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Pearls


‘Prescribing’ psychotherapy as if it were medication

Vol. 3, No. 7 / July 2004
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Early in training, psychiatry residents learn to formulate specific medication plans, but then add the vague, “I would recommend psychotherapy as well.” To help them understand each psychotherapy’s features and clinical applications, tell them to prescribe psychotherapy as if it were medication.

Like pharmacotherapy, psychotherapy has numerous forms, indications, and contraindications. It can be categorized by:

  • theoretical orientation (psychodynamic, cognitive-behavioral, interpersonal)
  • treatment duration (time-limited, open-ended)
  • number of persons in attendance (individual, couples, family, group).

Teach residents to prescribe psychotherapy in a specific dose and frequency to address target symptoms. A sample treatment plan for a patient with major depressive disorder is shown in the Table.

Table

Sample treatment plan for major depressive disorder

Therapy

Type of intervention

Specific intervention

Starting dosage, frequency

Target symptoms

Side effects

Pharmacotherapy

SSRI

Sertraline

50 mg/d

Depressed mood, anhedonia, sleep disturbance

Nausea, diarrhea, sexual dysfunction

Psychotherapy

Individual

Cognitive-behavioral

50 minutes weekly

Trauma, loss, low self-esteem

Anxiety, anger, grief

Urge residents to prescribe psychotherapy “off-label” if it might help. For example, some clinicians offered cognitive-behavioral therapy (CBT) to patients with schizophrenia before CBT gained wider acceptance for that disorder.

Finally—like any treatment—psychotherapy may be associated with side effects, including anxiety, anger, and grief. Encourage residents to review these risks with their patients before beginning psychotherapy.

Choosing a psychotherapy type

Psychotherapy may be prescribed alone or with pharmacotherapy, as clinically indicated. When choosing a particular psychotherapy, research supports use of:

  • behavior therapy, cognitive therapy, and CBT for depression, certain anxiety disorders (such as obsessive-compulsive disorder), and other mental disorders (substance use disorders, eating disorders, chronic pain syndromes)
  • dialectical behavior therapy for reducing self-injurious behavior and hospitalizations in borderline personality disorder
  • interpersonal psychotherapy for depression.

Some research supports using psychodynamic psychotherapy to treat severe, chronic personality disorders, but the nature of this therapy makes controlled studies difficult. Similarly, though no published data have shown supportive psychotherapy to be effective—in general or for specific disorders—lack of evidence does not necessarily correlate with lack of efficacy.

A model that’s easy to learn

Once residents become familiar with this model, it is remarkable to see the sophistication with which they incorporate specific psychotherapeutic recommendations into their treatment plans.

Use of this model need not be restricted to residents, however. A good model helps all clinicians sharpen their skills and improve the care they provide.

Related resources

  1. Hales RE, Yudofsky SC (eds). Textbook of clinical psychiatry (4th ed). Washington, DC: American Psychiatric Publishing, 2003.
  2. Sadock BJ, Sadock VA (eds). Kaplan & Sadock’s comprehensive textbook of psychiatry (7th ed). New York: Lippincott Williams & Wilkins, 1999.

Drug brand names

  • Sertraline • Zoloft

Dr. Campbell is assistant professor, department of psychiatry, Case Western Reserve University School of Medicine, Cleveland, OH, and is clinical director, division of ambulatory care, department of psychiatry, University Hospitals of Cleveland.

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