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type=\u0022text\/css\u0022 rel=\u0022stylesheet\u0022 href=\u0022\/\/d282kpwvnogo5m.cloudfront.net\/sites\/default\/files\/cdn\/css\/http\/css_Xg7z6oCTVgud_Q0huYz9x9iiD5H_2YPSJ5z2ZViSWdY.css\u0022 media=\u0022all\u0022 \/\u003E\n\u003Clink rel=\u0027stylesheet\u0027 type=\u0027text\/css\u0027 href=\u0027\/sites\/all\/modules\/contrib\/panels\/plugins\/layouts\/onecol\/onecol.css\u0027 \/\u003E\u003C\/head\u003E\u003Cbody\u003E\u003Cdiv class=\u0022panels-ajax-tab-panel panels-ajax-tab-panel-sageoa-tab-art\u0022\u003E\u003Cdiv class=\u0022panel-display panel-1col clearfix\u0022 \u003E\n  \u003Cdiv class=\u0022panel-panel panel-col\u0022\u003E\n    \u003Cdiv\u003E\u003Cdiv class=\u0022panel-pane pane-highwire-markup\u0022 \u003E\n  \n      \n  \n  \u003Cdiv class=\u0022pane-content\u0022\u003E\n    \u003Cdiv class=\u0022highwire-markup\u0022\u003E\u003Cdiv xmlns=\u0022http:\/\/www.w3.org\/1999\/xhtml\u0022 id=\u0022content-block-markup\u0022 xmlns:xhtml=\u0022http:\/\/www.w3.org\/1999\/xhtml\u0022\u003E\u003Cdiv class=\u0022article fulltext-view \u0022\u003E\u003Cspan class=\u0022highwire-journal-article-marker-start\u0022\u003E\u003C\/span\u003E\u003Cdiv class=\u0022section abstract\u0022 id=\u0022abstract-1\u0022\u003E\u003Ch2\u003ESummary\u003C\/h2\u003E\n\u003Cp id=\u0022p-1\u0022\u003EWhich is better: psychotherapy, pharmacotherapy, or a combination of the two? This article presents two differing views on this subject from a psychodynamic clinician\u0027s perspective. The psychodynamic model is derived from psychoanalysis, an intensive therapy that seeks to explore the unconscious to reveal to the patient the source of their psychiatric symptoms.\u003C\/p\u003E\n\u003C\/div\u003E\u003Cul class=\u0022kwd-group\u0022\u003E\u003Cli class=\u0022kwd\u0022\u003EPsychopharmacology\u003C\/li\u003E\u003C\/ul\u003E\u003Cp id=\u0022p-2\u0022\u003EWhich is better: psychotherapy, pharmacotherapy, or a combination of the two? Two experts gave a candid and entertaining presentation of their views on the subject at a session devoted to this topic. Steven P. Roose, MD, Columbia University, gave the psychodynamic clinician\u0027s perspective. The psychodynamic model is derived from psychoanalysis, an intensive therapy that seeks to explore the unconscious to reveal to the patient the source of their psychiatric symptoms. \u201cWhen medication was first introduced it was (not surprisingly) greeted in the [psycho] dynamic community with outright hostility, often suspicion. Medication was considered to be only for symptomatic relief, putting a bandage on the problem,\u201d noted Dr. Roose. The perception was that if you relieved that patient\u0027s symptoms of anxiety or depression that all motivation would be taken away. Over time this has changed. Dr. Roose presented data from the most recent 67 patients who came to the psychodynamic clinic at Columbia:\u003C\/p\u003E\u003Cdiv class=\u0022boxed-text\u0022 id=\u0022boxed-text-1\u0022\u003E\u003Cbr\/\u003E\u003Cdiv class=\u0022graphic\u0022 id=\u0022graphic-1\u0022\u003E\u003Cdiv class=\u0022graphic-inline anchor\u0022\u003E\u003Cimg class=\u0022highwire-embed\u0022 alt=\u0022Embedded Image\u0022 src=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/sites\/default\/files\/highwire\/spmdc\/7\/2\/8\/embed\/graphic-1.gif\u0022\/\u003E\u003C\/div\u003E\u003C\/div\u003E\u003Cp id=\u0022p-3\u0022\u003E\u003Cstrong\u003ECurrent Diagnoses:\u003C\/strong\u003E 54% with anxiety disorders, 36% with major depressive disorder, 12% with dysthymia.\u003C\/p\u003E\u003Cp id=\u0022p-4\u0022\u003E\u003Cstrong\u003EComorbid diagnoses:\u003C\/strong\u003E 31% with mood and anxiety disorders, 23% with anxiety disorders, 22% with mood disorders.\u003C\/p\u003E\u003Cp id=\u0022p-5\u0022\u003E\u003Cstrong\u003ELifetime Diagnoses:\u003C\/strong\u003E 81% with mood disorders and 54% with anxiety disorders\u003C\/p\u003E\u003C\/div\u003E\u003Cp id=\u0022p-6\u0022\u003EIn Dr. Roose\u0027s opinion, these findings suggest that psychoanalysis or psychodynamic therapy is being sought out by patients with mood and anxiety disorders who have not obtained relief using other methods. Surveys at Columbia and other institutions indicate that psychodynamic therapists now prescribe medication for the patients who need it, and that both the disorder and the psychoanalytic process improve as a result of the pharmacotherapy. \u201cYou can\u0027t do dynamic treatment or psychoanalysis in patients who are significantly depressed. In other data there was a very powerful, significant inverse correlation between the scales that measure what is referred to as psychological mindedness, the capacity for insight, and the ability to think psychologically about oneself, and one\u0027s depression scores. \u201cThe more severely depressed, the less psychologically minded you were,\u201d said Dr. Roose.\u003C\/p\u003E\u003Cp id=\u0022p-7\u0022\u003ECan a clinician really be effective in giving two therapies? In Dr. Roose\u0027s opinion, it can be difficult to do both adequately, because one of the two therapies is usually viewed as an adjunctive treatment by the clinician. \u201cThere is a hierarchy of treatments\u2026 whenever we have a concept of one thing being adjunctive to another, or in our own minds one thing being superior to another, I think we don\u0027t utilize the second treatment optimally,\u201d concluded Dr. Roose.\u003C\/p\u003E\u003Cp id=\u0022p-8\u0022\u003EMichael Thase, MD, University of Pennsylvania, presented reasons to support further studies of combined treatment. As observed in the Sequenced Treatments to Relieve Depression (STAR-D) trial, patients with depression treated with antidepressants continue to experience residual symptoms (\u003Ca id=\u0022xref-fig-1-1\u0022 class=\u0022xref-fig\u0022 href=\u0022#F1\u0022\u003EFigure 1\u003C\/a\u003E; STAR*D Study Team. \u003Cem\u003EAm J Psychiatry\u003C\/em\u003E 2006;163(1):28\u201340). For many reasons, many patients do not adhere to their pharmacotherapy, possibly because antidepressant medication still has a stigma associated with it. \u201cI don\u0027t need to tell you all about the endemic problem of nonadherence. At least 10% of our patients never fill their first prescription, and a third don\u0027t refill the initial prescription. Thoughts and feelings about \u2018Should I take this medicine? Should I keep taking it? Why am I enduring these side effects?\u2019 are a major factor \u2013 the treatment fails,\u201d said Dr. Thase.\u003C\/p\u003E\u003Cdiv id=\u0022F1\u0022 class=\u0022fig pos-float  odd\u0022\u003E\u003Cdiv class=\u0022highwire-figure\u0022\u003E\u003Cdiv class=\u0022fig-inline-img-wrapper\u0022\u003E\u003Cdiv class=\u0022fig-inline-img\u0022\u003E\u003Ca href=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/7\/2\/8\/F1.large.jpg?width=800\u0026amp;height=600\u0026amp;carousel=1\u0022 title=\u0022Total Exit Scores on the 16-Item Quick Inventory of Depressive Symptomatology, Self-Report (QIDS-SR), of 2,876 Outpatients with Nonpsychotic Major Depressive Disorder.\u0022 class=\u0022fragment-images colorbox-load\u0022 rel=\u0022gallery-fragment-images-783444945\u0022 data-figure-caption=\u0022Total Exit Scores on the 16-Item Quick Inventory of Depressive Symptomatology, Self-Report (QIDS-SR), of 2,876 Outpatients with Nonpsychotic Major Depressive Disorder.\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003E\u003Cimg class=\u0022fragment-image\u0022 alt=\u0022Figure 1.\u0022 src=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/7\/2\/8\/F1.medium.gif\u0022\/\u003E\u003C\/a\u003E\u003C\/div\u003E\u003C\/div\u003E\u003Cul class=\u0022highwire-figure-links inline\u0022\u003E\u003Cli class=\u00220 first\u0022\u003E\u003Ca href=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/7\/2\/8\/F1.large.jpg?download=true\u0022 class=\u0022highwire-figure-link highwire-figure-link-download\u0022 title=\u0022Download Figure 1.\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EDownload figure\u003C\/a\u003E\u003C\/li\u003E\u003Cli class=\u00221\u0022\u003E\u003Ca href=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/7\/2\/8\/F1.large.jpg\u0022 class=\u0022highwire-figure-link highwire-figure-link-newtab\u0022 target=\u0022_blank\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EOpen in new tab\u003C\/a\u003E\u003C\/li\u003E\u003Cli class=\u00222 last\u0022\u003E\u003Ca href=\u0022\/highwire\/powerpoint\/11135\u0022 class=\u0022highwire-figure-link highwire-figure-link-ppt\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EDownload powerpoint\u003C\/a\u003E\u003C\/li\u003E\u003C\/ul\u003E\u003C\/div\u003E\u003Cdiv class=\u0022fig-caption\u0022 xmlns:xhtml=\u0022http:\/\/www.w3.org\/1999\/xhtml\u0022\u003E\u003Cspan class=\u0022fig-label\u0022\u003EFigure 1.\u003C\/span\u003E \u003Cp id=\u0022p-9\u0022 class=\u0022first-child\u0022\u003ETotal Exit Scores on the 16-Item Quick Inventory of Depressive Symptomatology, Self-Report (QIDS-SR), of 2,876 Outpatients with Nonpsychotic Major Depressive Disorder.\u003C\/p\u003E\u003Cdiv class=\u0022sb-div caption-clear\u0022\u003E\u003C\/div\u003E\u003C\/div\u003E\u003C\/div\u003E\u003Cp id=\u0022p-10\u0022\u003EBecause of these issues, the APA recommends combined treatment in its practice guideline for major depressive disorder. Co-administration of pharmacotherapy and psychotherapy has bidirectional effects that could ultimately reduce the potential of relapse or recurrence of depressive symptoms. The addition of psychotherapy to pharmacotherapy can improve adherence to medications, develop coping mechanisms, enhance the patient\u0027s social network and increase problem solving skills. Adding pharmacotherapy to psychotherapy can decrease limbic activation, increase a patient\u0027s capacity for enjoyment, alleviate sleep problems, improve prefrontal cortex functioning, and dampen hypothalamic-pituitary adrenal system activity.\u003C\/p\u003E\u003Cp id=\u0022p-11\u0022\u003EThe two types of psychotherapy that Dr. Thase discussed were interpersonal psychotherapy (IPT) and cognitive behavioral therapy (CBT). IPT is a short-term focused therapy that seeks to elucidate how interactions between people affect psychiatric symptoms. CBT instead concentrates on how a patient\u0027s internal thoughts influence personal relationships and psychiatric symptoms, with the goal of thought pattern modification. IPT has some advantages over CBT in that it may be easier for clinicians to learn. Focused therapies such as IPT and CBT have some advantages over psychodynamic psychotherapy in that they are focused on the present time, very structured, time limited, practical, personally relevant, reproducible, and can give a patient immediate hope. \u201cI think sometimes inherent in these models of therapy is that they may better fit what people are looking for, what they believe their problems are related to. People often walk out of the first session with a little buzz, with a little sense of \u2018this matches what\u0027s wrong with me, this works for me,\u201d added Dr. Thase.\u003C\/p\u003E\u003Cp id=\u0022p-12\u0022\u003EThere are some impediments to researching combined therapy. Small effect sizes means larger samples sizes are needed for these types of trials, and Dr. Thase echoed Dr. Roose\u0027s observation that allegiances to therapies can obscure research findings. \u201cThis is not a mission impossible. If you\u0027re doing a study of IPT and CBT, you just need to be sure that IPT is done with the same enthusiasm\u2026as CBT,\u201d commented Dr. Thase. Patients perceive which therapy their doctors prefer, and will react accordingly.\u003C\/p\u003E\u003Cp id=\u0022p-13\u0022\u003E\u201cAt this moment in time we cannot assertively demand from those who fund health care that combined treatment be made available to the patients who have the most difficult to treat mood disorders,\u201d concluded Dr. Thase. Studies that are statistically powered to demonstrate a treatment difference and conducted in an appropriate non-biased manner are truly needed.\u003C\/p\u003E\u003Cul class=\u0022copyright-statement\u0022\u003E\u003Cli class=\u0022fn\u0022 id=\u0022copyright-statement-1\u0022\u003E\u00a9 2007 MD Conference Express\u003C\/li\u003E\u003C\/ul\u003E\u003Cspan class=\u0022highwire-journal-article-marker-end\u0022\u003E\u003C\/span\u003E\u003C\/div\u003E\u003Cspan id=\u0022related-urls\u0022\u003E\u003C\/span\u003E\u003C\/div\u003E\u003Ca href=\u0022http:\/\/mdc.sagepub.com\/content\/7\/2\/8.abstract\u0022 class=\u0022hw-link hw-link-article-abstract\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EView Summary\u003C\/a\u003E\u003C\/div\u003E  \u003C\/div\u003E\n\n  \n  \u003C\/div\u003E\n\u003C\/div\u003E\n  \u003C\/div\u003E\n\u003C\/div\u003E\n\u003C\/div\u003E\u003Cscript type=\u0022text\/javascript\u0022 src=\u0022http:\/\/mdc.sagepub.com\/sites\/all\/modules\/highwire\/highwire\/plugins\/highwire_markup_process\/js\/highwire_figures.js?nzlzq1\u0022\u003E\u003C\/script\u003E\n\u003Cscript type=\u0022text\/javascript\u0022 src=\u0022http:\/\/mdc.sagepub.com\/sites\/all\/modules\/highwire\/highwire\/plugins\/highwire_markup_process\/js\/highwire_openurl.js?nzlzq1\u0022\u003E\u003C\/script\u003E\n\u003C\/body\u003E\u003C\/html\u003E"}