Adding Psychotherapy to Medication in Depression and Anxiety
Dr Christian Jonathan Haverkampf, M.D.
The effects of combined treatment compared with placebo are usually larger than those of medication only compared with placebo, underscoring the clinical advantage of combined treatment. Combined treatment appears to be more effective than treatment with antidepressant medication alone in major depression, panic disorder, and OCD. Thus, adding psychotherapy to medication is, in the large majority of cases, necessary for optimum treatment.
Keywords: psychotherapy, medication, psychiatry
Table of Contents
Medication and Psychotherapy. 4
Communication between Psychotherapist and Prescriber. 5
Introduction
Psychotherapy and medication both affect how information is transmitted and processed within a person and between the person and the environment. Given the high plasticity and connectivity of the brain, information flows determine to a large extent the morphological and physiological network of neurons within the brain. Both, medication and psychotherapy, affect these information flows and thus also the neural networks within the brain.
Medication and psychotherapy affect the neural networks in different ways but lead to similar results in relieving symptoms. Their timing can be quite different. Medication may in some cases provide faster relied. While psychotherapy can take longer. However, it may also be the other way around, when only the prospect of help can bring changes in psychotherapy early on.
Due to the plasticity of the brain, psychotherapy can medication can bring about lasting changes. However, since psychotherapy changes information content and flows more selectively, and more specifically also to situations and events in the environment, can lead to better fine-tuned and more specific changes in the individual. This could at least in theory lead to longer lasting changes.
Anxiety and Depression
Anxiety and depressive disorders are highly prevalent and are associated with a substantial loss of quality of life for patients and stress for relatives and friends. They cause high substantial economic costs, and a considerable disease burden for public health. Effective treatments are available for these disorders, including several types of psychotherapy and antidepressant medication.
Medication and Psychotherapy
Although psychotherapy and antidepressants are about equally effective for most anxiety and depressive disorders, there is some evidence that combined treatments may be more effective than each of these treatments alone. At the same time, however, an increasing proportion of patients with mental disorders in the past decade have received psychotropic medication without psychotherapy.
Psychotherapy as a treatment option, and as a general approach to mental health using communication as the basic tool, should always be the starting point when it comes to treating a mental health problem. Medication is less specific than psychotherapy from an information and communication perspective but can be a very valuable support in many cases and gains significant relevance in more severe mental health conditions, particularly those which have primarily a biological explanation.
Communication
The detrimental effects of anxiety and depression come mostly from the impact they have on internal and external communication. Whether it is a greater disconnectedness from oneself or from the world, which are usually present in both anxiety and depression, developing better communication patterns with oneself and others is an important piece towards recovery in moat mental health conditions, particularly in anxiety and depression. (Haverkampf, 2010) Various techniques can be helpful in this regard, including also body focused work, but a communication-oriented psychotherapy is probably the most direct way of working with communication patterns that have become maladaptive and unhelpful to the individual.
Understanding
One of the main problems if medication is not working or compliance is low is that patients do not understand what the medication does and how it does it. The same applies also to psychotherapy. An understanding for how things work is an important element to make something work. The more a patient understands about how a medication or a psychotherapeutic technique works, the easier it is for the patient to see how they can fit together. This increases the effectiveness of both and the compliance.
Language
Understanding requires that the other person can encode a message in such a way that the meaning of it can be accurately decoded by the other person. This requires that the therapist, for example, uses words that can be easily understood by the patient. On the other side, it is important that the patient can communicate his or her thoughts about the medication. This requires a setting that conveys a sense of safety and openness. A communication-oriented psychotherapeutic approach can provide this.
Communication between Psychotherapist and Prescriber
If the psychotherapist is not also the prescriber, the communication between psychotherapist and prescriber is important. This communication can determine how effective the medication and the psychotherapy eventually will be. Regarding psychotherapy and medication as equally important instruments can be helpful in this communication. Information from a psychotherapeutic perspective helps the prescriber, while information from the medical perspective helps the psychotherapist.
Empirical studies
Since scientific journals are specialized in fields and their readership and editors usually practice in that field, whether medication or a specific brand of psychotherapy, there is, of course, a risk that a journal will publish reports that interest its readership, that is things that work than things that so not work. The publication bias is probably large when two approaches, medication and psychotherapy, are contrasted, in which one side often has incomplete knowledge about the other. This can lead to misunderstandings and dogmatic viewpoints.
At least one study showed that even after adjusting for publication bias, the superiority of combined treatment was still statistically significant. The researchers also found some indications that the difference between pharmacotherapy and combined treatment was especially high in clinical samples compared with samples that were (in part) recruited from the community. It may suggest that patients actively seeking treatment may benefit more from combined treatment than people who are recruited from the community.
Synergies
Studies have found indications that the effects of combined treatment compared with placebo only were about twice as large as those of pharmacotherapy compared with placebo only. This would imply that the effects of psychotherapy and pharmacotherapy may be largely independent from each other and additive, not interfering with each other, and both contribute about equally to the effects of combined treatment. However, this probably depends on the type of psychotherapy used. Since better communication is an important part of therapy, and it has been shown that better communication increases the effectiveness and compliance of medication, possible synergies are probably greater with a therapeutic approach that focuses on communication rather than a predominantly manualized technical approach.
Most patients receive either pharmacotherapy or psychotherapy, and only a minority receives combined therapy. The synergistic effect does not seem to depend on the severity of the condition in both anxiety and depression. Efforts should thus be increased to make both approaches available to patients, which does not mean both are always needed or recommended. However, open communication with the aim of mutual understanding between therapist and patient and a better understanding of the underlying condition should always be pursued.
Communication
Both therapies may be helped by the other. In clinical practice, medication seems to facilitate psychotherapy, and psychotherapy can raise the compliance and possibly the tolerance for medication. (Haverkampf, 2018) They thus work well together, and both can lead to enduring effects after treatment has ended. It is, however, the better communication with oneself and the world to be gained on the psychotherapeutic side which can lead to life-long effects. Improvements and more flexibility in internal and external communication patterns is a major part of it. (Haverkampf, 2017a) But even here medication can, if used correctly, be a helpful support in facilitating this.
Conclusion
It is important to use what achieves the greatest effect consistently and with the lowest risk. Communication plays here an important role on both the medication and the psychotherapy sides. Better ways of communicating help on the psychotherapy and the medication side, while both together in clinical practice often work synergistically. However, this combined effect often also depends on the type of psychotherapy used. For anxiety and depression a more communication focused therapy shows to be helpful. (Haverkampf, 2013, 2017b, 2017c, 2017d)
Dr Jonathan Haverkampf, M.D. MLA (Harvard) LL.M. trained in medicine, psychiatry and psychotherapy and works in private practice for psychotherapy, counselling and psychiatric medication in Dublin, Ireland. The author can be reached by email at jo****************@gm***.com or on the websites www.jonathanhaverkampf.com and www.jonathanhaverkampf.ie.
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