Re:Combining medication and CBT

In any science new knowledge is steadiy accumulating and old conclusions are periodically reevaluated, so I'm not sure I'd bill this as something that we definitely know. However, there is quite a bit of empirical evidence and clinical experience on this topic. Here is my sense of how things stand currently:

Depression - CBT and antidepressant medication seem to be about equally effective. CBT may have a lower dropout rate, a lower relapse rate, and be less expensive in the long run but more research will be needed to provide grounds for a firm conclusion on this. A combination of CBT and antidepressant medication isn't necessarily more effective than either treatment alone but it is no less effective. There doesn't seem to be much problem with combining the two treatments as long as the client doesn't attribute all of the improvement to the medication. A combined approach is most likely to be considered with more severe depression.

Bipolar Disorder - CBT is generally considered to be of limited effectiveness unless the mood swings are controlled by medication. Therefore, a combined approach is generally advocated by CBT practitioners. There is as least one documented case of sucessfully treating bipolar disorder with CBT alone but the client in that case study was unusually motivated and treatment-compliant.

Anxiety disorders - Benzodiazepines and other short-acting anxiolytics have significant problems with physical and psychological dependence, abuse potential, and very high relapse rates. CBT is at least as effective and doesn't have these problems. With some anxiety disorders, such as panic disorder and agoraphobia, there is evidence that a combined approach has a higher relapse rate than CBT alone. I won't be surprised if it turns out that combining benzodiazepines with CBT is generally less effective that CBT alone, especially when the medication is taken "as needed." Clients tend to rely on the medication for quick short-term relief and don't follow through on the steps they need to take to make lasting changes. Other medications, such as SSRIs for obsessive-compulsive disorder, don't have the same problem because they don't give immediate, short-term relief of anxiety. With OCD, a combining CBT and SSRIs usually works fine and, if anything, the medication facilitates the CBT.

Schizophrenia - Everyone I know agrees that appropriate medication is essential. There is growing evidence that a combined approach is more effective than medication alone.

While is seems logical to assume that medication would undercut motivation for cognitive restructuring, this usually isn't a problem. Afterall, medication usually isn't so effective that it completely alleviates all the client's problems. The main problem I run into is when clients attribute all of their improvement to the medication and therefore abandon the cognitive-behavioral techniques or when they conclude that if medication is effective, this means that they have a chemical imbalance and that therefore therapy is irrelevant. It usually isn't hard to get them to realize that it is great that the medication is helpful but that this doesn't mean that other things won't be helpful as well. It is great to have a tool that works, but isn't it even better to have a variety of tools in my toolbox?

Note: These conclusions are based on my recall of the literature and I'd welcome any corrections or extensions provided by forum participants who remember this literature more clearly than I do.

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