For patients with psychiatric illnesses, the treatment team today often consists of a psychotherapist, psychiatrist, and/or primary care physician—all of whom are motivated to achieve the same goals. These include full remission of symptoms; improvement and restoration of function, quality of life, and relationships; and the delay and preferably prevention of recurrence of symptoms. As a result of a variety of medical and socioeconomic factors, cotreatment is becoming the rule rather than the exception. The patient receives psychotherapy from a psychotherapist while receiving medication from a psychiatrist or primary care physician. Some psychiatrists embrace this model, while others vehemently oppose it.
Pitfalls and benefits of cotreatment
Cotreatment has potential dangers. These include inappropriate prescribing of medication without the physician's full knowledge of the patient's history (because the patient has been seen for only brief periods of time). The psychotherapist and psychiatrist may give discrepant information to the patient, creating confusion and misalliance. Splitting by the patient may occur. Unclear issues of confidentiality may occur, with associated clouded clinical and legal responsibility con cern ing who is responsible to the patient in times of emergencies and with whom the ultimate decision making rests when disagreements occur between the therapist and physician. Finally, reimbursement conflicts can occur if the patient has limited sessions authorized by the managed care company.
However, there are also many potential benefits of cotreatment. Psychiatrists, psychologists, and other psychotherapists bring to the treatment team different experiences, education, and approaches. Use of the special talents of each person on the treatment team can be of significant benefit to the patient. While controversial in some situations, use of a cotreatment model may represent a more cost-effective use of resources. There may be the opportunity for the patient to choose a therapist of similar ethnic background and gender if desired; this is especially beneficial if a psychiatrist/physician of that ethnic background or gender is not available in that location. There can be an increase in time and resources made available to the patient. Finally, cotreatment allows for support between the psychotherapist and the psychiatrist or other physician, which is especially important when dealing with complicated, difficult, challenging, and problematic cases.
Regardless of your opinion of cotreatment, this will likely be the continuing model, at least for the foreseeable future. In this article, I will discuss several keys to successful cotreatment.
Understanding the benefits
The first key is to understand the benefits of combining psychotherapy and pharmacotherapy. A number of studies have demonstrated that the combination of psychotherapy—for example, cognitive psychotherapy—and pharmacotherapy is more effective than either modality alone. A meta-analysis by Friedman and associates1 of 5 studies involving 685 patients demonstrated that rates of remission with the combination of cognitive therapy and medication were significantly higher than rates of remission with medication only.
The largest study included in this meta-analysis was that by Keller and colleagues2 that compared a cognitive behavioral-analysis system of psycho therapy versus nefazodone versus the combination in patients with chronic depression. The investigators found the combination to be clearly statistically superior to either of the individual treatments in this difficult and challenging group of patients. There is evidence that psychotherapy decreases relapse rates following incomplete remission of depression,3 that it attenuates panic at tacks during discontinuation of benzodiazepines,4 and that it is more effective in combination with drug therapy (than drug therapy alone) in the treatment of panic disorder5 and social anxiety disorder.6
1. Friedman ES, Wright JH, Jarrett RB, Thase ME. Combining cognitive therapy and medication for mood disorders. Psychiatr Ann. 2006;36:320-328.
2. Keller MB, McCullough JP, Klein DN, et al. A comparison of nefazedone, the cognitivebehavioral-analysis system of psychotherapy, and their combination for the treatment of chronic depression. N Engl J Med. 2000; 342:1462-1470.
3. Paykel ES, Scott J, Teasdale JD, et al. Prevention of relapse in residual depression by cognitive therapy: a controlled trial. Arch Gen Psychiatry. 1999;56:829-835.
4. Otto MW, Pollack MH, Sachs GS, et al. Discontinuation of benzodiazepine treatment: efficacy of cognitive-behavioral therapy for patients with panic disorder. Am J Psychiatry. 1993;150:1485-1490.
5. Grilo CM, Money R, Barlow DH, et al. Pretreatment patient factors predicting attrition from a multicenter randomized controlled treatment study for panic disorder. Compr Psychiatry. 1998;39:323-332.
6. Huppert JD, Franklin ME, Foa EB, Davidson JR. Study refusal and exclusion from a randomized treatment study of generalized social phobia. J Anxiety Disord. 2003;17: 683-693.
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8. Gundel H, O’Connor MF, Littrell L, et al. Functional neuroanatomy of grief: an fMRI study. Am J Psychiatry. 2003;160:1946-1953.
9. Goldapple K, Segal E, Garson C, et al. Modulation of cortical-limbic pathways in major depression: treatment specific effects of cognitive behavior therapy. Arch Gen Psychiatry. 2004;61:34-41.
10. Balon R. Positive and negative aspects of split treatment. Psychiatr Ann. 2001;31:598-603.
11. Balon R. Collaborative treatment: the practice of med ication backup. Primary Psychiatry. 1999;6:41-49.
12. Riba MB, Balon R. The challenges of split treatment. In: Kay J, ed. Integrated Treatment of Psychiatric Disorders. Washington, DC: American Psychiatric Press; 2001:143-164.