When do meds make the difference?

As new psychotropic drugs enter the marketplace, and more psychologists gain the ability to prescribe, an inevitable question arises: Are drugs, therapy or a combination the best form of treatment?

Research shows fairly consistent results: For most non-psychotic disorders, behavioral interventions are just as effective as medications, and they hold up better over time.

"When researchers have directly compared empirically supported therapies with drugs in nonpsychotic populations, they hold their own very nicely," says Vanderbilt University depression expert Steven D. Hollon, PhD. Such therapies are also stronger in terms of enduring effects, he says. "People come away from treatment not only having their symptoms relieved, but learning something they can use the next time," he notes.

The British government, for one, is taking strong action with such findings: The United Kingdom's National Health Service is investing millions of dollars over the next few years to train more psychologists in evidence-based practices, making these interventions the treatment of choice over medications (see "U.K. gives huge boost to psychologists" ).

Meanwhile, research is continuing on combining drugs and therapy in treatment, and there, results are more mixed, says David H. Barlow, PhD, director of Boston University's Center for Anxiety and Related Disorders. In some cases, one treatment may boost the other. In other cases, there is no effect. Other times, combining the two may undermine an effective treatment. In addition, combination studies have been hobbled by theory and design problems, but research is improving and eventually should lead to clearer outcomes, Barlow says (see "Combined-treatment research gains sophistication").

As the research continues to unfold, practicing psychologists-whether they prescribe themselves or collaborate with physicians-should educate themselves on psychopharmacological findings, says Jeff Matranga, PhD, one of two psychologists at the group practice Health Psych Maine who has completed postdoctoral psychopharmacology training.

"It is critically important that we gain information about the relative merits of medications, psychotherapy, a combination or a sequence for a given clinical problem," says Matranga, who lectures frequently on the topic. "Thankfully, this type of research has been increasing, and it is quite valuable for the treating clinician to help guide treatment choices."

The word on depression

Research on depression shows that medications and empirically supported therapies such as cognitive behavioral therapy (CBT) and interpersonal therapy are equally effective, with each modality helping about 60 percent of clients, notes Hollon. Combined treatments produce even better results: In a literature review in the April 2005 Journal of Clinical Psychiatry (Vol. 66, No. 4, pages 455-468), Hollon and colleagues found that, in general, combining medication and therapy raised treatment effectiveness to as much as 75 percent.

"While that's not a huge increment in terms of the likelihood that someone will get better, you get a faster, more complete and more enduring response when you put drugs and therapy together," Hollon says.

One subgroup of depressed clients seems particularly amenable to combined treatment: severely and chronically depressed adults. One large multisite study was reported in the May 2000 New England Journal of Medicine (Vol. 342, No. 20, pages 1462-1470), and conducted by Brown University psychiatrist Martin B. Keller, MD, Virginia Commonwealth University psychologist James P. McCullough Jr., PhD, Stony Brook University psychologist Daniel Klein, PhD, and colleagues. In the study, researchers randomized patients with major depression either to a depression-focused CBT developed by McCullough, or to the antidepressant Serzone (nefazodone).

"The combination of the two was whoppingly more effective than either one alone," says Klein: About three-quarters responded to the combination, compared with about 48 percent for each individual condition. "People suffering from chronic depression often have longstanding interpersonal difficulties, and the virtue of combined treatment in this case may be that it simultaneously targets both depressive symptoms and social functioning," he says.

Weighing in on anxiety disorders

Likewise, large-scale studies on anxiety disorders find that people do equally well with medication or CBT, but that fewer people relapse with CBT than with medication, says Barlow, a lead researcher in the area. Unlike with depression, however, combined treatments don't seem to confer extra benefits, he notes.

The same pattern holds true for social phobia, says Temple University's Richard G. Heimberg, PhD, who has conducted a number of studies in the area. "You might get a bigger short-term burst from medication, but CBT is about as effective, and it's also associated with better protection against relapse," he says.

A long-standing line of research on obsessive-compulsive disorder (OCD) that has tested therapy and medication interventions has yielded what is considered a "best practice" for the disorder: a cognitive behavioral treatment for OCD combining exposure and ritual prevention, known as EX/RP. In this line of research, University of Pennsylvania researcher Edna Foa, PhD, and colleagues have conducted systematic studies to identify the active ingredients of EX/RP. In one set of studies, the team compared separate components of EX/RP and found that exposure only and ritual prevention only were not as effective as the combination of the two. In another line of research, they compared the efficacy of the trycyclic antidepressant clomipramine with EX/RP. They found that EX/RP reduced symptoms more than clomipramine and that EX/RP improved the effects of clomipramine, but the reverse was not the case.

The results of these studies "show that EX/RP is the treatment of choice for OCD, both as a treatment by itself and as an augmentation to medication," says Foa. She has found similar results with children and adolescents, though a related study on young people at Duke University did find an optimal effect by combining the selective serotonin reuptake inhibitor (SSRI) Zoloft (sertraline) and EX/RP, she notes.

Foa and her colleagues are now looking at how to improve OCD treatment further. In a current study, for instance, they're exploring how adding different conditions and more time might influence outcome. In the first part of the study, they're examining what happens when they give OCD sufferers not responding well to an SSRI an additional treatment of either EX/RP or the antipsychotic medication risperidone. In the second part, they're extending the length of each additional treatment for those still not experiencing much symptom relief.

Real-world considerations

Transporting such findings into the real world can, of course, be challenging. Unlike the relative purity of the lab, the treatment world is a teeming bazaar of providers-many of whom do not have the credentials or training of psychologists-turf issues, cost concerns and varying patient inclinations and needs, experts say.

In the provider domain, practitioners both in psychology and medicine often are not as up to date on empirically tested treatments as researchers, Hollon says. "There's a large discussion in the literature about how few people in the real world tend to practice therapies with empirical support, and the same thing is true with pharmacotherapy," he notes.

And, of course, not everyone has access to mental health care. Even if they do, says Foa, "It's not easy for people to find this treatment, because there aren't a lot of experts in the area."

Meanwhile, cost issues can prevent the most effective treatments from being used, those involved say. For instance, therapy may be more expensive up front, though studies show it is often more cost-effective over the long run, Matranga notes.

Insurers are sometimes more willing to pay for medications than for therapy, and some primary-care physicians are more likely to prescribe medications before therapy for a range of psychological conditions, he says, particularly if they don't have easy access to someone trained in these therapies.

Patient variables present a mystery in need of greater understanding as well, says Heimberg: Some people don't believe that "talking" can help, others are too anxious to try medications on one side or therapy on the other, and still others can't tolerate medication side effects, for example.

Likewise, research is beginning to show that clients' preferences make a huge difference in outcome, says Klein. "They're more willing to stick with and invest in something they believe will work," he notes.

Finally, drugs and therapy each carry pros and cons that need to be assessed when finding the right treatment for someone, Hollon says. With therapy, there's a learning curve; with drugs, there are side effects, he says.

Given that we're moving into an era where pharmacological and behavioral strategies will be increasingly used and blended, it's wise to be as informed as possible, Heimberg emphasizes.

"The ultimate positive circumstance," he says, "is to have as many tools as you can."

Tori DeAngelis is a writer in Syracuse, N.Y.