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From the 111th
Annual Convention of the American Psychological Association:
A summary of a
CEU workshop
by Lise Osvold,
Ph.D.
Psychopharmacological
Management of Depression and Anxiety in Adults:
Clinical
Advances
Dr.
Morgan T. Sammons, a licensed psychologist who prescribes
psychotropic medications for military personnel, presented two
opposing theoretical models of prescribing psychotropic medications:
the Allopathic Model vs. the Psychological Model. Under the
Allopathic Model, a physician determines that patients should
benefit from taking a medication and tells them so, while handing
them a prescription. Research has shown that many individuals (as
many as 97% who report only two symptoms of depression) receive
prescriptions for antidepressant medications from their primary
physician, usually without being consulted. As many as 50
percent of those patients fail to fill their prescription, fail
to take the medication as prescribed, or stop using the medication
within the first month. Fortunately, many never needed the
medication to begin with.
The
Psychological Model, on the other hand, takes a much broader
approach. Under the Psychological Model, medications are considered
adjunctive rather than primary. Treatment is considered
collaborative, with the patient encouraged to take an active role in
deciding whether or not to take psychotropics; the doctor is there
to provide the patient with accurate information so the patient can
make an informed decision. In fact, according to Dr. Sammons,
research has demonstrated that treatment is more likely to benefit
the patient (whether pharmacological, psychotherapeutic, or both)
when the patient has actively chosen the mode or modes he or she
wants to be employed in treatment.
Prior
to giving any of his patients a prescription, Dr. Sammons said he
also likes to make several other points clear. He said he makes it
understood that any medication he prescribes is with the presumption
that the patient will also participate in psychotherapy. He said he
makes clear to his patients any potential side effects: “There’s
no free lunch,” just a balance between benefits and side effects.
He said he tells his patients about the limitations of medication in
treating depression, anxiety, and other disorders, especially long
term He said he specifically tells his patients that the medications
are not curative agents, and that they are ineffective for
psychosocial distress.
Although
insurance companies usually prefer to focus on the medical model,
believing it to be most cost-effective, research studies pitting
many antidepressants against placebos have demonstrated strikingly
similar outcomes between the two (Moncrieff J., Wessely, S., &
Hardy, R. (2002). Additionally, evidence increasingly demonstrates
that combined treatment of a psychotropic and psychotherapy has the
best short and long-term gains for the patient (Kocsis, J.H, et at.,
2002). And in runny cases, psychotherapy is the treatment of choice,
with significantly better curative rates for anxiety and panic
disorder than medication alone (McCusker, 35
al., 2000), which works best only as a stopgap measure.
While
no empirical support exists for long-term drug treatment for anxiety
and panic disorders, particularly with benzodiazepines, evidence
does exist of their occasional deleterious effects in patients.
Patients experiencing delirium or dementia, for example, who already
feel as though they are losing control, may react to a
benzodiazepine by exhibiting its paradoxical effect: becoming
increasingly agitated. Also, when a patient develops tolerance to
such a drug, the patient may endure “mini-withdrawal" between
doses that are of such agitation that they contradict their
continued use. Additionally, benzodiazepines have a prolonged
half-life in the elderly, due to an increased ration of fat to lean
tissue, which can cause a buildup of the drug in their system.
Finally, drug therapy has been shown to interfere with cognitive
behavioral treatment of panic arid anxiety disorders, as the patient
loses both the motivation and the clarity of mind necessary to
benefit from psychological treatments.
As
for Obsessive-Compulsive Disorder, psychological treatments have
been demonstrated as clearly the treatment of choice over
pharmacological treatment, when long-term gains are sought.
Specifically, repeated, massed exposure/response prevention
treatment has been found to be superior and produce curative rates
that far surpass that of other therapies. Although drug treatment is
commonly used to treat OCD, it must be maintained indefinitely in
order to prevent relapse (and even on medication the patient may
experience relapse without the benefit of psychological treatment).
Psychotherapy in combination with antidepressant treatment has also
been found to be effective for OCD.
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Other fun
facts to know and tell!
Antidepressant
medication is the second most commonly prescribed medication after
heart medication: 7.1 million U.S. citizens took antidepressants in
2001.
Increase
in spending for antidepressants and other psychotropics far
outstrips that for almost all other drugs.
Despite
huge increase in treatment of antidepressants, societal costs of
depression have not been reduced
SSRIs
are popular, even with they elderly, but they make the blood thinner
and, in the geriatric set, this can lead to more bruising and
gastrointestinal bleeding
Prozac
has the longest half-life of any of the SSRIs, so it takes 4-6 weeks
for it to leave the system, which could be more significant in the
elderly
Paxil
has been shown to have contraindications with antipsychotics and
pain medications
Discontinuation
syndrome: a rebound effect of negative symptoms (headache, nausea,
insomnia, agitation, depressed mood) when a patient stops taking an
antidepressant medication, especially without tapering down of the
dose (especially seen with Paxil, Effexor, and Zoloft).
References
Ablon,
J.S., & Jones, EE. (2002). Validity of controlled clinical
trials of psychotherapy: Findings from the NIMH treatment of
depression collaborative research program, American Journal of
Psychiatry, 159, 775-783.
Goode,
E. (200). Antidepressants lift clouds, but lose ‘miracle drug’
label. The New York Times, Sun, June 30, 2002.
Jarrett,
R.B., Krafi, D., Doyle, J., Foster, B.M., Eaves, G.G., & Silver,
P.C. (2001). Preventing recurrent depression using cognitive therapy
with and without a continuation phase. Archives of General
Psychiatry, 58, 381-388.
Kocsis,
J.H., Schatzberg, A., Rucby, AJ., Klein, D.H., Rowland, R.,
Gniwwesch, L., David, S.M., & Harrison, W. (2002). Psychosocial
outcomes following long-term double blind treatment of chronic
depression with Sertraline vs. placebo. Archives of General
Psychiatry, 59, 723 -728.
Mayberg,
HS., Silva, IA., Brannan, S.K., Tekell, J.L., Mahuriu, R.K.,
McGinnis, S., & Jarabek, PA (2002). The functional neuroanatomy
of the placebo effect. American Journal of Psychiatry, 159,
728-737.
Moncrieff,
J., Wessely, S, & Hardy, R. (2002). Active placebos versus
antidepressants for depression (Cochrane Review). The Cochrane
Library, 2, online access at www.update-swoftware.comfabstracts/ab003012.htm
verified 16 Aug 2003.
ACT
Anniversaries!
v John
Rucker, EdD 6 years as of October 6
v Aneel
Patel, MD 6 years as of October 24
v Susan Pollard 3 years as of September 5
v Scottie
Harrell 3 years as of October 30
v
Lise
Osvold, PhD 2 years as of October 1
v
Paul Bramblett 2 years as of October
18
v
Morina Ramsamooj 1 year as of September 23
Welcome
on Board!!
v
Reagan
Bell, NP serving Central NC
v
Tracey
Carstarphen, NP serving Southeastern NC
v
Karen
Campbell, PhD serving Eastern NC
v
Paul
Overman, PhD serving Southeastern NC
v
David
“Chris” Bullard, PhD serving
the Triad
v
Cassandra
Caver, NP serving the Triad
v
Sharon
Irving, NP serving Northeastern NC
Happy
Birthdays!!
v E
Newsom Williams, PhD on September 3
v Leslie
McNamara on September 18
v Lise
Osvold, PhD on September 21
v M
Elizabeth Rankin on September 22
v Jayleen
Magill on September 23
v Laura
Medlin, PA on October 1
v Suzanne
Moyers on October 19
v Smeeta
Souza-Roy on October 20
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