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Steven D. Hollon, Jan Fawcett: Chapter 26. Combined Medication and Psychotherapy, in Gabbard’s Treatments of

Psychiatric Disorders, 4th Edition. Edited by Glen O. Gabbard. Copyright ©2009 American Psychiatric Publishing, Inc.

DOI: 10.1176/appi.books.9781585622986.257298. Printed 5/10/2009 from www.psychiatryonline.com

Gabbard’s Treatments of Psychiatric Disorders > Part V. Mood Disorders >

Chapter 26. Combined Medication and Psychotherapy

INTRODUCTION

Both drugs and psychotherapy have a role to play in the treatment of the mood disorders.

Pharmacotherapy has been shown to be effective in literally hundreds of placebo-controlled trials

and represents the current standard of treatment for both depression and mania (American

Psychiatric Association 2000). Psychotherapy is widely practiced but has been less intensively

studied. It has fared well in direct comparisons with pharmacotherapy, particularly the newer

approaches tailored specifically for depressed populations (Hollon et al. 2002). Given the apparent

efficacy of both monotherapies, it is not surprising that the two are sometimes combined. Both

biological and psychosocial factors have been implicated in the etiology of the mood disorders, and

it is often assumed that both medications and psychotherapy work through different mechanisms

for different types of patients. Concerns among advocates that combined treatment might undercut

the efficacy of their preferred modality have proved to be largely unfounded, and many patients are

now treated with a combination of medication and psychotherapy (Thase and Jindal 2004).

Nonetheless, it is not clear that combined treatment is advantageous in all cases. Patients who

respond to psychotherapy may not need to be exposed to the risks and side effects of medications,

and patients who respond to medications may prefer not to bear the time and expense of

psychotherapy. A recent practice guideline suggested that combined treatment was most indicated

for patients who have more chronic or complex disorders or who show less than full response to

either monotherapy (American Psychiatric Association 2000).

This guideline is sensible as far as it goes, but it could be taken further. There are at least four

ways that combined treatment can prove superior to either single therapy (Depression Guideline

Panel 1993). First, combined treatment might increase the magnitude of response shown by any

given patient on a given outcome (Hollon et al. 2005b); that is, some patients might do better in

combined treatment than they would with either monotherapy. Second, combined treatment might

increase the probability of response (Pampallona et al. 2004); that is, if some patients are

responsive only to medications and others are responsive only to psychotherapy, then providing

both modalities in combination will increase the likelihood that each patient will receive something

to which he or she will respond. Third, combined treatment might enhance the breadth of response

(M. A. Friedman et al. 2004); that is, to the extent that each monotherapy affects different types of

outcomes, combined treatment might retain the unique advantages associated with each, producing

an overall pattern of response that is superior to either monotherapy alone. Finally, combined

treatment might enhance the acceptability of treatment relative to either monotherapy (Basco and

Rush 1995). Using psychotherapy to deal with misconceptions can enhance compliance, and adding

medications to speed response can make patients more amenable to self-exploration.

DIAGNOSTIC INDICATIONS AND CONTRAINDICATIONS

At this time, there are few indications for combined treatment that have been established on an

empirical basis, but some patterns are suggestive (Hollon et al. 2005b). Unipolar depression can be

treated with either monotherapy alone, whereas medications are almost always involved in the

treatment of bipolar disorder, but combined treatment can enhance response in each.

Pharmacotherapy and electroconvulsive therapy remain the treatments of choice for patients with

psychotic mood disorders, but psychotherapy is often added once the acute psychosis has been

stabilized. Severity or melancholia predicts superior response to drugs relative to placebo, and

psychotherapy alone may not be sufficient for some such patients (Thase et al. 1997). At the samePrint: Chapter 26. Combined Medication and Psychotherapy http://www.psychiatryonline.com/popup.aspx?aID=257302&print=yes…

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time, patients with interpersonal problems or recurring episodes may benefit from the greater

breadth or stability afforded by adding psychotherapy to medications (Hollon et al. 2002). Patients

with chronic depression or long-standing personality disorders tend to do less well with either

monotherapy and may be among those most in need of combined treatment (American Psychiatric

Association 2000).

Mood disorders are also commonly found in conjunction with other psychiatric or general medical

disorders. Whether the mood disorder should be treated first (or even at all) depends on the nature

of the other disorder and the specific clinical picture (Depression Guideline Panel 1993). In general,

when more than one psychiatric disorder is present, choosing a treatment regimen that has

demonstrable efficacy for all aspects is to be preferred, and there may be instances in which

combined treatment comes closer to satisfying this guideline than either monotherapy. Medical

illnesses with clear somatic bases are likely to be treated first before intensive

psychopharmacological or psychotherapeutic regimens are implemented.

Contraindications to combined treatment are those inherent in either monotherapy. Some patients

simply cannot tolerate medications or should not be treated pharmacologically because of

preexisting medical conditions or possible complications (Depression Guideline Panel 1993). There

are fewer known contraindications to the use of psychotherapy, but it does add time and expense

and may not be warranted in all cases.

EVIDENCE FOR ACUTE-PHASE EFFICACY

The first question of interest is whether providing combined treatment to patients who are acutely

symptomatic does anything to enhance response over that achieved with either monotherapy alone.

Only some of the psychosocial interventions have been evaluated in combination with medications.

Because claims of differential efficacy have been made for each of these approaches, we discuss

each in turn. Because allegiance to a particular approach is more likely to be found among

psychotherapists than among pharmacotherapists, we organize the review with respect to the type

of psychotherapy used.

Dynamic Psychotherapy

Early psychodynamic theories of depression focused on the role of retroflected anger and

unconscious masochistic drives, whereas more recent work has emphasized the diminution of

self-esteem following interpersonal loss in the context of unresolved conflict (Karasu 1990).

Interventions based on these models strive for personality change by means of facilitating an

understanding of past conflicts and providing insight into unconscious motivations.

Despite its widespread use in clinical practice, early studies suggested that dynamic psychotherapy

was less efficacious than and added little to medications in the treatment of depression. For

example, Daneman (1961) found that adding imipramine greatly enhanced response to dynamic

psychotherapy in an outpatient sample. Similarly, Covi et al. (1974) found that adding dynamic

psychotherapy did little to enhance response to imipramine alone, which was superior to pill

placebo whether provided alone or in combination. However, psychotherapy alone in both studies

was provided only in combination with pill placebo (which may have undermined its effects), and

the brief group intervention used in the latter study bore little resemblance to dynamic

psychotherapy as typically practiced.

More recent studies have provided more support. Burnand et al. (2002) found that adding dynamic

psychotherapy reduced treatment failure and enhanced work adjustment relative to clomipramine

alone, leading to better global functioning and fewer subsequent hospitalizations. De Jonghe et al.

(2001) found that adding dynamic psychotherapy to medication enhanced overall response by

reducing rates of attrition. In a subsequent trial, De Jonghe et al. (2004) found an advantage for

combined treatment over medications alone in patient reports of benefits. These studies suggest

that adding dynamic psychotherapy may enhance the efficacy of medications alone, although the

gains are usually modest.

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Systems theory posits that the interplay of forces within a marital or family system can produce

“psychopathology” within the individual. Traditionally, such approaches have placed less emphasis

on disorders in individuals and have concentrated on restructuring the larger system to produce

lasting change. More recent versions have recognized that psychopathology can also be a source of

disruption in the marital or family system and have emphasized the need to help spouses and

families cope with the demands of dealing with an afflicted family member.

In an early trial, A. S. Friedman (1975) found that amitriptyline pharmacotherapy produced greater

and more rapid reductions in depression and that marital therapy produced greater improvement in

quality of the relationship in a sample of depressed women with marital distress. Both advantages

were retained in the combined condition, suggesting that it enhanced the breadth of treatment

response. In a subsequent trial, Clarkin et al. (1990) found that adding family therapy to standard

inpatient treatment (including medications) led to greater symptom change among female patients

but that gains were maintained at subsequent follow-up only among women with bipolar disorder

(who also showed gains on measures of social role functioning). Male patients (especially those

with unipolar disorder) actually showed poorer outcomes with respect to both symptom status and

social role functioning in the combined condition than in standard treatment. It may be that the

psychoeducational approach used, which emphasized the chronic and recurrent nature of the

disorder, may have overstated the implications of pathology among unipolar males and adversely

affected their capacity to meet gender-specific role expectations.

More recent work with family-focused therapy (FFT) for bipolar disorder has provided consistently

positive findings. FFT is based on the notion that the family or marital environment moderates the

expression of underlying biological vulnerabilities (Miklowitz and Goldstein 1997). In FFT, patients

and their families are helped to recognize the prodromal signs that signal episode onset and taught

to use specific communication skills and problem-solving strategies to deal with the stressors that

can trigger its emergence. FFT has been shown to reduce risk for relapse in medicated patients in a

series of comparisons to conventional crisis management (Miklowitz et al. 2000), individual

counseling (Miklowitz et al. 2003), and individually focused patient treatment (Rea et al. 2003).

These studies suggest that FFT can buffer the effects of stress in bipolar disorder, and work is

under way to extend this effect to adolescents.

Interpersonal Psychotherapy

Klerman et al. (1984) developed an approach to therapy based on the notion that disturbances in

relationships can play a role in causing or maintaining clinical depression. This approach, called

interpersonal psychotherapy (IPT), is a neo-Sullivanian intervention that focuses on current life

situations and interpersonal relationships for the purpose of resolving problems in those areas and

reducing levels of distress. Originally developed for individual work with adult outpatients, it has

been modified for different ages and disorders and for conjoint marital and family interventions

(Weissman et al. 2000).

Weissman et al. (1979) found an advantage for combined IPT plus amitriptyline over either

monotherapy in the acute treatment of depressed outpatients. This advantage reflected different

loci of action associated with each monotherapy; pharmacotherapy had a more rapid effect on

vegetative symptoms, and psychotherapy had a greater but somewhat delayed effect on mood and

interest (DiMascio et al. 1979). There also was evidence of differential response as a function of

subtype: patients with endogenous symptom patterns did less well in IPT than they did with

medications, and patients with situational depressions showed the converse pattern (Prusoff et al.

1980). Moreover, patients treated with IPT (with or without medications) evidenced greater gains

in social functioning across a subsequent 1-year follow-up than did patients treated with

medications alone (Weissman et al. 1981). Thus, there were indications that combined treatment

enhanced not only the magnitude of the response but also its probability and breadth.

These findings are in at least partial accord with those from other related studies. IPT was found to

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NIMH Treatment of Depression Collaborative Research Program (Elkin et al. 1989), although

medications worked faster (Watkins et al. 1993). At the same time, IPT was less efficacious than

sertraline alone and did little to enhance medication efficacy when added in combination in a recent

study with dysthymic patients (Browne et al. 2000). Given that this was the first time that IPT has

been outperformed by medications, it remains to be seen whether this finding will replicate, but if it

does, it could mean that dysthymia represents a contraindication for IPT monotherapy.

IPT also has been extended to the treatment of bipolar disorder. Based on the notion that

disruptions in everyday routines can lead to affective instability, IPT has been extended to

incorporate efforts to regularize social rhythms. The resultant amalgamation, interpersonal and

social rhythm therapy (IPSRT), is combined with standard medication management. In one trial,

Frank et al. (1999) found that patients with bipolar disorder who maintained a consistent treatment

regime were less likely to relapse than patients who switched modalities.

Behavior Therapy

From a behavioral perspective, depression is a consequence of insufficient reinforcement or

inappropriate conditioning, and interventions based on social skills training or contingency

management have predominated. Closely related is a self-control approach that views depression

as a consequence of a deficit in self-reinforcement. Combined treatment involving behavior therapy

has been evaluated in several trials. Hersen et al. (1984) found that combining social skills training

with amitriptyline did little to enhance response over either monotherapy alone among depressed

female outpatients, although social skills training, alone or in combination, did produce greater

improvement in social functioning than did pharmacotherapy alone (Bellack et al. 1983). Wilson

(1982) found that adding amitriptyline enhanced the speed of response to behavioral task

assignment but not its magnitude. Roth et al. (1982) also found that adding desipramine enhanced

the rapidity but not the magnitude of response to self-control therapy. In a more recent study,

adding self-control therapy enhanced the efficacy of a day-treatment program that included

medications as needed (van den Hout et al. 1995).

On the whole, these studies are too few and the methods employed too weak to warrant drawing

any firm conclusions. Several used inexperienced therapists or included symptomatic volunteers,

and samples were often small and medication doses marginal. Nonetheless, there were repeated

indications that combined treatment produced greater breadth of response relative to medications

and more rapid symptom reduction relative to behavior therapy. This was the same pattern

observed for medication combinations involving either marital therapy or IPT.

More purely behavioral interventions have been undergoing a renaissance in recent years since

Jacobson et al. (1996) found that the behavioral activation component of cognitive therapy was as

effective as the full treatment package. Spurred by these findings, Jacobson and colleagues

developed a more purely contextual approach called behavioral activation (BA) that emphasizes

dealing with negative life events and reducing avoidant behavior patterns (Martell et al. 2001).

Although it has yet to be tried in combination, BA has been found to be both as efficacious as

medications and as enduring as cognitive therapy in the treatment of unipolar depression

(Dimidjian et al. 2006). Given its simplicity, BA may lend itself to incorporation in routine clinical

management by medical personnel.

Cognitive Therapy and Related Cognitive-Behavioral Approaches

A cognitive model of depression holds that the way a person interprets an event influences

subsequent affect and behavior. Depressed patients are seen as holding irrational negative beliefs

and falling prey to maladaptive information processing strategies in the face of negative life events.

Cognitive therapy (CT) is based on the notion that redressing problems in thinking can reduce

dysphoric affect and facilitate efforts to cope with stress (Beck et al. 1979).

Adding CT to medications typically has a modest effect on acute response and an enduring effect

that protects against subsequent symptom return. For example, Blackburn et al. (1981) found that

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monotherapy in a psychiatric sample and retained the enduring effect evident for CT relative to

medications alone in terms of preventing subsequent relapse following treatment termination

(Blackburn et al. 1986). Similarly, Murphy et al. (1984) found that patients treated with combined

treatment were more likely to respond than patients treated with either monotherapy (again

nonsignificant) and that patients who received CT were less likely to relapse following treatment

termination than patients who received medications only (Simons et al. 1986). Hollon et al. (1992)

also found a modest (albeit nonsignificant) advantage for combined treatment with imipramine

over either monotherapy alone and an enduring effect for CT relative to medications in terms of

preventing relapse following treatment termination (Evans et al. 1992). In aggregate, these studies

suggest that combined treatment may produce a modest advantage over either monotherapy in

terms of both the magnitude and probability of response and an enduring effect not found for

medications alone in the prevention of subsequent relapse. This latter indication is consistent with

a recent placebo-controlled trial that found that CT not only was as efficacious as paroxetine in the

reduction of acute distress (DeRubeis et al. 2005) but also had an enduring effect that reduced risk

for relapse and recurrence following treatment termination (Hollon et al. 2005a).

Several studies suggest that adding CT to ongoing medications can both reduce residual symptoms

and prevent subsequent relapse or recurrence. In the first, Paykel et al. (1999) found that adding

CT for patients who were partially remitted following drug treatment not only reduced residual

symptoms in medicated patients but also reduced subsequent relapse over the following year.

Similarly, Fava et al. (1998) found that adding an enhanced version of CT called “well-being

therapy” for patients first treated to remission with medications reduced the rates of recurrence

following treatment termination. Finally, Teasdale et al. (2000) found that adding

mindfulness-based cognitive therapy (an amalgamation of CT plus meditation) reduced risk for

relapse and recurrence following treatment termination in patients first treated to remission with

medications. Taken together, these studies suggest that adding CT to ongoing medications can both

reduce residual symptoms and prevent their subsequent return following treatment termination.

One other study deserves special mention. A multisite study found that patients with chronic

depression were more likely to respond to combined treatment than to monotherapy with either

nefazodone pharmacotherapy or a cognitive behavioral analysis system of psychotherapy (CBASP)

(Keller et al. 2000). CBASP was developed specifically for chronic depression and incorporates an

interpersonal focus with specific problem-solving strategies (McCullough 2000). One striking aspect

of the advantage provided by combined treatment was its timing. Patients treated with medications

responded more rapidly over the first several weeks than patients treated with psychotherapy

alone, whereas patients treated with CBASP continued to improve in the later stages of therapy.

Patients in combined treatment showed both the pattern of accelerated early response evident for

medications alone and the pattern of continued late response evident for CBASP monotherapy. It

remains to be seen whether these findings can be replicated and whether they are specific to

chronic depression, but combined treatment was better than either monotherapy in terms of rates

of both response and remission.

Finally, Lam et al. (2003) found that adding CT to medication management alone reduced risk for

relapse among bipolar patients not currently in episode. A subsequent follow-up found that this

advantage was maintained over the next 18 months but largely reflected differences that emerged

during treatment (Lam et al. 2005). This suggests that adding CT to ongoing medication may have a

beneficial effect in terms of preventing relapse in bipolar patients. There is a growing recognition

that ongoing maintenance medication (the current standard of treatment) is less than wholly

satisfying in the treatment of bipolar disorder (American Psychiatric Association 2002). In that

context, any indication that adding psychotherapy can improve the stability of response to

medications alone is quite encouraging.

Summary

Although few studies have documented a clear advantage for combined treatment over either single

modality with respect to the magnitude of acute symptom reduction in nonchronic populations,Print: Chapter 26. Combined Medication and Psychotherapy http://www.psychiatryonline.com/popup.aspx?aID=257302&print=yes…

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most studies have found a modest but clinically interesting advantage for combined treatment that

falls short of conventional levels of significance. Few of these studies have had sufficient power to

detect the kind of modest increments that might be expected when combining two effective

interventions. Similarly, the paucity of indices of differential response may reflect the fact that the

majority of studies in the literature have not been large enough or have not paid sufficient

attention to the assessment of individual differences to detect such patient-by-treatment

interactions if they did exist. The superiority of combined treatment over either monotherapy in

chronic depression suggests the utility of conducting larger studies in targeted samples.

There is consistent evidence that combined treatment enhances the breadth of response and

retains any specific advantage produced by either monotherapy. Medications often work more

rapidly than psychotherapy and may depend less on the skill of the practitioner for their effect.

Conversely, psychotherapy appears to do more to enhance social functioning (particularly marital

therapy or IPT) or reduce subsequent risk for relapse or recurrence (particularly CT or BA) than

does pharmacotherapy alone. In essence, pharmacotherapy provides rapid and reliable relief from

acute distress, whereas psychotherapy produces broad and enduring change, with combined

treatment retaining the specific benefits of each.

EVIDENCE FOR CONTINUATION- AND MAINTENANCE-PHASE EFFICACY

Relapse refers to the return of symptoms associated with the treated episode after initial remission,

whereas recurrence refers to the onset of a wholly new episode after recovery (Frank et al. 1991).

Continuing medications for patients who are in remission but not yet fully recovered appears to

prevent relapse, and maintenance pharmacotherapy after recovery appears to prevent recurrence.

There is currently no indication that pharmacotherapy does anything to reduce subsequent risk

once medications are withdrawn, whereas some of the newer psychotherapies appear to produce

lasting change (Hollon et al. 2002). Continuing or maintaining psychotherapy after acute response

or recovery has been studied less often. Only a handful of such trials are currently available in the

literature, most involving IPT.

In an early trial, Klerman, Weissman, and colleagues found that continuing patients who responded

to amitriptyline pharmacotherapy on medications reduced rates of relapse relative to withdrawal

onto pill placebo or no pill (Klerman et al. 1974), whereas adding IPT improved social functioning

and relationship quality over time (Weissman et al. 1974). Combined treatment retained the

specific benefits obtained with either monotherapy.

Frank et al. (1990) found that depressed outpatients with recurrent unipolar disorder treated to

recovery with the combination of IPT plus imipramine were less likely to recur if kept on

maintenance medications than if withdrawn onto pill placebo and somewhat less likely to do so if

kept in maintenance IPT. Keeping patients in combined maintenance treatment was no more

effective than pharmacotherapy alone in preventing recurrence, but did reduce attrition; only 8% of

the patients who received IPT in addition to medications dropped out of treatment as opposed to

21% of the patients maintained on medications alone. Possible effects of maintenance IPT on

interpersonal skills or relationship quality were not reported.

Reynolds et al. (1999) found an advantage for combined treatment over either drugs or IPT alone

in a maintenance trial with elderly depressed patients. In that trial, geriatric patients were first

treated to recovery with a combination of IPT plus nortriptyline and then randomly assigned to

maintenance treatment with combined treatment, IPT alone, drugs alone, or placebo. Recurrence

rates over the next 3 years favored combined treatment over either monotherapy (a trend in the

case of IPT), but they all were superior to placebo. Thus, combined treatment was superior not only

to IPT alone (as in Frank et al. 1990) but also to pharmacotherapy alone. Whether this advantage is

specific to elderly patients remains to be seen.

Finally, Jarrett et al. (1998) found that patients who responded to CT were less likely to relapse if

continued in treatment than if they were discontinued. It is unclear whether such continuation

treatment would prove useful for patients who are also kept on medications. Blackburn and MoorePrint: Chapter 26. Combined Medication and Psychotherapy http://www.psychiatryonline.com/popup.aspx?aID=257302&print=yes…

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(1997) found little difference whether patients were treated or maintained with medications or CT.

However, each was provided in sequence and no patients were treated with the combination

simultaneously.

In aggregate, these findings suggest that while ongoing medication monotherapy may be adequate

to suppress relapse or recurrence (geriatric patients being a possible exception), adding

psychotherapy can enhance the breadth of response just as it does when provided during acute

treatment. Moreover, the effect of IPT on social adjustment takes time to develop, suggesting that

this modality may have a long-term effect on symptomatic expression that has yet to be detected in

existing trials. On the whole, findings from these studies are consistent with those from acute

trials; medications produce rapid and robust effects on depressive symptoms, whereas

psychotherapy appears to enhance the breadth and stability of response.

SIDE EFFECTS AND SERIOUS ADVERSE EVENTS

Side effects associated with combined treatment are largely those associated with

pharmacotherapy. Such side effects are common but can be managed by altering the regimen or

changing medication. Adverse reactions are rare and typically occur early in treatment, if at all.

However, many patients prefer not to stay on medications indefinitely. If psychotherapy can reduce

subsequent risk, then adding psychotherapy during acute treatment might be preferred to

long-term continuation or maintenance medication (Hollon et al. 2002).

There are indications that adding psychotherapy may facilitate willingness to tolerate side effects

and thereby enhance compliance. Cochran (1984) found that bipolar patients treated with CT were

more compliant with standard lithium maintenance therapy than were patients treated with

pharmacotherapy alone. Similarly, adding psychotherapy can sometimes reduce attrition (Frank et

1. 1990). Concurrent psychotherapy provides an opportunity for patient and therapist to explore

concerns that may not always be raised in the course of pharmacological management (Basco and

Rush 1995), and there are indications that it can reduce risk for suicide in adolescent populations

(Treatment for Adolescents with Depression Study [TADS] Team 2004).

CLINICAL APPLICATIONS OF COMBINED TREATMENT

It is not always clear where pharmacotherapy ends and psychotherapy begins. Almost all

pharmacotherapy is provided in the context of a therapeutic relationship that goes beyond the mere

provision of medications, and it has long been recognized that the nonspecific aspects of the

patient–physician relationship play a role in determining both compliance and response. Fawcett et

1. (1987) articulated an approach to clinical management that is largely supportive in nature and

shares much in common with nonspecific aspects of psychotherapy. Even strategies as minimal as

teaching patients to recognize prodromal signs and seek prompt medical help have been shown to

reduce the frequency of full manic episodes (Perry et al. 1999).

Applications and Procedures

There has been little systematic research into the optimal timing for combined treatment. Most of

the studies comparing combined treatment with the respective single modalities have started both

treatments simultaneously, but adding psychotherapy can provide additional benefits for patients

already started on medications (as previously described) and patients who do not respond to one

monotherapy will often respond when switched to the other (Schatzberg et al. 2005). What is not

clear is how sequencing (or switching) compares to starting with combined treatment. Severely

depressed or manic patients often first are stabilized with medications (or somatic treatments)

before psychotherapy is instituted. Similarly, patients who fail to respond fully to one modality

sometimes benefit from having the other added. What remains unclear is whether it is better to

start some patients in combined treatment from the outset.

Patients who receive combined treatment often work with different therapists in each modality, but

this need not be the case when pharmacotherapists are also competent to do psychotherapy. If

multiple therapists are involved, it is important that they communicate with each other and not

work at cross-purposes. It is particularly helpful for both to describe depression as a disorder inPrint: Chapter 26. Combined Medication and Psychotherapy http://www.psychiatryonline.com/popup.aspx?aID=257302&print=yes…

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which biology and psychology often combine to produce distress and to present a rationale for

treatment that provides a complementary role for both monotherapies.

Case Examples

We next present two specific case examples that highlight general points of interest previously

discussed.

With the first patient, both imipramine pharmacotherapy and CT were started simultaneously.

Although each monotherapy proceeded separately, the cognitive therapist helped the patient work

through guilt feelings after missing a session with her prescribing clinician due to oversleeping that

might have kept her from returning for subsequent sessions (Hollon et al. 1986).

The second patient was a young male who suffered from bipolar disorder but refused medications

because of his involvement in Alcoholics Anonymous. A recovering alcoholic, he believed that using

medication would undermine his ability to remain abstinent and represented a sign of moral

weakness. After initial discussions failed to dislodge this view, the therapist moved to a course of

cognitive therapy that included attention to those beliefs and attitudes. Although cognitive

restructuring initially did little to lift the patient’s mood, he became more receptive to the notion

that he could take medications without undermining his control over alcohol, and a mood stabilizer

was added to the treatment regimen. Symptom improvement was rapid thereafter, and the patient

was able to resume a career that had been disrupted by his illness.

CONCLUSION

Combined treatment with medications and psychotherapy appears to retain the benefits of each

monotherapy. Pharmacotherapy produces rapid and reliable reductions in distress and suppresses

relapse or recurrence so long as it is continued or maintained, whereas different types of

psychotherapy can enhance social functioning or reduce subsequent risk. There are even

indications that combined treatment may produce a modest increment in acute response and some

indications of enhanced probability of response (particularly among patients with a history of

chronic depression). There are few contraindications to combining drugs and psychotherapy, other

than those associated with each monotherapy, and there are instances in which each appears to

enhance the effectiveness or acceptability of the other.

Given the general efficacy of each of the respective monotherapies, it is quite feasible to treat many

patients with either modality alone. Nonetheless, it often is advantageous to use the two in

combination. Combined treatment is likely to be indicated for patients who fail to show a full

response to either monotherapy. It also is indicated for patients who have a history of chronic or

nonremitting symptoms or for patients who present with multiple problems in addition to affective

distress. More work is clearly needed, but it appears that drugs and psychotherapy, far from being

competitors, often complement each other in the treatment of depressed patients.

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