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

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

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

In long term care and elsewhere physicians are comfortable writing prescriptions because they believe drugs will affect the functioning of the brain, thereby, improving symptoms. But so does psychotherapy. In fact, preliminary evidence suggests that some types of psychotherapy work, in part, by changing the physiological dynamics of the disorder. In so doing, psychotherapy, when combined with medication therapy, offers residents the best chance of returning to more normal functioning.

For example, in long term care, a psychiatrist might choose to use a combination drug/psychotherapy approach for 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 house psychologist for strength-embedded psychotherapy. If the patient responds early and well to the psychotherapy, the physician may not have to increase the medication, thereby limiting the side effect possibilities. But if the patient does not respond quickly to the psychotherapy or has multiple co-morbid conditions not targeted by it, the physician could then consider increasing the dosage of the drug. This type of combination is a treatment protocol that is comparable to the default model used in the rest of medicine. The problem is that psychiatric professionals in long term care and elsewhere simply neglect it.

One factor is the structure of our mental health system. Insurers don't often offer payment for integrated care that includes combined-treatment approaches and alliances with other providers that are evidence-based. Also, our society tends to be pill-happy. The pharmaceutical industry contributes to that by aggressively promoting its products through direct-to-consumer advertising that creates the impression that their products will bring quick results. Unfortunately, there is no pharmaceutical industry equivalent that promotes psychological and behavioral approaches. And the healthcare industry has yet to embrace disease management models in the treatment of psychiatric disorders that include evidence-based psychosocial treatments.

As a result, residents are mainly prescribed only drugs or several drugs in combination to treat psychiatric disturbances. Such interventions are helpful, but they could be more effective and less risky if psychotherapy were part of the central treatment mix. Psychiatric treatment in long term care and elsewhere is comparable to treating diabetes without addressing diet and exercise or treating an injured joint without prescribing physical therapy.

Similar to the treatment of other chronic illnesses, combining psychotherapy and pharmacotherapy would usually require collaborative treatment between psychologist and psychiatrist or attending physician. Combined treatment is beginning to show better and better results in research studies. In several areas combined therapy is found to produce better results than either treatment alone.

As more results like these continue to emerge, it will become hard for professionals in long term care to ignore. However, there is enough data now to warrant moving this enlightened approach forward. We need to demand that the better treatments be made available to our residents in long term care. As long term care professionals continue to hear about the promising results generated by psychotherapy, they will start demanding that this type of treatment be made widely available to their residents. This will likely require further utilization of the house psychologist to implement and design the psychological treatment plan.

It's time that we as health care and long term care professionals figure out ways to offer strength-embedded psychotherapy to residents who could benefit from this type of targeted 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 career information to long term care professionals. To get a copy of the special report, "How to Reduce Residents' Depression with Strength-Embedded Counseling," click drmike@nursinghomes.md. Put "Special Report" in the subject field.

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