What Is the Optimal Treatment of Mood and Anxiety Disorders? Giovanni A. Fava and Chiara Ruini, University of Bologna and State University of New York at Buffalo In clinical psychiatry, the underlying assumption of using an integrated approach (pharmacotherapy + psychother- apy) is that of an additive model of interaction between pharmacotherapy and psychotherapy, which could take place on the basis of specific changes to be induced by specific treatments. However, the simultaneous admin- istration of pharmacotherapy and psychotherapy is based on a cross-sectional, flat view of the disorders which ignores their longitudinal development. An alternative way of integrating pharmacotherapy and psychotherapy involves their sequential administration. In clinical psy- chiatry, administration of treatment in sequential order has been mainly limited to instances of treatment resistance and involved different types of drugs, such as in drug-refractory depression. This type of sequential approaches, however, was not targeted to the stages of illness or particularly to residual symptoms. In this paper we describe the development of a sequential strategy based on the use of pharmacotherapy in the acute phase of depression and cognitive therapy in its residual phase. The sequential model introduces a conceptual shift in therapeutic practice. It may also involve the use of pharmacotherapy after psychological treatment, the se- quential use of two psychotherapeutic techniques, and two pharmacological strategies. We will discuss the implications of the sequential model and some related issues which have clinical value. Key words: combination treatment, sequential treat- ment, mood disorders, anxiety disorders, cognitive– behavior therapy. [Clin Psychol Sci Prac 12: 92–96, 2005] According to a recent meta-analysis (Pampallona, Bollini, Tibaldi, Kupelnik, & Munizza, 2004), psycho- logical treatment combined with antidepressant therapy is associated with a higher improvement rate than that resulting from drug treatment alone. The study was well performed, but it yielded limited clinical implications. Should all patients be treated with this combination? Though nice in theory, to do so would be impossible in practice. Feinstein (1995) warned against the alchemy of meta-analysis, with its violations of scientific principles of precision and homogeneity: ‘‘Meta-analysis of randomised trials concentrates on the part of the scientific domain that is already reasonably well lit, while ignoring the much larger domain that lies either in darkness or in deceptive glitters’’ (p. 78). Fortunately, Otto, Smits, and Reese (this issue) did not perform a meta-analysis but did carefully examine the evidence available, differentiating between clinical populations and treatment strategies. Their paper contains several important implications for the clinician. The underlying assumption of the integrated approach is that of an additive model of interaction between pharmacotherapy and psychotherapy, which could take place on the basis of specific changes to be induced by specific treatments. However, the simultaneous administration of pharma- cotherapy and psychotherapy is based on a cross- sectional, flat view of the disorders that ignores their longitudinal development (Fava & Kellner, 1993). An alternative way of integrating pharmacotherapy and psychotherapy involves their sequential administration according to the stages of the disorder (Fava & Ruini, 2002). This article discusses the implications of the sequential model and some related issues that have clinical value. THE SEQUENTIAL APPROACH Administration of treatments in sequential order is a common practice in clinical medicine when a treatment fails. If the physician prescribes Antibiotic A to eradicate an infection and if the ensuing response is judged to be unsatisfactory, he or she switches to Antibiotic B, hoping to get a better outcome. The process is by approximation, applied only if treatment fails, and can be potentially avoided by appropriate pretreatment tests (e.g., in vitro determination of the susceptibility of bacteria to Address correspondence to Giovanni A. Fava, University of Bologna, Department of Psychology, Viale Berti Pichat 5, I-40127 Bologna, Italy. E-mail: gafava@libero.it. doi:10.1093/clipsy/bpi011 Clinical Psychology: Science and Practice, V12 N1, Ó American Psychological Association D12 2005; all rights reserved. 92