Current Medical Diagnosis & Treatment in Psychiatry

Combinations with Medications

Many of the disorders treated with behavioral or cognitive-behavioral therapy can also be treated pharmacologically, although some cannot. In some disorders, a combination of drugs and behavioral (or cognitive-behavioral) therapy is more effective than either modality alone. Despite the theoretically based concerns of advocates for each approach, one modality rarely interferes with the other, although such interference sometimes occurs. For many disorders, there are simply not adequate data to guide clinical practice; we often know that both modalities are effective in their own right but do not know whether their combination enhances treatment response.

Drugs and other somatic interventions appear to be essential to the treatment of the more severe disorders, particularly those that involve psychotic symptoms. Nonetheless, behavioral and cognitive-behavioral interventions can often play an important adjunctive role. Antipsychotic medications remain the most effective means of reducing the more florid symptoms of psychosis, and the newer, atypical antipsychotics show promise in relieving the negative symptoms of schizophrenia. Rehabilitation programs based on behavioral skills training appear to help redress impairments in psychosocial functioning in such patients and may allow the use of newer low-dose neuroleptic strategies. Lithium and the newer anticonvulsants provide the most effective means of prophylaxis in the bipolar disorders, but cognitive- behavioral therapy can enhance compliance with drug therapy.

The relative importance of pharmacotherapy is less pronounced among even the more severe, nonpsychotic disorders and quite possibly is nonexistent among the less severe disorders. Cognitive therapy appears to be about as effective as pharmacotherapy for all but the most severe nonbipolar depressions and may be more enduring in its effects. Exposure-based therapies are quite helpful in reducing compulsive rituals in OCD and behavioral avoidance in severe agoraphobia. Such therapies are often combined with medications to treat these disorders. Cognitive-behavioral therapy appears to be at least as effective and possibly longer lasting than pharmacotherapy in the treatment of panic disorder and social phobia, and the same can be said with respect to the treatment of bulimia. Exposure-based treatment is clearly superior to pharmacotherapy (or any other form of psychotherapy) in the treatment of social phobia. There is little evidence that drugs are particularly helpful in the treatment of the personality disorders, whereas a dialectic approach to behavior therapy appears to reduce the frequency of self-destructive behavior in patients with borderline personality disorder.

In general, the more severe the psychopathologic disorder, the greater the relative efficacy of pharmacotherapy and the more purely behavioral the psychosocial intervention needs to be. Medications are often useful to control disruptive symptoms, but behavioral interventions (especially operant ones) are uniquely suited to instilling new skills or restoring those that have been lost to illness or institutionalization. Behavioral interventions based on classical conditioning models appear to be particularly helpful in reducing undesirable states of arousal and affective distress; cognitive interventions appear to reduce the likelihood of subsequent relapse by correcting erroneous beliefs and attitudes that contribute to risk. These strategies rarely interfere with one another, and it is often useful to combine them in practice to achieve multiple ends.

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