Psychotherapy, Psychopharmacotherapy, and Neuromodulation

  • Peter HartwichEmail author
  • Heinz Boeker


Whether you want it or not, when psychopharmaceuticals are given, there is always involved a psychodynamic component. Thus, the prescription of the drug is embedded in the relationship of the two dissimilar partners: patient and doctor. In the case of many psychoses, the use of psychopharmaceuticals can help to build up a viable therapeutic relationship and can be the prerequisite for psychotherapy. The bottom-up effects by means of psychopharmacotherapy can be completed with the top-down effects which are mediated by means of psychotherapy. This underlines that psychotherapy modulates biological processes indirectly (by activating psychogenetic material). On the other hand, psychopharmaceuticals can change biological reaction patterns directly. Thus psychopharmacotherapy and psychotherapy are to be seen as different—but additional—components of a multimodal treatment concept.

Furthermore, different modalities of targeted neuromodulation (e.g., vagus nerve stimulation (VNS), deep brain stimulation (DBS)) are being actively researched as putative treatment options for treatment-resistant forms of depression.

A special challenge concerns the adequate weighting of the single component in different disorders regarding the individual situation of each single patient.

We show how this therapeutic approach is experienced in depressive patients, schizophrenics and other psychiatric disorders. Important is that the therapist reflects his inner position and represents a clear attitude in the interaction of psychodynamics and psychopharmaceuticals; we try to explain which factors are effective and how the role of relatives is in relation to the reliable intake of medication. In difficult patients, who omit their medication in a critical situation, it is important that a treatment partnership is established with a family member. The example of group psychotherapy serves to show that “experts among themselves” have a great influence on the willingness to take medication in a neuropsychodynamic context.


  1. Aderhold V, Weinmann S, Hägele C, Heinz A. Frontale Hirnvolumenminderung durch Antipsychotika? Nervenarzt. 2014;86:302–23.CrossRefGoogle Scholar
  2. Aldenhoff J. Biologische Veränderungen bei der Psychotherapie der depression. Nervenarzt. 2000;50:415–9.Google Scholar
  3. Benedetti G. Psychotherapeutische Behandlungsmethoden. In: Kisker KP, et al., editors. Schizophrenien. Psychiatrie der Gegenwart, vol. 4. Berlin: Springer; 1987. p. 285–323.Google Scholar
  4. Berman RM, Capiello A, Anand A, Oren DA, Heninger GR, Charney DS, et al. Antidepressant effects of ketamine in depressed patients. Biol Psychiatry. 2000;47:351–4.CrossRefGoogle Scholar
  5. Bewernick BH, Hurlemann R, Matusch A, Kayser S, Gubert C, Hadrysiewilz B, et al. Nucleus accumbens deep brain stimulation decreases ratings of depression and anxiety in treatment-resistant depression. Biol Psychiatry. 2010;67:110–6.CrossRefGoogle Scholar
  6. Blood AJ, Iosefescu DV, Makris N, Perlis RH, Kennedy EN, Daugherty DD, et al. Microstructural abnormalities in subcortical reward circuitry of subjects of subjects with major depressive disorder. PLoS One. 2010;5:e13945.CrossRefGoogle Scholar
  7. Boeker H. Selbstbild und Objektbeziehungen bei Depressionen: Untersuchungen mit der Repertory Grid-Technik und dem Gießen-Test an 139 PatientInnen mit depressiven Erkrankungen. In: Monographien aus dem Gesamtgebiete der Psychiatrie. Darmstadt: Steinkopff-Springer; 1999.Google Scholar
  8. Boeker H. Psychotherapie der Depression. Bern: Huber; 2011a.Google Scholar
  9. Boeker H. Ergebnisse der Therapie- und Psychotherapieforschung. In: Psychotherapie der Depression. Bern: Huber; 2011b. p. 195–212.Google Scholar
  10. Boeker H. Psychotherapie und Pharmakotherapie bei depressiv Erkrankten. In: Küchenhoff J, editor. Psychoanalyse und Psychopharmakologie. Stuttgart: Kohlhammer; 2016. p. 131–48.Google Scholar
  11. Boeker H. Psychodynamische Psychotherapie der Depression. Theorie und Praxis. Giessen: Psychosozial-Verlag; 2017.Google Scholar
  12. Boeker H, Hartwich P, Northoff G, editors. Neuropsychodynamische Psychiatrie. Heidelberg: Springer; 2015.Google Scholar
  13. Buchheim A, Viviani R, Kessler H, Kächele H, Cierpka M, Roth G, George C, Kernberg OF, Bruns G, Taubner S. Changes in prefrontal-limbic function in major depression after 15 months of long-term psychotherapy. PLoS One. 2012;7(3):e33745.CrossRefGoogle Scholar
  14. Gabbard GO. A neurobiologically informed perspective on psychotherapy. Br J Psychiatry. 2000;177:117–22.CrossRefGoogle Scholar
  15. Gabbard GO. Psychodynamic psychiatry in clinical practice. 5th ed. Washington DC: American Psychiatric Publishing; 2014.Google Scholar
  16. Goldapple K, Segal Z, Garson C, Lau M, Bieling P, Kennedy S, Mayberg H. Modulation of cortical-limbic pathways in major depression. Arch Gen Psychiatry. 2004;61:34–41.CrossRefGoogle Scholar
  17. Hartwich P, Grube M. Psychotherapie bei Psychosen. Neuropsychodynamisches Handeln in Klinik und Praxis. 3rd ed. Berlin: Springer; 2014.Google Scholar
  18. Hartwich P, Schumacher E. Zum Stellenwert der Gruppenpsychotherapie in der Nachsorge Schizophrener. Eine 5-Jahres-Verlaufsstudie. Nervenarzt. 1985;56:365–72.PubMedGoogle Scholar
  19. Janzarik W. Strukturdynamische Grundlagen der Psychiatrie. Stuttgart: Enke; 1988.Google Scholar
  20. Jessner M. Antipsychotika und Unbewusstes. In: Küchenhoff J, editor. Psychoanalyse und Psychopharmakologie. Stuttgart: Kohlhammer; 2016. p. 149–66.Google Scholar
  21. Kohut H. Narzißmus. Frankfurt: Suhrkamp; 1973.Google Scholar
  22. Küchenhoff J. Zum Verhältnis von Psychopharmakologie und Psychoanalyse – am Beispiel der Depressionsbehandlung. Psyche – Z Psychoanal. 2010;64:890–916.Google Scholar
  23. Küchenhoff J. Die analyse der therapeutischen Beziehung und die Psychopharmakotherapie. In: Küchenhoff J, editor. Psychoanalyse und Psychopharmakologie. Stuttgart: Kohlhammer; 2016. p. 13–33.Google Scholar
  24. Lehto SM, Tolmunen T, Joensuu M, Saarinen PI, Valkonen-Korhonen M, Vnninen R, Ahola P, Tihonen J, Kuikka J, Lehtonen J. Changes in midbrain serotonin transporter availability in atypically depressed subjects after one year of psychotherapy. Prog Neuro-Psychopharmacol Biol Psychiatry. 2008;32(1):229–37.CrossRefGoogle Scholar
  25. Lozano AM, Mayberg HS, Giacobbe P, Hamami C, Craddock RC, Kennedy SH, et al. Subcallosal cingulate gyrus deep brain stimulation of treatment-resistant depression. Biol Psychiatry. 2008;64:46–467.CrossRefGoogle Scholar
  26. Mallone DA Jr, Dougherty DD, Rezai AR, Carpenter LC, Friehs GM, Escander EN, et al. Deep brain stimulation of the ventral capsule/ventral striatum for treatment-resistant depression. Biol Psychiatry. 2009;65:267–75.CrossRefGoogle Scholar
  27. Martin-Soelch C. Is depression associated with dysfunction of the central reward system? Biochem Soc Trans. 2009;37:313–7.CrossRefGoogle Scholar
  28. Mayberg HS, Liotti M, Brannan SK, McGinnis S, Mahurin RK, Jerabek PA, Silva JA, Tekell JL, Martin CC, Lancaster JL, Fox PT. Reciprocal limbic-cortical function and negative mood: converging PET findings in depression and normal sadness. Am J Psychiatry. 1999;156:675–82.PubMedGoogle Scholar
  29. Mayberg HS, Brannan SK, Tekell JL, Silva JA, Mahurin RK, McGinnis S, Jerabek PA. Regional metabolic effects of fluoxetine in major depression: serial changes and relationship to clinical response. Biol Psychiatry. 2000;48:830–43.CrossRefGoogle Scholar
  30. Meißel T. Psychodynamik der Medikation bei schizophrenen Psychosen. In: Schwarz F, Maier C, editors. Psychotherapie der Psychosen. Stuttgart: Thieme; 2001. p. 48–52.Google Scholar
  31. Mentzos S. Psychodynamische Modelle in der Psychiatrie. Göttingen: Vandenhoeck and Ruprecht; 1991.Google Scholar
  32. Mentzos S. Depression und Manie; Psychodynamik und Therapie affektiver Störungen. Göttingen: Vandenhoeck & Ruprecht; 1995.Google Scholar
  33. Mentzos S. Psychoanalyse der Psychosen. Psychother Dialog. 2002;3:223–34.CrossRefGoogle Scholar
  34. Muench A. Psychodynamische Modelle der Medikamentenapplikation und ihre Synergien mit der Psychotherapie. In: Küchenhoff J, editor. Psychoanalyse und Psychopharmakologie. Stuttgart: Kohlhammer; 2016. p. 91–108.Google Scholar
  35. Nestler EJ, Carleson WA Jr. The mesolimbic dopamine reward circuit in depression. Biol Psychiatry. 2006;59:1151–9.CrossRefGoogle Scholar
  36. Ressler KJ, Mayberg HS. Targeting abnormal neural circuits in mood and anxiety disorders: from the laboratory to the clinic. Nat Neurosci. 2007;10(9):1116–24.CrossRefGoogle Scholar
  37. Rush AJ, Trivedi MH, Wisniewski SR, Nierenberg AA, Stewart JW, Warden D, et al. Acute and longer-term outcomes in depressed outpatients requiring one or several treatment steps: a STAR*D report. Am J Psychiatry. 2006;163:1905–17.CrossRefGoogle Scholar
  38. Schlaepfer TE, Bewernick BH, Sayser S, Mädler B, Koenen V. Rapid effects of deep brain stimulation for treatment-resistant Major Depression. Biol Psychiatry. 2013;73:1204–12.CrossRefGoogle Scholar
  39. Seminowicz DA, Mayberg HS, McIntos AR, Goldapple K, Kennedy S, Segal Z, Rafi-Tari S. Limbic-frontal circuitry in major depression: a path modeling metanalysis. NeuroImage. 2004;22:409–18.CrossRefGoogle Scholar
  40. Stassen HH, Angst J, Hell D, Scharfetter C, Szegedi A. Is there a common resilience mechanism underlying antidepressant drug response? Evidence from 2848 patients. J Clin Psychiatry. 2007;68:1195–205.CrossRefGoogle Scholar
  41. Szegedi A, Jansen WT, van Willigenburg AP, van der Meulen E, Stassen HH, Thase ME. Early improvement in the first 2 weeks as a predictor of treatment outcome in patients with major depressive disorder: a meta-analysis including 6562 patients. J Clin Psychiatry. 2009;70:344–53.CrossRefGoogle Scholar
  42. Viinamäki H, Kuikka J, Tiihonen J, Lehtonen J. Change in monoamine transporter density related to clinical recovery: a case-control study. Nord J Psychiatry. 1998;52:39–44.CrossRefGoogle Scholar
  43. Vollmoeller W. Psychodynamik in der medikamentösen Therapie. In: Vollmoeller W, editor. Integrative Behandlung in Psychiatrie und Psychotherapie. Stuttgart: Schattauer; 2003.Google Scholar
  44. Zarate CA Jr, Singh JB, Carlson PJ, Brutsche NE, Ameli R, Luckenbaugh DA, et al. A randomized trial of an N-methyl-D-aspartate antagonist in treatment-resistant major depression. Arch Gen Psychiatry. 2006;63:856–64.CrossRefGoogle Scholar
  45. Zeek A. SSRI in der psychodynamischen Psychotherapie der Bulimia nervosa. In: Küchenhoff J, editor. Psychoanalyse und Psychopharmakologie. Stuttgart: Kohlhammer; 2016. p. 187–98.Google Scholar
  46. Zellner MR, Watt DF, Solms M, Panksepp J. Affective neuroscientific and neuropsychoanalytic approaches to two intractable psychiatric problems: why depression feels so bad and what addicts really want. Neurosci Rev. 2011;35:2000–8.Google Scholar

Copyright information

© Springer International Publishing AG, part of Springer Nature 2018

Authors and Affiliations

  1. 1.Department of Psychiatry, Psychotherapy, PsychosomaticsGeneral Hospital of Frankfurt am Main, Teaching Hospital University FrankfurtFrankfurtGermany
  2. 2.Department of Psychiatry, Psychotherapy, and PsychosomaticsPsychiatric University Hospital Zurich, University of ZurichZurichSwitzerland

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