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Many depressed patients experience only limited improvement despite provision of appropriate therapies within a collaborative treatment arrangement (the integrated provision of psychotherapy and pharmacotherapy). In the interest of enhancing these patients' partial responses, it is valuable to examine the treatments provided and also the collaborative framework in which they are offered. The authors use vignettes to illustrate how each of several factors—the adequacy of treatment with each modality, behavioral impediments to response, compliance with treatments, recognition and appropriate matching of treatments to relevant concurrent diagnoses, and appropriate communication between collaborating clinicians—may affect treatment outcome. Recommendations are offered for clinicians engaging in a collaborative relationship, including attending carefully to the patients' comments about a complementary modality of treatment and the clinician delivering it, communicating useful information to the collaborating therapist, and being receptive to information that is offered by the collaborating therapist.
I have yet to see any problem, however complicated, which when you looked at it in the right way, did not become still more complicated. —Paul Anderson, “On the Nature of Physical Laws,” Physics Today, December 1990
any people who experience depression remain symptomatic despite treatment with an antidepressant and/or psychotherapy. Few data exist to describe the rate of resistance to psychotherapy, but it is reported that 30% to 40% of depressed patients who tolerate their first antidepressant trial will respond unsatisfactorily to the medication and 5% to 10% will remain depressed despite multiple pharmacologic interventions.1 Results from a large-scale controlled comparison of cognitive therapy, interpersonal psychotherapy, and medication trials found that of the depressed patients who completed the study, only 55% in the interpersonal therapy group, 51% in the cognitive therapy group, and 57% in the medication group actually met recovery criteria after 16 weeks of treatment.2 Thus, almost half of the patients in each of the treatment groups did not improve sufficiently to be considered “recovered.”
When response to treatment has been unsatisfactory, reassessment can reveal a variety of reasons for this outcome. ABCD, a simple mnemonic, summarizes the major obstacles to treatment response: A refers to the Adequacy of previous treatment. B reminds the clinician to consider Behavioral reinforcers of depressive symptoms. C represents Compliance with treatment. D signifies relevant comorbid or alternative Diagnoses. This mnemonic can be used as a framework for exploring poor responses to pharmacotherapy, psychotherapy, or their combination in the context of a collaborative treatment.
Collaborative treatment, often called split or dual treatment when the components are not actively integrated, refers to care in which one clinician provides psychotherapy in a way that is more or less coordinated with pharmacotherapy provided by another clinician. Many depressed patients receive treatment in this way, often with a psychiatrist or nurse clinical specialist providing the pharmacotherapy while a psychologist or social worker provides the psychotherapy. Collaborative treatment theoretically adds a relationship between psychotherapist and pharmacotherapist (collaboration) to those between psychotherapist and patient (psychotherapeutic alliance) and between pharmacotherapist and patient (pharmacotherapeutic alliance). In addition, as we will elaborate, each clinician maintains a relationship to the complementary treatment modality that can either support or undermine the effectiveness of that treatment. Illustrative composite clinical vignettes, with details altered to protect anonymity, will be used to emphasize aspects of these relationships.
Patients usually enter the collaborative treatment via referral to a pharmacotherapist by their psychotherapist or to a psychotherapist by their pharmacotherapist. The patient's treatment experience and expectations are influenced by the timing and sequencing of treatment modalities and the meanings that each individual in the treatment triangle attaches to the referral.
The clinicians' respective assessments and formulations of the patient also influence treatment goals. With respect to depression, the DSM-IV offers a variety of syndromes from which pharmacotherapists could choose. The vast psychodynamic and cognitive-behavioral literature on depression is beyond the scope of this article, but Westen has recently summarized two important categories (among many others) of depressive dynamics: one in which self-criticism and feelings of inadequacy predominate and another characterized by preoccupations with loss, separation, and abandonment (D. Westen, unpublished manuscript, 1998). Self-defeating thoughts, persistent internal critical dialogues, or maladaptive interpersonal patterns that maintain alienation and loneliness are a few of the issues with which psychotherapists may be concerned. Prescribing clinicians typically focus more on the objective medical indicators of depression (disturbance of sleep and appetite, altered level of energy, anhedonia). From the beginning of a collaborative treatment, the psychotherapist and pharmacotherapist should consider and discuss how each treatment will collaboratively target the patient's psychological and neurovegetative features.
In light of Ms. A.'s very limited response to 6 months of weekly psychodynamic psychotherapy augmented by 2 months of treatment with an antidepressant, her pharmacotherapist discussed further medication alternatives. Although there was room within accepted dosage guidelines to increase the initial antidepressant to a higher dose, the patient had some unpleasant side effects and feared these would worsen; nonetheless, to preserve the partial gains already made, pharmacotherapist and patient agreed to add a second antidepressant to the initial agent. Soon after, the pharmacotherapist received a phone call from Ms. A.'s psychotherapist, who expressed understandable curiosity about the pharmacotherapy. “Why should two antidepressants be given simultaneously? Doesn't this increase the likelihood of adverse effects? Shouldn't the patient just switch to a different medication altogether?” The pharmacotherapist, who had not included the psychotherapist in the earlier discussion about treatment options, explained how the new approach had been chosen and described the clinical reports on which this intervention was based. She explained to the psychotherapist some current practices regarding polypharmacy of depression. The psychotherapist was then able to offer greater support to the patient as she further pursued the pharmacotherapeutic treatment, which eventually appeared to reduce her depressive symptoms more effectively.
In an assessment of medication-resistant depressed patients, Schatzberg et al.3 found that fewer than 23% of their past antidepressant trials had been adequate, often because of intolerance of side effects. Inadequate dosing1 or inadequate duration4 of pharmacotherapy accounts for a large number of poor responders to antidepressant treatment, and studies have indicated that the correction of these problems helps many patients. Patients such as Ms. A., who respond partially to an antidepressant but cannot tolerate dose increases, might respond to innovative approaches such as polypharmacy. Pharmacotherapist and psychotherapist will most effectively coach a patient through changes in a treatment regimen, which may be accompanied by transient worsening of side effects, when they have communicated about the techniques and reasons for a treatment change.
In recent years the pharmacotherapy of depression has evolved to include more options. Higher doses of medications, augmentation of antidepressants with other medications, polypharmacy including coadministration of multiple antidepressants, sequential trials of different classes of medications, and prolonged maintenance treatment have resulted from the availability of new agents, studies of their efficacy, and our increasing understanding of the natural history of mood disorders. Some of these pharmacotherapy trends are unfamiliar or alarming to patients and to psychotherapists. If a psychotherapist understands the rationale for the decisions made in pharmacotherapy, the patient can be encouraged more successfully through treatment. Ms. A.'s psychotherapist appropriately discussed her concerns about the medications with the pharmacotherapist before conveying them to the patient.
Some psychotherapists resist concurrent pharmacotherapy of their patients on the basis of a concern that an antidepressant will undermine the effectiveness of psychotherapy. Available evidence favors the opposite view. Weissman et al.5 demonstrated some years ago that depressed patients receiving both antidepressant medication and psychotherapy showed greater compliance with psychotherapy than the comparison group of unmedicated depressed patients. A recent meta-analysis indicated that patients with more severe or recurrent depression showed greater benefit from treatment with both psychotherapy and pharmacotherapy.6
Just as psychotherapists occasionally resist their patients' concurrent pharmacotherapy, some prescribing clinicians may obstruct the adequacy of a patient's treatment by discouraging or devaluing the role that concurrent psychotherapy might have for that individual. Economic and social pressures lead many patients, primary care clinicians, and pharmacotherapists to regard antidepressant treatment, a modality that appears to work more quickly, as a better treatment. It must be emphasized, however, that a quick response does not imply a deep or lasting response.
The potential benefits of psychotherapy that exceeds several months or involves sessions more frequent than weekly are often overlooked. Depressed patients whose internal worlds are marked by perfectionism and self-lacerating criticism, for example, may achieve greater therapeutic success when engaged in frequent psychodynamically oriented psychotherapy sessions.7 Moreover, some research findings imply that brief courses of psychotherapy risk actually worsening more seriously depressed individuals.8 Although several treatment outcome studies support the efficacy of short-term cognitive behavioral psychotherapy for depression for some percentage of patients,9 this research is limited in several respects. Follow-up assessment of symptom recurrence performed, for example, is rarely beyond 3 months after termination of treatment (D. Westen, unpublished manuscript, 1998) performed. Studies that provide outcome data at 2 years after termination of short-term cognitive-behavioral psychotherapy demonstrate that about 50% of the improved patients have relapsed (Westen). Furthermore, symptom reduction as measured by standard depression inventories may not truly correlate with changes in psychological characteristics (such as maladaptive interpersonal patterns) that maintain depression. In the long run, adequate and effective treatment for some patients may require a longer and more intensive course of psychotherapy.10
Ms. B. called her pharmacotherapist to ask for a medication change. She complained that her sleep had again deteriorated and she was crying on a daily basis. This was unexpected, given her apparently good initial response to an antidepressant. The pharmacotherapist's brief inquiry identified no clear psychosocial or medical precipitants for this change, perhaps because of the patient's shame and her intensely private personality. When the pharmacotherapist attempted to understand the patient's relapse with the psychotherapist who had been providing supportive weekly sessions for the past year, however, the psychotherapist asked, “Did she tell you that her son is waiting for college acceptances and she doesn't know whether she can afford the college he hopes to attend?” Sure enough, her depressive symptoms improved the following week, once uncertainty had passed and decisions had been made. The collaborating clinicians' reassurance, without a change in medications, was sufficient to support this patient through a temporary apparent relapse.
Depression is generally accompanied by unusual or usual life stressors. Adverse life circumstances may undermine antidepressant response.11 Stressful losses, unhappy relationships, and demoralizing career failures or medical problems that arise during pharmacotherapy are likely to come to the psychotherapist's attention even before the pharmacotherapist is aware of them. Pharmacotherapists sometimes overlook the behavioral contexts of their patients' relapses or symptom recurrences and can benefit from information provided by the patients' psychotherapists. In general, the psychotherapist has a fuller appreciation of the events and relationships affecting a depressed patient than does the pharmacotherapist. This is not surprising in light of the psychotherapist's greater time and deeper relationship with the patient and the patient's typical feeling of greater comfort and familiarity with the psychotherapist. Collaborating clinicians must feel empowered to share their observations with each other and must welcome such input in order for this communication to become routine.
Mr. C., a moderately depressed graduate student, was referred by his psychotherapist for antidepressant treatment after 6 months of insight-oriented treatment seemed to have achieved too little improvement. At his early morning initial appointment, he spontaneously reported the preceding night's dream. In this dream he lay on the road, aware that he had been hit by a car. As he experienced the terror of his immobility, he saw that a group of onlookers was rushing toward him, his psychotherapist in the lead. “Move him, lift him up!” insisted the psychotherapist, and Mr. C. feared this might be dangerous if the accident had broken his spine. As he associated to this dream he expressed discouragement about his insight-oriented exploratory psychotherapist's effectiveness. His reluctance to share his hopelessness with his psychotherapist, whom he feared might abandon him if he were a “hopeless case,” had left him feeling distanced and alienated from his treatment. Despite strong ambivalence, he had acquiesced to the suggestion of a medication consultation. He expected the consultant to be uninterested in his feelings or beliefs and eager to medicate him. When he was encouraged to discuss his hopelessness with his psychotherapist, he expressed relief and elected to defer antidepressant treatment. His psychotherapy was greatly facilitated by this consultation, even though medication was not prescribed.
Given the conditions under which pharmacotherapy is typically now offered—appointments that are brief, focused, and infrequent—it is unlikely that the patient's transferences to psychotherapist or pharmacotherapist will be explicitly addressed by the pharmacotherapist. The depressed patient who has experienced some degree of treatment resistance, however, is ripe for the development of a negative transference that may remain unspoken. Sometimes the pharmacotherapist is in a position to clarify a transference issue that has impeded the psychotherapy of a depressed patient, as in the case of Mr. C., who perceived his psychotherapist as overly invested in “lifting” his mood at the expense of exploring other aspects of his depressive state. He feared raising with his psychotherapist the issue of his hopelessness (and his projection that the therapist, too, felt his case was hopeless), but he felt able to bring this up with his pharmacotherapist. Pharmacotherapists doing collaborative treatment should certainly address patients' feelings about being medicated but should generally avoid doing “unauthorized psychotherapy” such as exploring in depth the patient's unconscious conflicts. Information relevant to the psychotherapy should, with the patient's knowledge and permission, be transmitted back to the psychotherapist.
In turn, the psychotherapist may provide the pharmacotherapist with valuable insight into a patient's feelings or beliefs about medication,12 about being medicated,13 or about a patient's potentially disruptive transference to the pharmacotherapist. The psychotherapist who learns of a patient's belief that the pharmacotherapist “is angry,” “has given up hope,” or “has run out of ideas” can determine the validity of such beliefs by communicating with the pharmacotherapist and can facilitate the pharmacotherapy by urging the patient to discuss such concerns openly with the pharmacotherapist. When these beliefs are transferential, psychotherapy can also address ways in which similar expectations permeate the patient's other interpersonal interactions.
Ms. D., a woman with a long history of depression and self-destructive impulses, had received weekly treatment from a psychodynamic psychotherapist for the preceding few years and met with a pharmacotherapist every month. Ms. D. grew up in a single-parent family with a mother who was rarely present. The pharmacotherapist mentioned to the psychotherapist that she was frustrated at how often Ms. D. canceled their appointments and at Ms. D.'s delays in paying the pharmacotherapist's bills. Interestingly, Ms. D. did not behave in this manner toward her psychotherapist, who at that time had been exploring Ms. D.'s apathy toward people in her life who seemed uninterested in her. When the psychotherapist asked whether Ms. D. experienced her in this way, Ms. D. responded that she felt cared for in the psychotherapy but “that other doctor” (the pharmacotherapist) seemed “only interested in whether I pay my bills.” Ms. D. discussed her feeling that the pharmacotherapist's manner was cold and detached, a feeling exacerbated by the pharmacotherapist's writing notes in her chart during their conversations.
In this case, the different structural conventions of the sessions (psychotherapy versus pharmacotherapy) elicited different responses from the patient. Ms. D.'s typical experience of alienation was more evident in her relationship with the pharmacotherapist than with the psychotherapist. The information that the pharmacotherapist shared with the psychotherapist (e.g., about the patient not paying her bills) allowed the psychotherapist and patient to discuss ways in which the patient's own behavior (e.g., missing sessions) reinforced her alienation.
When either the pharmacotherapist or the psychotherapist remarks on the complementary treatment modality, the patient is likely to convey these comments to the collaborating clinician. These comments' actual or distorted contents can reinforce or antagonize the clinicians' interaction and affect the openness of their communication. It facilitates collaborative treatment when a clinician refrains from commenting on the patient's complementary treatment in a way that could be perceived as critical, instead engaging the collaborating clinician in a direct discussion of any concerns arising from a patient's comments.
Ms. E.'s psychodynamically oriented psychotherapist, who had met with her during the preceding 2 months on a weekly basis, informed the pharmacotherapist of their shared patient's growing disappointment with antidepressant treatment. When the pharmacotherapist interviewed the patient, Ms. E. concurred that little had been gained. “I'm sleeping better and I'm able to concentrate again,” she conceded, “and I'm coping with some difficult circumstances in my life better than I had been, but the depression hasn't lifted at all!” The pharmacotherapist discussed with patient and psychotherapist the encouraging meaning of the patient's observations, which indicated the beginnings of an antidepressant response. This discussion was useful to the patient and also to the psychotherapist, who had been relying on the patient's more global self-assessment of mood rather than assessing the medical syndromal symptoms in more detail.
Given the enthusiastic, sometimes even exaggerated discussions of antidepressants in popular magazines and newspaper articles, patients may unrealistically expect treatment to produce a very rapid or extensive change in mood, behavior, and sense of well-being.14 The depressed patient may adopt a passive, expectant role that undermines participation in psychotherapy while awaiting pharmacologic relief, a stance that sets the stage for later disappointment and noncompliance.14 Pharmacotherapist and psychotherapist can work together to assess what changes are actually occurring and to communicate optimism when subtle changes consistent with the beginning of an antidepressant response are observed, while encouraging the patient to maintain an active and participatory role in recovery. Sometimes an actual improvement in depressive symptoms becomes apparent to a patient's psychotherapist even before the patient experiences a lifting of depressed mood. The psychotherapist who perceives that a patient's complaints of continued depression are inconsistent with the emergence of greater energy, less withdrawal, more animated speech, or increased activity may explore a patient's expectations and/or offer encouragement regarding further improvement.
Mr. F.'s depression returned despite an initially good response to an antidepressant. His psychodynamically oriented psychotherapist, who had met with him weekly over a period of months, considered urging him to return to his pharmacotherapist, who might well have increased or changed his antidepressant. The psychotherapist, however, elicited information that put Mr. F.'s relapse into a behavioral context: as Mr. F.'s energy had improved with initial antidepressant treatment, he had been able to tackle his overwhelming and stressful job with new zeal, succeeding so well that he was quickly promoted into an even more overwhelming position. There, he once again found himself unable to function adequately and unable to sustain a feeling of efficacy and self-confidence. He had used his initial symptom relief as a means of taking on greater stress. Exploration of the sources of stress in his job and attention to this recurrent professional pattern rather than to his medication was now of greater importance.
A challenging issue in collaborative treatment results from what could be called “misuse of pharmacotherapeutic treatment gains.” A patient such as Mr. F. may take advantage of symptom relief in order to endure rather than alter a lifestyle associated with deleterious health consequences. When unrecognized, this behavior pattern leads to a never-ending sequence of escalating pharmacotherapeutic interventions, transient improvements, and consequent augmentation of life stresses. Communication between psychotherapist and pharmacotherapist may interrupt such a cycle in a way that enhances the patient's treatment response.
Ms. G., a 35-year-old accountant, sought pharmacotherapy for depressed mood and was diagnosed with a major depressive episode. Treatment alternatives were discussed and she agreed to a trial of a specific antidepressant. She concurrently sought psychotherapy from a psychodynamically trained psychotherapist whose approach included the uncovering and exploration of painful intrapsychic conflicts. When the patient's depressive symptoms increased, she asked what to do. Her psychotherapist, who had seen her weekly for only a few months, advised her to increase the frequency of her psychotherapy sessions and discouraged her from following her pharmacotherapist's suggestion to increase her antidepressant. The psychotherapist, when asked by the pharmacotherapist to justify this approach, expressed concern that overmedication would undermine the patient's ability to work through her conflicts.
For some patients in collaborative treatment, aspects of the treatment modalities themselves can impede antidepressant response. A patient such as Ms. G. may be referred for collaborative treatment after already becoming deeply engaged in an exploratory, insight-oriented psychotherapy that is experienced as both an important relationship and an additional source of stress. Michels15 has argued for the greater use of cognitive-behavioral and/or interpersonal therapy (IPT) techniques with depressed patients on the basis of studies that seem to show evidence of their effectiveness; however, it is also important to consider how elements of exploratory psychotherapy can enhance a patient's recovery. Many psychotherapists believe that depressive symptoms may be relieved by addressing unconscious as well as conscious self-defeating patterns of thought, motivation, and behavior. In addition, elements of the cognitive-behavioral treatment of depression that are quite compatible with exploratory psychotherapy include maintaining a focus on the present; avoiding unnecessarily stressful exploration of unresolved conflicts; remaining sensitive to the depressed patient's tendency to assume self-blame; adopting an active and optimistic therapeutic stance; and attending to the patient's interpersonal relationships, symptoms, and self-defeating behaviors or thoughts.15 Excessively probing psychotherapy can disturb a patient deeply, but even when the pharmacotherapist suspects that a patient is becoming overly stressed by anxiety-provoking psychotherapy sessions, it is essential to avoid inadvertently disparaging the psychotherapy, since this may only serve further to discourage the depressed and already demoralized patient. Instead, a treatment-reviewing discussion should take place between the two clinicians to share information and compare formulations.
In an analogous manner, excessively aggressive pharmacotherapy can impede a patient's use of psychotherapy and obstruct recovery from depression. Overuse of anxiolytic medications or sedating antidepressants, for example, can fatigue a patient to such a degree that cognitive processing of psychotherapeutic material is diminished. Excessively aggressive or frequent shifts of medication may serve to introduce physical symptoms and adverse effects that become the focus of attention in treatment, obscuring psychosocial concerns.
A final impediment to response in collaborative treatment arises from countertransference experiences. Shame, guilt, and hopelessness are central affects in the depressed patient. The collaborating clinicians, too, are at risk of experiencing these feelings in response to the patient's projective identification or to their own frustrating experience of real or perceived therapeutic failure. These feelings, when shared by patient and clinicians, can distort the communication between treating clinicians in destructive ways. Either clinician may withdraw from communication, feeling powerless, ineffective, or ashamed. Alternatively, one clinician might focus in an idealized way on the other clinician as a potential panacea. Some managed care insurers implicitly encourage the displacement of hope, for instance, onto pharmacotherapy by asking the psychotherapist who wishes to extend treatment whether a medication consultation has been obtained. We have not seen an analogous question about psychotherapy consultation directed to the pharmacotherapist requesting authorization of further medication appointments.
Mr. H., a 41-year-old depressed professor, proved unable to tolerate the sexual side effects of a selective serotonin reuptake inhibitor. When he complained to his supportive psychotherapist that he was again experiencing intolerable sexual dysfunction on the second agent to be tried, she empathically commented that this was a common side effect of the antidepressants. The patient stopped his medication and never followed up with the pharmacotherapist, who could have explored some treatment alternatives with different side effects.
Ten to twenty percent of patients fail to tolerate an initial antidepressant trial.16 Some such patients stop using their antidepressant without informing the pharmacotherapist and/or psychotherapist. Others may misrepresent their use of prescribed medications, use them irregularly, combine them with other substances, or terminate pharmacotherapy too early. For many patients, the side effects of the newer antidepressants are better tolerated than those of the older generations of medications. A range of side effects still occurs, however, and some of these will come as unexpected and unpleasant surprises when the informed-consent discussion has been brief. A patient such as Mr. H. may decrease antidepressant dose, use a medication intermittently, or stop prematurely, despite the beginnings of symptomatic improvement, because of concomitant effects such as weight gain, erectile or orgasmic dysfunction, or gastrointestinal disturbances. Other subtle side effects, for example decreased libido, diminished energy, or mild alterations in memory and concentration, may undermine a patient's compliance over time. Often, the patient actually forgets to bring up these side effects with the pharmacotherapist or avoids the discussion, sometimes even when asked directly.
The psychotherapist therefore may well be the first, if not the only, clinician to hear of drug side effects, and the attitude the psychotherapist conveys can facilitate pharmacotherapy or undermine it. Many psychotherapists, understandably, are not fully aware of the wide and varied range of antidepressant side effects and the variety of ways in which they can be diminished without sacrificing antidepressant treatment. Some side effects, such as decreased libido, may even mistakenly be attributed wholly to psychodynamic sources.
When the possibility of a medication side effect emerges in psychotherapy, the psychotherapist can discuss this with the pharmacotherapist and can also encourage the patient to be in touch with the pharmacotherapist to determine whether the medication is likely to be responsible and what remedies may exist. In our experience, the patient's compliance with pharmacotherapy is greatly enhanced when the psychotherapist expresses empathic concern about side effects, validates the patient's distress, and urges the patient to be in touch with the prescribing clinician about these issues. This need not deter further discussion of the patient's feelings, beliefs, and fears about potentially medication-related adverse experiences.
Many psychotherapists “stay out” of discussions about medication, even though they are the clinicians most available to provide encouragement, support, education, and appropriate referral back to the pharmacotherapist. Concerns about the meaning of taking a medication, including the fear of long-term need for such a medication, can be profitably discussed in the psychotherapy. In some community treatment settings or in managed care systems, where the pharmacotherapist meets with the patient briefly and infrequently, it is especially important that the psychotherapist take on this role, which requires a confident grasp of the general principles of acute and maintenance antidepressant therapy. Effective pharmacotherapy of depression requires adequately long treatment at adequately high dosage, and pharmacotherapists can enhance the likelihood of a successful treatment outcome by educating both patients and psychotherapists on this issue.
The psychotherapist, by remaining open for discussion of the patient's cognitive and emotional experience of the antidepressant treatment, can support the pharmacotherapist's effort to provide adequate pharmacotherapy. It is not inappropriate for the psychotherapist to inquire how the patient is experiencing the medication's effects and to discuss this in the same way other experiences are discussed. The psychotherapist can refer the patient back to the pharmacotherapist for discussion of issues such as doses, side effects, drug–drug interactions, and long-term pharmacotherapy treatment plans. The psychotherapist can also communicate directly with the pharmacotherapist regarding the patient's experience of the treatment. The pharmacotherapist must in turn be willing to listen respectfully to the psychotherapist's concerns and provide information about the treatment approach chosen.
Issues of compliance with pharmacotherapy that are important during the treatment of an acute episode remain important during maintenance treatment. During recent years, pharmacotherapists have advocated increasingly longer antidepressant treatments, at doses higher than maintenance doses of the past. Psychotherapists may not be fully aware of these changes in strategy, which are based on the results of longitudinal studies of treatment duration and recurrence rates. Antidepressant responders who prematurely discontinue pharmacotherapy expose themselves to an excessive risk of relapse or recurrence. It is important that a long-term treatment plan proposed by the pharmacotherapist be understood by the psychotherapist as well as by the patient. Pharmacotherapists who share patients with psychotherapists must be willing to educate their colleagues on these matters, and psychotherapists must be receptive to considering new information about evolving pharmacotherapy practices.
Compliance with psychotherapy, too, requires attentive monitoring, and it can be undermined when excessive focus is placed on pharmacotherapy. Although the “depression as illness” metaphor may be useful for some patients, others may accept this metaphor too concretely and disavow a personal role in the change process. Such patients may view medication as the sole agent of change and unconsciously subvert the potential help available from psychotherapy. Patients whose depression is characterized by negative expectations of other people, especially those patients who fear feelings of dependency on potentially unreliable others, may prefer to rely on inanimate objects for relief. Feelings of love, hate, and desire toward the clinician may be displaced onto medications. Pharmacotherapists who overvalue the role of medication in treating depression may support such displacements (missing the importance of psychotherapy that would increase tolerance for uncomfortable affects) and thus may further weaken the patient's already limited sense of agency.
Among groups of patients diagnosed with treatment-resistant depression, it is common to find some individuals who either have been incorrectly diagnosed with depression or carry additional diagnoses that should significantly alter the treatment approach. Comorbid bipolar or anxiety disorders, personality disorders, substance abuse disorders, psychoses, dementias, or mood-altering medical conditions are of particular importance. The psychotherapist is often the first to recognize the presence of these complicating disorders, but on occasion the pharmacotherapist will provide a “fresh view” that alters the psychotherapist's previous diagnostic formulation.
Ms. I. was referred by her psychotherapist, who expressed dissatisfaction with the antidepressant treatment already provided by a primary care practitioner. Two different antidepressants had failed to help, and the patient still experienced low mood, fatigue, and weight gain. The pharmacotherapist's initial evaluation included determination of thyroid function, discovery of hypothyroidism, and referral back to the primary care provider. The patient's mood improved with thyroid replacement therapy, and no antidepressant was required.
Detection of medical illnesses remains an important component of the assessment and treatment of depression. When treatment resistance is present, the clinicians may wish to reconsider whether medical illness is contributing.
Mr. J. was referred for pharmacotherapy of his anxious depression. Unknown and undisclosed use of readily available stimulants (caffeine, ephedra, yohimbine, and guarana) impeded his response to several different antidepressants. The supportive and cognitive-behaviorally oriented psychotherapist had met with this patient for several months and was the first to unravel the nature of his problem. She communicated this information to the pharmacotherapist, who was able to address the substance abuse issue with the patient and eventually offer more effective treatment.
Patients who surreptitiously use recreational or “enhancement”-oriented psychoactive substances may affect the quality of their antidepressant responses. On occasion, the possibility of this interaction is not considered by the patient, so careful inquiries are necessary by both pharmacotherapist and psychotherapist.
Mr. K. was referred by his primary care practitioner for treatment of resistant depression following an unsuccessful antidepressant trial. The patient, who had also been receiving psychodynamic psychotherapy on a weekly basis during the preceding year, had become discouraged about his career, his finances, and his house. The pharmacotherapist elicited some idiosyncratic (but not clearly delusional) concerns about cracks in the house's foundation and discussed these with the psychotherapist. Together, the two clinicians concluded that a delusional depression might be present. The addition of an antipsychotic medication to the antidepressant brought about a successful treatment response.
Depression with psychotic features responds far less effectively to antidepressant monotherapy than to a combination of antidepressant and antipsychotic medications. The presence of subtle delusional thinking may be more readily detected when pharmacotherapist and psychotherapist compare notes.
Agreement about diagnosis and formulation is fundamental to agreement about treatment planning, so discussion of these should take place very near the beginning of a patient's collaborative treatment. Periodic review of diagnosis is important, especially when the patient's depression appears resistant to treatment or when there appears to be a division between clinicians in their understanding of the patient's difficulties.
Few of us would disagree with the suggestion that clinicians who share a patient should be in touch periodically to hear each other's opinions in a respectful way; yet in practice such communication is less usual than it should be. At the heart of this discrepancy between principles and practices are some fundamental conflicts inherent in the relationship between a pharmacotherapist and a psychotherapist. A general discussion of obstacles to communication will provide the background for a series of recommendations regarding communication between collaborating clinicians.
The name collaborative treatment, unlike split treatment or dual treatment, highlights the working together of two providers rather than the coadministration of two treatment modalities. This treatment model seems to have arisen from at least three different sources. Initially, during an era when available pharmacotherapeutic agents were still very limited, some psychoanalysts divided the care of patients, entrusting pharmacotherapy to a different clinician, in order to avoid introducing nonpsychotherapeutic elements into the analytic relationship.17,18 Later, the growth of community psychiatry and the growing availability of nonphysician psychotherapists fostered collaborative relationships that would make psychotherapy more available to patients with greater levels of psychopathology while maximizing efficient use of prescribing clinicians. More recently, dual treatment has proliferated because of the availability of new psychiatric medications, the publicity these medications have received in the media for a range of indications, and the possibly erroneous perception by payers and institutions that collaborative treatment is more cost-effective than integrated psychotherapy/pharmacotherapy with one provider. (For a study in support of single-provider treatment, see Goldman et al.19) Many programs now employ clinical psychiatric time primarily for pharmacotherapy, and many patients now expect to receive treatment from two clinicians.
Despite its wide and growing prevalence, the division of treatment between two clinicians has from the start been a focus of professional conflict and ambivalence both for prescribing clinicians and for psychotherapists. By 1988, 85% of psychiatric training programs were requiring residents to provide “medication backup,”20 but many residency directors expressed concern about the ethics of this role. A group of practicing psychiatrists in Connecticut, surveyed by Goldberg et al.,21 were also highly ambivalent about this role. Only one-third of those who prescribed collaboratively considered medication backup to be generally ethical, their main caveat being that the psychiatrist must have a detailed knowledge of the nonmedical therapist's abilities. Nearly one-fifth of psychiatrists who prescribed, and nearly one-half of those who did not, agreed that “medication backup could be considered malpractice.”21 Despite perceiving some advantages to collaborative treatment, prescribing clinicians fear that it will increase their risk and liability, require extra uncompensated time, link their work with that of other clinicians whose qualifications may be unknown to them, restrict the scope of their clinical activities, and potentially threaten their earnings. Actual communication between psychiatrists and collaborating psychotherapists can be alarmingly infrequent.22
Nonprescribing psychotherapists have expressed concerns about engaging in collaborative treatment with a prescribing clinician, even though they are increasingly aware that failure to discuss the option of medication consultation with appropriate patients can be viewed as unacceptable.23 For the psychotherapist, collaboration facilitates care of a wider clinical population, but it also introduces some ambiguity about who is in charge, along with the necessity of sharing control, a vulnerability to potentially critical observation of the psychotherapist's work, and the need to clarify who will remain responsible for various types of crises.24 A pharmacotherapy referral may result in the psychotherapist's being devalued by a patient who comes to idealize the pharmacotherapist.18 In some cases, pharmacotherapy referral can mean losing a patient altogether.
Another issue is that the pharmacotherapist may not be easy to reach for discussion. Psychotherapists who value and attempt communication with prescribing clinicians are sometimes frustrated at their unavailability. Pharmacotherapists typically have greater numbers of patients in their practice than psychotherapists and therefore may claim difficulty in following through with appropriate, collaborative communication. A study of psychologists providing collaborative treatment found that more than one-third of these clinicians simply did not attempt to work with their patients' prescribing physicians.25
In addition to these practical and interpersonal concerns, difficulties in communication between collaborative care providers can arise from basic theoretical splits. These can develop over issues such as case formulation, prioritization of treatment goals and modalities, the role of the clinician, and the therapeutic elements of the relationship between clinician and patient.24 Intense differences in these areas can turn a case discussion into a miniature Tower of Babel. Despite these practical and theoretical areas of conflict (or perhaps especially because of them), the importance of an open and ongoing communication between clinicians sharing a patient has long been acknowledged.18,22,26–32
The Harvard Risk Management Foundation recently convened a task force of clinicians to address the role of a prescribing clinician in consultative, collaborative, and supervisory relationships. One outcome of this task force's work was a set of guidelines that focuses on the content and mechanics of communication between collaborating clinicians.33 Since depressed patients constitute one of the largest patient groups among those who receive collaborative treatment, the suggested guidelines are relevant both to collaborative treatment in general and the treatment of depression in particular.
The guidelines emphasize the importance of communication between the prescribing clinician and the psychotherapist. With the patient's knowledge and consent, collaborators should discuss a patient at the time that pharmacotherapy or psychotherapy consultation is first requested, addressing the context and circumstances of the request. After the patient is then assessed by the consulting clinician, informed consent for ongoing communication between the clinicians should be obtained from the patient. The collaborating clinicians should discuss treatment approach and goals. When they have not worked together previously, they should also discuss their credentials, experience, and attitudes toward collaborative treatment. Respective treatment roles and a communication plan for emergencies should be clarified. When a patient refuses to give informed consent to ongoing communication, the clinicians should seriously consider not collaborating. Continuing treatment with a patient who refuses open communication of relevant information among treating clinicians often invites treatment complication and failure.
After the initial discussions, each clinician must reliably inform the other of important matters such as prolonged absences, coverage arrangements, changes in treatment approach, crises relevant to the other clinician's work, or major clinical changes in the patient's status of which the other caregiver may not be aware. Each clinician should also know the other's general impression of how the patient is doing in treatment.18 Neither clinician should undermine the other, and neither should hold out unrealistic goals for the complementary treatment modality.
Sometimes, unfortunately, two clinicians employed by a patient will find themselves unable to collaborate. Because the patient's care should be each clinician's priority, it may be necessary to determine whether the patient's interest is better served by continuing the collaboration or dissolving it. Respectful and timely communication between the clinicians can prevent some treatment disruptions. On other occasions, a consultation with a mutually acceptable third clinician is necessary to reestablish successful collaboration between the treating clinicians. Dissolution of a collaborative treatment should be a rare event; it should take place if possible when the patient's symptoms are less acute; and it should be handled in a considerate manner, making certain to provide appropriate alternative treatment suggestions to the patient.24
Depression can be resistant to treatment for various reasons, and issues in the collaborative treatment arrangement may be relevant to any of these. Psychotherapist and pharmacotherapist can facilitate their patients' treatment responses by attending carefully to patients' comments about a complementary modality of treatment, communicating useful information to the collaborating therapist, and being receptive to information that may be offered by the collaborating therapist. Good communication within a collaborative treatment relationship can benefit the patient and help fulfill the clinicians' treatment goals. In this way, optimal treatment for the depressed patient can be taken a step further.
The authors thank Lloyd Sederer, M.D., for helpful comments on an earlier draft of this manuscript.