Psychiatric Annals

Editorial Free

What Is the Future of Psychotherapy in Psychiatry?

Jan Fawcett, MD

This issue of Psychiatric Annals, guest edited by Jeffrey W. Katzman, MD, and Patricia Coughlin, PhD, presents a focus on intensive short-term dynamic psychotherapy (ISTPD).

Drs. Coughlin and Katzman describe what this therapy aims to do and how it differs from more traditional, often longer-term dynamic psychotherapy. David M. Wolff, MD, describes the differences between practicing ISTDP and more-traditional dynamic psychotherapy and presents several cases to illustrate how IST-DP can be combined with the use of psycho-active medications. Allan Abbass, MD, FRCPC, and Dr. Katzman present a review of 13 cost-effectiveness studies of ISTDP-treated patients. Joel M. Town, DClinPsy, and Ellen Driessen, PhD, review the efficacy of ISTDP in the treatment of personality and somatic disorders. Lastly, Dr. Abbass, Steve Kisely, MD, PhD, Daniel Rasic, MD, MSc, and Dr. Katzman describe outcome studies in patients treated with ISTDP by psychiatric residents under supervision and shows positive outcomes correlated with the amount of video supervision provided to resident therapists.

This series also presents the outcome data, with follow-up data ranging from 1 to 3 years, showing efficacy. Follow-up outcome data were missing in the era of psychoanalytically oriented dynamic psychotherapy that dominated psychiatric practice before the dawn of the psychopharmacologic revolution in the mid-1960s.

Though initially conceptualized by psychiatrist Aaron Beck, MD, cognitive therapy was rapidly adopted by psychologists, with teaching in psychiatric residency programs gradually added over the past 5 to 10 years.

This raises the question, what will be the fate psychotherapy in psychiatric practice? Psychoanalytic psychotherapies could no longer dominate psychiatric practice in the face of medications approved for use on the basis of randomized, placebo-controlled, double-blind efficacy studies. Managed care, on the basis of these data, used economic leverage to favor the use of medications to treat psychiatric disorders, resulting in a total reversal in psychiatric practice over the past 50 years.

As a resident and beginning practitioner, I was frustrated by the apparent resistance to using medications in appropriate clinical situations. However, now that we know the limitations and the benefits of medications, there seems to be a reluctance to appropriately employ psychotherapies, despite evidence of their effectiveness and cost-effectiveness.

The field is now being presented with evidence of the cost-effectiveness of newer therapies such as ISTDP, and studies such as STAR*D, CATIE and STEP-BD have demonstrated the limitations of certain medications. Therefore, it seems we should reevaluate the appropriate use of both types of treatment. It is time to determine the cost-effectiveness of a mix of psychopharmacologic treatment and specific psychotherapies in various diagnoses and behavioral dimensions.

We need more federally funded studies of combination medication- and evidence-based, short-term psychotherapy treatments with a reasonable follow-up period (minimum 1 year) to allow for cost-benefit outcome studies.

We do not have to wait until research domain criteria studies reveal the biological basis of all of our heterogeneous disorders and their most-effective personalized treatment to demonstrate effectiveness. If studies are funded, we might show that the appropriate combination of effective psychotherapies and medications can produce good, lasting outcomes.

Authors

Jan Fawcett, MD, a graduate of Yale University School of Medicine, is a Professor with the Department of Psychiatry at the University of New Mexico School of Medicine. Prior to that, he served 30 years as the Stanley Harris, Sr. Chairman of the Department of Psychiatry at Rush Medical College in Chicago. He is a co-author of the American Psychiatric Association’s Practice Guidelines Committee on the assessment and management of suicidal patients and was chairperson of the Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-5), Mood Disorders Task Force. Dr. Fawcett maintains an active clinical practice focusing on patients with treatment-resistant major affective disorders. He  is the recipient of many awards, including the 2000 Menninger Award for research in mental health, and the Falcone Prize for affective disorders research.

Contact Dr. Fawcett via email:  Psychiatry@Healio.com.

10.3928/00485713-20131105-01

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