, sleep disorders, schizophrenia, bipolar disorder, borderline personality and generalized anxiety disorder. For each of these disorders they describe when to add medication to psychotherapy, add psychotherapy to medication, combine both from the start, transition from one to the other, and use psychotherapy to improve patient adherence to medications and prevent relapse.

The authors go on to say that both medical and psychological treatment success is often compromised, because the patient does not follow or adhere to the recommended treatment. Non-adherence to treatment can be due to factors related to the illness, the treatment or the patient. Unmentioned and/or untreated psychological, substance abuse, or medical issues can seriously threaten adherence to treatment and treatment success. Due to the fact that medical disorders are often accompanied by depression and anxiety due to other psychosocial issues, a careful assessment for co-morbid disorders should be undertaken.

When medications and psychotherapy are delivered by different professionals, the professionals must communicate and coordinate their efforts to achieve optimal success for the patient. Your psychotherapist and medical doctor should be asking each other questions like, “What symptoms are you targeting? Are you considering a change in medications? Has symptom severity improved?” The prescriber and therapist need to coordinate the management of emergencies, treatment changes, terminations, and differences in treatment philosophies.

While the authors often recommend starting treatment with psychotherapy, they caution us that medications should be considered from the start, if the patient has acute symptoms impairing their ability to perform important daily activities; is in an urgent or suicidal situation; or cannot access or afford psychotherapy.

Several types of psychotherapy, each with their own unique techniques, including individual and group, as well as telephone/online cognitive behavior therapy have proven effective, depending on the specific type of problem considered. These strategies are evidence-based and depend on symptom severity, chronicity, urgency, and the cost-benefit ratio at each step of the treatment process.

Overall, their strategies suggest that if symptoms are from mild to moderate severity, try psychotherapy alone. If the response is insufficient, or symptom severity is high, try medications. If the response to medications is still insufficient, combine medications with psychotherapy and maintain it until the patient is stable. Then taper-away treatment or maintain it at the lowest efficient level.

Combining medications with evidence-based psychotherapy techniques for the specific type of problem may produce more powerful and lasting outcomes. In situations where psychotherapy is either inaccessible or unaffordable, self-help books may have psycho-educational benefit, but research has not yet proven this to be the case. Dowd and Janicak conclude that “the existing evidence often supports an integrated approach and this strategy should be utilized more frequently in clinical practice.” (p. 159). 

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