BIOLOGICAL OR PSYCHOLOGICAL TREATMENT?
Both psychotropic medication and psychotherapy are clearly useful in treating psychological disorders. But if medication reduces psychological symptoms, does this mean that the roots of psychological disorders lie in biological dysfunction? On the other hand, does successful psychotherapy mean that the causes of psychological disorders are necessarily psychological? An affirmative answer to either question would mean we have fallen prey to the treatment–etiology fallacy – a logical error in which treatment mode is assumed to imply the cause of the disorder. After all, very few people would wish to argue that because aspirin relieves headache, headache is actually due to the lack of aspirin in the body. So even though an antidepressant medication regulates neurotransmitters in the brain, it is quite possible that a psychological event gave rise to the neurotransmitter changes in the first place. How then do we choose between biological and psychological treatments? In trying to answer this question we must w atch out for another logical error, similia similibus curantur – like is cured by like (a principle used in homeopathy). In fact, psychotherapy can be used to treat biologically caused psychological disorders and vice versa, although treatment of bipolar disorder, schizophrenia and other psychotic disorders without medication would be irresponsible. For anxiety disorders and depression, neither biological nor psychological treatment appears to be clearly superior (Antonuccio, Danton & DeNelsky, 1995). A large-scale, multi-site study of 240 people suffering from depression found that two forms of psychotherapy (i.e. cognitive and interpersonal) administered together were generally as effective as a tricyclic antidepressant (Elkin et al., 1989). However, drug treatment effects appeared sooner, were more consistent across sites and appeared to be more effective in treating severe depression. Similar findings have been obtained in studies of generalized anxiety disorder (Gould et al., 1997) and obsessive–compulsi ve disorder (Abramowitz, 1997).
What about combining the two forms of treatment? Surprisingly, studies that address this issue have found that concurrent, joint use of medication and psychotherapy produces little additional advantage (Elkin, 1994; Hollon, Shelton & Loosen, 1991). But it does appear that combined treatment can be more effective for some disorders, including attention deficit hyperactivity disorder in children, alcoholism, panic disorder and obsessive– compulsive disorder (e.g. DeBeurs et al., 1995; Engeland, 1993). Recent evidence suggests that combining treatments sequentially may be helpful, especially in preventing relapse. A combined treatment approach is particularly valuable with clients who may initially be too depressed or anxious to participate fully in psychotherapy. In these cases, symptomatic relief through drug therapy may be adequate, but if it is not, the drugs will most likely alleviate the symptoms sufficiently to allow the person to participate in, and benefit from, psychotherapy. An alternative, conservat ve approach would be to treat the patient with psychotherapy first (as it usually has no major side effects) and to add or change to medication only when it becomes apparent that the psychotherapy is not producing results. However, such an approach may be risky when there is perceived to be significant risk of suicide.
Combining psychotropic drugs and psychotherapy in the treatment of depression The research issue
Both psychotropic medication and psychotherapy are clearly useful in treating psychological disorders. But if medication reduces psychological symptoms, does this mean that the roots of psychological disorders lie in biological dysfunction? On the other hand, does successful psychotherapy mean that the causes of psychological disorders are necessarily psychological? An affirmative answer to either question would mean we have fallen prey to the treatment–etiology fallacy – a logical error in which treatment mode is assumed to imply the cause of the disorder. After all, very few people would wish to argue that because aspirin relieves headache, headache is actually due to the lack of aspirin in the body. So even though an antidepressant medication regulates neurotransmitters in the brain, it is quite possible that a psychological event gave rise to the neurotransmitter changes in the first place. How then do we choose between biological and psychological treatments? In trying to answer this question we must w atch out for another logical error, similia similibus curantur – like is cured by like (a principle used in homeopathy). In fact, psychotherapy can be used to treat biologically caused psychological disorders and vice versa, although treatment of bipolar disorder, schizophrenia and other psychotic disorders without medication would be irresponsible. For anxiety disorders and depression, neither biological nor psychological treatment appears to be clearly superior (Antonuccio, Danton & DeNelsky, 1995). A large-scale, multi-site study of 240 people suffering from depression found that two forms of psychotherapy (i.e. cognitive and interpersonal) administered together were generally as effective as a tricyclic antidepressant (Elkin et al., 1989). However, drug treatment effects appeared sooner, were more consistent across sites and appeared to be more effective in treating severe depression. Similar findings have been obtained in studies of generalized anxiety disorder (Gould et al., 1997) and obsessive–compulsi ve disorder (Abramowitz, 1997).
What about combining the two forms of treatment? Surprisingly, studies that address this issue have found that concurrent, joint use of medication and psychotherapy produces little additional advantage (Elkin, 1994; Hollon, Shelton & Loosen, 1991). But it does appear that combined treatment can be more effective for some disorders, including attention deficit hyperactivity disorder in children, alcoholism, panic disorder and obsessive– compulsive disorder (e.g. DeBeurs et al., 1995; Engeland, 1993). Recent evidence suggests that combining treatments sequentially may be helpful, especially in preventing relapse. A combined treatment approach is particularly valuable with clients who may initially be too depressed or anxious to participate fully in psychotherapy. In these cases, symptomatic relief through drug therapy may be adequate, but if it is not, the drugs will most likely alleviate the symptoms sufficiently to allow the person to participate in, and benefit from, psychotherapy. An alternative, conservat ve approach would be to treat the patient with psychotherapy first (as it usually has no major side effects) and to add or change to medication only when it becomes apparent that the psychotherapy is not producing results. However, such an approach may be risky when there is perceived to be significant risk of suicide.
Combining psychotropic drugs and psychotherapy in the treatment of depression The research issue
Major depression tends to be both chronic and recurrent. Biological and psychological therapies are both effective in treating depression. However, there is little evidence that administering both types of treatment at the same time yields better outcomes than administering either treatment alone. This study adopts a different approach to combining treatments by examining their sequential application. In particular, the researchers wondered whether cognitive behavioural treatment (CBT) after successful pharmacological treatment of depression would improve relapse rates. Design and procedure:- To examine this question, Fava et al. randomly assigned consecutive outpatients who had experienced three or more episodes of depression, to one of two treatment groups: pharmacotherapy and CBT, or pharmacotherapy and clinical management (CM). CBT consisted of Beck’s cognitive therapy and ‘lifestyle modificat on’ (patients were instructed that relapse might ensue if inappropriate lifestyle behaviours continued and were encouraged to modify their schedules, arrangements, etc. accordingly). CM consisted of monitoring medication, reviewing the patient’s clinical status and providing the patient with support and advice if necessary. Results and implications Short-term CBT after successful antidepressant drug therapy decreased relapse rate after discontinuation of antidepressants. As shown in figure 16.13, those who experienced CBT had a much lower relapse rate (25 per cent) during the twoyear follow-up than those assigned to CM (80 per cent).
This study challenges the widely held view that long-term drug treatment is the best tool to prevent relapse in patients with recurrent depression. Although maintenance pharmacotherapy may be necessary for some patients with recurrent depression, CBT appears to offer an alternative for others. This study adds to an emerging body of research (e.g. Paykel et al., 1999) that emphasizes the value of cognitive therapy in preventing relapse in depression.
Fava, G.A., Rafanelli, C., Grandi, S., Conti, S., & Belluardo, P., 1998, ‘Prevention of recurrent depression with cognitive behavioral therapy: Preliminary findings’, Archives of General Psychiatry, 55, 816–20.
This study challenges the widely held view that long-term drug treatment is the best tool to prevent relapse in patients with recurrent depression. Although maintenance pharmacotherapy may be necessary for some patients with recurrent depression, CBT appears to offer an alternative for others. This study adds to an emerging body of research (e.g. Paykel et al., 1999) that emphasizes the value of cognitive therapy in preventing relapse in depression.
Fava, G.A., Rafanelli, C., Grandi, S., Conti, S., & Belluardo, P., 1998, ‘Prevention of recurrent depression with cognitive behavioral therapy: Preliminary findings’, Archives of General Psychiatry, 55, 816–20.
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