Blog

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 (6^th 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.