A group of investigators of the University of Bologna (Giovanni Fava, Chiara Ruini and Chiara Rafanelli) have published an article on a novel approach to treatment of depression and anxiety in the November issue of the Journal of Clinical Psychiatry.

Administration of treatments in a sequential order is a common practice in clinical medicine, but has received insufficient attention in psychiatry. The aim of this article was to survey the literature concerned with a sequential use of pharmacotherapy and psychotherapy in affective disorders (mood and anxiety disturbances).

A review of the clinical trials where treatment components were used in a sequential order (pharmacotherapy followed by psychotherapy; psychotherapy followed by pharmacotherapy; one drug treatment following another; one psychotherapeutic technique following another) was performed using MEDLINE and a manual search of the literature and the Index Medicus.

In unipolar recurrent depression, the sequential use of pharmacotherapy was found to improve relapse rate. In bipolar disorder, the use of psychotherapeutic strategies in patients who were already assuming mood stabilizers was also found to yield clinical benefits. In anxiety disorders, the sequential use of pharmacotherapy and psychotherapy was not found to improve long-term outcome.

The sequential treatment of mood and anxiety disorders does not fall within the realm of maintenance strategies. It is an intensive, two-stage approach, which is based on the fact that one course of treatment with a specific treatment (whether pharmacotherapy or psychotherapy) is unlikely to entail solution to the complex array of symptoms of patients with affective disorders. The sequential model introduces a conceptual shift in current assessment methods.

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