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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, & 530 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).