Depression Information

Long term care facilities and residents' doctors shouldconsider combining medication treatment with psychological andbehavioral approaches, such as strength-embedded psychotherapy,for a range of psychological disorders.

Currently, psychiatrists and primary care providers in long term care are prescribingdrugs and more drugs as the only treatment for psychologicaldisorders. But the addition of Strength-Embedded Psychotherapy(SEP) is a targeted way to change behavior in the direction ofstrengths and improve results for residents.

If a resident develops a frozen shoulder or blows out a knee, the orthopedistwould refer him/her to physical therapy, prescribe an NSAID,and, if needed, consider surgery. In mental health, we owe ourpatients nothing less than the same multimodal approach. Addingpsychotherapy to a drug regimen, in this sense, is the mentalhealth equivalent of taking of a multi-modal approach totreatment.

In long term care and elsewhere physicians arecomfortable writing prescriptions because they believe drugswill affect the functioning of the brain, thereby, improvingsymptoms. But so does psychotherapy. In fact, preliminaryevidence suggests that some types of psychotherapy work, inpart, by changing the physiological dynamics of the disorder. Inso doing, psychotherapy, when combined with medication therapy,offers residents the best chance of returning to more normalfunctioning.

For example, in long term care, a psychiatristmight choose to use a combination drug/psychotherapy approachfor a resident with obsessive-compulsive disorder (OCD).S/he might start the resident on a serotonin reuptake inhibitor,while, simultaneously referring the resident to the housepsychologist for strength-embedded psychotherapy. If the patientresponds early and well to the psychotherapy, the physician maynot have to increase the medication, thereby limiting the sideeffect possibilities. But if the patient does not respondquickly to the psychotherapy or has multiple co-morbidconditions not targeted by it, the physician could then considerincreasing the dosage of the drug. This type of combination is atreatment protocol that is comparable to the default model usedin the rest of medicine. The problem is that psychiatricprofessionals in long term care and elsewhere simply neglectit.

One factor is the structure of our mental health system.Insurers don't often offer payment for integrated care thatincludes combined-treatment approaches and alliances with otherproviders that are evidence-based.Also, our society tends to bepill-happy. The pharmaceutical industry contributes to that byaggressively promoting its products through direct-to-consumeradvertising that creates the impression that their products willbring quick results. Unfortunately, there is no pharmaceuticalindustry equivalent that promotes psychological and behavioralapproaches. And the healthcare industry has yet to embracedisease management models in the treatment of psychiatricdisorders that include evidence-based psychosocialtreatments.

As a result, residents are mainly prescribed onlydrugs or several drugs in combination to treat psychiatricdisturbances. Such interventions are helpful, but they could bemore effective and less risky if psychotherapy were part of thecentral treatment mix. Psychiatric treatment in long term careand elsewhere is comparable to treating diabetes withoutaddressing diet and exercise or treating an injured jointwithout prescribing physical therapy.

Similar to the treatmentof other chronic illnesses, combining psychotherapy andpharmacotherapy would usually require collaborative treatmentbetween psychologist and psychiatrist or attendingphysician. Combined treatment is beginning to show better andbetter results in research studies. In several areas combinedtherapy is found to produce better results than either treatmentalone.

As more results like these continue to emerge, it willbecome hard for professionals in long term care to ignore. However, there is enough data now to warrant moving this enlightenedapproach forward.We need to demand that the better treatmentsbe made available to our residents in long term care. As longterm care professionals continue to hear about the promisingresults generated by psychotherapy, they will start demandingthat this type of treatment be made widely available to theirresidents. This will likely require further utilization of thehouse psychologist to implement and design the psychologicaltreatment plan.

It's time that we as health care and long termcare professionals figure out ways to offer strength-embeddedpsychotherapy to residents who could benefit from this type oftargeted behavioral approach.

Dr. Michael Shery is the founder of Long Term Care Specialists in Psychology, a mental health firm specializing in consulting to the long term care industry. Its website, WWW.NursingHomes.MD , provides state-of-the-art mental health treatment, facility staffing and careerinformation to long term care professionals. To get a copy ofthe special report, "How to Reduce Residents' Depression withStrength-Embedded Counseling," click drmike@nursinghomes.md. Put "Special Report" in the subject field.

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