Comparisons And Combinations Of Cbt And Medication

The few studies that have compared the efficacy of CBT to that of medication treatments have been difficult to interpret because of a variety of methodological problems. One study indicated that CBT was more effective than buspirone for socially anxious musicians (Clark & Agras, 1991) and another reported that combined imaginal and in vivo exposure was more effective than the beta-adrenergic blocker atenolol (Turner, et al., 1994a). However, neither atenolol nor buspirone has surpassed placebo in the treatment of social anxiety disorder (Liebowitz et al., 1992; van Vliet et al., 1997).

Other studies show that there were few significant differences in relative efficacy between CBGT and the high-potency benzodiazepine clonazepam (Otto et al., 2000), the high-potency benzodiazepine alprazolam, the monoamine oxidase inhibitor phenelzine, or placebo (Gelernter et al., 1991). In contrast, Clark et al. (2003) reported that individual CBT was superior to fluoxetine and placebo at post-treatment and one-year follow-up, although there was no difference between the fluoxetine or placebo. However, in these studies, instructions for self-directed in vivo exposure were included as part of the medication treatments.

Phenelzine has long been considered the best established pharmacological treatment for social anxiety, demonstrating the largest effect size across controlled trials (Blanco et al., 2003). However, it is not considered a first-line medication because of the risk of hypertensive reaction and the associated need for dietary restrictions. In a large, multisite collaborative study, Heimberg et al. (1998) examined the relative efficacy of CBGT, phenelzine (without exposure instructions), attention placebo, and pill placebo in 133 patients with social anxiety disorder. An important aspect of this study is that it controlled for the allegiance effect (the effect whereby more favourable results tend to be found for treatments conducted in settings of compatible theoretical orientation) by conducting all treatments at both a centre known for biological psychiatry and a centre known for cognitive-behavioural treatments. After the first six weeks of treatment, individuals receiving phenelzine were rated as more improved and less anxious than those in the other conditions. Following 12 weeks of treatment, CBGT and phenelzine were associated with similar rates of treatment response and were both superior to the control conditions. In a follow-up of post-treatment responders who received monthly maintenance treatment for six months followed by six months of follow-up, CBGT responders were less likely than phenelzine responders to relapse (Liebowitz et al., 1999). These results suggest that phenelzine may provide faster symptom relief, but CBGT may provide greater protection against relapse in the long term.

Empirical investigations of the efficacy of combined CBT and pharmacological treatment are limited and have yielded mixed results. Falloon et al. (1981) reported that the efficacy of social skills training was not enhanced by adding the beta-adrenergic blocker propranolol. Similarly, CBT plus buspirone was not more effective than CBT alone (Clark & Agras, 1991). Preliminary results from a multisite treatment outcome study suggest that the combination of phenelzine and group CBT was more likely to be superior to placebo than either CBGT or phenelzine alone (Heimberg, 2002). Pilot data also suggest that the combination of brief exposure therapy with the broad-band antibiotic D-cycloserine was superior to exposure plus placebo (Hofmann et al., 2006).

Initial results from a study conducted by Blomhoff and colleagues (2001) showed that the SSRI sertraline, exposure, and their combination were all superior to placebo after 12 weeks. The active treatments showed equivalent response after 24 weeks, although only the sertraline groups were significantly better than placebo. Follow-up one year after the beginning of treatment revealed, however, that patients who received exposure alone continued to improve whereas patients receiving sertraline alone or combined with exposure tended to deteriorate (Haug et al., 2003). Another multisite study examined the relative efficacy of group CBT, the SSRI fluoxetine, and their combination. The authors failed to find evidence for the enhanced efficacy of combined treatment compared to group CBT or fluoxetine alone, which also did not differ (Davidson et al., 2004).

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