Drugs and Psychotherapy

529
Biological Treatments
There is widespread concern that psychiatrists, and especially general practitioners, rely too heavily on drugs to deal with
psychological problems, partly because of
drug ads that fuel consumer demand
(Kravitz et al., 2005; Zuvekas, 2005). In
one case, dramatically increased medication failed to stop a patient with paranoid schizophrenia from repeatedly
running away from a mental hospital. But
allowing him to use a telephone at a
nearby shopping mall eliminated the
problem. A psychologist discovered that
the man had been afraid to use “bugged”
hospital phones and kept escaping to call
his mother (Rabasca, 1999).
© The New Yorker Collection 2000 Frank Cotham from Cartoonbank.com. All Rights Reserved.
benzodiazepines, haloperidol, clozapine, lithium, and possibly the tricyclic antidepressants in order to obtain equally beneficial effects (Lin & Poland, 1995; Matsuda et al.,
1996). In addition, African Americans may show a faster response to tricyclic antidepressants than European Americans and may respond to lower doses of lithium (Strickland
et al., 1991). There is also some evidence that, compared with European Americans or
African Americans, Hispanic Americans require lower doses of antipsychotic drugs to
get the same benefits (Ruiz et al., 1999). Some of these ethnic differences are thought
to be related to genetically regulated differences in drug metabolism, whereas others
may be due to dietary practices.
Males and females may respond in about the same way to tricyclic antidepressants
(Wohlfarth et al., 2004), but women may maintain higher blood levels of these and
other therapeutic psychoactive drugs and may show better response to neuroleptics
(Hildebrandt et al., 2003; Salokangas, 2004). They also may be more vulnerable to
adverse effects such as tardive dyskinesia (Yonkers et al., 1992). These gender differences in drug response appear less related to estrogen than to other hormonal or bodycomposition differences between men and women, such as the ratio of body fat to muscle (Dawkins & Potter, 1991; Salokangas, 2004). Continued research on these and other
dimensions of human diversity will undoubtedly lead to more effective and safer drug
treatments for all clients (Thompson & Pollack, 2001).
Drugs and Psychotherapy
Despite their widespread success in the treatment of psychological disorders, psychoactive drugs do have some drawbacks. As we have seen, some of them can result in
physical or psychological dependence, and their side effects can range from minor problems, such as the thirst and dry mouth caused by some antidepressants, to movement
disorders such as tardive dyskinesia caused by some neuroleptics. Although the most
serious of these side effects are relatively rare, some are irreversible, and it is impossible to predict in advance who will develop them. For example, although a clear causal
link has not yet been confirmed (Gibbons et al., 2005), the U.S. National Institute of
Mental Health (NIMH) and regulatory agencies in Canada and Britain have recently
issued warnings about the danger of suicidal behavior in children and adolescents who
are given Prozac and similar antidepressant drugs (Breggin, 2005; Hammad, Laughren, &
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Chapter 13 Treatment of Psychological Disorders
Racoosin, 2006; Martinez et al., 2005; NIMH, 2004; Jureidini et al., 2004; Vitiello &
Swedo, 2004; Whittington, Kendall, & Pilling, 2005). There is concern, too, about
whether psychoactive drugs are as effective as they appear to be, especially in research
sponsored by the drug companies that make them (Chan et al, 2004; Heres et al., 2006;
Melander et al, 2003; Moncrieff & Kirsch, 2005).
With these issues in mind, many clinicians and clients wonder which is better: drugs
or psychotherapy. Can they be effectively combined? A considerable amount of research
is being conducted to address these questions.
Although occasionally a study shows that one form of treatment or the other is more
effective, neither drugs nor psychotherapy has been shown to be clearly superior overall for treating problems such as anxiety disorders and major depressive disorder
(Antonuccio, Danton, & DeNelsky, 1995; DeJonghe et al., 2004). For example, several
studies of treatment for severe depression have found that behavior therapy, cognitivebehavior therapy, and interpersonal psychotherapy can be as effective as an antidepressant
drug (DeRubeis et al., 2005; Dimidjian et al., 2006; Hollon et al., 2002; March et al.,
2004; Spanier et al., 1996). Cognitive-behavior therapy has also equaled drug effects in
the treatment of phobias (Clark et al., 2003; Davidson et al., 2004; Otto et al., 2000;
Thom, Sartory, & Jöhren, 2000), panic disorder (Klosko et al., 1990), generalized anxiety disorder (Gould et al., 1997), and obsessive-compulsive disorder (Abramowitz, 1997;
Kozak, Liebowitz, & Foa, 2000). Further, the dropout rate from psychotherapy may
be lower than from drug therapies, and the benefits of many kinds of psychotherapy
may last longer than those of drug therapies (e.g., Casacalenda, Perry, & Looper, 2002;
Hollon, Stewart, & Strunk, 2006; Segal, Gemar, & Williams, 2000; Thom et al., 2000).
What about combining drugs and psychotherapy? Recent research suggests that
doing so can sometimes be helpful (Hofmann et al., 2006; Winston, Been, & Serby,
2005). Combined treatment is recommended in cases of bipolar disorder (Otto,
Bruce, & Deckersbach, 2005) and produces slightly better results than either psychotherapy or drugs alone in people suffering from severe, long-term depression
(Hegerl, Plattner, & Moller, 2004). The combination of drugs and psychotherapy has
been also shown to be more effective than either method alone in treating attention
deficit hyperactivity disorder, obsessive-compulsive disorder, alcoholism, stammering,
compulsive sexual behavior, and panic disorder (Barlow et al., 2000; deBeurs et al.,
1995; Engeland, 1993; Keller et al., 2000; March et al., 2004; Roy-Byrne et al., 2005).
The combined approach may be especially useful for clients who are initially too distressed to cooperate in psychotherapy. A related approach, already shown successful
with clients who had been taking drugs for panic disorder and depression, is to use
psychotherapy to prevent relapse and to make further progress as drug treatment is
discontinued (e.g., Bruce, Spiegel, & Hegel, 1999; Klein et al., 2004; Lam et al., 2003).
Preliminary evidence also suggests that a drug called D-cycloserine might be helpful
in preventing the reappearance of fears being extinguished through exposure techniques or other forms of behavior therapy (Davis et al., 2005; Hofmann et al., 2006;
Ressler et al., 2004).
However, many studies have found little advantage in combining drugs and psychotherapy (e.g., Davidson et al., 2004; Elkin, 1994; Nemeroff et al., 2003; Spiegel &
Bruce, 1997). One research team compared the effects of a form of in vivo desensitization called gradual exposure and an anti-anxiety drug (Xanax) in the treatment of agoraphobia. Clients receiving gradual exposure alone showed better short- and long-term
benefits than those getting either the drug alone or a combination of the drug and
gradual exposure (Echeburua et al., 1993). Other studies, too, have found that combining drugs and psychotherapy may produce surprisingly little added benefit (e.g.,
Elkin, 1994; Spiegel & Bruce, 1997).
Perhaps the most conservative strategy for treating most cases of anxiety and depression is to begin with cognitive or interpersonal psychotherapy (which have no major
negative side effects) and then to add or switch to drug treatment if psychotherapy
alone is ineffective (Jacobs et al., 2004; Schatzberg et al., 2005). Someday, research may
offer better guidelines as to which clients should be treated with psychotherapy alone,
medication alone, or a combination of the two (Hollon et al., 2005).