Ms. Suarez, a 48-year-old married Hispanic woman, came to her appointment at the outpatient psychiatry clinic asking for a second opinion. She told the admitting resident that she had had depression for years, and that nothing had helped. She said she had tried many medications and individual therapy, and she was feeling hopeless and frustrated. She worried that her husband would leave her. She was still working, but felt that the quality of her work was poor.
The psychiatric resident wondered whether to put her in the psychopharmacology clinic or in the psychotherapy clinic. What should the resident do? The American Psychiatric Association Symposium No. 81, from 9 a.m. to noon on May 8 in Philadelphia, will answer this question.
The symposium is called "Improving Quality of Care for Patients with Psychiatric Illness: Combining and Integrating Psychopharmacological, Individual, and Family Therapy." I will be presenting the symposium with Dr. Alan F. Schatzberg, Dr. Glen O. Gabbard, and Dr. Gabor I. Keitner as panelists, and Dr. Ira D. Glick as the discussant. We’ll be looking at the following topics:
• Dr. Schatzberg will discuss "Combining Pharmacotherapy With Other Modalities."
Psychopharmacology has become a major approach in the treatment of patients with psychiatric disorders. The discipline has evolved from its humble beginnings with a limited number of classes of agents that had a relatively narrow range of mechanisms of action, to the current host of classes and agents, many with disparate effects. This development demands considerable knowledge of the basic biology of the disorder, as well as the specific pharmacology of specific agents.
The development of this field, however, is not the only one in psychiatric treatment. Rather, parallel developments have taken place in the psychotherapies – as well as in devices – such that the practitioner needs to be able to incorporate advances in all of them to most optimally help his or her patient.
As models of other areas in psychiatry, recent developments in psychopharmacology and stimulatory device treatment of major depression will be reviewed, with data from studies on the biology of early abuse and cognitive deficits in depression and with an eye toward understanding how these various approaches can be integrated optimally to treating particular patients.
Early child abuse is associated with an increased risk for developing increased responsiveness to stress, as well as major depression in adulthood, and this risk interacts with specific genetic vulnerability. These patients might respond to medication, but do best when medications are combined with psychotherapy. Optimally, effective treatment outcomes will require the sophisticated application of knowledge of biology, pharmacology, and psychotherapy. In addition, training and education need to incorporate such approaches.
• Dr. Gabbard will discuss "Combining Individual Therapy With Other Modalities."
In the practice of general psychiatry, it inevitably becomes necessary to combine medication and psychotherapy techniques. However, this combination is undertheorized in our literature. In this presentation, the practice of combining individual therapy strategies and pharmacotherapy will be systematically considered from the standpoint of adherence, meanings of medication, enhancement of outcome, and different modes of therapeutic action. This presentation will address the practical matter of sequencing of the two modalities overall and within sessions.
• Dr. Keitner will discuss "Family Intervention by Psychiatrists as a Routine Component of Patient Care."
Illnesses begin and evolve in a social context, and affect friends and relatives of the ill person. The ways in which the patient’s significant others, in turn, deal with the illness influence its course and outcome.
It is necessary, therefore, to involve the families of patients in the assessment and treatment process. Family interventions can be stand-alone treatments or adjuncts to pharmacotherapy and psychotherapy. Numerous family-assessment and family-therapy models have been tested for use in many different illnesses. In general, family interventions have been found to be useful in the management of many chronic medical conditions as well as in major depression, bipolar disorder, anxiety disorders, schizophrenia, and substance abuse.
Most psychiatrists are not comfortable with or skilled in working with families, despite the evidence for its usefulness. This presentation will outline ways in which psychiatrists can systematically involve the families of patients in their assessment and treatment, and ways to combine and integrate family interventions with pharmacotherapy and psychotherapy.
For many decades, a biopsychosocial approach to patient care has meant a comprehensive assessment of the patient and the family environment. However, little discussion has occurred regarding what follows. What should follow is an extensive discussion with the patient and family about treatment. Clinical decision making should be done with the patient and the family, and should include a discussion of the biopsychosocial components that contribute to the illness, followed by a discussion of treatment options. The expected changes for each modality must be provided to the patient and family.