Blog
The Psychotherapy Practice Research Network (PPRNet) blog began in 2013 in response to psychotherapy clinicians, researchers, and educators who expressed interest in receiving regular information about current practice-oriented psychotherapy research. It offers a monthly summary of two or three published psychotherapy research articles. Each summary is authored by Dr. Tasca and highlights practice implications of selected articles. Past blogs are available in the archives. This content is only available in English.
This month...
…I blog about therapist variables leading to poor outcomes, aspects of the therapeutic relationship and outcomes, and psychological therapies and patient quality of life.
Type of Research
Topics
- ALL Topics (clear)
- Adherance
- Alliance and Therapeutic Relationship
- Anxiety Disorders
- Attachment
- Attendance, Attrition, and Drop-Out
- Client Factors
- Client Preferences
- Cognitive Therapy (CT) and Cognitive-Behavioural Therapy (CBT)
- Combination Therapy
- Common Factors
- Cost-effectiveness
- Depression and Depressive Symptoms
- Efficacy of Treatments
- Empathy
- Feedback and Progress Monitoring
- Group Psychotherapy
- Illness and Medical Comorbidities
- Interpersonal Psychotherapy (IPT)
- Long-term Outcomes
- Medications/Pharmacotherapy
- Miscellaneous
- Neuroscience and Brain
- Outcomes and Deterioration
- Personality Disorders
- Placebo Effect
- Practice-Based Research and Practice Research Networks
- Psychodynamic Therapy (PDT)
- Resistance and Reactance
- Self-Reflection and Awareness
- Suicide and Crisis Intervention
- Termination
- Therapist Factors
- Training
- Transference and Countertransference
- Trauma and/or PTSD
- Treatment Length and Frequency
July 2013
Combining Medication and Psychotherapy for Schizophrenia
Handbook of Psychotherapy and Behavior Change: Starting in March 2013 I will review one chapter a month from the Handbook of Psychotherapy and Behavior Change in addition to reviewing psychotherapy research articles. Book chapters have more restrictive copy right rules than journal articles, so I will not provide author email addresses for these chapters. If you are interested, the Handbook table of content can be viewed on Amazon.
Forand, N.R., DeRubeis, R.J., & Amsterdam, J.D. (2013). Combining medication and psychotherapy in the treatment of major mental disorders. In M.J. Lambert (Ed.) Bergin and Garfield’s handbook of psychotherapy and behaviour change (6th ed.), pp. 735-774. Hoboken, N.J.: Wiley.
This comprehensive chapter covers evidence for combining medication and psychotherapy for several disorders. This month I report on the section of the chapter on schizophrenia. Practice guidelines recommend antipsychotic medications as the first line treatment for Schizophrenia. However, up to 30% of individuals show an initial poor response and an additional 30% of patients continue to experience symptoms. Medication side effects can be debilitating, resulting in poor adherence and therefore reduced effectiveness. Further, Schizophrenia spectrum disorders are heterogenous in presentation and course, and so a “one size fits all” approach will not be effective for some or many. Psychotherapies can enhance the effectiveness of medications at different phases of treatment to hasten recovery or reduce medication-resistant symptoms. CBT for schizophrenia was developed to treat persistent medication-resistant positive psychotic symptoms (i.e., positive symptoms refer to delusions, hallucinations, disorganized speech and behaviour; whereas negative symptoms refer to restrictions in: emotions, thoughts, speech, and initiating goal directed behaviors). CBT focuses on reappraising the power and source of hallucinations, evaluating delusions, and addressing motivational deficits. CBT appears to be effective for chronic symptoms of schizophrenia with small to moderate effects, and these effects appear to be enduring. There is currently less and mixed evidence for CBT to speed recovery from first episode psychosis and to improve relapse rates. There is also evidence suggesting the effects of family psychoeducation to reduce relapse and to improve caregiver outcomes. However, family psychoeducation requires the participation of a caregiver, which may be a challenge that limits its utility. There is promising research on multidisciplinary rehabilitation programs that include case management, behaviour management, social skills training, social cognitive training, and cognitive remediation. There is also controversial research on providing psychological interventions alone or in a staged approach (i.e, in which earlier and less severe stages are treated with more benign interventions, and later stages are treated more aggressively with medication). However there are as yet no well-controlled clinical data to support this approach.
Practice Implications
Adjunctive psychosocial treatments appear to improve symptomatic and functional outcomes in individuals with schizophrenia spectrum disorders. CBT is best suited for treating chronic positive psychotic symptoms, but its effect on relapse prevention is equivocal. Individuals who are at risk for relapse might benefit from family psychoeducation, if the caregiver can be engaged. Multidisciplinary rehabilitation programs are a promising avenue of treatment.
May 2013
Combining Medication and Psychotherapy in the Treatment of Depression
Handbook of Psychotherapy and Behavior Change: Starting in March 2013 I will review one chapter a month the Handbook of Psychotherapy and Behavior Change in addition to reviewing psychotherapy research articles. Book chapters have more restrictive copy right rules than journal articles, so I will not provide author email addresses for these chapters. If you are interested, the Handbook table of content can be viewed on Amazon.
Forand, N.R., DeRubeis, R.J., & Amsterdam, J.D. (2013). Combining medication and psychotherapy in the treatment of major mental disorders. In M.J. Lambert (Ed.) Bergin and Garfield’s handbook of psychotherapy and behaviour change (6th ed.), pp. 735-774. Hoboken, N.J.: Wiley.
This comprehensive chapter covers evidence for combining medication and psychotherapy for several disorders. This month I report on the section of the chapter on depression. Psychotherapy and antidepressant medications appear to have similar efficacy in short-term treatment trials, though psychotherapy has better outcomes than medication in the longer term. Psychotherapeutic treatments including Brief Dynamic Therapy (BDT), Interpersonal Psychotherapy (IPT), and Cognitive Behavioral Therapy (CBT) confer enduring benefit by preventing relapse and recurrence when compared to discontinuing medication. Antidepressant medication is modestly effective during initial short-term treatments with remission rates less than 50% and long term recurrence range from 40% to 85%. Combining medication with psychotherapy provides a small to moderate short term advantage over monotherapy of medication or psychotherapy. Combining medication and psychotherapy is more useful for when considering chronicity rather than severity of depression. The results are consistent for BDT, IPT, and for CBT. In the longer term, efficacy of combined treatments is not better than either monotherapy. Taken together, the evidence for combined therapy for depression is modestly positive with little evidence that treatments interfere with each other (by contrast, see the March 2013 blog for findings of interference in combined therapy for anxiety disorders). Nevertheless, prolonged continuation of medication monotherapy is an added expense that is often ineffective. In fact, prolonged antidepressant medication maintenance can worsen the course of depressive illness for some, and efficacy tends to fade after 3 to 6 months of maintenance. Finally, there is emerging evidence of progressive tolerance (tachyphylaxis) or even worsening of symptoms during medication maintenance. Studies suggest that psychotherapy added to maintenance medication was associated with decreased relapse rates when compared to medication alone in the longer term.
Practice implications
Combined treatments (antidepressant medication plus psychotherapy) for major depression provide modest incremental improvements in response over monotherapy. Results of combination treatments are better, though still modest, for those with chronic depression. The evidence does not support the use of combined treatments for mild to moderate depression, unless the individual does not responds to initial monotherapy. Practitioners could consider monotherapy (i.e., psychotherapy or medication) first, followed by switching therapy or augmenting therapy for non-responders. If a patient is started on short term monotherapy of medication, practitioners may consider switching to psychotherapy for better long term relapse prevention.
April 2013
Combining Medication and Psychotherapy in the Treatment of Anxiety Disorders
Handbook of Psychotherapy and Behavior Change: The Handbook of Psychotherapy and Behavior Change is perhaps the most important compendium of psychotherapy research covering a large number of research areas related to psychotherapy. Starting in March 2013, I will review one chapter a month in addition to reviewing psychotherapy research articles. Book chapters have more restrictive copy right rules than journal articles, so I will not provide author email addresses for these chapters. If you are interested, the Handbook table of content can be viewed on Amazon.
Forand, N.R., DeRubeis, R.J., & Amsterdam, J.D. (2013). Combining medication and psychotherapy in the treatment of major mental disorders. In M.J. Lambert (Ed.) Bergin and Garfield’s handbook of psychotherapy and behaviour change (6th ed.), pp. 735-774. Hoboken, N.J.: Wiley.
This comprehensive chapter covers evidence for combining medication and psychotherapy for several disorders. This month I report on the section of the chapter on anxiety disorders. Monotherapy of medication or psychotherapy are each effective in treating anxiety disorders, though relapse rates can be high. Simultaneously combining medications and psychotherapy is a common practice that is endorsed by several treatment guidelines. Some may also believe that medication and psychotherapy have additive effects or that those who do not respond to one treatment might respond simultaneously to the other. For panic disorder, short term outcomes slightly favour combined therapy of medications (e.g., antidepressants like SSRIs) and psychotherapy (i.e., that often include exposure). However, long term outcome data indicate that combined treatment was no different than cognitive behavioural therapy (CBT) alone. There is also evidence that medications may interfere with exposure-based treatment of panic disorder so that relapse is greater with combination therapy. It is possible for example that medications may suppress fear-related cognitions thus preventing encoding of corrective information, and/or medication may inhibit extinction learning by suppressing cortisol secretion (in the short term) that facilitates consolidation of memories. The evidence for combining medication and psychotherapy for social anxiety disorder, post traumatic stress disorder, generalized anxiety disorder (GAD), and obsessive compulsive disorder are more mixed but still not clearly supportive of long term superiority of simultaneously combining medications and psychotherapy. Other combination approaches appear to show more promise. For example, there is better evidence for starting with a monotherapy initially and adding an alternative therapy for non-responders. Starting with medications first may allow allows cortisol to normalize over time perhaps reducing medication-induced inhibition of extinction learning. Then treatments such as exposure based CBT or brief dynamic therapy for GAD may be additionally helpful to those who do not respond to medication alone. The existing trials tend not to show evidence of incremental benefit of adding medication after initiating psychotherapy. CBT may be effective in helping individuals taper medications while maintaining treatment gains.
Practice implications
Simultaneously combining medication and psychotherapy for anxiety disorders may be common practice. There is an overall lack of evidence that combining treatments improves outcomes, especially in the longer term. Evidence points to medications interfering with the effectiveness of psychotherapy when they are initiated simultaneously. Compared to monotherapy, combined treatments are more complex, time-consuming, expensive, and expose the patient to increased side effect risk. Combination treatments may be best reserved for those who are refractory to initial monotherapy.