Combining CBT and Medication - 2011 - Sudak

Combining CBT and
Medication
An Evidence-Based

Approach
Donna M. Sudak, M.D.
John Wiley & Sons, Inc.

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Library of Congress Cataloging-in-Publication Data:
978-0-470-44844-1 (pbk)
978-1-118-07665-1 (ebk)
978-1-118-07666-8 (ebk)
978-1-118-07664-4 (ebk)
978-1-118-09336-9 (obk)
Printed in the United States of America
10 9 8 7 6 5 4 3 2 1
Contents
Preface v
1 Medication Versus CBT: How Did That Happen? 1
2 Neurobiological Evidence and Combined Treatment 9
3 Dual Responsibility Treatment: Principles That Facilitate

Collaborative Patient Care 19
4 Combining CBT Interventions and Medication to Enhance

Medication Adherence 35
5 Combined Treatment for Major Depression 55
6 Combined Treatment for Bipolar Disorder 81
7 Combined Treatment for Anxiety Disorders 103
8 Combined Treatment for Eating Disorders 119
9 Combined Treatment for Schizophrenia 139
10 Combined Treatment for Borderline Personality

Disorder 159
11 Combined Treatment in Pregnancy 181
12 Combined Treatment for Substance Abuse and

Dependence—written with Samson Gurmu, M.D. 193
iii
209
235
243
Author Index
Subject Index
References
Contents
iv
Preface
P ractitioners are equipped with a variety of treatments for the most common
psychiatric disorders. Unfortunately, there is little clear-cut evidence to
help with the choice between treating with medications, psychotherapy, or
both. Researchers have found that cognitive behavioral therapy (CBT)
and pharmacological treatments for psychiatric conditions are effective for
a number of diagnoses, but less evidence is available about how to determine
what sequence or combination of treatments would be best to help a particular
patient recover and stay well. Mental disorders are widespread, painful, and
expensive. A patient’s well-being hinges on a durable and complete recovery.
Once treatment starts and a patient is stabilized, it is even more complicated
to decide when, how, and in what sequence to withdraw treatment.
Practitioners are also charged with delivering the most cost-effective,
efficient care. Ideally, when data exists, mental health providers should
systematically approach problems in clinical care and recommend a sequence
or combination of treatments that is safe, effective, efficient, and durable.
Health care costs and human suffering make this an imperative part of clinical
work. What generally occurs in practice is that treatment decisions are
determined by a combination of factors including patient preference and diag-
nosis, therapist comfort, access to prescribers and/or qualified psychotherapists,
acuity and severity of symptoms, and financial resources. Many patients
who enter therapy have already been prescribed medication by a primary care
physician. In fact, one study found that 95% of patients with panic disorder in
the US seek treatment from their primary care physician first before obtain-
ing a referral to a psychiatrist (Craske & Rodriguez 1994). Between 55 and
95% of patients with anxiety disorders are already on medications at the time
they seek therapy (Wardle 1990). Waikar and colleagues (Waikar, Bystritsky,
Craske, & Murphy 1994) studied patient attitudes and beliefs about medi-
cation and determined that patients prefer to receive combined treatment.
Residency training programs in psychiatry and, to a lesser extent, in primary
v
vi Preface
care specialties have increased requirements for residents to be trained in both

modalities. Thus, combined treatment is often the rule and not the exception.
Another reason to consider combining medication and psychotherapy is
that patients on medication often continue to have residual symptoms or
will relapse despite continued use of medication or participation in therapy.
We have some data about residual symptoms in mood disorders that indicate that
patients who have residual symptoms have a greater vulnerability to relapse.
Adding a second treatment may make full recovery more likely. Combined
treatment could reduce costs by broadening the scope of treatment effects and
increasing the rate of response. Some patients who are in a single treatment
who could benefit from a combination of treatments are not inclined to seek
pharmacological treatment because of biases against physicians or medication.
Therapy could be useful to these patients to help them examine the atti-
tudes they have and perhaps make medication an acceptable option. Finally,
patients in psychotherapy have a greater awareness of pharmacotherapy
options because of the impact of advertising and the Internet. The quality of
the information they obtain can influence the acceptability of combined treat-
ment, so a well-informed therapist is essential.
The purpose of this book is to provide a review of the evidence currently
available about combining medication and CBT. It begins with an overview
of the research methods in existing studies of combined treatment in Chapter 1,
and a review of the current neuroimaging and neurobiological studies that
could influence our understanding of how the combination of treatments work
in Chapter 2. Combined treatment can be delivered by a single provider, or
by a therapist for psychotherapy and a prescriber. Chapter 3 will describe the
potential advantages and pitfalls of providing “collaborative treatment,” a term
coined by Riba & Balon (1999)—that is, treatment by a psychotherapist and a
prescriber. The original definition they provided denoted a psychiatrist as a pre-
scriber, but the term could apply to a primary care physician or nurse practitioner
as well. Clinical vignettes will illustrate strategies to enhance collaboration and
to avoid the ethical dilemmas that can arise in collaborative treatment. This
chapter will also discuss how to exploit the advantages of having two caregivers.
In addition, because thoughtful and deliberate implementation of combined
treatment can be a challenge in complex patients, Chapter 4 will present a
model for integrating pharmacotherapy and CBT that enhances adherence
to the two approaches whether therapy is given by single or multiple care
providers.
Preface vii
The remainder of the book details specific evidence for or against combining
treatment in particular disorders, and, in the case of Chapter 11, during preg-
nancy. The book is not designed to review all the diagnoses that are encountered
in clinical practice, but to focus attention to the most common clinical
presentations for which there is evidence as to how to proceed with both
treatments. Chapters are designed to review the evidence and to discuss specific
challenges in combined treatment with the particular disorder. Chapter 5 and
Chapter 6 present evidence for combined treatment in two debilitating mood
disorders—major depression and bipolar disorder. Each of these chapters
focuses on specific clinical characteristics that can benefit from collaborative
care as well as the evidence for better outcomes when CBT is combined with
medication. These chapters, along with Chapter 8, which addresses schizo-
phrenia, pay particular attention to suicidal behavior and managing this
difficult clinical problem when there are two treatment providers. Chapter 7
explores the evidence available for combining CBT with various medications
in anxiety disorders. Principles that facilitate consistent communication to
anxious patients in dual-responsibility treatment are presented, along with
clinical vignettes that illustrate key concepts.
The next three chapters share a common demographic group—women of
childbearing years. Chapter 9 reviews collaborative care in eating disorders.
This group of patients requires collaborative care even if psychotropic
medication is not prescribed, because of the need for dual responsibility in
conjunction with a primary care physician or pediatrician. A similar discussion
is contained in Chapter 11, Combined Treatment in Pregnancy. Pregnancy
does not protect women from psychiatric illness, and the principles of colla-
borative care are essential in the care of women who wish to become pregnant
and need to manage a chronic mental illness. Chapter 10 discusses combined
treatment for patients with borderline personality disorder, a condition that is
frequently challenging to navigate with multiple care providers.
The final chapter, Combined Treatment for Substance Abuse and
Dependence, is somewhat different from the previous chapters. It includes more
detailed information about the medications available to use in combination with
cognitive-behavioral interventions. Many practitioners are unfamiliar with the
newer drugs that are available; they can be helpful adjuncts in these com-
mon and debilitating conditions. This chapter was co-written with Samson
Gurmu, M.D., a talented chief resident at Drexel University College of
Medicine, whom I have the pleasure of supervising. His passion for studying
viii Preface
and treating substance-use disorders was an impetus for this chapter’s inclusion.
I am grateful to him for his participation and hope to see his name in print
with great frequency in the years to come.
Although several evidence-based forms of therapy are classified as CBT (for
example, problem-solving therapy, cognitive therapy), the CBT referred to in
the text is the version elaborated by Aaron T. Beck. Additionally, the clinical cases
presented are fictitious and represent examples of common clinical situations.
They are designed to illustrate the opportunities and challenges that present
to most clinicians. I have also used the convention of alternating pronouns
(he and she) for readability. I have used the terms patient, therapist, and
prescriber, with the knowledge that other practitioners have different conven-
tions and philosophies about such terms. I am aware that the role of prescriber
often entails much more than pharmacological expertise, and that patient is
frequently a term that is regarded as less apt for individuals in mental health
treatment.
Many people assisted in the completion of this book. I owe a great deal
to Cheryl Carmin, Irismar Reis De Oliveira, Wei Du, Kelly Koerner, Joan
Romano, and Deborah Gross Scott for their helpful suggestions. My residents,
supervisees, and patients inspire and motivate my work every day. Patricia
Rossi at John Wiley has been an unfailingly persistent and patient editor.
Finally, I am tremendously grateful for the love, support, and accurate feed-
back from my husband and most respected colleague, Howard Sudak, and the
unshakable good humor, confidence, and fast fingers of my daughter and
world-class word processor, Laura Ferguson.

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Combining CBT and

Donna M. Sudak, M.D.

John Wiley & Sons, Inc.

Published by John Wiley & Sons, Inc., Hoboken, New Jersey.

Library of Congress Cataloging-in-Publication Data:

Printed in the United States of America

1 Medication Versus CBT: How Did That Happen? 1

2 Neurobiological Evidence and Combined Treatment 9

3 Dual Responsibility Treatment: Principles That Facilitate

4 Combining CBT Interventions and Medication to Enhance

5 Combined Treatment for Major Depression 55

6 Combined Treatment for Bipolar Disorder 81

7 Combined Treatment for Anxiety Disorders 103

8 Combined Treatment for Eating Disorders 119

9 Combined Treatment for Schizophrenia 139

10 Combined Treatment for Borderline Personality

11 Combined Treatment in Pregnancy 181

12 Combined Treatment for Substance Abuse and

care specialties have increased requirements for residents to be trained in both

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