Note that this study was done with patients with panic disorder. It may not be generalizable to other patient populations.
Usage note: I always use the term "adverse effects" rather than "side effects," because it is more precise. Some side effects are good, some bad, some neutral. So if you are talking about bad side effects, you should say "adverse effects."
A Comparison of Medication Side Effect Reports by Panic Disorder Patients With and Without Concomitant Cognitive Behavior Therapy
Sue M. Marcus, Ph.D., et. al.
Am J Psychiatry 164:273-275, February 2007
OBJECTIVE: The authors assessed whether adding cognitive behavior therapy (CBT) to imipramine for patients with panic disorder decreased the severity of side effects and dropouts from side effects. METHOD: Data were analyzed for 172 panic disorder patients who were randomly assigned to receive imipramine alone, imipramine plus CBT, or placebo. Mixed-effects models were used to assess longitudinal differences among the treatment groups with respect to side effect burden and dropout rates during the acute, maintenance, and follow-up phases of treatment. RESULTS: Patients treated with imipramine plus CBT experienced less severe fatigue/weakness, dry mouth, and sweating and had a lower rate of dropout due to side effects compared with those treated with imipramine only. CONCLUSIONS: The addition of CBT to medication treatment with imipramine was associated with less severe side effects and fewer dropouts due to perceived side effects than treatment with imipramine alone.
There are a few points to make in the background, just to put this in context. Panic Disorder can be treated with medications (either antidepressants or anxiolytics) or with psychotherapy, or with both. For a decent review of the relative merits of the therapeutic options, see this article: Combined Pharmacotherapy and Cognitive-Behavioural Therapy for Anxiety Disorders, Medscape, free registration required. For a more controversial approach, see this article: A Randomized Controlled Clinical Trial of Psychoanalytic Psychotherapy for Panic Disorder.
Most often, these days, if an
antidepressant is used, it is one of the SSRIs. The choice
of imipramine for this study is interesting. Imipramine is a
tricyclic antidepressant, a member of a family known to have adverse
effects that are subjectively worse than those from the SSRIs.
Not only that, but it is a tertiary antidepressant, (the kind with the
extra methyl group) and they have even heavier adverse effect profiles
than the secondary tricyclics. I suppose that the choice served a purpose, in that it pretty much guaranteed that there would be a lot of patients reporting adverse effects. That might have made it easier to demonstrate the effect they were looking for.
Notice the wording in the title, and that in the abstract. The title, I think, is more precise. It refers to "side effect reports," rather than the incidence of the adverse effects themselves. There is no objective way to know the true incidence of adverse effects; all we can measure is the number of reported adverse effects.
Of greater interest, though, is the dropout rate. Medications do not work if the patients do not take them, so the dropout rate has a huge effect on the effectiveness of the treatment. (Search Medscape for "medication compliance" and you get 447 hits for the past year -- a crude index of the significance of the matter.)
So why is it that patients who are seeing a therapist for cognitive-behavioral therapy would report adverse effects less often than those on medication alone?
One obvious possibility is that the patients in psychotherapy were being taught to deal with their anxiety. Maybe that makes them less anxious about adverse effects, too, so they are less inclined to report them.
I think there is more to it than that, although I can't prove it.
Patients who trust their treatment providers are less likely to worry about adverse effects. The quality of the relationship matters. If all people see of their provider is a quick technically-oriented checkup every now and then, it is harder to feel a sense of confidence.
As an historical aside, there is one other thing I want to mention. In the 1980's, psychiatry split into two camps. There were those who were trained in, and clung to, the psychodynamic model; and those who were trained in psychopharmacology, many of whom spurned the psychodynamic model.
From time to time, I would see patients who had previously been getting medication from a psychiatrist who was trained in the psychodynamic tradition, who continued to interact with patients using the "blank slate" style. I got the impression that many patients really did not like that. If they had a question about the medication, they wanted an answer. They DID NOT want to be asked why they were asking the question.
Note I am not being critical of psychodynamic psychotherapy here, I'm just making the point that it does not mix well with psychopharmacology. In my view, it flirts with serious issues about informed consent, too. Patients need to feel 100% free to ask as much as they want to ask about the medication, and to get straightforward answers.
That does not relate directly to the article I cited, but there is a connection. It is subtle but important. Psychodynamic psychotherapy is all about the relationship between the therapist and the patient. Some persons have tended to assume that psychopharmacology, and to a lesser extent, cognitive-behavioral therapy, is not about the relationship with the patient. That is not the case at all.
I suspect that the findings in the Am J Psychiatry study cited above illustrate this point. If people have more contact, get a better sense of who they are dealing with, and fee free to ask questions, they are more likely to feel a sense of comfort in taking the medication -- even if they get adverse effects.
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