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Volume 21, Number 1 • 2007
Combined Cognitive-Behavior Therapy and Pharmacotherapy
Jesse H. Wright, MD, PhD
University of Louisville, Kentucky
ecause cognitive-behavior therapy (CBT) is based on a psychological model for understanding and treating mental disorders, the preponderance of the research and clinical development of this approach has been concerned with psychological mechanisms of action. Relatively little attention has been paid to potential interactions with biologically based treatments, the possible neurobiological effects of CBT, or the building of integrative methods for combining CBT with pharmacotherapy. For the most part, CBT and pharmacotherapy have developed as separate, and to some extent competing, treatment methods. Despite having different proposed mechanisms of action and treatment delivery methods, CBT and pharmacotherapy have several shared features. They both are: (1) empirically proven treatments with a history of extensive research on efficacy; (2) pragmatic and action oriented; (3) used with a broad range of patients who have a wide variety of diagnoses; and (4) endorsed as effective interventions by panels and organizations such as the American Psychiatric Association and the National Institute for Clinical Excellence (NICE). As two of the most widely used and respected treatments, CBT and pharmacotherapy would appear to have much to offer one another. For example, methods from CBT such as the collaborative-empirical therapeutic relationship, practical techniques to reduce hopelessness and reverse patterns of avoidance, and interventions to improve adherence might be beneficial for patients being treated with pharmacotherapy. In turn, targeted use of medication to lower agitation, improve energy, decrease psychotic symptoms, or improve concentration might make certain patients more accessible to CBT, promote learning in psychotherapy, or enhance the overall outcome (Wright, 2004). Research on combined CBT and pharmacotherapy began in the 1980s with classic trials, which compared CBT alone to tricyclic antidepressants plus clinical management and to the two treatments offered together (Blackburn, Bishop, Clen, Whalley, & Christie, 1981; Hollon et al., 1992; Murphy, Simons, Wetzel, Lustman, 1984). Although these trials found no statistically significant advantage for combined treatment over the treatments provided individually, there was a trend for superiority for CBT plus an antidepressant. Subsequent analyses of these trials, including meta-analyses (Friedman, Wright, Jarrett, & Thase, 2006; Hollon et al., 2005), have suggested that there was inadequate sample size in each individual study to find a significant
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The treatment of bipolar disorder requires pharmacotherapy with mood stabilizers or other effective medications.. comprehensive. However. 1997. bipolar disorder. 2000).. investigators and clinicians who have been working with schizophrenia. and his associates detail methods of combining CBT with medication for schizophrenia. van Balkom et al. delusions. and there is considerable evidence that they can provide effective treatment (Bakker et al. Simpson. Perhaps the greatest problem is that most research on combined therapy has pitted CBT versus pharmacotherapy and has not offered an integrated. & Anstee. Sharp et al.. Reviews of studies with tricyclic antidepressants (TCAs) have found that combined treatment is often more effective in the acute phase of therapy. 1998). Studies of combined therapy for depression and anxiety disorders have made significant contributions to the understanding of differential outcome between treatments.. These drugs offer advantages over benzodiazepines because they are less likely to cause dependence or impair learning and memory. 2000. Sharp. whereas in typical clinical practice. van Balkom. Hollon et al. Antidepressants are often used for anxiety disorders. 2005. van Balkom. Koele. De Beurs. Westra & Stewart.. 1993). 1998). medication regimens can be modified if side effects or lack of response are encountered. In fact. 2000. 2000. Larger trials or meta-analyses have substantiated a better outcome for combined treatment for depression (Friedman et al. and eating disorders describe key research findings and clinical methods for using medication together with CBT. They conclude that a growing number of research studies have documented that CBT can have add-on effects to antipsychotic medication. or flexible form of combined therapy that maximizes the potential advantages of this approach. but these advantages may disappear over the long term. as Monica Basco and her coworkers indicate in their article on combined therapy for this condition. 1995. who has played a leading role in developing CBT for severe mental disorders. 2004). Naturalistic follow-up studies are hard to interpret because patients often stop medications or enter other forms of therapy. 1995. De Beurs et al. such as atypical antipsychotics. & van Dyck. One of the most exciting recent developments in CBT has been the dramatic increase in research studies and clinical applications for the treatment of psychosis. Power. in which positive interactions between treatments may be encountered in some patients while negative interactions may occur in others. Differences between outcomes with TCAs and SSRIs may possibly be due to the enhancement of learning and memory with SSRIs as compared to a negative impact on learning and memory from TCAs (Wright.4 Introduction difference between treatments offered singly or together. Several major reviews and meta-analyses have found that benzodiazepines typically do not add to the efficacy of CBT for various anxiety disorders (Bakker. In this edition of the Journal of Cognitive Psychotherapy. Basco has pioneered efforts to .. 1997. analyses of mean responses in randomized. Patients are treated by clinicians who follow specific protocols for treatments as separate entities instead of offering an integrated method. there have been many problems with these studies that make it difficult to generalize findings to clinical practice (Wright. there is some evidence that high-potency benzodiazepines such as alprazolam may actually impair the efficacy of CBT for panic disorder (Marks et al.. Lange. Also. Westra and Stewart (1998) concluded that longer acting benzodiazepines such as diazepam did not have this deleterious effect on CBT. and thus are better choices for combined treatment with CBT. Keller et al.. Swanson. Studies of combined treatment of anxiety disorders have had mixed results. However. 2006. controlled trials may obscure individual variations. 2004). and negative symptoms of schizophrenia to a greater extent than treatment as usual with medication and clinical management. 1997). Research with selective serotonin reuptake inhibitors (SSRIs) for anxiety disorders has usually documented superior results for combined treatment with CBT (Bakker et al. Medication choices and doses are usually rigidly prescribed. Although the results of studies have varied. & van Dyck. there is substantial evidence that adding CBT to pharmacotherapy can reduce hallucinations. Westra & Stewart. David Kingdon.
A. 2005). CBT appears to offer promise as a treatment for bipolar disorder. Mazziota. 49.Introduction 5 develop adjunctive CBT methods for bipolar disorder (Basco & Rush. Schwartz. Research on combined treatment for bipolar disorder is still at a very early stage. For example. The potential interactions between treatments. M. which could enhance participation in CBT. ]. International Clinical Psychopharmacology. C. preliminary research with PET scan and other imaging techniques has found that CBT and pharmacotherapy can have similar actions on brain pathways for the treatment of obsessive-compulsive disorder (OCD) and anxiety disorders (Baxter et al. Because there are a significant number of patients with these conditions who do not respond to CBT. Baxter. J. Guza.. One of the intriguing possibilities of this type of research is that specific neural circuits could be detailed in which CBT and pharmacotherapy augment one another in reversing the CNS pathology associated with major mental disorders. REFERENCES Bakker.. an expert on the treatment of eating disorders. and reducing the risk of relapse. New York: Guilford.. A. M. R. then an antidepressant can be added. Furmark et al.. and judicious use of medications may offer opportunities for effective treatment in difficult clinical situations. H. (2000).. These methods are directed at symptom monitoring.. K. Research conducted by Goldapple and coworkers (2005) found that antidepressants activated brain pathways from the "bottom up. While clinicians await the results of future studies on combined CBT and biologically oriented interventions. ).. 1996) but quite different actions when the treatments are used for depression (Goldapple et al. but some studies have shown positive effects of adding CBT to mood stabilizers.. & Phelps. & van Dyck. If satisfactory results are not obtained. With anorexia nervosa. there is little solid evidence for the efficacy of CBT. P. R. Ir. in which CBT is first used alone." whereas CBT appeared to act from the "top down. developing effective coping strategies for symptoms not fully controlled by medication. a stepped-care approach is recommended. Caudate glucose metabolic rate changes with both drug and behavior therapy for obsessive-compulsive disoidei:. 2002. Bergman. but the results of early studies suggest that ongoing therapy may be required to obtain enduring effects. Basco M. but that combinations of CBT and medication typically lead to better outcomes than medication alone. or the biological effects of CBT. 2). 25-30. . et al. I. Wayne Bowers. Schwartz. and his associate Arnold Anderson observe that CBT has frequently been found to be superior to medication in the treatment of bulimia nervosa and binge-eating disorder.. 681-689. 1992. van Balkom. which could work together with medication in additive or synergistic mechanisms. A deeper understanding of the processes of interaction between CBT and pharmacotherapy could lead to advances in treatment methods. Selective serotonin reuptake inhibitors in the treatment of panic disorder and agoraphobia." with cortical activity preceding limbic system and deeper brain structure activity. such as the actions of medications on cognitive processing. Archives of General Psychiatry. B. have not been adequately investigated. Martin.. The great majority of the research studies completed to date on combined treatment have focused on comparing the differential outcomes of CBT versus pharmacotherapy or CBT plus medication versus treatment as usual. managing stress. cognitive and behavioral interventions. 2005). (1992). Baxter.. Stoessel. & Rush A. but a combination of nutritional counseling.. learning about the positive and negative features of medications. R. i5(Suppl. This edition of the Journal of Cognitive Psychotherapy contains three articles that should help readers learn more about combining CBT and medication in clinical practice. Szuba. (2005). practical issues such as choosing the form of treatment. L. Cognitive-behavioral therapy for bipolar disorder. and gaining skill in combining therapies continue to be important challenges. S.
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