Integration of Drugs and Psychological Therapies in Treating Mental and Behavior Disorders Chapter 19

Role of Medication Treat acute symptoms associated with a mental disorder by ameliorating debilitating symptoms Prophylactic function – altering brain chemistry to prevent the onset of a symptom complex Allows introduction of behavioral or psychological interventions -- cotherapy

Effectiveness of Drugs and Therapy In the treatment of panic disorder, agoraphobia, simple phobias, and to a lesser extent, social phobias, behavioral and cognitive-behavioral therapies have traditionally been thought to have more consistent and longer-lasting effects than medications

Effectiveness of Drugs and Therapy Psychotherapy, specifically panic-focused cognitive-behavioral therapy, and medications (SSRIs, TCAs, benzodiazepines, and MAO inhibitors) are equally effective in the acute treatment for panic disorder.

Effectiveness of Drugs and Therapy Combining cognitive-behavioral therapy and medication in the treatment of panic disorder has not yet been convincingly shown to be superior to cognitive- behavioral therapy alone, but additional studies may lead to modification of this statement.

Effectiveness of Drugs and Therapy Medications and behavioral techniques are equally effective in the treatment of obsessive-compulsive disorder, posttraumatic stress disorder, and generalized anxiety disorder.

Effectiveness of Drugs and Therapy In the treatment of major depressive disorder, antidepressant medications and cognitive-behavioral therapy are equally effective and display additional efficacy when used in combination.

Effectiveness of Drugs and Therapy Individuals who respond to cognitive- behavioral therapy for the treatment of depression “tend to be less severely impaired than those who do not respond.”

Effectiveness of Drugs and Therapy At the very least, cognitive-behavioral therapy added to pharmacological management of depression “reduces relapse rates for acute major depression and persistent severe residual symptoms.”

Effectiveness of Drugs and Therapy In the treatment of eating disorders such as bulimia nervosa, “cognitive-behavioral therapy is the psychological treatment of choice... and... medication with fluoxetine (an SSRI) adds modestly to the benefit of psychological treatment.

Effectiveness of Drugs and Therapy The positive effects of cognitive-behavioral therapy in treating depression in adults are also seen in adolescents, and treatment gains in adolescents are maintained over time.

Effectiveness of Drugs and Therapy In patients with cigarette dependence and comorbid history of depression, cognitive- behavioral therapy was more effective than an antidepressant (nortriptyline). However nortriptyline allayed the negative affect that occurs in the days following smoking cessation. Long term most return to smoking anyway.

Effectiveness of Drugs and Therapy In bipolar disorder and schizophrenia, drug therapy is essential as primary therapy and psychological therapies are introduced following control of symptomatology.

Effectiveness of Drugs and Therapy New generation of antipsychotic drugs which can effectively ameliorate both the positive and the negative symptomatology of schizophrenia, permitting the introduction of psychosocial interventions that can assist with the integration of the patient into society and improve functioning level.

Effectiveness of Drugs and Therapy Psychosocial interventions with schizophrenics can provide long term changes that persist long after drug therapy is discontinued.

Effectiveness of Drugs and Therapy Prescription of a psychotherapeutic medication is only the first step in treatment of schizophrenia. Following control of symptoms, introduction of psychological interventions optimizes therapy.

Treatment Team One team member is usually a clinician with prescription privileges (physician or psychiatric or mental health nurse practitioner). Other clinicians on team have responsibility for psychotherapeutic interventions. Other members include: nurses, pharmacists, counselors, vocational rehabilitation counselors, physical or occupational therapists, dieticians, spiritual counselors, family members, and psychiatric, occupational, or recreational assistants.

Treatment Team Nonprescribing members of the team should be familiar with the pharmacology, uses, limitations, and side effects of the drugs being used by their clients. They should know about alternative medications that might provide different spectrum of side effects.

Treatment Team Nonprescribing clinicians must be able to professionally converse with the prescribing physician, monitor drug therapy, and institute psychological therapies appropriate to the condition under treatment. All should monitor for both positive and negative effects and be sensitive to the meaning medications have to their clients Never forget that effective psychotherapy depends on the ability of patients to comply with treatment requirements All members of the team have responsibility for assessment as this relates to diagnosis, treatment planning, and outcome assessment.

Herbal Medicines Used in the Treatment of Psychological Disorders Chapter 20

Herbal Medicine Some believe that since they are ancient they are effective (some are some are not). Some believe that because they are natural they are safe (opium, marijuana, cocaine, caffeine, nicotine, etc. are herbals – are they all safe?) Some herbals can be abused

Herbals and the Law 1920’s government stepped in and severely restricted sale and non prescription use of many drugs – cocaine taken out of Coca Cola, bromides taken off market, etc Dietary Supplement Health Education Act – any product labeled a supplement could be sold as long as didn’t claim to cure a disease. Can’t say “alleviates depression;” rather it “promotes emotional balance.” Can’t say “alleviates the signs and symptoms of Alzheimer’s disease; rather it enhances “mental sharpness.” No scientific evidence of effectiveness is required

Herbals and Uses St John’s WortDepression – effective for mild or moderate depression, fewer side effects than prescription antidepressants Ginkgocognitive disorders/ promote mental sharpness Studies show very small but statistically significant effect. Effect not large enough to be clinically significant KavaIntoxicant with effects similar to alcohol/ induce relaxation/ antianxiety Ephedrine (Ma-huang)Pharmacologically closely resembles amphetamines but duration of effect much shorter. Used as appetite suppressant (Metabolife) and as psychostimulant. Can cause problems with blood pressure and cardiac arrhythmias. Deaths are not infrequent ValerianMild sedative and anxiolytic Action similar to benzodiazapines. It works but not as effective as prescription drugs German chamomileInsomnia and anxiety Evening primrose, hops, lemon balm Effectiveness unknown or no scientific evidence of effectiveness

Conclusions With the exception of St. John’s wort for depression and ginkgo for dementia, there is insufficient evidence to recommend the use of herbal medicines in the treatment of psychiatric illness None of the herbals is clearly superior to the prescription alternatives More research needed Experiences and healing traditions of other cultures make an important contribution to modern medicine and should not be ignored.