Psychotherapy and pharmacotherapy for depression. Regarding a clinical case.

Abstract

For several years there has been documentation (Vaughan et al., 2000) of the inverse correlation between the gravity of depression and the predisposition to adopt an attitude that can psychologically assess the connections between feelings, thoughts and actions. Such an attitude allows access to and thought about the origins and the meanings of subjective experiences. This predisposition, known in psychological terms aspsychological mindedness, is found to be lacking in the depressed patient, making him less able to get involved in a process of analysing and understanding his own psychological dynamics (Roose & Cabaniss, 2006). In the psychoanalytical context, the use of pharmacotherapy to facilitate the recuperation of psychological mindedness at the beginning of psychotherapy or during analysis of a depressed patient has also been recommended for some time. (Roose & Stern, 1995; Cabaniss, 2001).
In a recent monograph (Busch, Rudden, & Shapiro, 2007) the authors reaffirmed and argued the importance of treating people suffering from medium to serious depression disorders using psychodynamic psychotherapy combined with a pharmacological treatment.  In this perspective, the elements underlying the process of this choice should include the patient’s level of suffering and the degree to which the depression symptoms interfere with his daily functioning and with the psychotherapy process; if the symptoms do not lessen after two or three months of psychotherapy, the pharmacological therapy should be considered at every stage of the decisive process in the psychotherapeutic relationship.
Psychodynamic therapy has the task of exploring both the decision about whether to use the drug, and the conflicts that may derive. The introduction of the drug, in this context, at times seems essential not only to moderate the symptoms of depression but also to enable the psychotherapy to procede, facilitating the detailed exploration of the patient’s conflicts. According to Busch, Rudden, & Shapiro (2007), usually the combination of psychodynamic psychotherapy with a pharmacotherapy envisages the involvement of a psychotherapist coordinated with a psychiatrist, giving rise to a so-called “triangular treatment” (Beitman, Chiles, & Carlin, 1984; Busch & Gould, 1993; Riba & Balon, 2001), the points of which are made up of the patient, the psychotherapist and the psychiatrist. The “triangular treatment” may encounter serious difficulties, may fail or be interrupted for various reasons: the breakdown of the relationships, the fallout of conflicts on the interventions during the treatment, professional jealousy between the two figures involved. To try to avoid such an outcome it is therefore of fundamental importance for the two professionals involved to keep up constant productive communication, especially when difficulties arise during the treatment.

For the sake of completeness, it should be remembered that Busch, Rudden, & Shapiro (2007) also indicate the possibility that the combination of psychodynamic psychotherapy with the use of drugs may involve only the figure of the physician-therapist. The clinical case on which this article focuses is in fact a concrete example of this very eventuality. 
The results of psychotherapies in depressive disorders as well as the combination of psychotherapy and pharmacotherapy have been examined by in-depth quantitative studies. For an preliminary survey, see for instance Rush & Thase (2001) and de Maat et al. (2008). In Italy Fava (2001) and his group (Tomba & Fava, 2006; Ruini, Tomba & Fava, 2007; Tomba & Fava, 2007; Tomba & Fava, 2009) have repeatedly examined these questions with empirical studies.

We will present a single case, aware of the quantitative limitations but also of the fact that the in-depth study of a single case can reveal problem points and questions that can be further developed, play a heuristic role (Nasio, 2002) and find possible later validations or confutations also on the level of quantitative empirical research.