Combining Psychotherapy and Medication to Improve Outcomes in Patients With Axis I Disorders

Jaime Rosenberg

During a session at the 2017 Neuroscience Education Institute Congress, Ira D. Glick, MD, professor emeritus, Department of Psychiatry and Behavioral Sciences, Stanford School of Medicine, emphasized the importance of combining psychological and psychopharmacologic strategies for patients with Axis I disorders and provided guidelines for administering the combination. According to the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), Axis I represents acute symptoms that need treatment. These disorders include major depressive disorder (MDD), schizophrenia, and anxiety disorders.

“You’ve got to talk to your patients as well as prescribe them medicine,” said Glick.

Glick first outlined the rational for combining medication and therapy:
Psychotherapy is important because some conditions have no effective pharmacotherapy treatment available, medication can be contraindicated, and the patient may not want to take medication. Most importantly, most patients have social and interpersonal problems accompanying Axis I disorders either as the source of or the consequence of the illness, said Glick.

However, there are several reasons why combined therapy is not delivered, said Glick. Many providers deliver one or the other, most insurers pay for non-integrated treatment, many professionals are trained in one or the other, and there is still a presence of provider bias.

Psychotherapy has shown to improve outcomes over medication alone in bipolar disorder, childhood attention-deficit/hyperactivity disorder, MDD, schizophrenia, posttraumatic stress disorder, sleep disorders, and bulimia nervosa, said Glick.

Glick then provided the audience with guidelines for administering combined therapy for their patients:

1. Diagnosis
2. Goals
3. Sequencing of combined treatments
Glick ended the session by describing the advantages and disadvantages of combined therapy. For patients who are biologically-oriented, psychotherapy promotes a sense of increased collaboration and targets intrapsychic and interpersonal problems. For patients who are psychologically oriented, medication response relieves hopelessness associated with the lack of improvement in psychotherapy, as well as targeting the primary symptoms of the illness. In addition, it provides a faster response than either modality alone. Lastly, family and individual therapy can increase medication compliance, and medication can increase psychotherapy compliance.

However, there are several disadvantages. With medication, there is an increased risk for side effects and early termination of all therapies, and with psychotherapy the perceived need for medication decreases, Glick explained.
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