http://www.currentpsychiatry.com/article_pages.asp?AID=4445&UID=
Vol. 5, No. 10 / October 2006

Medications with psychotherapy:
A synergy to heal the brain

Henry A. Nasrallah, MD
Editor-in-Chief, Current Psychiatry,
henry.nasrallah@...

Pharmacotherapy works for psychiatric disorders, and
so does psychotherapy. That’s why I provide both to
each of my patients and why Current Psychiatry
articles address combination therapy (for example, see
“Treating psychiatric reactions to medical illness,”).
Many studies have concluded that combining
pharmacotherapy and psychotherapy produces better
outcomes than either treatment alone.

The apparent synergy between verbal therapy and
medications is often observed but rarely investigated.
Does it occur because two different mechanisms of
action work better than one, such as when we combine a
dopamine blocker (antipsychotic) with a GABA agonist
(mood stabilizer) in a patient with bipolar mania? Or
do drug therapy and psychotherapy share a common
pathway that is enhanced when they are administered
together, such as when we combine two antidepressants
to manage a patient with treatment-resistant
depression?

What is psychotherapy’s mechanism of action anyway,
and do various modalities—cognitive-behavioral,
interpersonal, or supportive—have the same
psychobiological mechanism of action?

Psychotherapy’s mechanism
Given the limited evidence and lack of clear answers
in this area, it is reasonable to use recent advances
in neuroscience to speculate on how two ostensibly
different treatment modalities improve clinical
manifestations—the mood, thought, and behavior
alterations—of psychiatric brain disorders.

Emerging discoveries over the past few years suggest
the common pathway of psychotherapy and
pharmacotherapy may be neuroplasticity—synaptogenesis,
dendritic spines, and neurogenesis. In other words,
talking to a person or giving that person a
psychotropic are both likely to modify that person’s
brain structure.

Unlike any other organ, the brain changes continuously
in response to external and internal stimuli, such as
verbal, visual, tactile, and olfactory perceptions as
well as chemical stimuli. Neural tissue also changes
in response to experiences—stressful or pleasurable,
real or imagined, emotional or cognitive.
Psychotherapy represents a targeted, strategic, and
tactical approach to stimulate specific feelings,
recollections, and insights. These are encoded into
the recipient’s neurobiological pathways and
ultimately translate into a change in behavior or
symptoms.

Every therapeutic encounter produces neuroplasticity,
and—as with drug therapy—the cumulative effect of
repeated doses of psychotherapy consolidates the
improvement. One way to conceptualize this mechanism
is that psychotherapy refurbishes the patient’s brain
structure at the molecular level, restoring resilience
to a brain/mind system that was compromised by genetic
factors or environmental stress.

‘Re-Wiring’ the brain
Where does pharmacotherapy fit into this model? Here,
too, evidence is emerging that psychotropics may exert
their therapeutic effect not only through
neurochemical pathways but also by stimulating
neurotropic factors and inducing beneficial
neuroplastic changes.

Antidepressants, mood stabilizers, and atypical
antipsychotics (but not conventional neuroleptics)
have been shown to induce synaptogenesis, neurite
extension, and neurogenesis. These actions result in
“re-wiring” and “re-sculpting” brain regions such as
the hippocampus and subventricular zone.

Psychotropics are known to trigger gene expression
within hours for some genes and after days or weeks
for others (which may explain short-term alleviation
of some symptoms but delayed response of others).
Psychotropics’ neuroprotective and neuroplastic
effects also appear to help “replenish” brain tissue
destroyed by the neurotoxic effects of repetitive
psychotic, manic, or depressive relapses. Increases in
nerve growth factor, brain-derived neurotropic factor,
and fibroblast growth factor have been implicated in
brain tissue regeneration in serious psychiatric
disorders. Animal and human studies support this
model, but more research is needed.

Accelerating Neuroplasticity
Using this neuroplasticity model, we can reasonably
postulate that the convergence of psychotherapy with
pharmacotherapy may accelerate and expedite the
clinical improvement that hinges on “therapeutic
restructuring” of certain neural pathways. I find it
intriguing to think that by repairing brain tissue
with two different stimuli—talking and medicating—we
can mend the fractured mind of an ailing brain.

As neuroscientists explore more deeply this area of
research, we clinicians will continue to use
concomitant pharmacotherapy and psychotherapy to help
our patients navigate the road to recovery.

Current Psychiatry ©2006 Dowden Health Media





________________________________________________________________________________\
__________
Check out the New Yahoo! Mail - Fire up a more powerful email and get things
done faster.
(http://advision.webevents.yahoo.com/mailbeta)