Combined Medication and Psychotherapy: Combined Treatment
It is not always clear where pharmacotherapy ends and psychotherapy begins; almost all pharmacotherapy is provided in the context of a therapeutic relationship that goes beyond the mere provision of medications. It has long been recognized that the nonspecific aspects of the patient-physician relationship play a role in determining both compliance and response (Rickels 1968). Fawcett and colleagues (1987) articulated an approach to clinical management that is largely supportive in nature and shares much in common with nonspecific approaches to psychotherapy. It has been suggested that it was the provision of pharmacotherapy in this fashion that accounted for the unexpectedly strong showing of the pill placebo condition in the National Institute of Mental Health Treatment of Depression Collaborative Research Program (Elkin et al. 1989), although this has not been examined empirically.

Applications and Procedures
There has been little systematic research into the optimal timing for combined treatment. Most of the studies comparing combined treatment with the respective single modalities have started both arms of treatment simultaneously, but it is by no means clear that this must be the case (see, e.g., Klerman et al. 1974). Clinically, more severely depressed or manic patients are often first stabilized with medications (or somatic treatments) before psychotherapy is instituted. Similarly, patients who fail to respond fully to one modality sometimes benefit from having the other added (Basco and Rush 1996). As has already been discussed, several recent studies have shown that CT can be effective in reducing residual symptoms in medicated patients and preventing subsequent relapse or recurrence.

Patients who receive combined treatment often work with a different therapist in each modality, although this need not be the case for pharmacotherapists who are also competent psychotherapists. If multiple therapists are involved, it is important that they communicate with each other and not work at cross-purposes. It is particularly helpful for both therapists to describe depression as a disorder in which biological and psychological factors often combine to produce distress, and to present a rationale for treatment that provides a complementary role for both medications and psychotherapy.

Case Examples
We next present two specific case examples that highlight general points of interest discussed in our previous review. The first describes a fairly typical example of combined treatment and is drawn from a more extensive case discussion that included commentaries by the patient and both therapists (Hollon et al. 1986). With that patient, both pharmacotherapy (up to 300 mg/day of imipramine) and CT were started simultaneously, with a different therapist providing each. Although the therapists discussed the case frequently (we cannot stress the importance of this strongly enough), each essentially proceeded as if providing his respective single modality alone, with two notable exceptions. First, both therapists made sure to provide a common rationale for treatment that incorporated elements of the other approach. That is, both therapists described depression as a biopsychosocial phenomenon in which cognition, affect, and behavior were all related to an underlying biology and in which changes in one aspect of the system might well have reciprocal causal influences on other aspects. Second, there was at least one instance in which the cognitive therapist helped the patient work through issues regarding her relationship to her pharmacotherapist that might have resulted in noncompliance or attrition. In that instance, the patient had slept through a scheduled session with her pharmacotherapist and had begun to experience strong feelings of guilt and shame regarding what she perceived as her incompetence and unreliability, concerns that she expected her pharmacotherapist to share. Although she was too embarrassed to talk with her physician (whom she regarded as an unapproachable authority figure), she was able to bring the matter up with her cognitive therapist. Her cognitive therapist then briefly assisted her in assessing the accuracy of her beliefs and encouraged her to test her beliefs by talking directly to her physician about her concerns. As a consequence of her pharmacotherapist’s unexpected openness and willingness to discuss the specific instance, she became more comfortable raising other issues regarding the medication regimen and their working relationship.

The second example provides an illustration of the use of psychotherapy to help a patient become more amenable to pharmacotherapy, which in turn had a profound effect on symptom reduction. The patient was a young adult man who suffered from severe recurrent depression (and some history of hypomania) but who refused medications because of his involvement in Alcoholics Anonymous. A recovering alcoholic, he had come to believe that the use of any medication would undermine his ability to remain abstinent from alcohol and represented a sign of moral weakness. After initial discussions failed to dislodge this view, the therapist proceeded with a standard course of CT. Treatment consisted of examination of the link between thoughts and feelings, training in systematic self-monitoring and behavioral activation, and the provision of strategies for systematically evaluating the accuracy and functionality of specific beliefs.

During the first several weeks of treatment, it became apparent that although the more behavioral strategies were having some effect by virtue of imposing structure on what had been a rather chaotic lifestyle, the more purely cognitive interventions were doing little to lift the patient’s mood. Although he could identify negative beliefs and examine their accuracy in a manner that typically proves effective in unipolar depressive patients, he remained quite depressed. At this point, the therapist again raised the prospect of adding medications to the treatment regimen and suggested that the patient reexamine his beliefs regarding the dangers of pharmacotherapy using his newly developed cognitive skills. This became the focus of the next several sessions, buttressed by outside readings and behavioral experiments with over-the-counter pharmaceuticals such as aspirin and vitamin supplements. Once the patient became convinced that he could take nonaddictive substances without undermining his own sense of control over alcohol, he was amenable to referral to a pharmacotherapist, who added an antidepressant to the CT regime. Symptom improvement was rapid after this point, and the patient was soon able to resume a career that had been disrupted by his illness.

Conclusions
Although there is little clear evidence that combined treatment is superior to either single modality with respect to acute symptom reduction, combined treatment does appear to enhance the breadth of response. Pharmacotherapy appears to produce rapid and reliable reductions in symptoms and to suppress relapse or recurrence, whereas psychotherapy can enhance social functioning or reduce subsequent risk, depending on the type of psychotherapy. There are even indications that combined treatment may produce a modest increment in acute response, and there are a few scattered suggestions of enhanced probability of response (particularly among patients with a history of chronic depression). There appear to be no contraindications to combining drugs and psychotherapy, other than those associated with each of the single modalities, and specific examples can be provided in which each appears to enhance the effectiveness or acceptability of the other. Given the general efficacy of each of the respective modalities, it remains quite feasible to treat many patients with either modality alone, but it may be advantageous for most patients to consider combined treatment. Combined treatment is particularly likely to be indicated for patients who fail to show a full response to either single modality. It is also indicated for patients who have a history of chronic or nonremitting symptoms or for patients who present with multiple problems beyond their affective distress. More work is clearly needed, but it appears that drugs and psychotherapy, far from being competitors, often complement each other in the treatment of depressed patients.

References