Introduction Combined cognitive-behavior therapy and pharnacotherapy

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Journal of Cognitive Psychotherapy: An International Quarterly

Volume 21, Number 1 • 2007

I N T R O D U C T I O N

Combined Cognitive-Behavior Therapy

and Pharmacotherapy

Jesse H . W right, MD, PhDUniversity of Louisville, Kentucky

B

ecause cognitive-behavior therapy (CBT) is based on a psychological model for under-

standing 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 w ith a history of extensive research on efficacy; (2) pragm atic an d action o riented ; (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 Am erican 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 sym ptoms, or im prove conce ntration 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 thetwo treatments offered together (Blackburn, Bishop, Clen, Whalley, & Christie, 1981; Hollon



4 Introduction

difference between treatments offered singly or together. Larger trials or meta-analyses have

substantiated a better outcom e for co mbined treatm ent for depression (Friedman et al., 2006;

Hollon et al., 2005; Keller et al., 2000). Studies of combined treatment of anxiety disorders have

had mixed results. Several major reviews and meta-analyses have found that benzodiazepines

typically do not add to the efficacy of CBT for va rious anxiety disorders (Bakker, van Balkom, &van Dyck, 2000; van Balkom et al, 1997; Westra & Stewart, 1998). In fact, there is some evidence

that high-potency benzodiazepines such as alprazolam may actually impair the efficacy of CBT

for panic d isorder (Marks et al., 1993). Westra and Stewart (1998) conclud ed th at longe r acting

benzodiazepines such as diazepam did not have this deleterious effect on CBT.

Antidepressants are often used for anxiety disorders, and there is considerable evidence that

they can provide effective treatment (Bakker et al., 2000; De Beurs, van Balkom, Lange, Koele,

& van Dyck, 1995; Sharp, Power, Simpson, Swanson, & Anstee, 1997; Westra & Stewart, 1998).

These drugs offer advantages over benzodiazepines because they are less likely to cause depen-

dence or impair learning and memory, and thus are better choices for combined treatment with

CBT. Reviews of studies with tricyclic antidepressants (TCAs) have found that combined treat-ment is often more effective in the acute phase of therapy, but these advantages may disappear

over the long term. Naturalistic follow-up studies are hard to interpret because patients often

stop medications or enter other forms of therapy. Research with selective serotonin reuptake

inhibitors (SSRIs) for anxiety disorders has usually documented superior results for combined

treatment with CBT (Bakker et al., 2000; De Beurs et al., 1995; Sharp et al., 1997). Differences

between outcomes with TCAs and SSRIs may possibly be due to the enhancement of learning

and m em ory w ith SSRIs as compared to a negative impact on learning and m em ory from TCAs

(Wright, 2004).

Studies of combined therapy for depression and anxiety disorders have made significant

contribu tions to the understan ding of differential outcom e between treatm ents. However, there

have been m any p roblem s with these studies that m ake it difficult to generalize findings to clinical

practice (Wright, 2004). Perhaps the greatest problem is that most research on comb ined therapy

has pitted CBT versus pharmacotherapy and has not offered an integrated, comprehensive, or

flexible form of combined therapy that maximizes the potential advantages of this approach.

Patients are treated by clinicians who follow specific protocols for treatments as separate entities

instead of offering an integrated method. Medication choices and doses are usually rigidly pre-

scribed, whereas in typical clinical practice, medication regimens can be modified if side effects

or lack of response are encountered. Also, analyses of mean responses in randomized, controlled

trials may obscure individual variations, in which positive interactions between tre atm ents maybe encountered in some patients while negative interactions m ay occur in others.

In this edition of the Journal of Cognitive Psychotherapy, investigators and clinicians who

have been working with schizophrenia, bipolar disorder, and eating disorders describe key

research findings and clinical methods for using medication together with CBT. 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. David Kingdon, who has played a

leading role in developing CBT for severe mental disorders, and his associates detail methods

of combining CBT with medication for schizophrenia. They conclude that a growing number

of research studies have documented that CBT can have add-on effects to antipsychotic

medication. Although the results of studies have varied, there is substantial evidence thatadding CBT to pharmacotherapy can reduce hallucinations, delusions, and negative symp-



Introduction 5

develop adjunctive CBT methods for bipolar disorder (Basco & Rush, 2005). These methods are

directed at symptom monitoring, developing effective coping strategies for symptoms not fully

controlled by medication, managing stress, and reducing the risk of relapse. Research on com-

bined treatment for bipolar disorder is still at a very early stage, but some studies have shown

positive effects of adding CBT to mood stabilizers. CBT appears to offer promise as a treatmentfor bipolar disorder, bu t the results of early studies suggest that ongoing th erapy may be required

to obtain enduring effects.

Wayne Bowers, an expert on the treatment of eating disorders, and his associate Arnold

Anderson observe that CBT has frequently been found to be superior to medication in the

treatm ent of bulimia nervosa and binge-eating disorder, but that com binations of CBT and me d-

ication typically lead to better outcomes than medication alone. Because there are a significant

num ber of patients with these conditions who do not respond to CBT, a stepped-care approach

is reco m m end ed, in w hich CBT is first used alone. If satisfactory results are not o btaine d, then an

antidepre ssant can be added . W ith anorexia nervosa, there is little solid evidence for the efficacy

of CBT, but a combination of nutritional counseling, cognitive and behavioral interventions, andjudicious use of medications may offer opportunities for effective treatment in difficult clinical

situations.

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

me dication versus treatme nt as usual. The potential interactions between treatm ents, such as the

actions of m edications o n cognitive processing, which could enh ance pa rticipation in CBT, or the

biological effects of CBT, which could wo rk together with m edication in additive or synergistic

mechanisms, have not been adequately investigated.

A deeper understanding of the processes of interaction between CBT and pharm acotherap y

could lead to advances in treatment methods. For example, preliminary research with PET scanand othe r imaging techniques has found that CBT and pha rma cotherapy can have similar actions

on brain pathways for the treatment of obsessive-compulsive disorder (OCD) and anxiety disor-

ders (Baxter et al., 1992; Furmark et al., 2002; Schwartz, Stoessel, Baxter, Martin, & Phelps, 1996)

but quite different actions when the treatments are used for depression (Goldapple et al., 2005).

Research conducted by Goldapple and coworkers (2005) found that antidepressants activated

brain pathways from the "bo ttom up," whereas CBT appeared to act from the "top down," with

cortical activity preceding limbic system and deeper brain structure activity. One of the intrigu-

ing possibilities of this type of research is that specific neural circuits could be detailed in which

CBT and pharm acotherapy augm ent one an other in reversing the CNS pathology associated w ith

major mental disorders.

W hile clinicians await the results of future studies on co mbined CBT and biologically oriented

interventions, practical issues such as choosing the form of treatment, learning about the posi-

tive and negative features of medications, and gaining skill in combining therapies continue to be

im por tant challenges. This edition of the Journal of Cognitive Psychotherapy contains three article

that should help readers learn m ore ab out com bining CBT and me dication in clinical practice.

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6 Introduction

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Corresponde nce regarding this article should be directed to Jesse H. Wright, MD , PhD, Departm ent of Psychiatry

and Behavioral Sciences, Norton Psychiatric Ce nter, 200 East Chestnut Street, Louisville, KY 40232. E-mail:jwrigh t@iglou. com



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Introduction Combined cognitive-behavior therapy and pharnacotherapy