Combining High-Yield CBT Methods and Pharmacotherapy in Brief Sessions

Psychiatric Times.Vol. 27No. 10

By Jesse H. Wright, MD, PhD and Michael E. Thase, MD |November 2, 2010

Dr Wright is professor in the department of psychiatry and behavioral sciences at the University of Louisville School of Medicine in Kentucky. Dr Thase is professor in the department of psychiatry, mood and anxiety disorders treatment and research program at the University of Pennsylvania School of Medicine in Philadelphia.

As psychiatric practice moves increasingly to brief treatment sessions, fewer psychiatric office visits are being devoted to providing traditional-length psychotherapy.1 Yet, there are many reasons to consider using psychotherapeutic methods in the briefer sessions that dominate contemporary clinical practice.2-6 A primary reason is the lack of full symptom control from psychopharmacological treatment for a large number of patients.

There is evidence that the combination of medication and psychotherapy improves outcomes for many psychiatric illnesses, including depression, bipolar disorder, and schizophrenia. Among the several forms of psychotherapy that might be considered, cognitive-behavioral therapy (CBT) is the most extensively studied. A meta-analysis of combined treatment for depression has shown that using medication plus CBT has an advantage over monotherapy.7 Several trials have also shown superiority for adding CBT to antipsychotic medication for schizophrenia.8,9

Other reasons for psychiatrists to use psychotherapy, even in relatively brief sessions, when they are also providing medication management, include:

• Findings that the majority of patients come to treatment with psychosocial issues and stresses that lead them to prefer psychotherapeutic interventions over a treatment plan that uses medication management alone10,11

• The value of conceptualizing and treating psychiatric illnesses with a biopsychosocial treatment model4,5

• Possible advantages, such as cost-effectiveness, of delivering pharmacotherapy and psychotherapy as an integrated method4-6

• Evidence that psychotherapy can complement the effects of medication via biologically mediated mechanisms4,5

Recognizing the importance of psychotherapy skills in psychiatric practice, the Accreditation Counsel for Graduate Medical Education psychiatry residency program requirements ( mandate that residents must achieve competency in cognitive-behavioral, psychodynamic, and supportive therapy approaches. But what happens when residents enter practice and must face the reality of demands to treat patients in efficient ways that de-emphasize the use of longer psychotherapeutic interventions? And how can practicing psychiatrists respond to the challenge of incorporating psychotherapeutic methods into brief sessions when the primary focus may be on providing effective pharmacotherapy?

Surprisingly little has been written about specific methods for using psychotherapy in brief sessions. Our literature review found a limited number of citations that described the use of CBT in brief sessions.12-16 Clearly more research is needed, but sufficient clinical experience has been accumulated to develop a guide for psychiatrists who wish to use CBT principles and techniques in their brief treatment sessions.17

CBT is an ideal psychotherapy method to consider for use in brief sessions with pharmacotherapy because of the following:

• It is fully compatible with an integrated biopsychosocial treatment approach

• Many psychotherapeutic interventions can be delivered within a short time frame

• The structured techniques of CBT can help clinicians and patients make the best use of available time

• Psychoeducation is a central element of therapy

• The CBT skills that are taught in brief sessions can be practiced as self-help exercises during regular homework assignments

Our book, High-Yield Cognitive-Behavior Therapy for Brief Sessions: An Illustrated Guide,17 includes video illustrations of a variety of CBT applications that last from about 5 to 15 minutes. Examples of methods that can be delivered in a short time frame are listed in Table 1.

To illustrate the use of CBT in brief sessions, the applications for 3 common psychiatric disorders are described below.

Obsessive-compulsive disorder
Exposure therapy in brief sessions along with an SSRI were used to treat a patient with obsessive-compulsive disorder (OCD) who had counting rituals. After the patient was educated about the CBT model for OCD, she agreed to a plan of setting targets for exposure therapy and carrying out the assignments between sessions. During 15 brief sessions that lasted about 20 minutes each, the psychiatrist checked for effects of the medication, reviewed the patient’s homework, assisted her with setting targets for progressing with exposure therapy, and helped her troubleshoot any problems with completing exposure tasks.

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