Combining CBT and Medication: An Evidence-Based Approach

By Donna M. Sudak

Combining medication and cognitive behavioral therapy (CBT) can be challenging but can also enhance patient care. This book reviews the existing literature about the neurobiological and clinical basis in combining CBT and medication for non-psychiatrist mental health clinicians. Filled with case studies drawn from the author's extensive clinical and teaching experience, this book breaks new ground in bringing together the most current, proven protocols for using drugs and CBT to improve client care. Practitioners will find in this volume the tools to make informed recommendations to patients.

• Language: English
• Publisher: Wiley
• Release date: Mar 29, 2011
• ISBN: 9781118076668

Book preview

Contents

Preface

Chapter 1 : Medication Versus CBT

Studies of Combined Treatment

What Mechanisms Could Influence Combined Treatment Effects?

Chapter 2 : Neurobiological Evidence and Combined Treatment

How Medication and Psychotherapy Change Brains

Neuroimaging: The Good, The Bad, and The Ugly

Chapter 3 : Dual Responsibility Treatment

Establishing a Collaborative Relationship

Advantages of Dual Responsibility Treatment

Models for Dual Responsibility Treatment

Integrated Treatment Solves Many Problems that can Occur Between Two Care Providers

Problems in Dual Responsibility Treatment

Chapter 4 : Combining CBT Interventions and Medication to Enhance Medication Adherence

Evidence Supporting Combining CBT with Medication to Enhance Adherence

Conceptualizing Difficulties With Adherence

Techniques That Facilitate Medication Adherence

Techniques to Use When Medication Adherence is a Problem

Chapter 5 : Combined Treatment for Major Depression

Overview

Evidence For Combining Medication and Cognitive Behavior Therapy in Depression

How Effective Are Antidepressants?

Special Issues in Combined Treatment for Depression

Chapter 6 : Combined Treatment for Bipolar Disorder

Overview

Evidence for Use of Combined Treatment in Bipolar Disorder

Treatment of Bipolar Disorder

CBT for Bipolar Disorder

Special Issues in The Combined Treatment of Bipolar Disorder

Chapter 7 : Combined Treatment for Anxiety Disorders

Overview

Principles That Facilitate Dual Responsibility Treatment in Anxiety Disorders

Evidence for Combining Medication and Cognitive Behavioral Therapy for Anxiety Disorders

Chapter 8 : Combined Treatment for Eating Disorders

Overview

Evidence for The Use of Combined Treatment With CBT and Medication

Special Problems in The Management of Patients With Eating Disorders

Chapter 9 : Combined Treatment for Schizophrenia

Overview

Evidence For Combining CBT With Medication in Schizophrenia

Fundamentals of The CBT Approach to The Patient With Schizophrenia

Special Problems in Treating The Patient With Schizophrenia

Chapter 10 : Combined Treatment for Borderline Personality Disorder

To Medicate Or Not To Medicate: That is The Question

Challenges in Prescribing Medications in Borderline Personality Disorder

Chapter 11 : Combined Treatment in Pregnancy

Overview

Principles of Managing Pregnant Women With Psychiatric Disorders

Clinical Approaches To Women On Psychotropic Medication Who Wish To Become Pregnant

Chapter 12 : Combined Treatment for Substance Abuse and Dependence

Overview

Evidence For The Use of Medication for Substance Use Disorders

Evidence For Combined Treatment With CBT and Medication for Substance Use Disorders

Special Considerations in Combined Treatment for Substance Abuse and Dependence

References

Author Index

Subject Index

Copyright © 2011 by John Wiley & Sons, Inc. All rights reserved.

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

Published simultaneously in Canada.

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Library of Congress Cataloging-in-Publication Data:

978-0-470-44844-1 (pbk)

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978-1-118-07666-8 (ebk)

978-1-118-07664-4 (ebk)

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Preface

Practitioners 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 diagnosis, 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 obtaining 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 medication and determined that patients prefer to receive combined treatment. Residency training programs in psychiatry and, to a lesser extent, in primary 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 attitudes 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 treatment, 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 prescriber, 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.

The remainder of the book details specific evidence for or against combining treatment in particular disorders, and, in the case of Chapter 11, during pregnancy. 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 schizophrenia, 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 collaborative 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 common 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 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 conventions 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 feedback 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.

CHAPTER 1

Medication Versus CBT

How Did That Happen?

Mary is a 40-year-old woman who has been in therapy for six months for a severe depression, which developed after her husband of 15 years left her for another woman. Unfortunately, her depressive symptoms include fairly routine and significant insomnia—she wakes up at four a.m. nearly every night. The sleep disturbance has been not responsive to her therapist’s suggestions to make her bedtime and waking time the same each day and to employ other sleep hygiene measures. Mary is a pharmacist in a busy chain-operated drugstore. She is in danger of being fired because her work performance has been altered by fatigue and poor concentration. Her therapist is reluctant to refer her for a medication evaluation because she believes Mary’s depression has such a clear-cut psychological precipitant.

John is a 60-year-old man who was recently diagnosed with lung cancer. He has developed fairly significant anxiety about an impending surgical procedure to remove the lobe of his lung that contains the primary lesion. He has suffered multiple panic episodes, and in the past month he has started to avoid going out to the mall or to football games. His primary care physician prescribes Clonazepam 0.5 mg twice a day and tells John that it makes sense that he would be anxious given his circumstances. He does not refer John for therapy.

Mary and John are both in treatment with practitioners who have beliefs about the origins of their patients’ illness that influence the treatment they provide. The decisions we make as clinicians are informed by our understanding of the nature and best available treatment of particular psychological problems. Most of us have a view of combined treatment with medications and CBT that is influenced by how research studies of combined treatment were conducted in their earliest iterations. It helps to retrace some of this history to assess the quality of the data we use to make clinical decisions.

STUDIES OF COMBINED TREATMENT

Studies conducted about treatment combining medications and CBT evolved with the aim of establishing comparative efficacy. A tremendous increase in effective novel medications for depression and anxiety occurred in the 1960s and 1970s. Although it is an imperfect system, the development of the Diagnostic and Statistical Manual of Mental Disorders (DSM) meant that researchers were able to make clearer distinctions between groups of patients and actually determine what treatments worked in particular disorders. Structured interviews became available that increased the consistency of diagnoses in patients—so that more homogeneous and accurately diagnosed groups of patients could be studied in either medication or psychotherapy treatment trials. This was a major advance in the field and increased the ability to develop and test new treatments. Once an accurate diagnosis was made, clinicians could treat patients with greater effectiveness.

The previously mentioned explosion in biological treatments was paralleled by substantial new knowledge about manual-based psychotherapeutic treatments—such as CBT and interpersonal therapy (IPT)—that could rapidly and effectively work to treat major depression, panic disorders, and phobias. Medications were considered the gold standard as a treatment approach; psychotherapy was evaluated for comparative efficacy. Most research trials were conducted to determine whether individual treatments worked. Unfortunately, investigators who considered the question of whether these treatments were effective were generally quite invested in the approaches they evaluated. Thus, they often framed questions that were inadvertently biased to favor the form of treatment that they espoused. For example, many of the studies that evaluated the efficacy of medication treatment for panic disorder versus the efficacy of CBT were done with patients who did not display agoraphobic avoidance. This would naturally dilute the efficacy of exposure-based procedures in the CBT provided. Certainly the outcome measures chosen to evaluate what constituted response in any study of combined treatment would influence what view we had about the utility of either approach and for which groups of patients. Research about the positive and negative effects of combined treatment was rarely performed in these early comparative studies. Process research that could inform us about any differential effects of medication or therapy or their combination in particular types of patients is still largely uncharted territory. Pooled data that are evaluated at the end of treatment do not allow us to determine individual differences in response to combined treatment over time. Such studies would be expensive and complicated. Early studies considered outcomes at the end of therapy without any effort to look at process issues, interactions between treatments, or specific patient variables that would make patients more suitable for one particular approach or the combination.

As treatments became more effective, it became more difficult to determine if the combination of two treatments would be even more powerful than either treatment alone. Highly effective treatments require very large studies to determine whether any benefit is derived from their combination. The expense and complexity of such studies limit the frequency with which they occur. Because medication and therapy independently have a substantial impact relative to placebo in depression and anxiety, there is less incentive to conduct complex and costly evaluations of the beneficial or deleterious effects of the combination. Early studies of combined treatment for depression were small, but had some nonsignificant trends toward an increased response rate for those patients who received combined treatment. At least one large-scale clinical trial (Keller et al., 2000) indicates a fairly substantial benefit from combining a form of CBT with medication versus either treatment alone in a group of chronically depressed patients who had a limited response to prior treatment.

Ideally, a heterogeneous group of investigators should develop and execute combined treatment research and pool expertise so that process variables could be measured in the widest possible manner. Gorman and his colleagues (Gorman, Barlow, Ray, Shear, & Woods, 2001) detail the complexity of such a collaboration in an article describing the work they did in evaluating the differential efficacy of CBT, imipramine, and CBT combined with imipramine for panic disorder. Several recent studies, for example, the Treatment for Adolescents with Depression (TADS) study (March et al., 2009), were similarly well designed. They were developed by a multidisciplinary team of investigators and will likely increase our knowledge about variables that influence positive patient outcome.

In the context of the early horse race model designed to evaluate the differential efficacy of medications, therapy, or both, many of the completed and published studies evaluate combined treatment with medications that are currently not in common use. A majority of the studies in depression and anxiety investigate the efficacy of tricyclic antidepressants alone, compared to, and in combination with CBT, for example. Unfortunately, the data we have from these studies has limited applicability to current practice. The vast majority of patients do not take these medications for depression or anxiety because of the debilitating side effects and risk of suicide inherent in their use. There is less incentive to pursue combined treatment research with newer medications, because CBT has been established as an effective treatment for depression and anxiety and newer antidepressants have not been found to be more effective than tricyclic antidepressants, so that testing them head-to-head with CBT and evaluating the combination has less value to researchers.

Another limitation to generalizing the research data available about combined treatment to clinical practice is that research studies do not employ optimal or acceptable standards of care. Separate clinicians deliver each treatment in research studies with minimal, if any, communication with one another. Medications in most clinical trials are prescribed with limited dosage adjustments, if at all. If there is no response, research protocols prohibit switching or augmenting medications. Patients generally continue on the same medication for the full duration of the study, regardless of their response, when in clinical practice another method of treatment would be added if medication was ineffective. Pharmacotherapy protocols in research studies generally do not allow for any addition of pharmacological treatments for debilitating and common symptoms when they are incompletely treated by the prescribed medication. Insomnia or severe anxiety would typically be managed by additional medications in the acute treatment of a severely ill patient. Providers who prescribe in research trials are often instructed to limit the interpersonal interactions they have with patients to reduce any study error caused by variation in therapy time. Murphy and colleagues (Murphy, Carney, Knesevich, Wetzel, & Whitworth, 1995) have shown that antidepressant medication is far less effective when providers are instructed to not interact with patients in a positive and engaged way—largely because of adherence issues. In a meta-analysis, Pampallona and colleagues (Pampallona, Bollini, Tibaldi, Kupelnick, & Munizza, 2004) determined that 33% of patients in treatment with antidepressants who are not provided therapy drop out of treatment and do not take medication. Gorman and colleagues (2001) describe a situation in the combined treatment study of CBT and imipramine in panic disorder in which one practitioner had an unusually low response rate to the medication provided. Upon review, this practitioner was interacting minimally with patients because of his concern that he could confound the study results by providing additional therapy. Therefore, medication treatment provided with minimal interaction with care providers may not accurately reproduce clinical outcomes with optimal care. Therapists with a positive attitude toward medication can enhance the placebo response to medication (Barrett & Wright, 1984). This potentiating effect is absent in blinded combined treatment trials.

In the psychotherapy arm of research projects, therapy is often unlike clinical practice. It is generally manual-based with less emphasis on individual patient conceptualization. Patients are assessed with multiple measures throughout treatment—which could alter patient expectations and motivation in a positive or negative way. If patients have co-morbid Axis II psychopathology, there is rarely the flexibility to slow the therapeutic process to allow for the type of alliance-building that is necessary to employ CBT effectively.

Another difficulty we face in determining the best evidence-based option to recommend to a patient is that patients who are eligible to participate in clinical trials represent a very narrow spectrum of the individuals afflicted by a particular diagnosis. An estimated 80% of applicants to antidepressant trial research are excluded (Posternak, Zimmerman, Keitner, & Miller, 2002). Zimmerman and his colleagues (Zimmerman, Mattia, & Posternak, 2002) looked at the medical records of patients seen in a large general psychiatry clinic to see how many of them would be eligible for a clinical trial of antidepressant medications. Of 803 patients, 346 had major depression. Of these patients, 86%—all but 41—would be excluded from a typical efficacy trial due to co-morbidity, chronic illness, severity, or suicidal ideation. Patients seen by therapists and prescribers in routine clinical practice are often far more complicated and have more chronic conditions than those who participate in clinical trials. Bockting and colleagues (2008) determined that patients with greater numbers of episodes of illness derive the most benefit from combined treatment—again, these patients were often excluded from early efficacy trials. The complexity of the typical patient who seeks mental health care makes it more difficult to determine what treatment makes sense; studies of patients with co-occurring disorders are even scarcer. Patients who respond to treatment in typical efficacy trials may be very different from the typical patient who seeks treatment, accepts and adheres to treatment, and recovers and stays well.

In summary, the research evidence that we have available to us about when combined treatment might be helpful has limits to its clinical applicability and may not reflect the potential benefits or detractions of combined treatment in a particular patient. What may help us best is to consider the combination of genetic/biological, interpersonal/developmental, and temperamental risk factors that any patient has in order to determine who might benefit from combined or sequenced treatment until we have better data to help us to make determinations about what would constitute optimal care. Newer practical clinical trials will hopefully help us to determine the best interventions to help a patient obtain and sustain a full recovery.

WHAT MECHANISMS COULD INFLUENCE COMBINED TREATMENT EFFECTS?

We can generate hypotheses about the possible effects of combined treatment by considering the mechanisms of action of the individual effects of medications and psychotherapy. To benefit from psychotherapy, patients must be able to learn. Wright (2003) details the ways that medication or psychiatric illness could each alter attention, memory, and the ability to integrate new information. We know that a substantial number of psychiatric disorders interfere with the acquisition and retention of information. Severe anxiety, depression, mania, and psychosis, for example, can hamper normal learning. Sleep problems are common in major psychiatric disorders, and insomnia can decrease the capacity to learn and remember. Distractibility is common to many Axis I disorders—rumination, hallucinations, flight of ideas, and attention to threat can interfere with patient attentiveness. The speed of thought can be accelerated or decreased by mood disorders, hindering attention and recall. Therapy can proceed more effectively if these impediments to learning are addressed by pharmacotherapy. CBT, in particular, is primarily a treatment that relies on the patient’s ability to learn new skills, so a fundamental requirement is that patients must have the ability to learn and to remember.

The downside can also be true—combined treatment has the potential to impede learning and memory. Prescribers must be aware of medications that can sedate patients and interfere with learning. Anticholinergic side effects were once a predominant feature of medications used for depression and psychosis. This particular side effect could interfere with new learning and memory functions in all patients. Specific side-effect profiles of many tricyclic antidepressants listed possible alterations in memory, including problems with word-finding. This type of alteration in memory could slow therapeutic progress. Benzodiazepines can also impair learning and recall, so when they are used for anxiety, they could interfere with exposure treatment by preventing new learning as well as habituation.

So a practitioner may ask Why is this important? If medication and therapy are each so effective, what difference does it make? And the answer—obvious to anyone in clinical practice for very long—is that our treatments, although better than ever, are still not that good. In the best hands, response to a single-modality treatment for depression in the limited, uncomplicated population studied in most clinical trials is a bit better than 50%. Our treatments are