Kombinacja terapii antydepresantami z terapią CBT - Info

[Sosen]

Jeśli macie jakieś informacje na ten temat, to proszę umieszczajcie je tutaj. Myślę, że to ważny temat. Sam jestem okropnie ciekawy jak to wygląda, nie znalazłem na ten temat jeszcze dokładnych badań. Czy terapia lekami skojarzona później z CBT daje dłuższe efekty.

Osobiście jestem zdania, że jest to mało prawdopodobne. Przyjmując leki nie czujemy tyle lęku, nie mamy takich głupich negatywnych myśli, więc nie możemy nad nimi pracować. Ja tak miałem przynajmniej jak brałem leki. Chociaż na jednej stronie napisali, że leki zmniejszają fizyczne symptomy i możemy pracować nad myśleniem. Nie jestem co do tego pewien.

Jeśli ktoś już tego próbował, czyli brał leki a później uczestniczył w terapii CBT(dalej przyjmując leki), a następnie odstawił leki to dobrze by było napisać swoje doświadczenia. Czy fobia wróciła, czy po odstawieniu leków pojawiła się depresja?

Tutaj bodajże na dole mamy napisane, że sama terapia lekami nie przynosi długofalowych efektów.

http://clinicaltrials.gov/ct2/show/NCT00074802

http://www.ehow.com/how_2088489_treat-so...itive.html

Tips & Warnings

* Cognitive behavioral therapy can be combined with drug therapy to treat social anxiety disorder. Approaching treatment from several different directions can provide more significant results.
* Drug therapy can actually complement cognitive behavioral therapy by alleviating some of the physiological symptoms of the disorder, so that you can concentrate on changing the way you think and behave.
* Repetition is key to both parts of cognitive behavioral therapy.

Jakby ktoś mógł się zalogować i ściągnąć te artykuły, ja narazie nie mam czasu:

http://linkinghub.elsevier.com/retrieve/...2799001408
http://linkinghub.elsevier.com/retrieve/...2301011830

Tutaj mamy dużo artykułów:

http://archpsyc.ama-assn.org/cgi/content...61/10/1005

Fluoxetine, Comprehensive Cognitive Behavioral Therapy, and Placebo in Generalized Social Phobia

Jonathan R. T. Davidson, MD; Edna B. Foa, PhD; Jonathan D. Huppert, PhD; Francis J. Keefe, PhD; Martin E. Franklin, PhD; Jill S. Compton, PhD; Ning Zhao, PhD; Kathryn M. Connor, MD; Thomas R. Lynch, PhD; Kishore M. Gadde, MD

Arch Gen Psychiatry. 2004;61:1005-1013.

Background Generalized social phobia is common, persistent, and disabling and is often treated with selective serotonin reuptake inhibitor drugs or cognitive behavioral therapy.

Objective We compared fluoxetine (FLU), comprehensive cognitive behavioral group therapy (CCBT), placebo (PBO), and the combinations of CCBT/FLU and CCBT/PBO.

Design Randomized, double-blind, placebo-controlled trial.

Setting Two academic outpatient psychiatric centers.

Patients Subjects meeting a primary diagnosis of generalized social phobia were recruited via advertisement. Seven hundred twenty-two were screened, and 295 were randomized and available for inclusion in an intention-to-treat efficacy analysis; 156 (52.9%) were male, 226 (76.3%) were white, and mean age was 37.1 years.

Interventions Treatment lasted for 14 weeks. Fluoxetine and PBO were administered at doses from 10 mg/d to 60 mg/d (or equivalent). Group comprehensive cognitive behavioral therapy was administered weekly for 14 sessions.

Main Outcome Measures An independent blinded evaluator assessed response with the Brief Social Phobia Scale and Clinical Global Impressions scales as primary outcomes. A videotaped behavioral assessment served as a secondary outcome, using the Subjective Units of Distress Scale. Adverse effects were measured by self-rating. Each treatment was compared by means of {chi}2 tests and piecewise linear mixed-effects models.

Results Clinical Global Impressions scales response rates in the intention-to-treat sample were 29 (50.9%) (FLU), 31 (51.7%) (CCBT), 32 (54.2%) (CCBT/FLU), 30 (50.8%) (CCBT/PBO), and 19 (31.7%) (PBO), with all treatments being significantly better than PBO. On the Brief Social Phobia Scale, all active treatments were superior to PBO. In the linear mixed-effects models analysis, FLU was more effective than CCBT/FLU, CCBT/PBO, and PBO at week 4; CCBT was also more effective than CCBT/FLU and CCBT/PBO. By the final visit, all active treatments were superior to PBO but did not differ from each other. Site effects were found for the Subjective Units of Distress Scale assessment, with FLU and CCBT/FLU superior to PBO at Duke University Medical Center, Durham, NC. Treatments were well tolerated.

Conclusions All active treatments were superior to PBO on primary outcomes. Combined treatment did not yield any further advantage. Notwithstanding the benefits of treatment, many patients remained symptomatic after 14 weeks.
Konkluzja. Wszystkie formy leczenia wykazywały większą efektowność niż placebo w pierwszych wynikach. Kombinowane formy leczenia nie przyniosły żadnych długodystansowych wyników. Nie zależnie od korzyści z leczenia, wielu pacjentom symptomy powróciły po 14 tygodniach.

Author Affiliations: Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, Durham, NC (Drs Davidson, Keefe, Compton, Connor, Lynch, and Gadde); and the Department of Psychiatry, University of Pennsylvania, Philadelphia, Pa (Drs Foa, Huppert, Franklin, and Zhao).

[Sosen]

Cognitive Behavioral Therapy, Sertraline, or a Combination in Childhood Anxiety
John T. Walkup, M.D., Anne Marie Albano, Ph.D., John Piacentini, Ph.D., Boris Birmaher, M.D., Scott N. Compton, Ph.D., Joel T. Sherrill, Ph.D., Golda S. Ginsburg, Ph.D., Moira A. Rynn, M.D., James McCracken, M.D., Bruce Waslick, M.D., Satish Iyengar, Ph.D., John S. March, M.D., M.P.H., and Philip C. Kendall, Ph.D.

Background Anxiety disorders are common psychiatric conditions affecting children and adolescents. Although cognitive behavioral therapy and selective serotonin-reuptake inhibitors have shown efficacy in treating these disorders, little is known about their relative or combined efficacy.

Methods In this randomized, controlled trial, we assigned 488 children between the ages of 7 and 17 years who had a primary diagnosis of separation anxiety disorder, generalized anxiety disorder, or social phobia to receive 14 sessions of cognitive behavioral therapy, sertraline (at a dose of up to 200 mg per day), a combination of sertraline and cognitive behavioral therapy, or a placebo drug for 12 weeks in a 2:2:2:1 ratio. We administered categorical and dimensional ratings of anxiety severity and impairment at baseline and at weeks 4, 8, and 12.

Results The percentages of children who were rated as very much or much improved on the Clinician Global Impression–Improvement scale were 80.7% for combination therapy (P<0.001), 59.7% for cognitive behavioral therapy (P<0.001), and 54.9% for sertraline (P<0.001); all therapies were superior to placebo (23.7%). Combination therapy was superior to both monotherapies (P<0.001). Results on the Pediatric Anxiety Rating Scale documented a similar magnitude and pattern of response; combination therapy had a greater response than cognitive behavioral therapy, which was equivalent to sertraline, and all therapies were superior to placebo. Adverse events, including suicidal and homicidal ideation, were no more frequent in the sertraline group than in the placebo group. No child attempted suicide. There was less insomnia, fatigue, sedation, and restlessness associated with cognitive behavioral therapy than with sertraline.

Conclusions Both cognitive behavioral therapy and sertraline reduced the severity of anxiety in children with anxiety disorders; a combination of the two therapies had a superior response rate. (ClinicalTrials.gov number, NCT00052078 [ClinicalTrials.gov] .)

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W skrócie. Artykuł opisuje badania nad leczeniem zaburzeń lękowych w tym fobii społecznej w grupie wiekowej 7-17 lat. W jednej grupie ludzi leczono za pomocą terapii CBT, w drugiej za pomocą sertraliny, w trzeciej połączono te dwie metody, a w czwartej podano placebo. W skombinowanej terapii bardzo znaczne polepszenie stanu oraz znaczne polepszenie osiągnęło 80 % badanych. W pierwszej i drugiej około 55 - 60 %. W 3, czyli w grupie placebo było to 24 %.

Czyli pozytywny jak dla mnie wniosek, kombinowanie tych terapii się opłaca. Brakuje mi tylko informacji na temat długoterminowych rezultatów, po odstawieniu leków.

[Sosen]

In 2006, the efficacy of combination treatments for social phobia (social anxiety disorder) has been assessed in a new randomized controlled trial by Prasko et al. (ref. 4). The authors conducted a study to assess the 6-months treatment efficacy and 24-month follow up of three different therapeutic programs: moclobemide and supportive guidance, group cognitive-behavioral therapy and pill placebo, and combination of moclobemide and group cognitive-behavioral therapy in patients with a generalized form of social phobia.

81 patients (38 males and 43 females) were randomly assigned to one of the three treatments. 66 patients completed the six month treatment period. 15 patients dropped out. All therapeutic groups showed significant improvement. The combination of CBT and pharmacotherapy yielded the most rapid effect. Moclobemide was superior for the reduction of the subjective general anxiety during the first 3 months of treatment, but its influence on avoidant behavior was less pronounced.

Conversely, CBT was the best choice for reduction of avoidant behavior while a reduction of subjective general anxiety appeared later than in moclobemide. After 6 months of treatment the best results were reached in groups treated with CBT and there was no advantage of the combined treatment. The relapse rate during the 24-month follow up was significantly lower in the group treated with CBT in comparison with the group formerly treated with moclobemide alone.

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Podobne badanie, ale na dorosłych. 6 miesięcy. Połączenie metod po tym okresie nie dało większych efektów niż same leki, albo sama terapia. Wniosek może być taki, że starsze osoby zdają sobie już sprawę z nieracjonalności swoich lęków. Dla dzieci połączenie leków z CBT daje większe korzyści.

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Conclusion

The hope that combination treatments might significantly increase the efficacy of current treatments for anxiety disorders has not been confirmed by recent empirical data. This fact is disappointing, all the more since a substantial proportion of patients do not respond or do not fully respond to either pharmacotherapy or CBT alone.

In the acute phase, current treatments for anxiety disorders combining pharmacotherapy and CBT do not seem to be associated with greater overall efficacy than that achieved with either treatment given alone. In the long-term treatment of anxiety disorders, combination treatments may be more effective than pharmacotherapy alone, but not more effective than CBT alone.

Data from the recent literature suggest a complex relationship between pharmacotherapy and CBT and highlight the need for more extensive studies, concerning, in particular, the long-term efficacy and effectiveness of combination treatments, the effect of discontinuation of either treatment after combined treatment, and the use of new strategies for combining pharmacotherapy and CBT.

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Konkluzja z badań(cały artykuł zawierał opisy badań różnych zaburzeń lękowych).

W skrócie.
Nadzieja, że leczenie skojarzone może znacznie zwiększyć efektywność leczenie zaburzeń lękowych nie znalazła potwierdzenia w badaniach.

Połączenie farmakoterapii i CBT w leczeniu zaburzeń lękowych wydaje się nie połączone z większą efektywnością niż leczenie tylko jedną z tych dwóch metod. W długoterminowym leczeniu zaburzeń lękowych skojarzone leczenie może być bardziej efektywne niż sama farmakoterapia, ale nie bardziej efektywne niż sama terapia CBT.

Badania nad terapią skojarzoną muszą być kontynuowane.

[Sosen]

http://books.google.pl/books?id=2RzFWRIA...#PPA545,M1

Od strony 545. Wcześniej też jest wiele informacji, dalej chyba też.

[Sosen]

Combining Cognitive-Behavioural Therapy and Pharmacotherapy in the Treatment of Anxiety Disorders

Jeanne D. Talbot, MD, PhD, FRCPC
Lecturer, Department of Psychiatry, Faculty of Medicine, University of Ottawa, Ottawa, Ontario.
Lisa McMurray, MD, FRCPC
Medical staff, Clinique des troubles anxieux, Centre Hospitalier Pierre-Janet, Gatineau, Quebec.


Key Words: cognitive-behavioural therapy, pharmacotherapy, anxiety disorders

Rapid growth in cognitive science has led to improved psychological treatments for anxiety disorders. There are now cognitive models of posttraumatic stress disorder (PTSD) (1,2), obsessive–compulsive disorder (OCD) (3), generalized anxiety disorder (GAD) (4,5), panic disorder (PD) (6), social anxiety disorder (SAD) (7,8) and specific phobias. These models have led to empirically validated treatment approaches for anxiety. Cognitive-behavioural therapy (CBT) is a time-limited, present-oriented approach to psychotherapy that teaches patients the cognitive and behavioural competencies needed to function adaptively (9). Reports of nonresponders and considerable relapse rates after either pharmacologic (10–12) or cognitive-behavioural treatments have led to a search to maximize the benefit of these treatment modalities.

The relative efficacy of CBT and medication alone or of the two in combination is now being studied. This research trend is particularly relevant to clinicians treating patients with anxiety disorders. Some important questions to consider are as follows: Is it best to start a medication first to promote quicker entry into feared situations? Should CBT be administered sequentially to medication to decrease relapse rate? Might CBT interventions be used most effectively to augment gains in partial responders to pharmacotherapy? These commonly encountered questions are the impetus for this article, which describes an empirically proven cognitive-behavioural approach to anxiety disorders and then reviews recent literature that has begun to examine some of the advantages and disadvantages of combining medication and CBT.

A comprehensive review of CBT is beyond the scope of this article. Simply put, however, most variations of CBT for anxiety disorders include as central components exposure and exploration of thoughts about feared situations. Exposure techniques are designed to help patients face the situations they fear and yet stay psychologically engaged, so that the natural conditioning processes involved in fear reduction (for example, habituation and extinction) can occur. As a first step, patient and therapist develop a rank- ordered list of anxiety-provoking situations. To keep anxiety within a tolerable range, the patient begins by facing the least-feared situation; as mastery of the lesser situations is achieved, the patient approaches increasingly more difficult situations. It is also important for patients to examine their thoughts about feared situations and the beliefs that may underlie them. In cognitive restructuring, individuals are taught to 1) identify negative thoughts that occur before, during or after anxiety-provoking situations; 2) evaluate the accuracy of their thoughts in light of data derived from Socratic questioning or as a result of so- called behavioural experiments; and 3) derive rational alternative thoughts based on acquired information. Cognitive restructuring techniques contain a significant exposure component; however, exposure in this context focuses on collecting information that will allow patients to revise their judgements about the degree of risk to which they are exposed in feared situations. The essence of both exposure and behavioural experiments is to engineer fear-arousing situations in which the patient is expecting unrealistically that something bad will happen but in which the negative consequences do not occur.

To date, only 26 randomized clinical studies involving CBT and medication treatment of either OCD, SAD, GAD, PD or other anxiety disorders have been reported. Methodological limitations in some of these studies excluded them from a recent meta-analysis undertaken by Foa (13). After setting stringent inclusion criteria, this author reviewed 10 studies and calculated within-subject effect sizes to compare treatment conditions within and across studies. The results suggest that combining CBT and medication may have differing effects across anxiety disorders. Combined medication and CBT were found to be no more effective than CBT alone for OCD, SAD and GAD (13). Interestingly, a multisite study found group CBT and phenelzine treatment of SAD to be comparable (14), yet relapse was lower in those who received group CBT alone (15).

A more complex picture emerges from the few studies allowing a direct comparison of combined treatment and pharmacotherapy alone. Franklin and others have reported preliminary data showing that CBT in combination with medication is better than medication alone for the treatment of OCD (16). Similarly, preliminary results by Connor and others suggest that adding CBT to sertraline substantially improved a modest response in PTSD patients (17). In contrast, a recent one-year follow-up of SAD patients treated with placebo, exposure, exposure plus sertraline or sertraline alone found that only those treated with exposure alone or placebo alone did not deteriorate after the completion of treatment (18). This suggests that there may be a negative effect of simultaneously combining medication and CBT for the treatment of SAD. A negative benefit of combined treatment has been more clearly shown with PD. Two studies of combined treatment of PD showed that the addition of medication interfered with long-term maintenance of gains arising from CBT (19,20). A plausible explanation for these findings is found in the cognitive model of panic. It is postulated that panic patients are hyper- sensitive to anxiety-related physiological responses such as tachycardia or dizziness. Moreover, these physiological responses are interpreted as potentially dangerous; that is, as signs of impending heart attack or seizure. For PD, CBT is designed to elicit such responses, with the absence of the anticipated disaster providing corrective information about their safety. Medication diminishes anxiety responses and thus may interfere with CBT exercises aimed at allowing patients to understand their erroneous beliefs about these responses.

Several methodological limitations bear mentioning. First, many studies of combined treatment define combined as simultaneous treatment; however, sequential treatment may be more optimal and better reflect clinical reality. Further, studying the interaction between medication and CBT is daunting because there is little a priori reason to assume that all medications combine with CBT in the same way. A reasonable hypothesis is that medications exerting their therapeutic effects with the fewest obvious side effects may be less likely to interfere with patients’ abilities to learn new skills and to believe that they can apply them. Medications with more intrusive side effects may lead the person to attribute positive changes to the medication (21) and to be more vulnerable to relapse. Similarly, we cannot automatically assume that different dosages will combine in the same way with CBT. Modest dosages of benzodiazepines may facilitate approach to a feared stimulus when treating a specific phobia; however, larger dosages may reduce the efficacy of exposure by inhibiting the physiological arousal necessary for habituation and extinction to occur.

The limited number of studies thus far, as well as methodological limitations, make it difficult to draw conclusions about combined treatments across different anxiety disorders, different CBT protocols and different medication classifications. A cautious reading of current findings is that combined medication and CBT is no more effective than CBT alone for OCD and GAD, while simultaneous addition of medication may detract from CBT treatment of SAD and PD. The finding that the addition of CBT to medication decreases relapse in SAD is important and parallels reports of decreased relapse after CBT for depression (22,23).

These studies of combined CBT and medication raise several therapeutic points. First and foremost, it is important for clinicians to be aware of empirically proven treatments to provide a rationale to anxiety patients for choosing CBT, medication or both. Second, the addition of CBT has never been found harmful and may likely decrease relapse. Further, the benefit of adding basic principles of CBT to the pharmacologic treatment of anxiety requires further exploration. Little formal CBT training is required to 1) carefully explore the extent of avoidance and beliefs underlying patients’ fears; 2) share a cognitive model of anxiety, with its emphasis on facing fear gradually by breaking the tasks into small steps; 3) guide patients through the growing array of self-help booklets and Internet resources; and 4) explore the meaning of taking medication (that is, do patients attribute their improvement to the medication or to acquired skills on their part?). Finally, until more definitive results from studies of combined CBT and medication of anxiety disorders are available, patients remain our most valuable resource as we adopt a basic tenet of CBT and enlist them in a collaborative examination of their treatment’s effect, whether the treatment be medication, CBT or a combination.

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Ten artykuł jest też o badaniach nad kombinowaną formą leczenia. Podobnie jak w poprzednich. Brak dowodów na to, że łącznie tych form terapii przynosi jakiś skutek. Wiadomo jedno, że dodanie CBT do farmakoterapii nie zaszkodzi, a może ograniczyć nawrót fobii. Natomiast dodanie farmakoterapii do CBT jest raczej niewskazane. Tak jak mi się wydawało. W przypadku fobii leki mogą utrudnić pracę nad myśleniem i założeniami na temat własnej osoby, które leżą u podłoża tego zaburzenia. Po lekach czujesz się ze sobą dobrze, więc tak naprawdę nie czujesz, że jesteś inny, czy dziwny, więc nie możesz nad tym pracować, a przynajmniej jest to trudniejsze.

W innym badaniu czytałem, że jeśli przyczyną są konflikty wewnętrzne, czyli chodzi o teorię psychodynamiczną, to wtedy rozwiązanie tych konfliktów podczas leczenia antydepresantami może przynieść skutek. Ale też nie ma badań to potwierdzających.

Więc ogólnie lipa jak dla mnie. Jak ktoś chcę się porządnie leczyć, to lepiej zacząć od razu CBT. Bo leczenie w trakcie zażywania leków może być trudne do przeprowadzenia, a wręcz niemożliwe. Jeśli ktoś umie żyć z tym, że będzie całe życie na lekach, to może tak wybrać, dla mnie to nie do zaakceptowania.

[marcin1980]

Tak, czy siak, nie ma wyboru. Trza parć do proda i wierzyć w lepsze jutro