Combining CBT with Pharmacotherapies
Many clinicians believe the optimal treatment consists of drugs combined
with some form of psychosocial intervention. This view arose from observations
that even the most effective drugs and the most effective psychosocial
interventions do not elimi-nate panic disorder in all cases. It was thought
that combination treatments might be a way to improve treatment outcome. The
available evidence provides mixed support for this view. Evi-dence suggests
that the efficacy of CBT is not improved when it is combined with either
diazepam or alprazolam. In fact, some studies have found that the efficacy of
situational exposure is worsened when
alprazolam is added.
Several studies have compared CBT with CBT combined with imipramine.
These results have also been mixed. Adding imipramine in the range of 150–300
mg/day to either situational exposure or CBT sometimes improves treatment
outcome in the short term, provided that patients are able to tolerate the
dose. Any advantage of combined treatment tends to be lost at follow-up.
Similarly, studies of combining CBT with SSRIs (fluvox-amine or paroxetine)
have produced mixed results, with some studies finding the combination is no
better than CBT.
It remains unclear whether treatment outcome is enhanced by combining
CBT with SSRIs. The neuroanatomical model with its dual emphasis on cortical
and serotonergic mechanisms suggests that this combined treatment might be
superior to CBT alone and to SSRIs alone. On the other hand, pharmacothera-pies
such as SSRIs might undermine the patient’s confidence in implementing CBT,
particularly if they attribute their gains to medications rather than to their
own efforts at using the skills learned in CBT. Large, well-designed studies
are needed to ex-plore these important issues.
A more promising type of combined therapy is a sequential ap-proach,
where patients are treated with pharmacotherapy during the acute phase, and
then are treated with CBT as the medication is phased out. Several studies have
shown that adding CBT dur-ing the tapering period for alprazolam and clonazepam
reduces the relapse rate associated with these drugs. It remains to be
dem-onstrated that CBT can reduce relapse when patients are tapered off other
antipanic drugs such as SSRIs. However, there is no reason to expect that CBT
would not be helpful in these cases.
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