TREATMENT OPTIONS: CBT OR MEDICATION?
Cognitive and behavior therapies (CBT) have been shown to work in broad range of disorders and for many problems in living not typically classified as psychiatric disorders in both children and adults. The same can be said for many of the effectiveness of several psychoactive medications. How do you choose between these two treatment options and when should they be combined?
This section offers information on:
CBT or Medication for Non-psychotic and Psychotic Disorders
Non-psychotic Disorders (e.g., Disorders NOT involving a loss of contact with reality, such as schizophrenic or manic disorders)
- As a general rule, findings suggest that CBT can do anything that medications can do in the treatment of the nonpsychotic disorders and it can do so without causing problematic side effects. CBT also can address symptoms on a more enduring basis.
- Research suggests that medications often work but they do so only for so long as you keep taking them, whereas CBT may reduce risk for subsequent symptom return long after treatment is over.
- Psychiatric medications typically treat the symptoms but do not cure the disorders, whereas you can learn things in CBT that may reduce your risk of the disorder coming back.
- People with more severe symptoms may benefit from adding medications, particularly among disorders like depression, obsessive-compulsive disorder, attention deficit hyperactivity disorder. For the less severe instances of these disorders the evidence for CBT is at least as strong as that for medications and for some disorders it is even stronger.
- Medications tend to work a little faster than CBT (by a matter of weeks) and there are sometimes benefits from using the two in combination or in sequence.
- CBT represents a viable alternative to medications for people with nonpsychotic disorders in most instances. However, there are indications that taking medications may undermine the enduring effects of CBT in some patients.
- Findings regarding the effectiveness of psychotherapy as an alternative to medications is mostly available for CBT therapy. There are many other approaches to psychotherapy; data indicating whether these other approaches are effective are still emerging.
A different rule applies for the psychotic disorders (those involving a loss of contact with reality like schizophrenia or mania). For those disorders, medication treatment has the best empirical support and represents the current standard of treatment.
- People with psychotic disorders are advised to seek good psychiatric treatment and to stay on their prescribed medication.
- CBT and certain family focused interventions often can play a useful adjunctive role in these disorders but they should not be used instead of medications.
What if I just have a minor or specific problem?
There also are many problems in living not typically classified as psychiatric disorders that benefit from CBT.
- People who have trouble standing up for themselves or who are prone to anger or acting in an aggressive fashion often benefit from CBT.
- Marital and family problems often benefit from CBT as well and anyone who has ever raised a child can attest the benefits of applying basic learning principles in a warm and systematic fashion.
- Psychoactive medications also can have a role to play in dealing with everyday stress or its consequences; for example, the newer specific serotonin reuptake inhibitors (SSRIs) like fluoxetine or sertraline may have beneficial effects on stress reactivity and impulsivity.
- There is nothing that medications can do for everyday problems in living that cannot be done (often better and longer-lasting) by the application of cognitive and behavioral principles.
- It is important to keep in mind when considering how to deal with long-standing aspects of temperament or everyday problems in living that some of the most widely prescribed medications can be addictive.
Most people have a personal physician that they see on a regular basis, whereas few will ever see a psychotherapist. With the advent of the newer and safer medications like the SSRIs, more people are getting medicated than ever before for problems like depression and anxiety. On the one hand this may be good, since these problems might otherwise have gone untreated. On the other hand, this can represent an opportunity lost, since these drugs do nothing to resolve the underlying propensity to get anxious or depressed. Given current trends in medical practice, many people face a lifetime of more or less continuous reliance on medications when equally efficacious and longer lasting alternatives exist. It is not that primary care physicians do not want to help; they do, but often the only way that they know how to help is by prescribing medications. Your primary care physician will likely refer you on to a psychiatrist if you have a more severe disorder (as they should) but many people with nonpsychotic disorders like depression and anxiety or people dealing with everyday stress and problems in living would benefit as much or more from learning CBT. With the advent of the Internet it is increasingly possible to educate yourself (and your primary care physician) about the possible alternatives.
There are several different types of psychiatric medications.
- Antipsychotics are used in the treatment of schizophrenia and other psychotic disorders like mania. They include the typical antipsychotics like chlorpromazine or haloperidol and the newer atypical antipsychotics like aripiprazole or olanzapine. These are powerful medications that are intended to treat serious disorders and they can sometimes have serious side effects or complications so that they typically require psychiatric management.
- Mood stabilizers like lithium and the anticonvulsants are used to reduce the risk for mania and depression in bipolar patients and like the antipsychotics typically require psychiatric management.
- Antidepressants are widely used in the treatment of depression and anxiety. The newer SSRIs are relatively safe and widely prescribed in primary care settings; older types of antidepressants like the tricyclic antidepressants (TCAs) and monoamine oxidase inhibitors (MAOIs) work at least as well but are more difficult to manage.
- Stimulants like methylphenidate and dextroamphetamine are sometimes used in the treatment of attention deficit disorder (with or without hyperactivity) in children and adolescents or to augment other medications in the treatment of depression. Stimulants can be addictive and there are ongoing concerns about their effects on growth and development, but they appear to have a role in conjunction with behavior management in the treatment of more severe instances of ADHD.
- Anxiolytics include benzodiazepines like diazepam and chlordiazepoxide and are used to treat anxiety and stress-related disorders. Although widely prescribed and providing very rapid symptom relief, they can be addictive if for too long and it can be difficult to stop (especially the high-potency benzodiazapines like alprazolam). CBT sometimes is used to help patients withdraw from these medications and many psychiatrists now prefer to treat these disorders with the slower acting but nonaddictive antidepressants.
- Hypnotics include medications like zolpidem that are widely used to treat insomnia but also can be addictive if taken for too long. Once again, CBT has been shown to provide comparable and more lasting relief in insomnia without the risks associated with medication.
Each of these medication classes has its uses and its contraindications. CBT is largely adjunctive to the antipsychotics and mood stabilizers in the treatment of patients with psychotic and bipolar disorders, a viable alternative to the antidepressants and stimulants for less severe nonpsychotic disorders and best used in combination with medication for more severe nonpsychotic disorders, and generally superior over time to the anxiolytics and hypnotics for the anxiety and sleep disorders.
- It can be sometimes be hard to find a good CBT therapist. ABCT maintains a website to help in that regard (see our Find a Therapist pages).
- It has become fashionable for therapists to describe themselves as offering CBT even when they do something quite different; it is perfectly appropriate to ask what kind of training your potential therapist has received.
- It still may be hard to find a well-trained CBT therapist in some communities; in that case medications may represent the best available option and likely should be used.
- CBT will not work for everyone and if it does not work for you within a reasonable period of time then it might be wise to consider switching to, or adding medications.
- It also may help to add medications if CBT produces some relief but does not fully resolve the problems that brought you first to treatment.
Some people may prefer taking medications to CBT, since medications typically work a little faster and may involve less time and effort. That is perfectly alright (therapists work for patients and not the other way around) and it is good to live in an age in which there are multiple efficacious treatment options. Just as adding medications can sometimes help when CBT alone is not enough, adding CBT to medications can often help when drugs alone are not enough.
Navigating Recent Treatment Controversies
There are several recent controversies that deserve to be addressed.
- Recent studies suggest that some antidepressant medications such as the SSRI's may actually increase the risk of suicidal thoughts and behaviors in children and adolescents (and perhaps young adults under the age of 25). Although these findings and their implications remain controversial (suicide rates have increased among young people in recent years as the number of prescriptions written have declined), CBT may provide a particularly valuable alternative intervention if it proves to work as well as medications for these age groups.
- There has been a striking increase in the rate at which children and adolescents have been diagnosed with bipolar disorders including mania. This has led in turn to a marked increase in the numbers of prescriptions written for the mood stabilizers and the antipsychotic medications. This too remains controversial and parents are strongly advised to secure a second opinion when starting treatment on such medications.
- It remains controversial whether children with attention deficit hyperactivity disorder (ADHD) truly benefit from being placed on stimulant medications. The current literature would appear to suggest that cognitive and especially behavioral interventions may produce comparable benefits to medications without their risks in less severe cases, but that CBT and medication may need to be combined when symptoms are more severe.
Chambless, D. L., & Ollendick, T. H. (2001). Empirically supported psychological interventions: Controversies and evidence. Annual Review of Psychology, 52, 685-716.
Hollon, S. D., Stewart, M. O., & Strunk, D. (2006). Cognitive behavior therapy has enduring effects in the treatment of depression and anxiety. Annual Review of Psychology, 57, 285-315.
Roth, A. R., & Fonagy, P. (2005). What works for whom? A critical review of psychotherapy research (2nd ed.). New York: Guilford press.
Thase, M. E., & Jindal, R. D. (2004). Combining psychotherapy and psychopharmacology for treatment of mental disorders. In M. J. Lambert (Ed.), Bergin and Garfield's Handbook of Psychotherapy and Behavior Change (5th ed., pp. 743-766). New York: Wiley.
See also Wikipedia at http://en.wikipedia.org/wiki/Psychiatric_medications