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Book Forum: Aspects of Treatment   |    
Combined Treatments for Mental Disorders: A Guide to Psychological and Pharmacological Interventions
Am J Psychiatry 2003;160:202-a-203. doi:10.1176/appi.ajp.160.1.202-a
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Seattle, Wash.

Edited by Morgan T. Sammons and Norman B. Schmidt. Washington, D.C., American Psychological Association, 2001, 384 pp., $39.95.

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The coeditors of this volume note in their introductory chapter,

This book is aimed at psychologists and other mental health practitioners who desire to understand how psychotropic drugs can be combined with psychotherapy and other behavioral treatments to produce optimum patient outcome. (p. 3)

The book has an introduction and 11 chapters: "Combined Treatments for Mental Disorders: Clinical Dilemmas," "Prescriptive Authority for Psychologists: Law, Ethics, and Public Policy," "Comparative and Combined Treatments for Obsessive-Compulsive Disorder," "Combined Treatment for Phobic Anxiety Disorders," "Combined Treatment of Insomnia," "Combined Treatment for Depression," "Combined Treatment and Rehabilitation of Schizophrenia," "Combined Treatment for Smoking Cessation in Rational Psychopharmacology: A Guide for Psychologists," "Combined Treatments for Substance Dependence," "Combined Treatment of Obesity and Binge Eating Disorder," and "Clinical Outcomes Assessment for the Practicing Clinician."

In actuality, this book is really two books. The first includes the introduction, the first two chapters, and, to some extent, the third chapter on obsessive-compulsive disorder (OCD) (the only one that has a psychiatrist as a coauthor). These chapters represent a political treatise that psychiatrists with a tendency to hypertension should not read. A flavor of the political agenda can be gained by the following quote from the editors:

Readers will discover that the science underlying combined treatments remains underdeveloped. This is in part a reflection of the inattention paid to investigating combined treatments, in part a reflection of guild-based biases that champion one form of treatment over another, and in part because of the complexity and increased costs associated with combined-treatment research designs. (p. 3)

Perhaps the political nature is understandable given that one of the editors (Morgan Sammons) is a graduate of the first group of military psychologists trained to prescribe medications and the senior author of the second chapter (Patrick DeLeon) is a politician who works for Senator Daniel Inouye (Democrat, Hawaii). This section of the book stresses the importance of combined treatment for the best clinical care and the importance of efficacy data to guide treatment (as if these were new concepts). The implication of both exhortations is that the only way this will be accomplished is by allowing psychologists to prescribe psychotropic drugs. What makes the third chapter irritating is not a political tone but its superficial discussion of the use of psychotropic agents in OCD. As such it fulfills the fears and fantasies of most physicians that the pharmacological education of nonphysicians will come from such "cookbooks." In these chapters the term "combined treatment" becomes almost a code word for "prescribing privileges for psychologists," with the implication that patients are now being deprived of adequate treatment because there are two camps in the field of mental health—those who use drugs exclusively and those who use psychotherapy exclusively. It is also interesting that although the authors do not define psychotherapy, probably in an attempt to avoid alienating support from the majority of psychologists, almost all of the examples of combined treatments represent some form of behavior therapy.

The second "book" is really an excellent comprehensive review of the combined use of psychopharmacological agents and behavior therapy that would be useful for any clinician. This "book" also supports the clinical impression that the majority of patients, particularly those with depression and schizophrenia, are already receiving combined treatment. As Jeremy Pettit et al. note in chapter 6, "Combined therapy is frequently used in the treatment of depression. In fact, combination treatments probably represent the most common form of treatment received by depressed individuals" (p. 139). In the chapter on schizophrenia, William Spaulding et al. describe the contemporary combined treatment approach:

This chapter is for mental health practitioners who work with clients who have schizophrenia or similar disorders, as a member of an interdisciplinary treatment and rehabilitation team. Psychopharmacology usually plays a significant role in the work of such teams. Although a physician member of the team usually has direct responsibility for prescribing the medications, all team members should share responsibility for identifying targets for treatment, monitoring medication effects, and integrating pharmacological and psychosocial approaches. Psychologists are often the team members most knowledgeable and experienced in assessment of cognition and behavior. (p. 161)

The chapters on combined treatments for depression, anxiety, and OCD point out that the data on the efficacy of combined treatments for these conditions are just emerging. However, the evidence presented for the effectiveness of combined treatment approaches in what might be called habit disorders (smoking, substance abuse, eating disorders, and insomnia) is impressive. The chapter on clinical outcomes assessment is an important and useful chapter on a needed approach for most clinicians.

The reader of this book is continually impressed by both the sophistication and complexity of the behavioral and psychopharmacological interventions and by the questions that remain to be answered. In fact, there is so much that remains to be done on combining treatment for most disorders that one wonders why psychiatrists and psychologists are spending so much energy on prescribing rights. The issue has assumed the irrationality of the wars between the Irish and the British, the Israelis and the Arabs. If all stepped back and saw what they have accomplished so far and how unique the contribution of each is, perhaps the current mutually destructive energy could be directed to more productive tasks. This book is a dramatic statement of how effective treatments can be developed in collaboration by each specialty applying its own expertise to the same problems. The prescription of medications has become an increasingly complex process, and although it is a routine procedure in most cases, only someone well versed in anatomy, physiology, and pharmacology can deal with the situations that are not routine and become life-threatening if not recognized.

Reprints are not available; however, Book Forum reviews can be downloaded at http://ajp.psychiatryonline.org.




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