Morgan T. Sammons, PhD, ABPP

 

eo-for-mts-columnCombining psychopharmacological and psychological interventions for most mental disorders works. Whatever the outcome measure chosen (response/remission, medication adherence, quality of life, symptom severity, or others), the accumulated evidence is convincing that pharmacotherapy alone is a suboptimal treatment for most forms of mental disorder. We as psychologists have probably intuited this throughout our professional lives, and those of us who were fortunate enough to be practicing during the heyday of combined treatment (arguably, the community mental health movement of the 1960s and 1970s) acquired early clinical evidence that such interventions were effective.

But the literature did not keep up with our clinical observations, and for a long while empirically demonstrating the value of combined treatments was challenging, in large part because we were simply asking the wrong questions. The NIMH “decade of the brain” of the 1990s reflected the prevailing philosophy that all mental disorders were rooted in some neuronal perturbation. We were confident that with new neuromolecular breakthroughs, advanced neuroimaging technology, and a spate of new drugs, we could discover the final common biological pathway for almost any mental disorder. This neurobiological tilt was also prevalent in treatment. Doing my postdoctoral work in the early 1990s on an inpatient unit, I was repeatedly told that patients with schizophrenia or bipolar disorder were the exclusive purview of the psychopharmacologists. Psychotherapy for such conditions was not effective, and psychologists need not apply. And the evidence was pretty convincing, at least that provided by the head-to-head, or “horse-race” investigational rubrics that were then prevalent. In any study comparing treatment A to treatment B, drugs won, hands-down. Discussion over. All we needed to do to take care of those patients that didn’t improve was to wait for the development of new and more effective drugs.

But then a funny thing happened. First, those new drugs never appeared. After the promises of Prozac in the 1980s as a harbinger of a new serotonergic dawn for depression, we slowly came to realize that new antidepressants were no more effective than older ones, although they were definitively safer and better tolerated. Even after we tweaked those serotonergic drugs a bit and came up with the mixed function agents, like Effexor, efficacy stayed the same. Today, 30 years after the introduction of Prozac, the heralded antidepressant breakthrough has not occurred. The same story applies for the newer antipsychotic drugs. All of the newer antipsychotic drugs have the same basic efficacy as the first specific antipsychotic (chlorpromazine) introduced in the 1950s. Though a few potentially different drugs are being developed, most deal with the same neurotransmitters and biological hypotheses we’ve worked with for decades. Some, including this author, have argued that unlike the newer antidepressants, the newer antipsychotics really aren’t any safer than the older ones, and may actually be a bit more inherently dangerous; we’ve just learned to use them in a safer manner (i.e., lower doses).

Most of the new antidepressants and many of the new antipsychotics have gone off patent, which means that pharmaceutical manufacturers have less motivation to promote these drugs, and drugs that are not promoted get used less. The fact that we’ve pretty much been unable to come up with convincing alternative neurobiological theories for mental illness suggests that, at least for the present while, we must accept that our pharmacological interventions, while by no means negligible, are not going to usher in a new era of more effective treatments.

But in spite of our almost single-minded focus on biological cures, or perhaps because of it (causality is hard to determine here), something else began to happen in the 1990s: the development of investigative strategies that allowed us to begin to appreciate the potency of combined treatments. This is harder than it seems. The effect sizes of treatment with either pharmacotherapy or psychotherapy are not great. Their modest efficacy makes it much more difficult to detect any additional interactive effect. “Horse-race” or head-to-head comparisons are much easier to design and analyze, particularly in the good old days when drug companies were allowed to pick and choose study end-points after enrollment had been completed.

Use of more complex methods has not revolutionized mental health treatment, but it has given us a much better understanding of the fundamental necessity of incorporating psychological and behavioral treatments into a medical treatment regimen, even for disorders where such interventions had been given short shrift. As early as 1994, a landmark study of a century’s worth of schizophrenia outcomes indicated that the introduction of antipsychotic drugs had not appreciably improved overall results—save for a period in the 1960s and 1970s when, as noted earlier, it was perhaps more likely that combined treatments were offered [1]. Since then, evidence has accumulated in favor of combined treatments. CBT plus psychoeducation has been demonstrated to reduce relapse, assist symptom reduction, and improve adherence in bipolar disorder [2]. Bipolar-specific psychotherapies, whether administered in group or individual fashion, seem particularly useful in managing symptoms and reducing relapse [3]. Brief behavioral therapy offered in primary care helps children with anxiety or depressive disorders [4]. Adding CBT to a pulmonary rehabilitation program improved exercise tolerance, fatigue and anxiety [5]. This column is obviously not the place for a comprehensive review, but you get the point. Adding a validated form of psychotherapy to a medical or medication regimen generally provides specific and often substantial benefit.

As I said, evidence supporting combined therapies has slowly accrued over the past two decades. In my opinion, we have now reached the point where we have sufficient data to argue that if we do not do so, our patients risk suboptimal outcome. Yet, combined treatments are not the norm. For example, most patients in the U.S. treated for depression in primary care get medication. Fewer than 20% of those receiving medication get any form of psychotherapy—a percentage that has decreased over the years [6]. Given the fact that most depressed patients are seen in primary care and never referred to specialty care, the inescapable conclusion is that monotherapy with medication is the de facto standard of care for depression in the U.S., and likely the world.

The reasons for this are as plentiful as blossoms in May. Too few psychologists are present in primary care settings, where most patients are seen. Too few of us are trained in combined methodologies, including the prescription (or unprescription) of antidepressants. Our training programs do not equip graduates to work in the integrated care environment. Reimbursement rates for psychological service provision in medical settings are low, and psychologists do not have access to a full range of health and behavior codes (including the new collaborative care codes). The exclusion of psychology from the Medicare definition of physician further limits our reimbursement. Again, this column is not the place for a comprehensive review of these limiting factors. Besides, I think we are all pretty aware of them. The question is what will motivate us—both as providers and as a profession—to do something about it. No one else will if we don’t. Our patients deserve nothing less of us.

Read the May 2017 Newsletter.

References

  1. Hegarty JD, Baldessarini RJ, Tohen M, Waternaux C, Oepen G. One hundred years of schizophrenia: a meta-analysis of the outcome literature. Am J Psychiatry. 1994 Oct;151(10):1409-16. https://www.ncbi.nlm.nih.gov/pubmed/8092334
  2. Chatterton, M. L., Stockings, E., Berk, M., Barendregt, R. C., & Mihalopoulis, C. Psychosocial therapies for the adjunctive treatment of bipolar disorder in adults: network meta-analysis. The British Journal of Psychiatry, Feb, 2017, bjp.bp.116.195321; DOI: 10.1192/bjp.bp.116.195321
  3. Swartz, H. A., & Swanson, J. (2014). Psychotherapy for bipolar disorder in adults: A review of the evidence. Focus, 12, 251-266.
  4. Van Weersing, V. R., Brent, D. A., Rozenman, M. S., Gonzalez, A., Jeffreys, M., et al (2017). Brief behavioral therapy for pediatric anxiety and depression in primary care. JAMA Psychiatry, doi: 10.1001/jamapsychiatry.2017.0429
  5. Luk, E. K., Gorelik, A., Irving, L., & Khan, F. (2017). Effectiveness of cognitive behavioural therapy in a community-based pulmonary rehabilitation programme. Journal of Rehabilitation Medicine, 49, 264-269.
  6. M., & Marcus, S. C. (2009). National patterns in antidepressant medication treatment. Archives of General Psychiatry; 66, 848-856, doi:0.1001/archgenpsychiatry.2009.81.