COGNITIVE BEHAVIOUR THERAPY AND MEDICATION: ADDITIVE EFFECTS? Gregoris Simos CMHC/ Central District, Thessaloniki, Greece.

COGNITIVE BEHAVIOUR THERAPY COGNITIVE BEHAVIOUR THERAPY AND MEDICATION: ADDITIVE AND MEDICATION: ADDITIVE

EFFECTS?EFFECTS?  

Gregoris SimosGregoris SimosCMHC/ Central District, Thessaloniki, CMHC/ Central District, Thessaloniki,

GreeceGreece

Reference

Wright J. (2004). Integrating Cognitive-Behavioral Therapy and Pharmacotherapy. In Leahy R. (Ed.) Contemporary Cognitive Therapy: Theory, Research, and Practice. Guilford Press, NY (pp 341-366)

IntroductionIntroduction

• Pharmacotherapy and cognitive-behavior therapy Pharmacotherapy and cognitive-behavior therapy (CBT) are the two most heavily researched forms (CBT) are the two most heavily researched forms of treatment for Axis I disorders.of treatment for Axis I disorders.

• Both treatments have been well established as Both treatments have been well established as effective therapies for depression, anxiety effective therapies for depression, anxiety disorders, eating disorders, and other non-disorders, eating disorders, and other non-psychotic illnesses psychotic illnesses

(Marangell, et al., 2002, Dobson, 1989; Robinson, Berman, (Marangell, et al., 2002, Dobson, 1989; Robinson, Berman, and Neimeyer, 1990; Wright. Beck, and Thase, 2002). and Neimeyer, 1990; Wright. Beck, and Thase, 2002).

CBT and psychosisCBT and psychosis

• Although psychopharmacology is generally Although psychopharmacology is generally accepted as the standard treatment for accepted as the standard treatment for psychoses, CBT has recently been shown to psychoses, CBT has recently been shown to have significant effects in reducing symptoms have significant effects in reducing symptoms of schizophreniaof schizophrenia11 and bipolar disorder and bipolar disorder22

11Drury et al., 1996; Kuipers et al., 1997; Tarrier et al., 1998; Pinto et al. 1999; Sensky Drury et al., 1996; Kuipers et al., 1997; Tarrier et al., 1998; Pinto et al. 1999; Sensky et al., 2000; Rector and Beck, 2001et al., 2000; Rector and Beck, 2001

22 Lam et al, 2004; Jones, 2003; Gonzalez-Pinto et al., 2004Lam et al, 2004; Jones, 2003; Gonzalez-Pinto et al., 2004

CBT and medicationCBT and medication

• Because both CBT and Because both CBT and psychopharmacology are effective psychopharmacology are effective interventions for a wide range of disorders, interventions for a wide range of disorders, there could be possible advantages to there could be possible advantages to combining these empirically proven combining these empirically proven approaches in an integrated treatment approaches in an integrated treatment package package

Psychotherapy and pharmacotherarapy: Psychotherapy and pharmacotherarapy: Possible interactions (Possible interactions (Uhlenhuth et al., Uhlenhuth et al., 1969)1969)

1) 1) additionaddition – treatments given together produce – treatments given together produce results that are greater than the action of either results that are greater than the action of either component alone component alone

2) 2) potentiationpotentiation (or synergism) – a positive (or synergism) – a positive interaction which is larger than the sum of the interaction which is larger than the sum of the effects of individual treatments effects of individual treatments

3) 3) inhibitioninhibition (or subtraction) – results of treatment (or subtraction) – results of treatment are impaired by combining therapies are impaired by combining therapies

Psychotherapy and pharmacotherarapy: Psychotherapy and pharmacotherarapy: Possible interactionsPossible interactions

• Most of the research on treatment Most of the research on treatment interaction in the subsequent three decades interaction in the subsequent three decades was designed to measure the results of was designed to measure the results of combining medication and psychotherapy combining medication and psychotherapy on symptom measures at the end of on symptom measures at the end of treatment, thus determining whether the two treatment, thus determining whether the two treatments together were superior, equal, or treatments together were superior, equal, or inferior to the therapies given alone. inferior to the therapies given alone.

The cognitive-biological modelThe cognitive-biological model• The cognitive-biological modelThe cognitive-biological model1 1 provides a provides a

useful vantage point to view possible useful vantage point to view possible interactions between therapies. interactions between therapies.

• This model specifies that there may be This model specifies that there may be influences from multiple systems (eg., influences from multiple systems (eg., biological, cognitive, behavioral, biological, cognitive, behavioral, interpersonal, and social) on the interpersonal, and social) on the development and expression of mental development and expression of mental disorders.disorders.

1 1 Wright and Thase, 1992; Wright, Thase, and Sensky, 1993 Wright and Thase, 1992; Wright, Thase, and Sensky, 1993

The cognitive-biological modelThe cognitive-biological model

• A broad array of studies have confirmed A broad array of studies have confirmed significant relationships between elements of this significant relationships between elements of this modelmodel

• Application of the cognitive-biological model to Application of the cognitive-biological model to the study of combined therapy suggests that the study of combined therapy suggests that outcome could be improved by directing treatment outcome could be improved by directing treatment at more than one system simultaneously or by at more than one system simultaneously or by promoting interactions with possible favorable promoting interactions with possible favorable influences (Wright and Schrodt, 1989; Gabbard influences (Wright and Schrodt, 1989; Gabbard and Kay, 2001)and Kay, 2001)

Positive InteractionsPositive Interactions Medications improve concentration and thus facilitate Medications improve concentration and thus facilitate

CBTCBT Medications reduce painful affect and/or Medications reduce painful affect and/or

physiological arousal, thereby increasing accessibility physiological arousal, thereby increasing accessibility to CBTto CBT

Medications can decrease distorted or irrational Medications can decrease distorted or irrational thinking, thus adding to the effect of CBTthinking, thus adding to the effect of CBT

CBT improves medication complianceCBT improves medication compliance

(Group for the Advancement of Psychiatry, 1975; Wright and (Group for the Advancement of Psychiatry, 1975; Wright and Schrodt, 1989)Schrodt, 1989)

Positive InteractionsPositive Interactions CBT helps patients better understand and CBT helps patients better understand and

manage illnessmanage illness CBT can facilitate withdrawal from medication CBT can facilitate withdrawal from medication

when desiredwhen desired CBT has biological effects and can work in CBT has biological effects and can work in

concert with medication to influence concert with medication to influence biochemical abnormalitiesbiochemical abnormalities

(Group for the Advancement of Psychiatry, 1975; (Group for the Advancement of Psychiatry, 1975; Wright and Schrodt, 1989).Wright and Schrodt, 1989).

Negative InteractionsNegative Interactions Medications interfere with learning and memory which Medications interfere with learning and memory which

negatively influences CBT. negatively influences CBT. Medications cause dependency which impairs the Medications cause dependency which impairs the

effectiveness of CBT.effectiveness of CBT. Medications lead to premature relief of symptoms and Medications lead to premature relief of symptoms and

undermine motivation to continue in therapy.undermine motivation to continue in therapy. CBT places stress on patients with biological illnesses and CBT places stress on patients with biological illnesses and

thus adds a burden to those who should be treated with thus adds a burden to those who should be treated with medication.medication.

(Group for the Advancement of Psychiatry, 1975; Wright and (Group for the Advancement of Psychiatry, 1975; Wright and Schrodt, 1989).Schrodt, 1989).

InteractionsInteractions

• Most research studies have focused on Most research studies have focused on comparing the outcome of treatment with comparing the outcome of treatment with medication versus psychotherapy or medication versus psychotherapy or combined therapy instead of evaluating combined therapy instead of evaluating possible mechanisms of interactionpossible mechanisms of interaction

• Thus, only a few of the proposed Thus, only a few of the proposed interactions have been investigated in a interactions have been investigated in a systematic mannersystematic manner

Learning and memory functioningLearning and memory functioning• The effects of different types of medication on learning and The effects of different types of medication on learning and

memory functioning have been evaluated in a large number of memory functioning have been evaluated in a large number of pharmacologic studies pharmacologic studies

• For example, tricyclic antidepressants For example, tricyclic antidepressants (a)(a) with strong with strong anticholinergic properties and benzodiazepines anticholinergic properties and benzodiazepines (b)(b) have typically have typically been found to impair learning ability. been found to impair learning ability.

• In contrast, serotonin reuptake inhibitorsIn contrast, serotonin reuptake inhibitors©© and newer and newer antipsychotic medicationsantipsychotic medications(d)(d) usually improve cognitive usually improve cognitive functioningfunctioning

(a) Curran, Sakulsriprong, and Lader, 1988; Knegtering, Eijck, and Huijsman, 1994; Richardson et al., 1994(a) Curran, Sakulsriprong, and Lader, 1988; Knegtering, Eijck, and Huijsman, 1994; Richardson et al., 1994(b) Hommer, 1991; Wagemans, Notebaert, and Boucart, 1998; Verster, Volkerts, and Verbaten, 2002(b) Hommer, 1991; Wagemans, Notebaert, and Boucart, 1998; Verster, Volkerts, and Verbaten, 2002© Hasbroucq et al., 1997; Levkovitz et al., 2002; Harmon et al., 2002© Hasbroucq et al., 1997; Levkovitz et al., 2002; Harmon et al., 2002

(d) Harvey et al., 2000; Stevens et al., 2002; Weiss, Bilder, and Fleischhackler, 2002(d) Harvey et al., 2000; Stevens et al., 2002; Weiss, Bilder, and Fleischhackler, 2002

Learning and memory functioningLearning and memory functioning• Learning and memory functioning has rarely been Learning and memory functioning has rarely been

examined as a possible mechanism of interaction examined as a possible mechanism of interaction between CBT and pharmacotherapybetween CBT and pharmacotherapy

• One group of investigators determined that the One group of investigators determined that the benzodiazepine, alprazolam, interfered with benzodiazepine, alprazolam, interfered with performance on a word recall task, but not implicit performance on a word recall task, but not implicit memory or digit span, in patients being treated with memory or digit span, in patients being treated with exposure therapy (Curran et al., 1994)exposure therapy (Curran et al., 1994)

• However, the possible actions of other medications on However, the possible actions of other medications on cognitive functioning in patients receiving CBT cognitive functioning in patients receiving CBT remain largely unexploredremain largely unexplored

CBT in medication compliance CBT in medication compliance

• Several investigations have Several investigations have documented positive effects for documented positive effects for CBT in improving medication CBT in improving medication compliancecompliance

• (Cochrane, 1984; Perris and Skagerlind 1994; Lecompte, (Cochrane, 1984; Perris and Skagerlind 1994; Lecompte, 1995, Basco and Rush, 1995; Kemp et al., 1996). 1995, Basco and Rush, 1995; Kemp et al., 1996).

CBT in medication compliance CBT in medication compliance

• Cochrane (1984) found that patients taking Cochrane (1984) found that patients taking lithium who received a CBT compliance lithium who received a CBT compliance intervention were more likely to adhere to the intervention were more likely to adhere to the medication regimen than those who received medication regimen than those who received standard carestandard care

• Patients who received CBT also had Patients who received CBT also had significantly lower rates of stopping lithium significantly lower rates of stopping lithium against medical advice, rehospitalization, or against medical advice, rehospitalization, or noncompliance-precipitated episodes of illnessnoncompliance-precipitated episodes of illness

CBT in medication compliance CBT in medication compliance

• Perris and Skagerlind (1994) found that Perris and Skagerlind (1994) found that CBT enhanced medication adherence in CBT enhanced medication adherence in schizophrenics treated in group homesschizophrenics treated in group homes

• Lecompte (1995) also described CBT Lecompte (1995) also described CBT methods for improving medication methods for improving medication adherence in patients with schizophrenia adherence in patients with schizophrenia and observed that this intervention led to a and observed that this intervention led to a decline in the frequency of rehospitalization decline in the frequency of rehospitalization

Negative interactions?Negative interactions?

Outcome studies have revealed little evidence Outcome studies have revealed little evidence to suggest that most types of medication to suggest that most types of medication impair participation in CBT or that CBT has impair participation in CBT or that CBT has any adverse effects on biological treatmentsany adverse effects on biological treatments

Instead, the weight of evidence supports the Instead, the weight of evidence supports the concept that CBT and pharmacotherapy concept that CBT and pharmacotherapy often compliment one another in enhancing often compliment one another in enhancing the response to therapy the response to therapy

Outcome ResearchOutcome Research

• DepressionDepression

• Anxiety disordersAnxiety disorders

• Bulimia NervosaBulimia Nervosa

• Schizophrenic DisorderSchizophrenic Disorder

• Bipolar DisorderBipolar Disorder

Depression.Depression.• Blackburn and coworkers (1981) performed the first Blackburn and coworkers (1981) performed the first

controlled trial that compared CBT alone to controlled trial that compared CBT alone to pharmacotherapy (tricyclic antidepressants) and pharmacotherapy (tricyclic antidepressants) and combined treatment for depressioncombined treatment for depression

• Results differed depending on the treatment settingResults differed depending on the treatment setting• Combined treatment was superior to medication in Combined treatment was superior to medication in

both hospital and general practice patients and to CBT both hospital and general practice patients and to CBT alone in the hospital outpatientsalone in the hospital outpatients

• The overall results of this study support an additive The overall results of this study support an additive effect for CBT and antidepressant therapyeffect for CBT and antidepressant therapy

Depression.Depression.• Another trial comparing CBT with a Another trial comparing CBT with a

tricyclic antidepressant (Murphy et al; tricyclic antidepressant (Murphy et al; 1984) did not find a significant advantage 1984) did not find a significant advantage for combined treatmentfor combined treatment

• At the end of treatment, all therapies were At the end of treatment, all therapies were found to be equally effectivefound to be equally effective

• However, the percentage of patients with However, the percentage of patients with the best outcome (BDI the best outcome (BDI << 9) was higher for 9) was higher for combined therapy (78%) than the other combined therapy (78%) than the other treatments (CBT plus placebo = 65%, CBT treatments (CBT plus placebo = 65%, CBT = 53%, pharmacotherapy = 56%)= 53%, pharmacotherapy = 56%)

Depression.Depression.• Hollon and coworkers (1992) tested the efficacy Hollon and coworkers (1992) tested the efficacy

of CBT, imipramine, or combined therapy in the of CBT, imipramine, or combined therapy in the treatment of 107 non-psychotic depressed treatment of 107 non-psychotic depressed outpatientsoutpatients

• The overall treatment response in the Hollon et al The overall treatment response in the Hollon et al (1992) study was excellent for all conditions(1992) study was excellent for all conditions

• Although there was no significant advantage Although there was no significant advantage found for combined treatment, there was a trend found for combined treatment, there was a trend for superior outcome in those who received both for superior outcome in those who received both CBT and pharmacotherapyCBT and pharmacotherapy

Depression.Depression.• For example, mean post-treatment Hamilton For example, mean post-treatment Hamilton

Rating Scale for Depression (HRSD) scores Rating Scale for Depression (HRSD) scores were lowest for combined treatment (4.2) as were lowest for combined treatment (4.2) as compared to CBT (8.8) and pharmacotherapy compared to CBT (8.8) and pharmacotherapy (8.4, significance = .17)(8.4, significance = .17)

• Mean MMPI Depression scores were Mean MMPI Depression scores were significantly lower in patients treated with significantly lower in patients treated with combined therapy (61.4) than CBT (71.8) or combined therapy (61.4) than CBT (71.8) or pharmacotherapy (72.5, significance = .04)pharmacotherapy (72.5, significance = .04)

CBT and medication in double depressionCBT and medication in double depression• Miller, Norman, and Keitner (1999) randomly assigned Miller, Norman, and Keitner (1999) randomly assigned

26 inpatients with double depression to 20 weeks of 26 inpatients with double depression to 20 weeks of treatment with pharmacotherapy or combined treatment with pharmacotherapy or combined antidepressant and cognitive therapyantidepressant and cognitive therapy

• At the end of treatment, those who received combined At the end of treatment, those who received combined therapy had significantly greater improvement in therapy had significantly greater improvement in depressive symptoms and higher social functioningdepressive symptoms and higher social functioning

• Differences between pharmacotherapy and combined Differences between pharmacotherapy and combined treatment were quite large in this studytreatment were quite large in this study

• Mean post treatment HRSD scores were 25.8 for Mean post treatment HRSD scores were 25.8 for pharmacotherapy and 13.1 for combined treatmentpharmacotherapy and 13.1 for combined treatment

CBT and medication in chronic depressionCBT and medication in chronic depression• Large multicenter group headed by Keller and Large multicenter group headed by Keller and

McCullough (Keller et al., 2000). McCullough (Keller et al., 2000). • A particularly large sample size (n = 662). A particularly large sample size (n = 662). • Patients with chronic major depression were randomly Patients with chronic major depression were randomly

assigned to pharmacotherapy with nefazadone (an assigned to pharmacotherapy with nefazadone (an antidepressant with serotonin and norepinephrine antidepressant with serotonin and norepinephrine agonist properties), treatment with the cognitive-agonist properties), treatment with the cognitive-behavioral-analysis system of psychotherapy (CBASP), behavioral-analysis system of psychotherapy (CBASP), or combined therapy. CBASP is a form of CBT with or combined therapy. CBASP is a form of CBT with modifications for chronic depression (McCullough, modifications for chronic depression (McCullough, 2000). 2000).

• Treatment response rates for study completers were Treatment response rates for study completers were 55% for nefazadone, 52% for CBASP, and 85% for 55% for nefazadone, 52% for CBASP, and 85% for combined treatmentcombined treatment

Anxiety Disorders.Anxiety Disorders.• Studies of CBT for anxiety disorders compared to Studies of CBT for anxiety disorders compared to

pharmacotherapy alone versus a combination of pharmacotherapy alone versus a combination of CBT and medications of various types have been the CBT and medications of various types have been the subject of three major reviews (Spiegel and Bruce, subject of three major reviews (Spiegel and Bruce, 1997; Westra and Stewart, 1998; Bakker, van 1997; Westra and Stewart, 1998; Bakker, van Balkom, and van Dyck, 2000) and a meta-analysis Balkom, and van Dyck, 2000) and a meta-analysis (Van Balkom et al., 1997)(Van Balkom et al., 1997)

• Most studies reviewed by these authors examined Most studies reviewed by these authors examined the efficacy of a benzodiazepine compared to a CBT the efficacy of a benzodiazepine compared to a CBT intervention such as exposure therapy or a combined intervention such as exposure therapy or a combined treatment approachtreatment approach

Anxiety, CBT and SSRIsAnxiety, CBT and SSRIsA review of studies of SSRIs combined with CBT A review of studies of SSRIs combined with CBT

found that combination therapy led to the greatest found that combination therapy led to the greatest treatment gains (Bakker, van Balkom, and van treatment gains (Bakker, van Balkom, and van Dyck, 2000)Dyck, 2000)

The positive effects of SSRIs in enhancing learning The positive effects of SSRIs in enhancing learning and memory (Levkovitz et al., 2002), as compared and memory (Levkovitz et al., 2002), as compared to negative actions of tricyclic antidepressants on to negative actions of tricyclic antidepressants on cognitive functioning (Curran, Sakulsriprong, and cognitive functioning (Curran, Sakulsriprong, and Lader, 1988), suggest that SSRIs might have a Lader, 1988), suggest that SSRIs might have a more favorable interaction profile with CBT than more favorable interaction profile with CBT than older antidepressant medicationsolder antidepressant medications

Anxiety, CBT and Anxiety, CBT and tricyclic antidepressantstricyclic antidepressants

The largest and most recent trial of combined therapy with a The largest and most recent trial of combined therapy with a tricyclic antidepressant and CBT for panic disorder was tricyclic antidepressant and CBT for panic disorder was conducted at multiple centers by Barlow and coworkers conducted at multiple centers by Barlow and coworkers (2000)(2000)

Patients with panic disorder with or without mild Patients with panic disorder with or without mild agoraphobia were randomly assigned to treatment with agoraphobia were randomly assigned to treatment with

• CBT alone, CBT alone, • imipramine, imipramine, • placebo, placebo, • CBT plus imipramine, or CBT plus imipramine, or • CBT plus placebo CBT plus placebo

Anxiety, CBT and Anxiety, CBT and tricyclic antidepressantstricyclic antidepressants• The acute treatment phase lasted 3 months. Responders were The acute treatment phase lasted 3 months. Responders were

seen monthly for 6 months in the maintenance phase of therapy seen monthly for 6 months in the maintenance phase of therapy and then were followed for an additional 6 months after and then were followed for an additional 6 months after maintenance therapy was discontinuedmaintenance therapy was discontinued

• At the end of acute treatment, all active treatments were At the end of acute treatment, all active treatments were effective and were superior to placeboeffective and were superior to placebo

• After 6 months of maintenance therapy, CBT plus imipramine After 6 months of maintenance therapy, CBT plus imipramine was clearly superior to the other active treatments (57.1% was clearly superior to the other active treatments (57.1% response rate for combined treatment compared to 39.5% for response rate for combined treatment compared to 39.5% for CBT and 37.8% for imipramine)CBT and 37.8% for imipramine)

• However, this advantage disappeared by the end of the 6 month However, this advantage disappeared by the end of the 6 month follow-up intervalfollow-up interval

Panic disorderPanic disorder• A meta-analysis of studies of pharmacological, cognitive-A meta-analysis of studies of pharmacological, cognitive-

behavioral, and combined treatment for panic disorder, behavioral, and combined treatment for panic disorder, including a total of 5,011 patients, was conducted by Van including a total of 5,011 patients, was conducted by Van Balkom et al (1997). The results of this meta-analysis are Balkom et al (1997). The results of this meta-analysis are consistent with the conclusions of Westra and Stewart (1998) consistent with the conclusions of Westra and Stewart (1998)

• The combination of antidepressants plus exposure therapy The combination of antidepressants plus exposure therapy was found to be the most effective treatment for panic was found to be the most effective treatment for panic disorder disorder

• The mean effect size for combined treatment of agoraphobia The mean effect size for combined treatment of agoraphobia was 2.47 as compared to 1.00 for benzodiazepines, 1.02 for was 2.47 as compared to 1.00 for benzodiazepines, 1.02 for antidepressants, 1.38 for exposure alone, and .32 for control antidepressants, 1.38 for exposure alone, and .32 for control conditionsconditions

Bulimia NervosaBulimia Nervosa. .

• Most research on combined therapy for Most research on combined therapy for bulimia nervosa has found advantages for bulimia nervosa has found advantages for using CBT and an antidepressant together using CBT and an antidepressant together (Bacaltchuk, et al., 2000) (Bacaltchuk, et al., 2000)

Bulimia: Meta-analysisBulimia: Meta-analysis• The results of 7 studies of psychological The results of 7 studies of psychological

treatments given in combination with treatments given in combination with pharmacotherapy for bulimia nervosa were pharmacotherapy for bulimia nervosa were examined in a meta-analysis by Bacaltchuk et al examined in a meta-analysis by Bacaltchuk et al (2000)(2000)

• Five of the seven trials in this analysis included a Five of the seven trials in this analysis included a CBT treatment conditionCBT treatment condition

• Although this meta-analysis is confounded by Although this meta-analysis is confounded by including different forms of psychotherapy, the including different forms of psychotherapy, the overall results favored combined treatment over overall results favored combined treatment over medication or psychotherapy alonemedication or psychotherapy alone

Bulimia: Meta-analysisBulimia: Meta-analysis• Bacaltchuk (2000) noted that the remission Bacaltchuk (2000) noted that the remission

rate (100% reduction in binge episodes) rate (100% reduction in binge episodes) was 42% for combined treatment as was 42% for combined treatment as compared to 23% for medication alone in compared to 23% for medication alone in these studiesthese studies

• Remission also was more likely for Remission also was more likely for combined treatment when compared to combined treatment when compared to psychotherapy alonepsychotherapy alone

PsychosisPsychosis..• Several studies: the impact of adding CBT to Several studies: the impact of adding CBT to

medication for psychotic illnesses. medication for psychotic illnesses.

• Most patients in these studies have suffered Most patients in these studies have suffered from schizophrenia or related disorders. from schizophrenia or related disorders.

• Because of the severity of the illness and strong Because of the severity of the illness and strong evidence for effectiveness of antipsychotic evidence for effectiveness of antipsychotic medication, there have been no trials that have medication, there have been no trials that have examined the efficacy of combined treatment examined the efficacy of combined treatment compared to CBT alonecompared to CBT alone

PsychosisPsychosis..• Instead, investigators have focused on Instead, investigators have focused on

determining whether CBT adds to the effect of determining whether CBT adds to the effect of medication plus treatment as usualmedication plus treatment as usual

• All studies completed to date have demonstrated All studies completed to date have demonstrated a positive benefit for combined therapya positive benefit for combined therapy

Family Behaviour Therapy and Family Behaviour Therapy and Expressed EmotionExpressed Emotion

• After treatment, mean number of critical comments After treatment, mean number of critical comments was reduced by was reduced by 60% (16% 60% (16% in control groupin control group (Lieberman et al., 1984)(Lieberman et al., 1984)

• During the following 9 months only 21% of patients During the following 9 months only 21% of patients exhibited a significant increase in positive exhibited a significant increase in positive schizophrenic symptoms compared to schizophrenic symptoms compared to 56% 56% in the in the control groupcontrol group (Wallace and Liberman, 1985) (Wallace and Liberman, 1985)

• Family interventions have repeatedly shown that they Family interventions have repeatedly shown that they decrease rates of relapsedecrease rates of relapse (Tarrier et al al, 1994; (Tarrier et al al, 1994; Pitschel-Waltz, et al al, 2001); Barrowclough Pitschel-Waltz, et al al, 2001); Barrowclough et et al, al, 1999; Sellwood, et al, 2001).1999; Sellwood, et al, 2001).

CBT and medications in schizophreniaCBT and medications in schizophrenia

• CBT has been well tested in CBT has been well tested in relation to the treatment of residual relation to the treatment of residual symptoms of schizophrenia and is symptoms of schizophrenia and is of proven efficacy and cost-of proven efficacy and cost-effectiveness (National Institute for effectiveness (National Institute for Clinical Excellence, 2002)Clinical Excellence, 2002)

CBT and medications in schizophreniaCBT and medications in schizophrenia

To date, sTo date, several everal controlled studies controlled studies have examined the efficacy of CBT have examined the efficacy of CBT for schizophreniafor schizophrenia..

Some Some studies have assessed the role studies have assessed the role of CBT during the chronic phase of of CBT during the chronic phase of the illnessthe illness, while others , while others tested the tested the impact of CBT during the acute impact of CBT during the acute phasephase

CBT and medications in schizophreniaCBT and medications in schizophrenia• Hallucinations, delusions, negative symptioms and Hallucinations, delusions, negative symptioms and

depression have all been shown to be responsive depression have all been shown to be responsive to CBT (Sensky et al., 2000)to CBT (Sensky et al., 2000)

• CBT is the only psychological treatment in CBT is the only psychological treatment in chronic schizophrenia with proven durability at chronic schizophrenia with proven durability at short-term follow-up (Could et al., 2001)short-term follow-up (Could et al., 2001)

• The benefits of CBT translate into community The benefits of CBT translate into community settings (Turkington et al., 2002)settings (Turkington et al., 2002)

• CBT wpould appear to have the posibility of an CBT wpould appear to have the posibility of an enhanced effect when given with cognitively enhanced effect when given with cognitively sparing antipsychotic medication (Pinto et al., sparing antipsychotic medication (Pinto et al., 1999)1999)

Cognitive therapy for schizophrenia: a preliminary Cognitive therapy for schizophrenia: a preliminary randomized controlled trialrandomized controlled trial

Neil A. Rector *, Mary V. Seeman, Zindel V. Neil A. Rector *, Mary V. Seeman, Zindel V. SegalSegal

Schizophrenia Research 63 (2003) 1– 11Schizophrenia Research 63 (2003) 1– 11

Negative symptomsNegative symptoms

Meta-analysis: Meta-analysis: CBT and medications CBT and medications in schizophreniain schizophrenia

• A meta-analysis of controlled research on combined A meta-analysis of controlled research on combined CBT and medication for psychosis (Rector and CBT and medication for psychosis (Rector and Beck, 2001) found significant advantages for using Beck, 2001) found significant advantages for using CBT and medication togetherCBT and medication together

• The mean effect sizes for positive symptoms were The mean effect sizes for positive symptoms were 1.31 for CBT plus medication and routine care, 1.31 for CBT plus medication and routine care, 0.04 for medication and routine care, and .63 for 0.04 for medication and routine care, and .63 for supportive therapy plus medication and routine caresupportive therapy plus medication and routine care

• Similar findings were observed for negative Similar findings were observed for negative symptoms. symptoms.

Review: CBT and medications in Review: CBT and medications in schizophreniaschizophrenia

• Taken together the results of studies of CBT Taken together the results of studies of CBT in psychotic patients indicate that CBT and in psychotic patients indicate that CBT and medication have significant additive effects. medication have significant additive effects. These research findings have led to These research findings have led to treatment guidelines for including CBT in treatment guidelines for including CBT in the clinical management of schizophrenia in the clinical management of schizophrenia in the United Kingdom.the United Kingdom.

Review: CBT and medications in Review: CBT and medications in schizophreniaschizophrenia

• In 2002 the In 2002 the Department of Health in the Department of Health in the U.K. sent out a notice that all patients in the U.K. sent out a notice that all patients in the first three years of a psychotic disorder first three years of a psychotic disorder must have access to cognitive therapy by must have access to cognitive therapy by 20042004

CBT and medication in Bipolar DisorderCBT and medication in Bipolar DisorderGonzalez-Pinto et al. (2004). Psychoeducation and Gonzalez-Pinto et al. (2004). Psychoeducation and

CBT in bipolar disorder: an update. Acta CBT in bipolar disorder: an update. Acta Psychiatr Scand, 109, 83-90Psychiatr Scand, 109, 83-90

“ … “ … CBT diminishes depressive symptoms and CBT diminishes depressive symptoms and improves quality of life in BD.”improves quality of life in BD.”

Jones S., (2003). Psychotherapy of bipolar disorder: Jones S., (2003). Psychotherapy of bipolar disorder: a review. J Affect Dis, a review. J Affect Dis, XXXXXX

“… “… The clearest evidence is for individual CBT The clearest evidence is for individual CBT which impacts on symptom, social functioning which impacts on symptom, social functioning and risk of relapse.”and risk of relapse.”

CBT and medication in Bipolar CBT and medication in Bipolar DisorderDisorder

LamLam D., Watkins E., Hayward P., Bight J., D., Watkins E., Hayward P., Bight J., Wright, K., Kerr N., Parr-Davis, G., Sham Wright, K., Kerr N., Parr-Davis, G., Sham

P. (2003). P. (2003). A randomised controlled study of cognitive A randomised controlled study of cognitive

therapy of relapse prevention for bipolar therapy of relapse prevention for bipolar affective disorder – outcome of the first affective disorder – outcome of the first

yearyear Archives of General Psychiatry.Archives of General Psychiatry.

CT in Bipolar DisorderCT in Bipolar Disorder• Randomized controlled (medication only) trial Randomized controlled (medication only) trial • Emphasis on relapse preventionEmphasis on relapse prevention• CT had significant effects both at short and long term CT had significant effects both at short and long term

(12 months)(12 months)• During 12 months: The CT group had fewer bipolar During 12 months: The CT group had fewer bipolar

episodes, fewer days in a bipolar episode, and fewer episodes, fewer days in a bipolar episode, and fewer hospitalizationshospitalizations

• CT group had significantly higher social functioning CT group had significantly higher social functioning and fewer affective symptoms in the monthly records of and fewer affective symptoms in the monthly records of moodmood

CT and Bipolar DisorderCT and Bipolar Disorder

Dominic H. Lam, Peter Hayward, Edward R. Dominic H. Lam, Peter Hayward, Edward R. Watkins, Kim Wright, Pak ShamWatkins, Kim Wright, Pak Sham

Outcome of a two-year follow-up of Outcome of a two-year follow-up of cognitive therapy of relapse prevention in cognitive therapy of relapse prevention in

bipolar disorderbipolar disorder

In press in American Journal of PsychiatryIn press in American Journal of Psychiatry

CT and Bipolar DisorderCT and Bipolar Disorder• During the 30 month observation period: CT During the 30 month observation period: CT

group did significantly better in terms of time group did significantly better in terms of time till relapse. Relapse prevention was mainly till relapse. Relapse prevention was mainly evident during the first year.evident during the first year.

• CT group spent 110 less days in a bipolar CT group spent 110 less days in a bipolar episode during the 30 months and 54 days less episode during the 30 months and 54 days less in a bipolar episode during the last 18 monthsin a bipolar episode during the last 18 months

• CT group did better during the last 18 months CT group did better during the last 18 months in mood records, in social functioning, in the in mood records, in social functioning, in the management of prodromal symptoms and in management of prodromal symptoms and in dysfunctional cognitionsdysfunctional cognitions

Diagram 1: survival analysis of bipolar episodes throughout the Diagram 1: survival analysis of bipolar episodes throughout the

whole 30 monthswhole 30 months

Controlling for previous admissions and medication compliance, hazard Ratio = 0.50, 95% CI 0.29 - 0.85, p=0.012; N=85

Survival Function at mean of covariates

Time of first bipolar episode (weeks)

140120100806040200-20

Cu

m S

urv

iva

l

1.2

1.0

.8

.6

.4

.2

0.0

ALLOC

therapy

control

ConclusionsConclusions

• CBT when combined with medication, CBT when combined with medication, whenever appropriate, has an additive whenever appropriate, has an additive therapeutic effect.therapeutic effect.

• This effect has been evident in a variety of This effect has been evident in a variety of studies for a variety of mental disordersstudies for a variety of mental disorders

Thank you Thank you

for your attentionfor your attention