COMBINING CBT AND PHARMACOTHERAPY

IN CLINICAL PRACTICE

Although the overali results of outcome studies have supported additive cffects between therapies,
combined therapy may have been somewhat handicapped in these investigations. Most studies
have been designed to pit one therapy against the othei thus creating a competitive instead of a
cooperative environment. Combined therapy could have the greatest chance of being effective in
real-world, clinical practice settings if it is offered in a uni fied package by clinicians

who understand and endorse a fully integrated approach to treatment.

A comprehensive cognitive—biological model for combined therapy has been detailed elsewhere
(Wright & Thase, 1992). This model (diagrammed in Figure 16.1) assumes the following:
1. Cognitive processes modulate the effects of the externa1 environment (e.g., stressful life events,
interpersonal relationships, social forces) on the CNS substrate (e.g., neurotransmitter function,
activation of CNS pathways, autonomic and neuroendocrine responses) for emotion and behavior.
2. Dysfunctional cognitions can be produced by both psychological and biological influences.
3. Biological treatments can alter cognitions.

4. Cognitive and behavioral interventions can change biological processes.

5. Environmental, cognitive, biological, emotional, and behavioral processes should be
conceptualized as part of the same system.
6. It is valuable to search for ways of integrating or combining cognitive and biological interventions
to enhance treatment outcome.

The first assumption is a component of the basic cognitive model (Wright, Beck, & Thase, 2002).
Assumptions 2—5 are supported by research reviewed earlier in this chapter on the effects of CBT
on CNS function (see, e.g., Baxter et al., 1992; Furmark et al., 2002); by studies of the int]uence of
pharmacotherapy on maladaptive cognitions (Blackburn & Bishop, 1983; Simons, Garfield, &
Murphy, 1984); and by the integratjv formulations of Akiskal and McKinney (1975), Kandel (2001),
and others. Assumption 6 is supported by the generally favorable results of outcome studies on
combining treatment strategies.

The cognitive—biological model can be implemented in clinical practice in rwo major ways: (1)
by a psychiatrist who is trained in both CBT and pharmacotherapy, or (2) by teams of physicians
and nonmedical therapists. The most common approach is a team approach to integrated therapy.
Bur growing numbers of psychiatrists are skilled cognitive therapists and may deliver ah of the
treatment (medication and CBT) in a comprehensive package and/or work with nonmedical
cognitive therapists for the delivery of integrated care. The recent mandate in the United States for
psychiatry residents to achieve competency in CBT may increase the likelihood that psychiatrists
will provide combined CBT and biological therapy by theniselves and also be effecrive members of
cognitive—biological treatment teams.
 When CBT and medication are administered by different clinicians, several steps can be taken
to promote collaboration and strengthen the impact of combining treatments (Wright, 1987; Wright
& Thase, 1992). First, the chinicians should work together regularly if possible. The ideal
arrangement is for the therapist providing CT and the pharmacotherapist to be part of the sarne
practice group or clinic. The clinicians should agree on a general formulation for combined
treatment, such as the cognitive—biological model descrihed aboye. They also should discuss what
will be told to the patient about using the two treatments together, and should present a
knowledgeable and generally favorable opinion of integrated therapy. It can help a great deal if a
nonmedical therapist is conversant with the mechanisms of action, indications, and side effects of
medication. Thus the therapist providing CBT can help educate the patient about pharmacotherapy,
answer general questions and promote compliance with the medication regimen. In a similar
manner, the pharmacotherapist who knows the basics of CBT can support the work of the
nonmedical therapist, reinforce homework adherence, and encourage the use of CBT skills to
manage symptoms.

Specific methods for integrating CBT and pharmacotherapy have been described previously
(Wright & Schrodt, 1989; Wright & Thase, 1992; Wright et al., 1993). The structure of therapy
provides an excehlent opportunity for uniting the different treatment approaches. Structuring
techniques, such as agenda setting, feedbacks, and homework assignmeflts, are core elements óf
CBT. In a similar manner, pharmacotherapy is organized around symptom assessments, side effect
monitoring, directions for taking medication, and the writing of prescriptions. If one therapist is
providing both pharmacotherapy and CBT, the agenda for the session should contain one or more
items from each approach (e.g., side effects, drug interactions, homework assignments, improving
self-esteem, coping with an environmental problem). The two treatments should be valued equally,
but the time devoted to each will vary from session to session. In my own experience with combined
therapy, sessions are usually weighted more heavily to CBT interventions than to discussions about
pharmacotherapy.

If there are dual therapists, agenda setting can be used to link the therapies. For example, the
pharmacotherapist can place items such as “progress in using CBT” and “How is the homework
going?” on the agenda; the therapist providing CBT can help the patient address such topics as
“attitudes about taking medication.” In this manner, the two therapists can convey the importance
of a combined approach to the patient and use a similar agenda setting method to help bring
together the different elements of therapy.

Psychoeducation, another important shared feature of CBT and pharmacotherapy, can be used
to forge an integrated treatment method. CBT is well known for using psychoeducational
procedures to assist patients with learning new patterns of thinking and behaving. Typical
educational methods include explanations in sessions, reading assignments, audio- and
videotapes, computer-assisted instruction, modeling, homework, and cognitive and behavioral
rehearsal (Wright, Thase, & Beck, 2002).

Pharmacotherapists employ psychoeducational methods to help patients acquire knowledge

about psychiatric disorders, the biological model, medications, and side effects. Commonly used
techniques include minididactic presentations in treatment sessions, videos, and readings in books
or pamphlets. To combine therapies effectively, clinicians should carefully review educational
materials provided to patients in order to minimize presentation of contradictory or strongly biased
information (e.g., pharmaceutical company pamphlets that extol the value of their product instead
of giving a balanced and comprehensive view of treatment).
There are several books for the general public that discuss both CBT and pharmacotherapy in
a favorable light and can help readers understand how both treatments can be used effectively in
psychiatric treatment. Getting Your Li/e Back: The Complete Guide to Recovery from Dep ression
(Wright & Basco, 2002) presents a fully integrated cognitive—biological treatment method. Feeling
Good (Burns, 1999) includes a section on medications. A newly developed technology, computer-
assisted CBT, is now aya ilable for teaching patients CBT skills. Empirically tested programs such
as Good Days Ahead: The Multimedia Program for Cognitive Therapy (Wright, Wright, Salmon, et
al., 2002; Wright, Wright, & Beck, 2002) and Fear Fighter (Kenwright, Liness, & Marks, 2001) can
assist clinicians in helping patients understand and use CBT methods.

Adherence to treatment recommendations is a critical element for implementation of both CBT

and pharmacotherapy. In CB’g attendance at therapy sessions and homework are important for
success In pharmacotherapy, medication compliance, accurate reporting of side effects, and
sticking with maintenance therapy regimens are key components of effective treatment. CBT
interventions for improving treatment compli ance are particularly well suited for integrating
therapies and promoting adherence to ah components of the treatment plan (Cochran, 1984; Wright
& Thase, 1992; Basco & Rush, 1995; Kemp et al., 1996).

Simple behavioral interventions—such as using reminder systems, pa iring medication taking

with routine activities (e.g., brushing teeth, meals), and developing behavioral contracts—can be
integrated into pharmacotherapy. sessions in a time-efficient manner and can be utilized by
nonmedical therapists to improve medication compliance. More detailed interventions, such as
reinforcement programs and behavioral analyses of barriers to harmacotherapy adherence, also
can be employed when needed.

Maladaptive cognitions about medication or medical treatment are other potential targets for
combined CBT and pharmacotherapy. Treatment compliance can be undermined by dysfunctional
cognitions related to schematic themes, such as (1) personal weakness (e.g., “Taking a medication
means that 1 am weak,” “1 should be able to do this on my own”); (2) distrust in the therapeutic
relationship (e.g., “Doctors just try to push medication instead of understanding people,” “You can’t
trust doctors”); (3) fears of dependency (e.g., “1’!! be dependent on the medication,” “1 won’t be in
control”); and (4) fears of medication effects (e.g., “I’m always the one to get side effects,” “These
drugs are dangerous”) (Wright & Schrodt, 1989; Wright & Thase, 1992). Negative automatic
thoughts and core beliefs such as these can go unrecognized if the clinician does not inquire about
the patient’s reactions to medication prescription. When maladaptive responses to
pharmacotherapy are uncovered, therapists can use CBT methods, such as thought recording and
examining the evidence, to develop realisti cognitions that will support medication adherence.
 A flexible, customized approach to the “dosing” and timing of interventions for individual patients
can provide an additional opportunity for enhancing the effects of combined therapy. In most
outcome studies, ah patients receive essentially the same dose of medication and psychotherapy
along a strictly controlled time course. However, in clinical practice, therapists can capitalize on the
specific attributes of various medications and CBT interventions to arrange a sequence and dosing
regimen to help meet treatment goals. For example, in my own work with highly suicidal inpatients,
1 target hopelessness and suicidal ideation with CBT interventions 00 the day of admission to
reduce suicidal risk and dysphoria rapidhy. A1 though antidepressants are also started
immediately, these medications are unlikely to exert positive effects until severa! days have
elapsed. A different clinical situation may be encountered with patients in the midst of severe manic
or psychotic episodes, who may require stabilization with medication before meaningful
psychotherapy can begin.

The response, or lack of response, to treatment also may cal! for adjustments in the combined
therapy approach. Psychopharmacological considerations may include increasing the dose of
medication if there is inadequate relief of symptoms, utilizing augmentation strategies for treatment
resistance, or adding an antipsychotic medication if psychotic features are detected. In a parallel
manner, CBT interventions can be intensified, reformulated, or modified in other ways to meet the
specific problems and needs of each patient. When a fully integrated therapy approach is used,
these adjustments are part of a comprehensive treatment plan that seeks to draw the best from
both CBT and pharmacotherapy to maximize the chances of response.

SUMMARY

Outcome studies of combined CBT and medication have focused on testing for superiority of
therapies at the end of treatment and thus have not helped elucidate possible mechanisms of
interaction and have not encouraged the development of integrative treatment modeis.
Nevertheless, the overail results of outcome research support additive effects between treatments
for most disorders and combinations of treatment interventions. Strong evidence has been
collected for enhanced treatment response for combinations of antidepressants and CBT for severe
or chronic depression, anxiety disorders, and bulimia nervosa. The newest area of research,
combined treatment for psychosis, has consistently documented advantages for adding CBT to
treatment with antipsychotic medication. The only form of combined treatment that may show
negative interactions is short-term alprazolam use in patients receiving CBT.
Possible future research directions for combined CBT and pharmacotherapy could include
designs with larger sample sizes and/or “megaanalyses” (Entsuah et al., 2001) to detect effects
that may be obscured in smaller studies; investigations of combined therapy for severe and
treatment-resistant symptoms; and explorations of ways for making combined therapy more
efficient or effective. Also, research directed at the processes of interaction could help in the
development of more refined and more specific treatment methods for utilizing a combined therapy
approach. ExampIes of such refinements might include titration of medication dose to ideal leveis
that would enhance learning and memory function or reduce other barriers to effective
psychotherapy, or the development of CBT methods targeted directly at facilitating the CNS effects
of pharmacotherapy. Research on the biological actions of CBT offers a significant opportuni, to
understand how cognitive and behavioral interventions might work in concert with medication to
augment treatment response.

Clinical implementation of the combined therapy approach may varv widely, depending on the
theoretical orientation of clinicians and the degre of communication between therapists. It is
recommended that Cliflicjans adopt an integrated cognitive—biological model, develop a unified
and comprehensive therapy plan for each patient, and draw from the advantages of both CBT and
pharmacotherapy in selecting interventions.

Although CBT and biological psychiatry have evolved from different theoretical and scientific
backgrounds, these two important treatment approaches have many things in common. They share
a strong empirical basis, an emphasis on structure and psychoeducation, a pragmatic view of
therapy, and the common objective of reducing psychiatric symptoms to the greatest extent
possible. Both treatments influence thoughts, emotions, and the biological substrate for human
behavior. A partnership between CBT and pharmacotherapy offers potential for advancing the
treatment of mental disorders.