Sequential treatment of mood and anxiety disorders.
OBJECTIVE
Administration of treatments in a sequential order is a common practice in clinical medicine, but has received insufficient attention in psychiatry. The aim of this review was to survey the literature concerned with a sequential use of pharmacotherapy and psychotherapy in mood and anxiety disturbances.


METHODS
A review of the clinical trials in which treatment components were used in a sequential order (i.e., pharmacotherapy followed by psychotherapy, psychotherapy followed by pharmacotherapy, one drug treatment following another, or one psychotherapeutic technique following another) was performed. Studies were identified by using MEDLINE (English language articles published from 1967 to March 2005; keywords: sequential treatment, drugs and psychotherapy, combined treatment related to depressive disorder, bipolar disorder, depression, mania, anxiety disorders, panic disorder, social phobia, obsessive-compulsive disorder, generalized anxiety disorder, and posttraumatic stress disorder) and a manual search of the literature and Index Medicus for the years 1960 to 2005.


RESULTS
In unipolar recurrent depression, the sequential use of pharmacotherapy was found to reduce relapse rate. In bipolar disorder, the use of psychotherapeutic strategies in patients who were already undergoing treatment with mood stabilizers was also found to yield clinical benefits. In anxiety disorders, the sequential use of pharmacotherapy and psychotherapy was not found to improve long-term outcome.


CONCLUSIONS
The sequential treatment of mood and anxiety disorders does not fall within the realm of maintenance strategies. It is an intensive, 2-stage approach, which is based on the fact that one course of treatment with a specific treatment (whether pharmacotherapy or psychotherapy) is unlikely to entail solution to the complex array of symptoms of patients with mood and anxiety disorders. The sequential model introduces a conceptual shift in current assessment methods.
Fava
Giovanni A
GA
Affective Disorders Program and Laboratory of Experimental Psychotherapy, Department of Psychology, University of Bologna, Viale Berti Pichat 5, 40127 Bologna, Italy. giovanniandrea.fava@unibo.it
Ruini
Chiara
C
Rafanelli
Chiara
C
D000928:Antidepressive Agents / Q000627:therapeutic use*; D001008:Anxiety Disorders / Q000188:drug therapy / Q000523:psychology / Q000628:therapy*; D001714:Bipolar Disorder / Q000188:drug therapy / Q000523:psychology / Q000628:therapy; D002985:Clinical Protocols; D015928:Cognitive Behavioral Therapy; D003131:Combined Modality Therapy; D003866:Depressive Disorder / Q000188:drug therapy / Q000523:psychology / Q000628:therapy*; D004334:Drug Administration Schedule; D004359:Drug Therapy, Combination; D006304:Health Status; D006801:Humans; D010347:Patient Care Planning; D011613:Psychotherapy / Q000379:methods*; D016032:Randomized Controlled Trials as Topic; D055502:Secondary Prevention; D016896:Treatment Outcome
D000928:Antidepressive Agents