COMBINING PSYCHOTHERAPY AND PSYCHOPHARMACOLOGY: RATIONALE, - - PowerPoint PPT Presentation

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…
• We assume that during a

10-30 min medication session that the prescriber conducts and exhibits gold standard skills

• May improve compliance

with visits, adherence with meds, placebo effects and lower nocebo effects

• Motivation - Empathy - Openness -

Collaboration - Warmth - Positive Regard- Sincerity -

• Corrective Experience – Catharsis
• Established Goals
• Establish Time Frame
• Establish Patient Effort Needed

VERSUS 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
• utcomes 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
• r 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

• f 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.

Sequential Treatment Approaches

• Therapy post medication failure > Medication post therapy failure
• Caveat: most therapy provided outside of studies is supportive,

eclectic, short term with varied compliance

• REVAMP and STAR*D trials showed no clear benefit of continuing a

med, changing med or continuing therapy

• STAR*D showed CBT and antidepressants comparable
• However antidepressants had faster onset of action
• CoBalT showed that adding CBT post medication failure was doubly

superior to medication alone, CBASP had similar findings and MBCT did not

Dunlop BW et al. Focus. 2016;14(2):156-173.

Major Depressive Disorder

• Meta-analysis (23 trials/2184 participants)
• Combined therapy with ADT outperformed ADT alone at six

months+

• Combination resulted in equal response compared to

psychotherapy alone at six months+

• Combined maintenance therapy resulted in better-sustained

treatment response compared to antidepressants at six months+

Karyotaki E et al. J Affect Disord. 2016;194:144-52.

Major Depressive Disorder (cont.)

• Another found combined treatment had a moderate effect compared with

placebo

• Combination allowed small/moderate effects compared to ADT alone
• Similar for therapy alone and psychotherapy plus placebo
• Publication bias noted
• No significant differential predictors
• Meta-analysis suggests combined treatment may be best available for adult

depression

• Significantly more effective than placebo, pharmacotherapy alone,

psychotherapy alone and the combination of psychotherapy and placebo

Cuijpers P et al. World Psychiatry. 2014;13(1):56-67.

SSRI, Psychodynamic Psychotherapy Long Term Approaches

• 272 depressed patients randomized to receive Long Term

Psychodynamic Psychotherapy (LTPP) (one session/week), fluoxetine treatment (20–60 mg/day) or combination for 24 months

• All treatments were associated with significant reductions in the

BDI scores

• LTPP and combination therapy were more effective in reducing

BDI scores than fluoxetine alone

• Interestingly in TADS trial, Combination>SSRI>CBT

Bastos AG et al. Psychother Res. 2015;25(5):612-24.

Persistent Depressive Disorder

• Network meta-regression analysis of 3 identified studies

(n=1036)

• Combination therapy showed significant superiority over

both monotherapies in terms of efficacy and acceptability

• Both mono-modality approaches showed essentially

similar results

Furukawa TA et al. Psychother Psychosom. 2018;87(3):140-153.

Bipolar II Disorder, Depressed

• Non-medicated adults (n = 92)
• Interpersonal and Social Rhythm Therapy (IPSRT)

plus placebo or IPSRT plus quetiapine for 20 weeks

• Combination yielded significantly faster

improvement on HAM-17 and greater improvement

• n YMRS
• Both groups improved significantly over time with

comparable response rates

Swartz HA et al. J Clin Psychiatry. 2018;79(2)

PTSD

• Analysis of 12 trials/922 subjects
• Psychotherapeutic treatments showed greater benefit than

pharmacological

• No difference between treatments over long-term
• Combined treatments were associated with better outcomes than

pharmacological only treatments

• No evidence was found for differential acceptability of the 3

treatment approaches

Merz J et al. JAMA Psychiatry. 2019;76(9):904-913

Social Anxiety

• CBT vs ADT vs Combination studies lacking for

generalized anxiety disorder (GAD)

• For SAD combination trials use SSRI, MAOi plus

therapy with mixed results

• Initial accelerated recovery effects have been noted but

without significant difference after 6 months

Oliveira IR et al. Integrating Psychotherapy and Psychopharmacology, A Handbook for Clinicians. Routledge; 2013.

OCD

• Much data for behavior therapy(BT) + SSRI/TCAs

(specifically clomipramine)

• Some advantage to BT over ADT regardless
• Meta-analysis suggested no differences before 1980s,

but after found minor advantages to combination treatment

Oliveira IR et al. Integrating Psychotherapy and Psychopharmacology, A Handbook for Clinicians. Routledge; 2013.

Panic

• Slight advantage noted with combined treatment
• CBT tends to be most effective over long term and

more cost-effective

• BZ combined with psychotherapy seems to be less

effective when compared to using TCA or SSRI

Oliveira IR et al. Integrating Psychotherapy and Psychopharmacology, A Handbook for Clinicians. Routledge; 2013.

Eating Disorders

• For anorexia nervosa, meta-analyses suggest that

drug only treatments are less effective than combination strategies

• Medication augmentation of CBT for bulimia nervosa
• r binge eating disorder have not shown tremendous

effectiveness

Oliveira IR et al. Integrating Psychotherapy and Psychopharmacology, A Handbook for Clinicians. Routledge; 2013.

ADHD

• 3 meta-analyses available
• Large effect sizes when psychosocial treatments are

added to stimulant medications for childhood ADHD

• Combination approach more effective than

psychosocial alone but sometimes not greater than stimulant alone

Oliveira IR et al. Integrating Psychotherapy and Psychopharmacology, A Handbook for Clinicians. Routledge; 2013.

Insomnia

• At least 8 RCT exist comparing CBT to BZ or BZRAs
• Medications clearly work faster but relapse to insomnia

far higher when medication discontinued

• 4 trials suggest combined treatment greater effectiveness

than single treatment with varying effect sizes

Oliveira IR et al. Integrating Psychotherapy and Psychopharmacology, A Handbook for Clinicians. Routledge; 2013.

Conclusions

• A clear shift from integrated treatment where one psychiatrist

typically provides both psychotherapy and medication management in one setting towards split-model or collaborative care has occurred

• Appears mainstream that patients receive combined treatment

modalities where medications and psychotherapy are started roughly at the same time (albeit by two providers)

• There is no absolute benefit to any model, nor by combining

treatments or sequencing…

A Savvy Provider Must Be Able To

• Make an accurate diagnosis
• Develop patient rapport
• Formulate a biopsychosocial opinion
• Be cognizant of which specific medications/specific

psychotherapies are warranted and validated to

• btain expected outcomes for each individual patient

in their care in order to see clinical differences

Posttest Question

Mary is going to begin psychotherapy. Research indicates that on average how many weekly sessions are required for patients to recover?

• 1. 5 sessions
• 2. 10 sessions
• 3. 20 sessions
• 4. 40 sessions

Posttest Question

Cognitive behavioral therapy (CBT) and dialectical behavior therapy (DBT) have been shown to:

• 1. increase 5-HT1A density
• 2. increase neuroplasticity and BDNF activity
• 3. decrease 5-HT1A density
• 4. decrease neuroplasticity and BDNF activity

Posttest Question

Psychodynamic psychotherapy has been shown to:

• 1. increase 5-HT1A density
• 2. increase neuroplasticity and BDNF activity
• 3. decrease 5-HT1A density
• 4. decrease neuroplasticity and BDNF activity