Adverse Effects and Psychotherapy

This is a nice little study that deserve a brief comment.  It's
from Am J Psychiatry this month.  What is shows is that
participation in psychotherapy can alter the rate of reported adverse
effects from medication, and decrease the rate at which patients stop
their medication because of adverse effects.



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."

href="http://ajp.psychiatryonline.org/cgi/content/abstract/164/2/273">

href="http://ajp.psychiatryonline.org/cgi/content/abstract/164/2/273">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: href="http://www.medscape.com/viewprogram/6600">Combined
Pharmacotherapy and Cognitive-Behavioural Therapy for Anxiety Disorders,
Medscape, free registration required.  For a more controversial
approach, see this article: href="http://ajp.psychiatryonline.org/cgi/content/abstract/164/2/265">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 href="http://en.wikipedia.org/wiki/SSRI">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.  ( href="http://search.medscape.com/medscape-search?queryText=medication%20compliance">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.