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CBT and Medication for Severe Mental Illness

In this video from a recent Beck Institute Workshop, Dr. Aaron Beck and Dr. Judith Beck discuss the effects of combining CBT and medication in the treatment of depression and schizophrenia. They also compare research findings on CBT treatment alone, medication alone, and a combination of CBT and medication among clients with severe depression and schizophrenia.

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CBT for Medication-Resistant Psychosis: A Meta-analytic Review

OBJECTIVE:
Support for cognitive-behavioral therapy (CBT) for psychosis has accumulated, with several reviews and meta-analyses indicating its effectiveness for various intended outcomes in a broad variety of clinical settings. Most of these studies, however, have evaluated CBT provided to the subset of people with schizophrenia who continue to experience positive symptoms despite adequate treatment with antipsychotics. Despite several reviews and meta-analyses, a specific estimate of the effects of CBT for patients with medication-resistant positive symptoms, for whom CBT is frequently used in outpatient clinical settings, is lacking. This meta-analysis examined CBT’s effectiveness among outpatients with medication-resistant psychosis, both on completion of treatment and at follow-up.

METHODS:
Systematic searches (until May 2012) of the Cochrane Collaborative Register of Trials, MEDLINE, PsycINFO, and PubMed were conducted. Sixteen published articles describing 12 randomized controlled trials were used as source data for the meta-analysis. Effect sizes were estimated using the standardized mean difference corrected for bias, Hedges’ g, for positive and general symptoms.

RESULTS:
The trials included a total of 639 individuals, 552 of whom completed the posttreatment assessment (dropout rate of 14%). Overall beneficial effects of CBT were found at posttreatment for positive symptoms (Hedges’ g=.47) and for general symptoms (Hedges’ g=.52). These effects were maintained at follow-up for both positive and general symptoms (Hedges’ g=.41 and .40, respectively).

CONCLUSIONS:
For patients who continue to exhibit symptoms of psychosis despite adequate trials of medication, CBT for psychosis can confer beneficial effects above and beyond the effects of medication.

Burns, A., Erickson, D., & Brenner, C. (2014). Cognitive-behavioral therapy for medication-resistant Psychosis: a meta-analytic review. Psychiatric Services. doi: 10.1176/appi.ps.201300213

CT is as Effective as Fluoxetine in Preventing Depressive Relapses

A recent study published in JAMA Psychiatry showed Cognitive Therapy (CT) to be as effective as medication (Fluoxetine) in reducing the risk of major depressive disorder (MDD) relapse. Participants in the current study included 523 adults with a diagnosis of MDD and a score of 14 or higher on the Hamilton Rating Scale for Depression. They were recruited from clinical referrals and advertisements during 2000 to 2008. Researchers employed a sequential, 3-stage design with an acute phase in which all patients received 12 weeks of CT; an 8-month experimental phase in which responders at higher risk were randomized to receive either a continuation of CT, fluoxetine, or a pill placebo; and a 24-month longitudinal, posttreatment follow up. At the end of the 8-month experimental stage, participants were assessed without treatment at 4 month intervals, continuing for 32 months. Results showed that CT and fluoxetine had almost equal relapse rates during the 8-month experimental phase, which were maintained during the assessment following termination of treatment. While further research is needed to fully understand the differences between psychopharmacological treatment and CT for depression, these finding suggest that CT is a valid alternative to drug therapies.

Jarret, R. B., Minhajuddin, A., Gershenfeld, H., Friedman, E. S., & Thase, M. E. (2013). Preventing depressive relapse and recurrence in higher-risk cognitive therapy responders: A randomized trial of continuation phase cognitive therapy, fluoxetine, or matched pill placebo. JAMA Psychiatry, 70(11), 1152-1160. doi:10.1001/jamapsychiatry.2013.1969

CBT plus Medication is Effective for Chronic Migraine in Children and Adolescents

According to a recent study published in JAMA, cognitive behavior therapy (CBT) plus amitriptyline (a tricyclic antidepressant used in the treatment of migraines) may be an effective treatment for chronic migraines in children and adolescents. In the current study, researchers compared the efficacy of CBT plus amitriptyline versus headache education plus amitriptyline. Participants included 135 youth aged 10 to 17 diagnosed with chronic migraine. They were randomized to either the CBT plus amitriptyline group (n = 64) or headache education plus amitriptyline group (n = 71). Participants received either 10 CBT sessions or 10 headache education sessions involving equivalent time and therapist attention. At post-treatment, 66% in the CBT group had at least a 50% reduction in headache days versus 36% in the headache education group. At the 12-month follow up, 86% in the CBT group had at least a 50% reduction in headache days versus 69% in the headache education group. These findings support the efficacy of CBT in the treatment of chronic migraine among children and adolescents.

Powers, S. W., Kashikar-Zuck, S. M., Allen, J. R., LeCates, S. L., Slater, S. K., Zafar, M., Kabbouche, M. A., … Hershey, A. D. (December 25, 2013). Cognitive Behavioral Therapy Plus Amitriptyline for Chronic Migraine in Children and Adolescents. Jama, 310, 24, 2622.

Cost-Effectiveness and Clinical-Effectiveness of Combined Therapy versus Medication Only in Adolescents with Resistant Major Depression

Depression in adolescents is a significant issue. Research has focused on treating major depression in adolescents with psychotherapy (CBT), medication (selective serotonin reuptake inhibitors, SSRIs), or a combination of both.  As treatment is not inexpensive, researchers have been looking into the cost-effectiveness of different treatment models.  Previous research has shown that CBT treatment and medication is the most expensive treatment model in the short run.  The least expensive model is medication only.  However, some adolescents do not respond to medication alone.

A recent randomized trial was published in the Archives of General Psychiatry. 334 adolescents with SSRI-resistant depression, were randomly assigned to one of two groups for 24 weeks: a change in medication or a change in medication plus CBT.   Throughout the treatment they were assessed at 6, 12, and 24 weeks for symptom changes, depression-free days, and depression-improvement days.  The researchers also examined the clinical outcomes within certain subgroups of participants: patients with histories of abuse, comorbid disorders, and levels of hopelessness.

The study found that using a combined treatment of CBT and medication led to more depression-free and depression-improved days.  It worked best for patients without a history of abuse or with low levels of helplessness.  While the combined treatment was more costly in the short-run, it may be most cost-efficient in the long run.  This study demonstrates the benefits of further examining the use of combined treatment in adolescents with SSRI-Resistant Depression.

Lynch, F. L., Dickerson, J. F., Clarke, G., Vitiello, B., Porta, G., Wagner, K. D., … Brent, D.  (2011). Incremental cost-effectiveness of combined therapy vs medication only for youth with selective serotonin reuptake inhibitor – resistant depression.  Arch Gen Psychiatry, 68 (3), 253-262.

Cognitive Behavior Therapy and other Evidenced Based Treatments are New Standards for Certain Sleep Disorders

After a consensus meeting in May 2009, members of the British Association for Psychopharmacology set new guidelines for treatment of certain sleep disorders.  These guidelines established evidence-based treatment as the leading model of therapy for insomnia, parasomnias, and circadian rhythm disorders.  The results were published in the Journal of Psychopharmacology. Among the evidenced-based treatment protocols was Cognitive Behavior Therapy (CBT).  CBT was recommended as a primary treatment for chronic insomnia.  CBT was also recommended during the tapering of long-term hypnotic drugs, since it has been proven to be effective in improving outcomes.  Behavioral strategies were specifically recommended for children with sleep problems. The decision by the British Association for Psychopharmacology to update guidelines for certain sleep disorders illustrates the efficacy of evidence-based treatments such as CBT.

CBT is Effective for Tourette’s Syndrome

researchlogo72x65bl-new.jpgA new study is the first to show that CBT (cognitive behavioral therapy) is effective in patients with Tourette’s syndrome and tic disorders, regardless of their medication status or symptom severity. 76 adult participants, all of whom had been diagnosed with the aforementioned conditions, were divided into two groups; those who were prescribed medication and those who were not. All of the participants underwent four months of individualized, manual-based CBT. Before and after receiving CBT, measures were taken to assess depression, anxiety, obsessive-compulsive symptoms, and planning style. Also, the Tourette Syndrome Global Scale was employed to assess various factors, including severity and treatment outcome.

 The results demonstrated that both groups—medicated and unmedicated—greatly improved from the CBT. The unmedicated group improved in terms of anxiety, while both groups’ depressive symptoms decreased.

CBT and CBT Plus Medication for the Treatment of OCD in Children

NewStudy-Graphic-72x72_edited-3 A recent study published in Child and Adolescent Mental Health found both Cognitive Behavior Therapy (CBT) and CBT in combination with medication to be effective in the treatment of Obsessive Compulsive Disorder (OCD) in children. During a ten-year period, 75 children were evaluated and treated for OCD in an outpatient setting. Investigators later contacted a subset of that sample to investigate the long-term maintenance of their therapeutic gains. Treatment groups in this follow up investigation included, (1) those treated with medication before beginning CBT, (2) those treated with CBT only, and (3) those treated with CBT and medication, simultaneously. Participants in each group had all met diagnostic criteria for OCD as determined by their Children’s Yale Brown Obsessive-Compulsive Scale (CYBOCS) scores. Long term maintenance was assessed by comparing post-treatment and pre-treatment CYBOCS scores. Results showed significant improvement for each group, yielding further support for the use of CBT and CBT plus medication (SSRIs) in the treatment of OCD.

Reference

Nakatani, E. (2009). Outcomes of cognitive behaviour therapy for obsessive compulsive disorder in a clinical setting: A 10-year experience from a specialist OCD service for children and adolescents. Child and Adolescent Mental Health, 14, 133-139.

Research Results: CBT May Reduce Depression Relapse after ECT

 

Many studies have demonstrated that Cognitive Therapy (CT) is effective for depression, and twice as effective as medication in preventing relapse among depressed patients. So what’s new in CT for Depression research? A recent initial study shows that Cognitive Behavior Therapy (CBT) may decrease the risk of relapse specifically for depressed patients who are undergoing electroconvulsive therapy (ECT). For this study, six patients received 12 weeks of CBT following a course of ECT-only treatment. At follow up, five of the six patients had “much improved” or “very much improved” scores on depression measures, as compared to their measures after ECT treatment. Results indicate that CBT may prolong improvement among depressed patients who have received ECT.