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The Rationale for Combining Medication and Psychotherapy
Abstract
p>We practice in an era where medication and psychotherapy are used in combination for the treatment of most psychiatric disorders. These treatments are sometimes administered by the same psychiatrist but also may be divided between a psychiatrist and another mental health professional. The conceptual basis for providing both treatments is complex. One approach to dealing with this complexity is a simple dichotomizing of psychotherapy as a treatment for the “psychological” elements of a disorder and medication as a treatment for the “biological” aspects of the disorder. This rationale effectively resurrects an outmoded Cartesian dualism that splits the patient into a mind and a brain.
ABOUT THE AUTHOR
Dr. Gabbard is Brown Foundation Chair of Psychoanalysis and professor of psychiatry, Baylor College of Medicine, Houston, TX.
Address reprint requests to: Glen O. Gabbard, MD, 6655 Travis, Suite 500, Houston, Texas 77030; or e-mail ggabbard@bcm.edu .
Dr. Gabbard has no industry relationships to disclose.</p
... Having the skills and ability to prescribe medications allows for the viability of nurse practitioners in the mental health field. However, evidence is beginning to emerge that supports the efficacy of combined psychotherapeutic and pharmacological treatments (Arnow & Constantino, 2003;Cooper & Nasr, 2006;Elder, De Gasperi, & Gama Soso, 2006;Gabbard, 2006). PMH nurses, given adequate opportunities for developing these psychotherapy skills, are excellent candidates for a role that combines these two approaches. ...
The goal of excellence in nursing education has led to efforts to recruit students into baccalaureate and graduate programs. Additionally, a need exists to prepare practitioners to meet the mental health needs of health care recipients, including veterans. As a strategy for meeting these objectives, educators from an urban private college proposed a Psychiatric Mental Health Nurse Practitioner (PMHNP) program. This program was developed in response to an identified need in the community for improved mental health services. Although several groups in need would be served, attention was focused on veterans in need of care as well as those veteran students interested in Psychiatric Mental Health (PMH) nursing. Some factors that supported this thinking included the proximity of the campus to the Veterans Administration Medical Center and other veteran community services, the college's significant number of student veterans, and its distinction as among the most veteran friendly campuses in the nation. This article reviews the literature that supports the need for graduate education in this specialty and the value of providing educational opportunities for interested veterans.
... Research on the differential effects of psychotherapy and medication is growing but difficult to cover comprehensively because of the various types of psychotherapy (cognitive, behavioral, psychodynamic, interpersonal, etc.), the multiple medications available, and the different disorders being treated. Nonetheless, there is evidence that using psychotherapy and pharmacotherapy may provide better outcomes that either modality alone (Gabbard 2006). have a recognition, if they do need it, that maybe they need to stay on it. ...
Thispaperanalysestheconnectionbetweenpsychotherapyandneuroscience,exploringexistingliteratureandresearchfindingsonthistopic.Itfocusesonthefundamentalprinciplesofresearchingpsychotherapywithintheframeworkofneuroscience,investigatingthementalcorrelatesofpsychotherapy.Psychotherapyprovidesdeepinsightintopatients'unconsciousprocessesandthenecessityofreconstructinglatentmemorieswithinthetherapeuticenvironment.Therelationshipbetweentherapistandpatientcreatesanewaffectiveconfigurationthatenablesthereinterpretationofimplicitmemories,withneuronalchangesreflectingpsychictransformations.Byintegratingwithneuroscientificresearch,itprovidestheopportunitytoanalysetheimpactofotherscientificdisciplinesonpsychotherapeuticpracticeandensurestheintegrationofcomplexpsychotherapeuticconceptswithperspectivesfromotherscientificfields.Thisinterdisciplinaryapproachenrichesthedisciplineofpsychotherapy,successfullyincorporatingnewinsightsfromvariousareasofscience.Theconnectionofdifferentscientificdisciplinesreflectstheimprovementofunderstandingcomplexdynamicsofthemindandencouragesfurtherresearchandapplicationinthefieldofpsychotherapyandneuroscience. Keywords:psychotherapy,neuroscience,interdisciplinarity
Patients with eating disorders often rely on dissociation, cordoning off parts of the self that come to reside in disconnected mind and body states. In this paper, I explore the use of the multidisciplinary treatment team as a vehicle for accessing, engaging and linking the patient’s dissociated self-states as they emerge within different therapeutic dyads. While it is common for therapists who work with eating disorders to collaborate with other clinicians, the team has not typically been viewed as playing a role in the psychoanalytic process. Through a detailed case illustration, I demonstrate some of the ways that the treatment team can help to provide multiple perspectives on the same patient, generating a rich multiperson field that enhances and augments the psychoanalytic work. I also discuss challenges that can arise in concurrent therapy situations.
W miarę postępu w badaniach psychofarmakologicznych zaczęto podkreślać celowość łączenia prowadzenia farmakoterapii i psychoterapii, jako metod równoległego postępowania. Takie postępowanie — w świetle dostępnych badań okazuje się skuteczniejsze w leczeniu schizofrenii, dużej depresji, zaburzeń lękowych, choroby afektywnej dwubiegunowej, zaburzenia obsesyjno-kompulsywnego, dystymii, bulimii oraz uzależnienia od nikotyny. W literaturze obecne są zalecenia łączenia psychoterapii i farmakoterapii w zaburzeniach tak różnych, jak zaburzenia somatyzacyjne, osobowość typu borderline czy zaburzenia erekcji. Farmakoterapię łączy się z różnymi rodzajami psychoterapii: poznawczo-behawioralną, psychodynamiczną, interpersonalną, wspierającą i innymi. Łączenie farmakoterapii i psychoterapii, zarówno w podejściu zintegrowanym jak i rozdzielonym, staje się coraz częstszym podejściem w leczeniu zaburzeń psychicznych. Autor przedstawia poglądy z piśmiennictwa dotyczące łączenia farmakoterapii i psychoterapii, zestawia argumenty zwolenników i przeciwników takiego podejścia oraz wskazuje na problemy wynikające z połączenia obu metod.
Psychiatric Mental Health (PMH) Nurses are challenged to maintain the viability of their roles in today's healthcare climate as advances in research and complexity of mental healthcare needs of society continue to unfold. Today's mental health practice environment includes disciplines with marketable credentials. Roles for PMH nurses in recent decades are less clearly defined than for other disciplines, much of this related to changes in educational and practice settings. This article reviews literature on the topic of psychotherapy and a call for a renewed emphasis on this mode of treatment for psychiatric mental health advance practice nurses.
Combining medication and cognitive behavioral therapy (CBT) can be challenging but can also enhance patient care. This book reviews the existing literature about the neurobiological and clinical basis in combining CBT and medication for non-psychiatrist mental health clinicians. Filled with case studies drawn from the author's extensive clinical and teaching experience, this book breaks new ground in bringing together the most current, proven protocols for using drugs and CBT to improve client care. Practitioners will find in this volume the tools to make informed recommendations to patients.
Based on 11 months of ethnographic fieldwork at a residential treatment center in the United States, this article explores the varied meanings that female youth attribute to behavior and the strategic (mis)use of knowledge about psychiatric diagnosis and medication at a time when the scope of behaviors pathologized in young people continues to expand. Drawing upon psychological and critically applied medical anthropology, as well as contributions from philosophy on how classifications of people come into being and circulate, attention is paid to the multiple contradictions at work in diagnosing young people with mental disorders. A detailed examination of an exchange that occurred during one particular group therapy session is presented to demonstrate how psychiatric selves emerge in this environment when conventional labeling practices no longer suffice as an explanation of behavior. This turn to psychiatry reveals both the salience of and confusion around mental health treatment and diagnosis among adolescents, opens up the distinctions young people make between "real selves" and "medicated selves," and invokes the possibility of psychiatric disorder as a means to both forgive and discredit.
Cognitive Behavioral Therapy for the Busy Child Psychiatrist and Other Mental Health Professionals is an essential resource for clinical child psychologists, psychiatrists and psychotherapists, and mental health professionals. Since 2001, psychiatry residency programs have required resident competency in five specific psychotherapies, including cognitive-behavioral therapy. This unique text is a guidebook for instructors and outlines fundamental principles, while offering creative applications of technique to ensure that residency training programs are better equipped to train their staff.
Abstract The practice patterns of US psychiatrists have changed over the last two decades, favoring brief clinical encounters and a primary emphasis on pharmacologic care. The main focus of this paper is to illustrate the relevance of psychodynamic principles to prescribing practices. Psychodynamic aspects of pharmacotherapy will be described, including the dynamics of treatment adherence and nonadherence, medication selection, discontinuation, as well as aspects of transference and countertransference relevant to the practice of psychopharmacology. The dynamics of medication choice, underprescribing, and overprescribing will be reviewed to highlight the importance of psychodynamically informed psychopharmacology in the care of psychiatric patients. Special emphasis will be given to the contributions of attachment theorists to our understanding of treatment adherence. Psychoanalysts and dynamic psychiatrists are in a unique position to enhance psychopharmacologic case management by exploring the unconscious determinants of behavior.
The relationship between psychotherapy and psychiatry has become a beleagured one in recent years. The swing of the pendulum in the direction of biological psychiatry has led to a marginalization of psychotherapy within the discipline of psychiatry as a whole. However, psychotherapy continues to be a basic science of psychiatry with application in all clinical settings. It must be regarded as a biological treatment that works by changing the brain and is therefore just as important as pharmacotherapy in terms of overall treatment planning. The combined treatment of medication and psychotherapy has become the most common mode of psychiatric treatment planning in current practice. Both the two-treater model and the single-treater model have a set of advantages and disadvantages that are explicated. Further research is needed to identify clinical situations in which psychotherapy is essential, whether alone or in combination with medication. Moreover, as greater insights are gained into the brain mechanisms responsible for therapeutic changes, more specifically targeted psychotherapies can be developed.
At the time of discharge from their first stay in psychiatric hospital, 78 male schizophrenic patients were randomly assigned to a family intervention (experimental) group or a 'standard care' control group and were followed for the next 18 months. The family intervention consisted of both group and individual counselling sessions every 1-3 months that focused on education about the illness and on methods of dealing with the patient. There was a significantly lower rate of hospital readmission in the family intervention group than in the control group (15.4% versus 53.8%, chi 2 = 12.75, P < 0.01), and the mean hospital-free period for those who were readmitted was significantly longer in the experimental group than in the control group (245 days versus 130 days, t = 2.91, P < 0.01). Moreover, the clinical status and overall level of functioning in patients who were not readmitted were significantly better in experimental subjects than in control subjects. Stratified analysis showed that family intervention and regular use of medication had independent and additive effects on the outcome. During the 18 months after the index discharge patients who did not take medication regularly and who did not receive family intervention were 7.9 times as likely to be readmitted to hospital as patients who took medication regularly and received family intervention.
Panic disorder (PD) may be treated with drugs, psychosocial intervention, or both, but the relative and combined efficacies have not been evaluated in an unbiased fashion.
To evaluate whether drug and psychosocial therapies for PD are each more effective than placebo, whether one treatment is more effective than the other, and whether combined therapy is more effective than either therapy alone.
Randomized, double-blind, placebo-controlled clinical trial conducted in 4 anxiety research clinics from May 1991 to April 1998.
A total of 312 patients with PD were included in the analysis.
Patients were randomly assigned to receive imipramine, up to 300 mg/d, only (n=83); cognitive-behavioral therapy (CBT) only (n=77); placebo only (n=24); CBT plus imipramine (n=65); or CBT plus placebo (n=63). Patients were treated weekly for 3 months (acute phase); responders were then seen monthly for 6 months (maintenance phase) and then followed up for 6 months after treatment discontinuation.
Treatment response based on the Panic Disorder Severity Scale (PDSS) and the Clinical Global Impression Scale (CGI) by treatment group.
Both imipramine and CBT were significantly superior to placebo for the acute treatment phase as assessed by the PDSS (response rates for the intent-to-treat [ITT] analysis, 45.8%, 48.7%, and 21.7%; P=.05 and P=.03, respectively), but were not significantly different for the CGI (48. 2%, 53.9%, and 37.5%, respectively). After 6 months of maintenance, imipramine and CBT were significantly more effective than placebo for both the PDSS (response rates, 37.8%, 39.5%, and 13.0%, respectively; P=.02 for both) and the CGI (37.8%, 42.1%, and 13.0%, respectively). Among responders, imipramine produced a response of higher quality. The acute response rate for the combined treatment was 60.3% for the PDSS and 64.1% for the CGI; neither was significantly different from the other groups. The 6-month maintenance response rate for combined therapy was 57.1% for the PDSS (P=.04 vs CBT alone and P=.03 vs imipramine alone) and 56.3% for the CGI (P=.03 vs imipramine alone), but not significantly better than CBT plus placebo in either analysis. Six months after treatment discontinuation, in the ITT analysis CGI response rates were 41.0% for CBT plus placebo, 31.9% for CBT alone, 19.7% for imipramine alone, 13% for placebo, and 26.3% for CBT combined with imipramine.
Combining imipramine and CBT appeared to confer limited advantage acutely but more substantial advantage by the end of maintenance. Each treatment worked well immediately following treatment and during maintenance; CBT appeared durable in follow-up. JAMA. 2000;283:2529-2536
Patients with chronic forms of major depression are difficult to treat, and the relative efficacy of medications and psychotherapy is uncertain.
We randomly assigned 681 adults with a chronic nonpsychotic major depressive disorder to 12 weeks of outpatient treatment with nefazodone (maximal dose, 600 mg per day), the cognitive behavioral-analysis system of psychotherapy (16 to 20 sessions), or both. At base line, all patients had scores of at least 20 on the 24-item Hamilton Rating Scale for Depression (indicating clinically significant depression). Remission was defined as a score of 8 or less at weeks 10 and 12. For patients who did not have remission, a satisfactory response was defined as a reduction in the score by at least 50 percent from base line and a score of 15 or less. Raters were unaware of the patients' treatment assignments.
Of the 681 patients, 662 attended at least one treatment session and were included in the analysis of response. The overall rate of response (both remission and satisfactory response) was 48 percent in both the nefazodone group and in the psychotherapy group, as compared with 73 percent in the combined-treatment group. (P<0.001 for both comparisons). Among the 519 subjects who completed the study, the rates of response were 55 percent in the nefazodone group and 52 percent in the psychotherapy group, as compared with 85 percent in the combined-treatment group (P<0.001 for both comparisons). The rates of withdrawal were similar in the three groups. Adverse events in the nefazodone group were consistent with the known side effects of the drug (e.g., headache, somnolence, dry mouth, nausea, and dizziness).
Although about half of patients with chronic forms of major depression have a response to short-term treatment with either nefazodone or a cognitive behavioral-analysis system of psychotherapy, the combination of the two is significantly more efficacious than either treatment alone.
The aim of the study is to test whether fluvoxamine affects the function of the hypothalamic pituitary adrenal (HPA) axis in female borderline (borderline personality disorder, BPD) patients with and without a history of sustained childhood abuse. Special attention is given to the presence of comorbid major depressive disorder (MDD) and post-traumatic stress disorder (PTSD). The HPA axis of 30 female BPD patients with (n = 17) and without (n = 13) a history of sustained childhood abuse was challenged with a combined dexamethasone and corticotropin releasing hormone test (DEX/CRH test) before and after 6 (n = 14) and 12 (n = 16) weeks of fluvoxamine treatment (150 mg/day). Both 6- and 12-week fluvoxamine treatments were associated with a significant and robust reduction of the adrenocorticotrophic hormone (ACTH) and cortisol response to the DEX/CRH test. The magnitude of the reduction was dependent on the presence of sustained childhood abuse, but not on the presence of comorbid MDD or PTSD: patients with a history of sustained childhood abuse showed the strongest reduction in ACTH and cortisol. In conclusion, Fluvoxamine treatment reduces the hyperresponsiveness of the HPA axis in BPD patients with a history of sustained childhood abuse. This effect is likely to be obtained in the first 6 weeks of treatment.
Functional imaging studies of major depressive disorder demonstrate response-specific regional changes following various modes of antidepressant treatment.
To examine changes associated with cognitive behavior therapy (CBT).
Brain changes underlying response to CBT were examined using resting-state fluorine-18-labeled deoxyglucose positron emission tomography. Seventeen unmedicated, unipolar depressed outpatients (mean +/- SD age, 41 +/- 9 years; mean +/- SD initial 17-item Hamilton Depression Rating Scale score, 20 +/- 3) were scanned before and after a 15- to 20-session course of outpatient CBT. Whole-brain, voxel-based methods were used to assess response-specific CBT effects. A post hoc comparison to an independent group of 13 paroxetine-treated responders was also performed to interpret the specificity of identified CBT effects.
A full course of CBT resulted in significant clinical improvement in the 14 study completers (mean +/- SD posttreatment Hamilton Depression Rating Scale score of 6.7 +/- 4). Treatment response was associated with significant metabolic changes: increases in hippocampus and dorsal cingulate (Brodmann area [BA] 24) and decreases in dorsal (BA 9/46), ventral (BA 47/11), and medial (BA 9/10/11) frontal cortex. This pattern is distinct from that seen with paroxetine-facilitated clinical recovery where prefrontal increases and hippocampal and subgenual cingulate decreases were seen.
Like other antidepressant treatments, CBT seems to affect clinical recovery by modulating the functioning of specific sites in limbic and cortical regions. Unique directional changes in frontal cortex, cingulate, and hippocampus with CBT relative to paroxetine may reflect modality-specific effects with implications for understanding mechanisms underlying different treatment strategies.
Adherence to antidepressant medication use is a problem in clinical practice. Some authors have posited that combined psychological treatment facilitates adherence to pharmacotherapy.
To study the relationship between adherence to use of and efficacy of antidepressant drugs plus psychological treatment vs drug treatment alone in depressive disorders.
MEDLINE, Current Contents, PsychInfo, Cochrane Library, and reference lists were searched, from January 1980 to November 2002.
Randomized clinical trials comparing antidepressant treatment alone with antidepressant treatment in combination with a psychological intervention in depressive disorders were considered. The decision to include studies in the meta-analysis was performed by 2 reviewers.
Three independent reviewers extracted the data, using a precoded form. Methodological quality of the studies was evaluated in terms of allocation concealment and independence of evaluators.
Sixteen trials met the inclusion criteria, with 932 patients randomized to pharmacotherapy alone and 910 to combined treatment. Overall, patients receiving combined treatment improved significantly compared with those receiving drug treatment alone (odds ratio [OR], 1.86; 95% confidence interval [CI], 1.38-2.52), but dropouts and nonresponders did not differ in distribution between the 2 treatment modalities (OR, 0.86; 95% CI, 0.60-1.24). Studies longer than 12 weeks showed a significant advantage of combined treatment over drug treatment alone (OR, 2.21; 95% CI, 1.22-4.03), with a significant reduction in dropouts compared with nonresponders (OR, 0.59; 95% CI, 0.39-0.88). These estimates were not affected by study quality.
Psychological treatment combined with antidepressant therapy is associated with a higher improvement rate than drug treatment alone. In longer therapies, the addition of psychotherapy helps to keep patients in treatment. Further studies are needed to investigate whether the improvement in response attributable to the combination of drug treatment and psychotherapy can be achieved by a combination of pharmacotherapy and a compliance-enhancing intervention.
Studies comparing the efficacy of combined psychotherapy and pharmacotherapy to single treatment (i.e., either psychotherapy or pharmacotherapy alone) for major depression have not found consistent differences in outcome, resulting in a range of conclusions regarding the efficacy of combined treatment. In order to clarify the efficacy of combined treatment for depression, the authors conducted both a meta-analytic and qualitative review. Our findings suggest that combined treatment is associated with a small improvement in efficacy, and that this finding appears consistent across studies. Trends in the literature suggest that adding psychotherapy to antidepressant medication may be particularly efficacious among chronic or severely depressed patients. Further, adding cognitive-behavioral therapy to medication may be particularly efficacious in preventing relapse, particularly among individuals discontinuing medication use. The authors propose an illness-cognition model for better understanding outcomes in combined treatment.
Brain research on mental illnesses has made substantial advances in recent years, supported by conceptual and technological
developments in cognitive neuroscience. Brain-based cognitive models of illnesses such as schizophrenia and depression have
been tested with a variety of techniques, including the lesion method, tract tracing, neuroimaging, animal modeling, single-cell
recording, electrophysiology, neuropsychology, and experimental cognitive psychology. A relatively sophisticated picture is
emerging that conceptualizes mental illnesses as disorders of mind arising in the brain. Convergent data using multiple neuroscience
techniques indicate that the neural mechanisms of mental illnesses can be understood as dysfunctions in specific neural circuits
and that their functions and dysfunctions can be influenced or altered by a variety of cognitive and pharmacological factors.
Polarisation of biological and psychosocial aspects of psychiatry has promoted a form of Cartesian dualism. Current knowledge of the interaction between biology and psychology makes it possible to consider a truly integrative approach to treatment.
The aim of this overview is to consider conceptual models of how psychotherapy may affect the brain.
The literature discussing the mutual influence of genes and environment is surveyed. Relevant data involving the influence of psychotherapy on the brain are also reviewed.
Research findings suggest that the brain responds to environmental influence through the alteration of gene expression; that psychotherapy has specific measurable effects on the brain; and that implicit memory may be modified by psychotherapeutic interventions.
Advances in neuroscience research have led to a more sophisticated understanding of how psychotherapy may affect brain functioning. These developments point the way towards a new era of psychotherapy research and practice in which specific modes of psychotherapy can be designed to target specific sites of brain functioning.
The aim of this study was to determine whether the substantial gains made by patients with borderline personality disorder following completion of a psychoanalytically oriented partial hospitalization program, in comparison to patients treated with standard psychiatric care, were maintained over an 18-month follow-up period.
Forty-four patients who participated in the original study were assessed every 3 months after completion of the treatment phase. Outcome measures included frequency of suicide attempts and acts of self-harm, number and duration of inpatient admissions, service utilization, and self-reported measures of depression, anxiety, general symptom distress, interpersonal functioning, and social adjustment.
Patients who completed the partial hospitalization program not only maintained their substantial gains but also showed a statistically significant continued improvement on most measures in contrast to the patients treated with standard psychiatric care, who showed only limited change during the same period.
The superiority of psychoanalytically oriented partial hospitalization over standard psychiatric treatment found in a previous randomized, controlled trial was maintained over an 18-month follow-up period. Continued improvement in social and interpersonal functioning suggests that longer-term changes were stimulated.
Of all the human professions, psychiatry is most centrally concerned with the relationship of mind and brain. In many clinical interactions, psychiatrists need to consider both subjective mental experiences and objective aspects of brain function. This article attempts to summarize, in the form of a dialogue between a philosophically informed attending psychiatrist and three residents, the major philosophical positions on the mind-body problem. The positions reviewed include the following: substance dualism, property dualism, type identity, token identity, functionalism, eliminative materialism, and explanatory dualism. This essay seeks to provide a brief user-friendly introduction, from a psychiatric perspective, to current thinking about the mind-body problem.
The authors suggest that pharmacotherapy and psychotherapy, the major treatment modalities in psychiatry, have become fragmented from one another, creating an artificial separation of the psychosocial and biological domains in psychiatry.
After a brief discussion of the economic factors influencing this trend, the authors provide a selective overview of recent research. In the absence of systematic empirical data regarding which patients and which conditions might benefit from integrated treatment by one psychiatrist, the authors propose specific clinical situations that call for such integration and also discuss concerns about cost-effectiveness.
Recent research suggests that combining psychotherapy and pharmacotherapy may have advantages over either treatment alone in certain clinical situations involving specific disorders. While few of the studies on combined treatment have tested whether a one-person or two-person model of treatment provision is more effective, there are a number of advantages to the one-person treatment model in which a psychiatrist conducts the psychotherapy and prescribes medication for the same patient.
The authors suggest that further research is needed to clarify the optimal situations for the one-person model of integrated treatment and also propose systematic teaching of integrated treatment in all residency training programs.
The authors compared a combination of clomipramine and psychodynamic psychotherapy with clomipramine alone in a randomized controlled trial among patients with major depression.
Seventy-four patients between the ages of 20 and 65 years who were assigned to ten weeks of acute outpatient treatment for major depression were studied. Bipolar disorder, psychotic symptoms, severe substance dependence, organic disorder, past intolerance to clomipramine, and mental retardation were exclusion criteria.
Marked improvement was noted in both treatment groups. Combined treatment was associated with less treatment failure and better work adjustment at ten weeks and with better global functioning and lower hospitalization rates at discharge. A cost savings of 2,311 dollars per patient in the combined treatment group, associated with lower rates of hospitalization and fewer lost work days, exceeded the expenditures related to providing psychotherapy.
Provision of supplemental psychodynamic psychotherapy to patients with major depression who are receiving antidepressant medication is cost-effective.
High coincidence of childhood abuse, major depressive disorder (MDD), and posttraumatic stress disorder (PTSD) has been reported in patients with borderline personality disorder (BPD). Animals exposed to early trauma show increased stress-induced hypothalamic-pituitary-adrenal (HPA) axis activity due to an enhanced corticotropin-releasing hormone (CRH) drive and glucocorticoid feedback resistance. In humans, PTSD and MDD are associated with decreased and increased resistance to glucocorticoid feedback, respectively, which might reflect persistent changes in neuroendocrine sequelae following childhood abuse.
We investigated the relationship between childhood abuse and HPA axis function using a combined dexamethasone/CRH (DEX/CRH) test in 39 BPD patients with (n = 24) and without (n = 15) sustained childhood abuse and comorbid PTSD (n = 12) or MDD (n = 11) and 11 healthy control subjects.
Chronically abused BPD patients had a significantly enhanced corticotropin (ACTH) and cortisol response to the DEX/CRH challenge compared with nonabused subjects. Comorbid PTSD significantly attenuated the ACTH response.
Hyperresponsiveness of the HPA axis in chronically abused BPD subjects might be due to the enhanced central drive to pituitary ACTH release. Sustained childhood abuse rather than BPD, MDD, or PTSD pathology accounts for this effect. Possibly due to an enhanced efficacy of HPA suppression by dexamethasone, PTSD attenuates the ACTH response to DEX/CRH.
The relative efficacy of psychotherapy and combined therapy in the treatment of depression is still a matter of debate.
To investigate whether combined therapy has advantages over psychotherapy alone.
A 6-month randomised clinical trial compared Short Psychodynamic Supportive Psychotherapy (n=106) with combined therapy (n=85) in ambulatory patients with mild or moderate major depressive disorder diagnosed using DSM-IV criteria. Antidepressants were prescribed according to a protocol providing four successive steps in case of intolerance or inefficacy: venlafaxine, selective serotonin reuptake inhibitor, nortriptyline and nortriptyline plus lithium. Efficacy was assessed using the 17-item Hamilton Rating Scale for Depression, the Clinical Global Impression of Severity and of Improvement, and the depression sub-scale of the Symptom Checklist.
The advantages of combining antidepressants with psychotherapy were equivocal. Neither the treating clinicians nor the independent observers were able to ascertain them, but the patients experienced them clearly.
The advantages of combining antidepressants with psychotherapy are equivocal.
The use of the terms "mind" and "brain" in psychiatry is often associated with a set of polarities. Concepts such as environment, psychosocial, and psychotherapy are linked with "mind," while genes, biology, and medication are often associated with "brain." The author examines these dichotomies as they apply to personality disorders.
Research on antisocial and borderline personality disorders that is relevant to these dichotomies is evaluated. The implications of the findings for the understanding of pathogenesis and treatment are reconsidered.
In the clinical setting, it is problematic to lump together terms such as "genes," "brain," and "biological" as though they are separate and distinct from terms such as "environment," "mind," and "psychosocial." These dichotomies are problematic, because genes and environment are inextricably intertwined in the pathogenesis of personality disorders, psychosocial experiences may result in permanent changes in the brain, and psychotherapy may have its effect by altering brain structure and function. The "theory of mind" is a useful construct for bridging "mind" and "brain" in the treatment of personality disorders.
Severe personality disorders are best understood and treated without "either-or" dichotomies of brain and mind. Each domain has a different language, however, and the language of the mind is necessary to help the patient develop a theory of mind.