Psychotherapy antidepressants

Antonuccio, D., Danton, W., DeNelsky, G., Greenberg, R., 8c Gordon, J. (1999). Raising questions about antidepressants. Psychotherapy and Psychosomatics, 68, 3-14. 

Benzodiazepines are prescribed commonly for SAD. Clonazepam is the most extensively studied benzodiazepine for the treatment of generalized SAD. " Clonazepam improved fear and phobic avoidance, interpersonal sensitivity, fears of negative evaluation, and disability measures. " Adverse effects included sexual dysfunction, unsteadiness, dizziness, and poor concentration. " Clonazepam is often prescribed in conjunction with an antidepressant, psychotherapy, or both for initial symptom relief. Comorbid alcohol or substance abuse are contraindications to the use of benzodiazepines. Other limitations of clonazepam therapy include lack of efficacy in depression and difficulty with discontinuation. Because of the risk of dependency, benzodiazepines should be reserved for patients at a low risk of substance abuse, those who require rapid relief of symptoms, or those who have not responded to other therapies. 

Depression is treated with the use of antidepressan t drugs. Psychotherapy is used in conjunction with the antidepressant drug s in treating major depressive episodes. The four types of antidepressants are ... 

Antidepressant drugs are used to manage depressive episodes such as major depression or depression accompanied by anxiety. These drugs may be used in conjunction with psychotherapy in severe depression. The SSRIs also are used to treat obsessive-compulsive disorders. The uses of individual antidepressants are given in the Summary Drug Table Antidepressants. Treatment is usually continued for 9 months after recovery from the first major depressive episode. If the patient, at a later date, experiences another major depressive episode, treatment is continued for 5 years, and with a third episode, treatment is continued indefinitely. 

Various forms of psychotherapy are regarded as effective interventions in mild to moderate depression, but studies comparing the economics of psychotherapy and pharmacotherapy are few (Rosenbaum and Hylan, 1999). One study found that the total health-care costs for patients who received psychotherapy were no different from those for patients who received an antidepressant. However, no efficacy measure was used (Edgell and Hylan, 1997). A randomized, prospective study which evaluated the treatment of depression with nortriptyline, interpersonal therapy or treatment as usual, with outcomes expressed in quality-adjusted life years, found that nortriptyline but not interpersonal therapy was a cost-effective alternative to treatment as usual (Lave et al, 1998). 

Benzodiazepines are used commonly in SAD however, there are limited data supporting their use. Clonazepam has been effective for social anxiety, fear, and phobic avoidance, and it reduced social and work disability during acute treatment.58 Long-term treatment is not desirable for many SAD patients owing to the risk of withdrawal and difficulty with discontinuation, cognitive side effects, and lack of effect on depressive symptoms. Benzodiazepines may be useful for acute relief of physiologic symptoms of anxiety when used concomitantly with antidepressants or psychotherapy. Benzodiazepines are contraindicated in SAD patients with alcohol or substance abuse or history of such. 

Like most people, I used to think that antidepressants worked. As a clinical psychologist, I referred depressed psychotherapy clients to psychiatric colleagues for the prescription of medication, believing that it might help. Sometimes the antidepressant seemed to work sometimes it did not. When it did work, I assumed it was the active ingredient in the antidepressant that was helping my clients cope with their psychological condition. 

For the purpose of our research, Sapirstein and I were not particularly interested in the effects of the antidepressants or psychotherapy. What we were interested in was the placebo effect. But since we had the treatment data to hand, we looked at them as well. And, as it turned out, it was the comparison of drug and placebo that proved to be the most interesting part of our study. 

Of all the alternatives to antidepressant medication, psychotherapy is the most thoroughly researched. It has been the subject of... 

Psychotherapy looks even better when its long-term effectiveness is assessed.17 Formerly depressed patients are far more likely to relapse and become depressed again after treatment with antidepressants than they are after psychotherapy. As a result, psychotherapy is significantly more effective than medication when measured some time after treatment has ended, and the more time that has passed since the end of treatment, the larger the difference between drugs and psychotherapy. This long-term advantage of psychotherapy over medication is independent of the severity of the depression. Psychotherapy outperforms antidepressants for severely depressed patients as much as it does for those who are mildly or moderately depressed.18... 

Why does psychotherapy - either alone or in combination with antidepressants - have more lasting effects than medication If you take antidepressants and get better, you are likely to attribute your improvement to the medication. So when you stop taking it, you might expect to get worse again. In Chapter... 

If both drugs and psychotherapy alleviate depression, maybe the combination of the two would work even better. This could be true even if the effects of antidepressants are placebo effects. As we saw in Chapter 4, taking two placebos can be more effective than taking only one. 

The central theme of this book is that much - if not all - of the therapeutic effects of antidepressants are due to the placebo effect. Might this not also be true of the effect of psychotherapy on depression Could this also be a placebo effect This is one of the objections that I hear quite often when I am invited to speak about my research. Psychotherapy is no more effective than antidepressant medication, these critics contend. So if antidepressants are merely placebos, so too is psychotherapy. 

If you look back again at the graph in Chapter i (page 10) showing the results of the first meta-analysis that I published on the treatment of depression, you can see why people might conclude that psychotherapy - like antidepressants - is merely a placebo. My own analysis showed that the effectiveness of psychotherapy is about the same as that of drugs, and that although both are much better than no treatment at all, neither is much better than placebo pills.29... 

There seems to be considerable reluctance in some parts of the medical community to acknowledge the benefits of exercise in the treatment of depression. One meta-analysis of clinical trials showed that physical exercise was as effective as psychotherapy or antidepressant medication and much better than no treatment. But the authors concluded that the effectiveness of exercise in reducing symptoms of depression cannot be determined ,45 and the editors of the journal introduced the article with an editorial comment entitled effectiveness of exercise in managing depression is not shown by meta-analysis .46 Why not Because there were flaws in the way many of the studies had been designed. To be fair, there were indeed shortcomings in the studies, but these shortcomings also characterize clinical trials of antidepressants.47 If clinical trials like these do not establish the effectiveness of physical exercise as a treatment for depression, neither do they establish the effectiveness of antidepressants. 

For people who are depressed, and especially for those who do not receive enough benefit from medication or for whom the side effects of antidepressants are troubling, the fact that placebos can duplicate much of the effects of antidepressants should be taken as good news. It means that there are other ways of alleviating depression. As we have seen, treatments like psychotherapy and physical exercise are at least as effective as antidepressant drugs and more effective than placebos. In particular, CBT has been shown to lower the risk of relapsing into depression for years after treatment has ended, making it particularly cost-effective. 

At the beginning of the twenty-first century, the century of psychoanalysis may be giving way to that of brain chemistry and neuroscience. Psychotherapy is now supplemented and sometimes even replaced by antidepressants, anti-psychotics, and other pharmaceutical responses to the chemistry of the brain. Neuroscience is beginning to provide physical explanations for cognition, emotion—even subjectivity. At this border of science and our deepest sense of our mental and even spiritual selves, alchemy is again demonstrating its relevance and durability. One final realm in which alchemical tropes became (and remain) common is that of psychedelic drugs.7... 

The efficacy of psychotherapy and antidepressants is considered to be additive. Psychotherapy alone is not recommended for the acute treatment of patients with severe and/or psychotic major depressive disorders. For uncomplicated nonchronic major depressive disorder, combined treatment may provide no unique advantage. Cognitive therapy, behavioral therapy, and interpersonal psychotherapy appear to be equal in efficacy. 

The practice guideline of the American Psychiatric Association recommends that after 6 to 8 weeks of antidepressant treatment, partial responders should consider changing the dose, augmenting the antidepressant, or adding psychotherapy or ECT. For those with no response, options include changing to another antidepressant or the addition of psychotherapy or ECT. 

For example, if one were studying an herb to treat depression, one would want to control as many factors as possible that could influence the outcome. People already taking an antidepressant drug would have to be excluded. One might also balance the subjects in different groups for severity of depression, psychotherapy treatment, or even levels of physical exercise. Certainly, the subject groups should be balanced for number of males and females, because sex differences in depression could contaminate the results. 

Should patients be referred to psychiatrists or primary care physicians Our bias is that the referral should almost always be to a psychiatrist. The patient is already seeing a specialist, the therapist, for psychotherapy and deserves the advantage of seeing a specialist for pharmacotherapy. This is not to suggest that certain primary care physicians, physician assistants, or nurse practitioners are not skilled pharmacotherapists. In fact, nonpsychiatric physicians prescribe the majority of psychotropic medications, particularly antidepressants and antianxiety medicines. 

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