Adjunctive Psychopharmacology in Couple and Family Therapy
KeywordsBipolar Disorder Depressive Episode ADHD Symptom Psychotropic Medication Family Therapy
This entry reviews five major categories of psychopharmacological medications used to treat mood disorders, anxiety disorders, bipolar disorders, psychotic disorders, and attention-deficit/hyperactivity disorder. The term adjunctive distinguishes how therapists should approach medication. Medication should be viewed as supplemental. Only one role of the therapist is as medication manager with tasks like identifying target symptoms to treat with medications, assessing medication responsiveness, confirming use as directed, coping with side effects, and working with the prescribing physician.
The systemic perspective notes multiple influences on the client. Therapists treat the whole family to use relationships to heal. Working with the family provides the best support for the individual using psychotropic medication. Yet, the medical model should be incorporated into therapy to ensure the client is receiving the best standard of care. For example, lithium has a success rate between 48% and53% of clients seeing greater than 50% reduction of bipolar disorder symptoms (Girardi et al. 2016). Anticonvulsants are effective in 41–53% of cases to reduce mania with a long-term effect size of about 10% (Poon et al. 2015). There are similar response rates across antipsychotics. For example, 40–50% of individuals with a psychotic disorder respond to medication, 30–40% of individuals receive some symptom relief, and only 20% do not respond to antipsychotic medications (Smith et al. 2010). Marrying the systemic and medical paradigms provides a framework that supports treating the whole person.
Rationale for Strategy
Psychotropic medications are frequently prescribed to treat mental health concerns. They are consumed by all age groups. Approximately 3.5% of children were prescribed stimulant medication in 2008 to treat ADHD (De Sousa & Kalra 2012). Benzodiazepines (e.g., Xanax, Valium), associated with treating anxiety, are popular with 5.2% of adults using them (Olfson et al. 2015). Benzodiazepines are about twice as common among women and, as individuals age, the rate increases with 8.7% of the geriatric population using them. Antidepressants are used by approximately 13% of Americans (National Health and Nutrition Examination Survey 2015). Given the high prevalence of individuals using psychotropic medications, therapists need to understand their responsibilities in helping clients manage their medications.
Description of the Strategy
Medications used to treat ADHD include stimulants and non-stimulants. Stimulant medications, amphetamine (e.g., Adderall) and methylphenidate (e.g., Ritalin and Concerta), are a first-line treatment. Stimulant medication treats hyperactivity/impulsivity or the combined type of ADHD. Non-stimulant medications are used as alternative or adjuncts to stimulants. Non-stimulant medications include alpha-2A-adrenoceptor agonist (e.g., Catapres, Intuniv), selective norepinephrine reuptake inhibitors (e.g., Strattera, Vivalan), and norepinephrine–dopamine reuptake inhibitors (e.g., Wellbutrin). Non-stimulant medications treat the inattentive type of ADHD. Non-stimulants are used in combination with a stimulant to treat the ADHD combined type. Some side effects for both stimulants and non-stimulants are typical like decreased appetite and disturbed sleep. Stimulants have black box warning for cardiovascular risks, and Strattera has a black box warning for suicidal thoughts in youth.
Even with medication, 10–30% of individuals still meet criteria for ADHD (De Sousa and Kalra 2012). Some concerns that the therapist may address with the client and prescribing physician include selecting medication by symptoms and ADHD type, length of time expected to be on medication, and side effects such a growth concerns. ADHD symptoms may overlap with other disorders (e.g., bipolar). Therapists need to be careful in their differential diagnosis to ensure the client is receiving the correct treatment. If a client has a history of substance use, using a stimulant medication may not be the best option due to abuse potential. Therapists should be aware how family dynamics have shifted to accommodate and adjust to a family member living with ADHD. Examining the familial environmental spaces and how the individual functions across various settings will inform treatment. Including the family in the treatment process shifts the family dynamics. A lack of family therapy may result in patterns and stressors that maintain symptoms.
Antidepressants are prescribed for mental health concerns like depression or anxiety and physical health conditions like chronic pain or menopause. There are a variety of antidepressants including monoamine oxidase inhibitors (e.g., Nardil, Marplan), selective norepinephrine reuptake inhibitors, norepinephrine–dopamine reuptake inhibitors, serotonin–norepinephrine reuptake inhibitors (e.g., Effexor, Cymbalta), selective serotonin reuptake inhibitors (e.g., Prozac, Lexapro), serotonin antagonists and reuptake inhibitors (e.g., Serzone, Desyrel), serotonin modulators and stimulators (e.g., Viibryd, Trintellex), tricyclic antidepressants (e.g., Anafranil, Elavil), and tetracyclic antidepressants (e.g., Remeron, Asendin). Other types of medications to treat depression or augment antidepressants include atypical antipsychotics, thyroid medications, bipolar medications, St. John’s wort, and SAMe. Antidepressants face controversy due to effectiveness concerns. Meta-analyses demonstrate antidepressants may not outperform placebo. Other concerns are related to increased risk of suicide among adolescent users and usage of antidepressants in pregnancy being linked to birth defects and autism spectrum disorders. Many side effects are typical of medications like dry mouth, weight gain, or drowsiness. However, some side effects can cause interpersonal problems like sexual side effects or are more serious like serotonin syndrome.
Clients considering antidepressants should be informed about benefits and concerns. For example, antidepressants do not outperform psychotherapy for treatment of depression (Weitz et al. 2015). When individuals do not respond to antidepressants, the reason for the lack of remission may be related to the impetus for depression. Research suggests individuals with a history of early life traumas may not respond to traditional antidepressants (Meyer 2014). Clients should be knowledgeable about the likelihood of needing antidepressants in the future. About half of all individuals experiencing depression will not experience another episode. Yet, when individuals go off antidepressants, they are more likely to relapse. Most physicians will prescribe an antidepressant beyond the traditional depressive episode lasting 6 months. For those individuals who may not have another depressive episode, they are potentially using a medication longer than needed and increasing their likelihood of developing another depressive episode. However, for the half of individuals who will experience another depressive episode or those with chronic depression, antidepressants can improve the quality of life.
Anxiolytics, minor tranquilizers, treat anxiety disorders. These medications target the fight-or-flight response, fear, worry, and rumination associated with anxiety disorders. These medications also treat seizure disorders, insomnia, alcohol withdrawal, or muscle spasms. Other medications that treat anxiety include Buspar, barbiturates (e.g., Amytal, Prominal), antidepressants (e.g., venlafaxine, Remeron), anticonvulsants (e.g., Lyrica, Neurontin), antihypertensives sympatholytics (e.g., clonidine, propranolol), antihistamines (e.g., Atarax, Benadryl), and herbal remedies (e.g., kava, valerian root). Selecting a medication depends on the length of need. Medications like barbiturates are highly addictive and can be lethal, so they are rarely prescribed for anxiety. Benzodiazepines can also be addictive and should only be prescribed for short-term daily use (i.e., 2–4 weeks, McIntosh et al. 2004). Benzodiazepines are best prescribed on an as needed basis (e.g., during a panic attack). Antidepressant medications are beneficial for long-term use to treat anxiety.
Benzodiazepines side effects can be typical like dry mouth, headache, or upset stomach. However, these medications are not recommended when individuals need to be alert, use fine motor or cognitive skills. Other troubling conditions are related to long-term memory issues. Benzodiazepines can be habit forming. Therapists need to help clients monitor usage. Individuals may have the urge to use benzodiazepines anytime anxiety arises. However, therapists need to communicate that the symptoms are an adrenalin rush. Helping clients to reframe the feelings as similar to exercise make the symptoms less scary. Benzodiazepines should not be used with alcohol; however, often individuals use alcohol to self-medicate their anxiety. This may be particularly dangerous. Benzodiazepines are not recommended in geriatric population.
Not only because of genetic predispositions, depression and anxiety can be a mood shared among family members. While this demonstrates empathy, it may be difficult when family members experience stress overload. Unfortunately, family members often only synchronize negative not positive moods (Mancini and Luebbe 2016) making it difficult for family members to help their loved ones recover. For example, Nicolas et al. (2009) found when a family member has depression, other family members are more likely to develop mental health distress. When individuals are depressed, they become less socially responsive and display fewer positive nonverbal behaviors adding strain to relationships. Strained relationships may increase one’s anxiety. As individuals spend more time with others who cause them stress, the stress response may become the homeostatic state. As individuals become more stressed, they become more sensitive to stress and more easily overload from stress. Working with a client and their family may be necessary to teach the system relaxation techniques to create a homeostatic state more tolerant of stress.
Bipolar disorders medications include lithium, anticonvulsants, antipsychotics, and in some cases antidepressants. Lithium is a standard treatment for bipolar disorders due to success with mania and reducing suicidality. It is important that the therapist consults with the prescribing physician to ensure blood levels and side effects are monitored. Lithium can have severe side effects including damage to physical health and cognitive impairments such as reduced vigilance, alertness, learning, and short-term memory. Other side effects include thyroid changes, minor cardiovascular changes, rash and acne-like lesions, weight gain, and pregnancy problems. Adherence to medication is difficult when the client is experiencing or fears side effects. Open communication about what to expect can help reduce fears. Anticonvulsants are the second most common form of bipolar medication. Anticonvulsants (e.g., Depakote, Lamictal) are often prescribed to reduce mania and work by calming the hyperactivity in the brain. Possible side effects include weight loss, cardiovascular risk, sleep disturbances, nausea, vomiting, diarrhea, dizziness, drowsiness, and tremors. Therapists should be aware that each anticonvulsant effects the body differently. For example, Lamictal is often used to reduce recurrences of depression.
In consultation with a physician, therapists have a responsibility to assess for medication appropriateness. Antidepressants should be used with caution with bipolar disorder. Antidepressants should not be used with mania or mixed episode, history of rapid cycling, and should be used if clients relapse into depression without an antidepressant. Family members may be the first to notice an individual is relapsing. Family therapy may be a critical component of treatment to address symptom manifestation, increase family cohesiveness, and address how this disorder affects the family. Family therapy may enhance treatment, specifically if the family may be triggering symptoms. For example, clients from families with higher expressed emotion have a greater likelihood of relapse and poorer treatment outcomes. Implementing family therapy to impact change at the familial level can increase the likelihood of success for the client.
Antipsychotic medications, known as major tranquilizers or neuroleptics, treat psychotic disorders such as schizophrenia or schizoaffective disorder. Older antipsychotic medications (e.g., Haldol, Thorazin) are often called conventional, typical, or first-generation antipsychotics, and newer medications, atypical antipsychotics, are called second- (e.g., Risperdal, Zyprexa) and third-generation antipsychotics (e.g., Abilify). Older medications treat the positive symptoms of schizophrenia, whereas the newer medications treat the positive and negative symptoms. There are similar response rates across types of antipsychotics.
Antipsychotic medications have a range of side effects. Some may be mild (e.g., headaches, dry mouth, fatigue). However, all types of antipsychotics may produce dangerous side effects like extrapyramidal symptoms (movement disorders). Examples include dystonia (muscle spasms), Parkinson-like symptoms (rigidity), tremors, tardive dyskinesia (jerky movements), akathisia (restlessness), and bradykinesia (slowness in movement). Extrapyramidal side effects may be less frequent with atypicals; however, atypicals may increase the risk of developing type 2 diabetes. Other side effects include weight gain, hyperlipidemia, gastrointestinal issues, sexual side effects, cognitive concerns, risk of seizure, and cardiac dysfunction. The side effects may make it difficult for individuals to adhere to treatment, although, most tolerate atypicals more easily than typical antipsychotics.
Taking antipsychotic medications may be difficult for individuals as some medications require behavioral changes multiple times per day (i.e., a large caloric intake at ingestion, no smoking). Individuals needing antipsychotics usually require multiple medications to manage symptoms and side effects, thus, contributing to more planning difficulties. Other medication adherence challenges include delusions about the medication, medication affordability, lack of consistent routine, chaotic home life, lack of social support, loss of autonomy, side effects, and substance use. Individuals not compliant with medications risk relapse, poor insight, mental clarity issues, high-risk behaviors, increased aggression, violence, substance use, hospitalization, worse prognosis, and even suicide. Therapy is an opportunity to confront challenges and brainstorm solutions.
Despite challenges, most individuals report reduce symptoms and lead a more normal life. Improving quality of life requires the client to have a good relationship with the therapist and physician. The client needs to communicate their concerns with their physician and therapist. The therapist will see the client more frequently than the physician, thus, may recognize an increase in symptoms before they become problematic. Family therapy may help to reduce symptoms, alleviate side effects, improve medication adherence, establish patterns of support, foster relationships, develop routines, recognize relapse, and help individuals stay socially connected. The family may need to take an active role in changing their lifestyle to support the client and report concerns. The therapist needs to target building family bonds as individual who feel supported report fewer symptoms and relapse.
Kim, a 20-year-old, Korean, female was diagnosed with schizophrenia in her first year in college. After the diagnosis, she moved back home with her parents. Kim wants to complete college, but struggles with paranoid delusions. Her delusions are exacerbated when she does not take medication, but she is concerned the medication is poisoning her. Kim’s parents initiated Kim’s therapy to improve medication adherence. In therapy, Kim noted her parents were treating her like a child, stated her goal to live on her own, and indicated how terrible her medication made her feel. The therapist suggested Kim’s parents attend therapy. The parents noted concerns about Kim’s ability to live alone if she will not take her medication. They were concerned Kim would be confused and hurt herself. Kim felt that they did not trust her. The therapist began by rebuilding the relationships between Kim and her parents. The therapist reframed the parental overprotection as concern, provided Kim an outlet to express independence and voice medication concerns. Kim, her parents, and the therapist met with Kim’s psychiatrist to express concerns about treatment adherence, side effects, and Kim’s other medication concerns. The psychiatrist switched Kim to another atypical antipsychotic and used a long-lasting injectable to improve adherence. The psychiatrist prescribed a medication to treat side effects and a benzodiazepine for Kim to use when overwhelmed by her thoughts. The therapist started weekly sessions with a medication check-in for Kim to voice concerns and the therapist to assess for medication dependence. Kim moved into an apartment over her parents’ garage. It gave her freedom, but Kim also agreed to have dinner with her parents every night. This ensured her parents could provide support, check for relapses, and confirm Kim was using her medications as directed.
- McIntosh, A., Cohen, A., Turnbull, N. et al. (2004). Clinical guidelines and evidence review for panic disorder and generalised anxiety disorder. National Collaborating Centre for Primary Care.Google Scholar
- Meyer, D. (2014). Candidates for Antidepressants: Assessing a history of early life stressors CounselingVistas. Retrieved from http://www.counseling.org/docs/default-source/vistas/article_65.pdf?Sfvrsn=8