Combined Medication and Psychotherapy: Other Indications and Contraindications
As suggested by the AHCPR guidelines, combined treatment may be indicated when clinical circumstances suggest two discrete targets of therapy that are each best addressed by one or the other of the respective modalities (Depression Guideline Panel 1993). For example, patients who are both depressed and experiencing significant interpersonal or vocational problems may benefit from receiving both drugs and psychotherapy. This is consistent with the notion that combining medication and psychotherapy may enhance the breadth of response associated with each. Moreover, pharmacotherapy probably has a more robust effect on acute symptom reduction than does psychotherapy. For example, drug-placebo differences were relatively robust across sites in the National Institute of Mental Health Treatment of Depression Collaborative Research Program (Elkin et al. 1989), whereas the effects of psychotherapy varied considerably as a function of site (Jacobson and Hollon 1996a, 1996b). Conversely, some types of psychotherapy appear to have more enduring effects after treatment termination than do medications (Hollon et al. 1991a; Rush and Thase 1999). It is probably the case that pharmacotherapy depends less on the skill of the individual practitioner to be effective than does psychotherapy, with the latter being more likely to redress existing defects or provide lasting skills that survive the end of treatment.

Contraindications to combined treatment are those inherent in either single modality. Some patients simply cannot tolerate medications or should not be treated pharmacologically because of preexisting medical conditions or possible complications. There are fewer known contraindications to the use of psychotherapy, but it does add time and expense and may not be warranted in all cases. As we shall see, the existing literature is at best suggestive about the utility of combining drugs and psychotherapy. There is substantial evidence that combined treatment is at least as effective as either single modality alone, but it remains unclear whether the real or suggested benefits outweigh the added risks or additional costs for most patients.