What Is Psychopharmacology?

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Combined treatment often works better than medication or therapy alone.

Medication reduces pervasive symptoms so therapy can work more effectively.

Psychotherapy helps change patterns that contribute to anxiety and depression.

While the primary focus of this blog will be skills training and targeting problems with psychodynamic psychotherapy (Busch, 2022), I thought it would be useful to begin with a discussion about how medication and psychotherapy work together.

Many studies and wide-ranging clinical experiences have found that a combination of medication and psychotherapy is often more effective than either treatment alone for depressive and anxiety disorders (Cuijpers et al., 2019; Cuijpers et al., 2024). Recent guidelines have recommended that combination treatment is particularly valuable for depression that is moderate to severe or recurrent (American Psychiatric Association, 2023; National Institute for Health and Care Excellence (NICE), 2022), and similarly useful for anxiety that is severe, persistent, or recurrent (National Institute for Health and Care Excellence (NICE), 2011). It is also common for patients to start either medication or psychotherapy alone and then have the other treatment added if symptoms persist (Guidi et al, 2021).

Explanations for the combined effectiveness include that medication leads to a reduction of pervasive mood and anxiety symptoms, improving energy, sleep, and concentration, while psychotherapy enables modification of maladaptive expectations and relational patterns that trigger negative mood states and improve psychological skills that reduce recurrence of symptoms (Breedvelt et al., 2023). Psychotherapy can also aid medication treatment, in understanding and addressing why patients sometimes skip or even stop their medication (Busch and Sandberg, 2007).

Not all psychopharmacologists or psychotherapists accept that treatment combinations are most effective, and it is sometimes up to patients to seek them out. Some psychopharmacologists see anxiety and depression as biological and do not believe therapy adds much of value. Some therapists believe that anxiety or down mood are useful in therapy as signals to identify the source of these symptoms. This is sometimes true, but if you are always anxious and depressed, it’s hard to use it as a signal. Proper medication treatment (often antidepressants) will help to ease pervasive anxiety and depression. At that point occasional anxiety or down mood may be more useful signals of problems that need to be addressed from a psychotherapeutic standpoint. Let’s say you’re worried all the time about several issues in your life (finances, health, your relationship) and after you improve with medication you just get worried when you separate from your partner. This anxiety is now a signal for you to explore in therapy: What psychologically is causing you to get anxious when you separate from your partner? Are there particular problems with your partner? Has separation from important people in your life always been scary for you?

I’ve often been asked by patients (and sometimes therapists) to explain how medication and psychotherapy could be understood to work together. In addition to providing evidence from the literature and the clinical explanations described above, I’ve found certain metaphors to be particularly useful.

One way I describe the combined effectiveness of medication and psychotherapy is using the metaphor of a river. The river overflowing represents an anxiety or depressive disorder. Three streams flow into the river: a biological stream, a psychological stream, and an environmental stream. The environmental stream would refer to various stresses in your life: financial, health, tensions in your relationship, etc. In this model, when there is too much flow from the tributaries it leads to anxiety or depressive disorders. Medication helps diminish the flow from the biological tributary and therapy helps reduce the psychological tributary, causing the river to recede, leading to the relief of symptoms.

This model is helpful but is simplified in a number of ways. Medication can have placebo effects that are essentially a psychological change. Psychotherapy can sometimes by itself relieve anxious and depressive disorders, affecting the biological tributary without medication. And relief of anxiety and depression can sometimes help to reduce your perception of environmental stresses. For instance, anxiety and depression can lead you to be much more worried about money than you need to be. And when your symptoms are better you often are better able to manage the stress in your life, e.g. budget more carefully. So the model should probably include channels that connect the tributaries, but that starts to make it more complex than helpful.

Another metaphor for explaining the impact of and need for medication is a blood pressure model. Some peoples’ blood pressure increases from stress alone. If they can reduce their life stresses (not always so easy) their blood pressure goes down. But they would still need medication as long as their stress remains high. Another group may reduce their stress but still need medication: They have more of a “biological” blood pressure problem. What works best for most people? Stress reduction and medication. This can be seen as similar to whether you need medication for anxiety and depression: Some people require it for improvement, whereas others may only need psychotherapy (another means of stress reduction).

This metaphor is also useful in answering the question people often ask of whether they will continue to need medication after they improve. And as with blood pressure, some will and some won’t. That is, some people have a biological component to their anxiety and depression that requires medication in an ongoing way. Patients may assume that as they learn coping strategies in treatment they will no longer need medication, but this isn’t necessarily true. The blood pressure model may help them understand that they may still require it in spite of their improved psychological skills.

What Is Psychopharmacology?

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Additionally, people often want to understand why their anxiety or depression could recur or did in fact come back after they had treatment. The metaphors described above can help. Perhaps their environmental pressures increased (e.g., a new baby or more pressure at their job). Or for some reason there may have just been a shift in their biology. For example, when some people go in for their yearly checkup they find their blood pressure has increased for no apparent reason; there has been a shift in their biology that requires an increase in their medication dose or perhaps another medication.

Finally, back problems can be used as another metaphor, particularly for people who have suffered from them. Like anxiety and depression, once you have back problems you are vulnerable to getting them again. Sometimes there is a clear trigger (you twist your back) and sometimes there isn’t. Life stress can also trigger back problems. Ibuprofen may be needed (medication) and physical therapy (therapy) can be used to strengthen your muscles to reduce risks, but the right combination of factors can still cause a recurrence of pain.

In most cases of depression and anxiety, therapy plus medication can help diminish the intensity and length of time you experience symptoms. The metaphors I described provide a better understanding and some additional relief for people who are suddenly beset with these symptoms.

To find a therapist, visit the Psychology Today Therapy Directory.

American Psychiatric Association. (2023). Practice Guideline for the Treatment of Patients With Major Depressive Disorder (4th ed.).

Breedvelt, J. J. F., et al. (2023). Psychological relapse prevention interventions for depression: Individual participant data meta-analysis. Nature Mental Health, 1, 1–12.

Busch, F.N. Problem Focused Psychodynamic Psychotherapy. Arlington, VA, American Psychiatric Press, 2022.

Busch, F.N. and Sandberg, L.: Psychotherapy and Medication: The Challenge of Integration. Hillsdale, NJ: The Analytic Press, 2007

Cuijpers, P., et al. (2019). Psychological treatment of generalized anxiety disorder: A meta-analysis. Clinical Psychology Review, 73, 101753.

Cuijpers, P., et al. (2024). Long-term outcomes of psychotherapy versus pharmacotherapy for depression. Frontiers in Psychiatry, 15, 1415905.

Guidi, J., Tomba, E., & Fava, G. A. (2021). Sequential combination of pharmacotherapy and psychotherapy in major depressive disorder: A meta-analysis. JAMA Psychiatry, 78(3), 261–269.

National Institute for Health and Care Excellence (NICE). (2011).Generalised anxiety disorder and panic disorder in adults: management (CG 113)

National Institute for Health and Care Excellence (NICE). (2022). Depression in adults: Treatment and management (CG 222).

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