Combination Therapy A Brief Relevant History

During the 1970s, psychiatrists and psychoanalysts argued, with analysts insisting that psycho-pharmaceuticals interfered with analysis. Today, mainstream psychiatry is characterized by a CT of psychotherapy and psychopharmacology. In the 1990s, psychiatrists finally integrated SSRIs synergistically with cognitive-behavior therapy to treat depression. Indeed such a model, frequently practiced in modified form by PCPs, probably dominates the treatment of depression today. There is an emerging literature demonstrating the benefit of combining both pharmacological and psychological treatments for a number of psychiatric conditions (24-26).

In urology and many medical specialties, CT usually referred to a, two or more drug regimen, such as the 2003, AUA guidelines for BPH (27). There already is a history of using CT in sexual medicine. In the 1990s, sex therapists worked with urologists combining either ICI or vacuum tumescence therapy. Turner et al. (28a) found that psychological counseling was necessary to augment a pharmaceutically induced erection, for a man with a psychogenic ED. Kaplan managed "resistance to ICI," helping five couples find satisfaction with pharmaceutical restoration of potency (28b). Hartmann and Langer (29) integrated injection therapy and sexual counseling concluding that a combined approach was beneficial. Colson described the results of a study integrating cognitive-behavior therapy and ICI technique. Of their patients, 51% were still able to experience satisfactory sexual intercourse after discontinuing injection therapy (30). Lottman et al. (31), integrated short-term therapy with intracaver-nosal injections and counseling, improving erectile function and facilitating couples communication. Wylie et al. (32) reported a successful combining of "vacuum treatment" and couple's therapy for primarily psychogenic ED patients using a group approach.

Multiple case reports have summarized the benefits of combining sexual pharmaceuticals with cognitive or behavioral treatments for ED (33-37). There were also multiple articles recommending the combination of medical and psychological approaches to the treatment of ED (15,20,32,38,39). Unfortunately, at this point there are no well-designed randomized control studies focused on integrated approaches to the treatment of SD. However, many are optimistic that the data supporting this approach will be forthcoming. An excellent summary of this material on CTs, primarily for ED, with a few FSD studies, can be found in Table 10 of the WHO 2nd Consultation on Erectile and Sexual Dysfunction, Psychological and Interpersonal Dimensions of Sexual Function and Dysfunction Committee report (40).

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