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Cognitive Behavioral Psychopharmacology

The Clinical Practice of Evidence-Based Biopsychosocial Integration

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Edited by Mark Dana Muse

 

 

 

 

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Notes on Contributors

Donald Black, MD, is professor of psychiatry and director of the Psychiatry Residency Training Program at the University of Iowa Carver School of Medicine.

Taylor Bos, MA, was a junior fellow at the National Sleep Foundation before joining the Center for Sleep and Wake Disorders as clinical research coordinator.

James H. Bray, PhD, is former president of the American Psychological Association (APA), and former president of the American Society for the Advancement of Pharmacotherapy.

Christopher Brown, PsyD, ABPP, is a clinical psychologist who has published in the area of the integration of psychotherapy and psychiatric medication.

Ronald T. Brown, PhD, is professor of psychology and university president at the University of North Texas, Dallas. Dr. Brown chaired the APA work group on psychotropic medications for children and adolescents, and coauthored the work group's report in the publication Psychopharmacological, Psychosocial, and Combined Interventions for Childhood Disorders: Evidence Base, Contextual Factors, and Future Directions (2008, APA).

Kelly L. Cozza, MD, is an associate professor of psychiatry at Uniformed Services University, Bethesda, Maryland, and psychiatric consultant to the Department of Psychiatry, Walter Reed Army Medical Center. She is a senior author/editor of the Handbook of AIDS Psychiatry (2010, Oxford University Press) and the Clinical Manual of Drug–Drug Interaction Principles for Medical Practice (2009, American Psychiatric Publishing).

David F. Curtis, PhD, is an associate professor of psychology in the Department of Pediatrics at Baylor College of Medicine. He leads behavior therapy services for children with disruptive behaviors and he is the program director for Pediatric Primary Care Psychology at Texas Children's Hospital in Houston, Texas.

Catherine A. DeGood, DO, is the medical director of the Rhode Island-based Continuum Behavioral Health and faculty at the Warren Alpert Medical School of Brown University. She specializes in treating co-occurring chronic pain and substance use disorders.

Douglas E. DeGood, PhD, now a retired faculty, was previously director of psychology in the Pain Management Clinic at the University of Virginia Health Sciences Center. He has published extensively in the areas of biofeedback and pain assessment and treatment. He is author of The Headache and Neck Pain Workbook (1997, New Harbinger Publications) and senior co-author of The Behavioral Medicine Treatment Planner (1999, Wiley).

Samuel Dutton, PhD, MP, is a prescribing medical psychologist within the US Public Health Service at the United States Naval Academy, Annapolis, Maryland.

Helene A. Emsellem, MD, is medical director of the Center for Sleep and Wake Disorders and is clinical professor of neurology at George Washington University Medical Center.

Robert M. Julien, PhD, MD, is a retired research pharmacologist and anesthesiologist. His 13th edition of Julien's Primer of Drug Action (2014, Worth) is regarded as a definitive textbook of psychopharmacology.

George Kapalka, PhD, MP, is a pharmacologically trained medical psychologist who has written extensively on childhood disorders. His most recent books are Collaboration between Pediatricians and Pharmacologically-trained Psychologists (2010, Springer) and Treating Disruptive Disorders: A Guide to Psychological, Pharmacological, and Combined Therapies (Clinical Topics in Psychology and Psychiatry (2015, Routledge).

Mary Kelleher, MD, is clinical assistant professor, Department of Psychiatry at New York University. Her recent publications include Dementia and Other Neurocognitive Disorders: An Overview (2015, IGI Global), and Psychosocial Studies of the Individual's Changing Perspectives in Alzheimer's Disease (2015, IGI Global).

Mario Marquez, PhD, MP, is a prescribing child/adolescent medical psychologist in New Mexico. He is former president of the Society for the Advancement of Pharmacotherapy of the APA.

Robert E. McCue, MD,1 was director of the Fellowship in Geriatric Psychiatry program and clinical associate professor of psychiatry at the New York University School of Medicine. He was also deputy chief of psychiatry/director of inpatient services, Woodhull Medical and Mental Health Center.

Kevin McGuinness, PhD, MP, is a retired captain with the United States Public Health Service. Dr Mc Guinness has practiced as a prescribing medical psychologist since 2006. He is a former president of the American Society for the Advancement of Pharmacotherapy.

Mikel Merritt, PhD, MP, is a prescribing medical psychologist with the United States Air Force.

Bret A. Moore, PsyD, MP, is a prescribing medical psychologist with the US Army. He co-edited Pharmacotherapy for Psychologists: Prescribing and Collaborative Roles (2010, APA), as well as the Handbook of Clinical Psychopharmacology for Psychologists (2012, Wiley).

Mark D. Muse, PhD, MP, is a prescribing medical psychologist and past president of the Maryland Academy of Medical Psychologists. He is author/editor of Cognitive-Behavioral Therapy: Theoretical Foundations (1996, MENSANA) as well as the Handbook of Clinical Psychopharmacology for Psychologists (2012, Wiley).

Joel Paris, MD, is professor in the Department of Psychiatry, McGill University, and author of Treatment of Borderline Personality Disorder: A Guide to Evidence-Based Practice (2010, Guilford Press).

Brenda J. B. Roman, MD, is professor of psychiatry at Wright State University School of Medicine. She is author of numerous book chapters and journal articles, including “Beyond Psychopharmacology for Bipolar Disorder: Psychotherapeutic Interventions for the Patient and Family” (2004).

Marla Sanzone, PhD, MP, is a former president of the Maryland Psychological Association and is a medical psychologist in private practice in Annapolis, Maryland. She has contributed to several books, including her recent chapter “Collaborative Treatment of Eating Disorders” in George Kapalka's (Ed.) Pediatricians and Pharmacologically Trained Psychologists: Practitioner's Guide to Collaborative Treatment (2011, Springer).

David Shearer, PhD, MP, is a civilian prescribing medical psychologist in the primary care clinic at Madigan Army Medical Center. He has researched and written on the topics of integrated psychotherapy and psychopharmacology in primary care settings.

Charles Schulz, MD, is professor of psychiatry at the University of Minnesota, where he has researched and taught on borderline personality disorder.

Peter Smith, PsyD, MP, is president of the Maryland Academy of Medical Psychologists, and chair of the workgroup on clinical psychopharmacology, Maryland Psychological Association.

Stephen M. Stahl, MD, PhD, is an internationally recognized clinician, researcher, and teacher in psychiatry, with subspecialty expertise in psychopharmacology. He has authored many books, including the seminal Stahl's Essential Psychopharmacology (4th ed., 2013, Cambridge University Press).

Randon Welton, MD, is director of the Residency Training Program, Boonshoft School of Medicine, Wright State University.

Tony C. Wu, PhD, ABPP, MP, is a pharmacologically trained medical psychologist and faculty member of clinical psychology, School of Social and Behavioral Sciences, Walden University.

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Foreword

Science of Prescribing

The need for evidenced-based treatment guidelines is more important than ever, since mental illness affects one in five adults in the US each year, with nearly 10 million adults (4% of the US adult population) suffering with mental disorders serious enough to impact one or more areas of social and occupational functioning. There are nearly 4 million patients with depression followed by primary care in the US, with nearly four out of every five prescriptions for antidepressants being written by nonpsychiatrists. Clinicians and researchers must find a way to evaluate and disseminate the best treatments, individualized for each patient.

Treatments for behavioral and mental health disorders are an evolving area of science and practice that have substantial impact on the people who suffer from them. It is estimated that 47% of the US population will suffer from one or more mental health problem during their lifetime at a cost of over $57 billion (APA, 2016; Kessler et al., 2007 ). Research indicates that up to 25% of patients in primary care suffer from a mood disorder and this substantially impacts other health issues such as diabetes and hypertension (AHRQ, 2017). Prior to the 1990s the major treatments for behavioral health problems were psychotherapies, mainly based on psychodynamic theories, which had little evidence for their effectiveness. There were a few psychotropic medications available and many of them had significant and potentially severe side effects, and could be deadly with 1 month's prescription. The “Decade of the Brain” (Library of Congress/NIMH, 2000; Morris, 2000 ), and the focus on the neural and biological mechanisms of these disorders have radically changed treatment options since the 1990s. At the same time, research on evidence-based psychotherapies has increased, and proved that behavioral and other psychosocial therapies are also effective treatments for many mental health disorders.

Following the development of Prozac and the selective serotonin reuptake inhibitors (SSRIs), which provided a relatively safe treatment option, there has been a substantial increase in the use of psychotropic medications, especially by nonpsychiatric physicians in the United States (Wang et al., 2005 , 2006 ). The National Institute of Mental Health's (NIMH) “Depression Awareness, Recognition, and Treatment (DART) Program” was a multiphase information and education program designed to educate health professionals and the general public that depressive disorders are prevalent and treatable (Regier et al., 1988 ). Part of the DART program targeted primary care physicians and coincided with the introduction of the SSRIs for treatment of depression. During the same period there was a dramatic decrease in the use of behavioral and other psychosocial therapies, despite evidence that they are effective (Wang et al., 2005 ). The increase in the use of psychotropic medications and decline in behavioral and psychotherapies is also linked to changes in reimbursement and the rise in managed mental healthcare by insurance companies (Phelps, Bray, & Kearney, 2017). The focus on either the exclusive use of psychotropic medications or the preferential use of behavioral therapies has not served the public well, and such a practice results in many people not getting the most effective treatments available. Hence the need for an integrated, evidenced-based approach.

An exciting recent study by Dunlop et al. ( 2017 ) provides enticing evidence that we are at a new and important watershed in our understanding of effective therapies for mental illness. This group has identified how to use imaging techniques like functional magnetic resonance imaging (MRI) to differentiate probable remission of depressive symptoms or failure of treatment with either cognitive-behavioral therapy (CBT) or medication before treatment by identifying “brain subtypes” in their research sample of patients with depression.

It is not very often that a book comes along that provides a new and innovative way to integrate two areas of science and practice, while providing a comprehensive and valuable review of the literature. Most books on psychopharmacology focus on the neurobiological aspects of medications and their use with specific disorders. There is relatively little about integration of how the psychosocial impact of taking a medication impacts its functioning and effectiveness, nor have psychopharmacology texts seriously looked at the science of prescribing; rather, they tend to focus on the chemical prescribed and its impact on symptoms. In this volume Muse and colleagues break away from the unidimensional, one-sided analysis of psychopharmacology as a stand-alone intervention. Indeed, they go even further by exploring the relative value of psychotherapy, and by integrating psychosocial interventions with pharmacotherapy according to the evidence at hand. There are chapters on each of the major categories of mental and behavioral health problems that review the existing literature and provide recommendations for the appropriate use of psychotropic medications and behavioral therapies for these disorders. What is refreshing is the perspective on the integration of the two approaches, while relying on the existing evidence for making recommendations.

The first chapter by Mark Muse provides an overview and summary of each of the chapters in the book. He provides a conceptual framework to understand the chapters and outlines the criteria for the evidence-based reviews that rely on the recommendations of Sackett, Rosenberg, Gray, Haynes, and Richardson ( 1996 ). He then summarizes the major, first-line recommendations for each of the disorders. This chapter alone is worth the price of the book and is an excellent reference chapter. The remaining chapters provide in-depth coverage of all recommended treatments, first-line, as well as secondary and tertiary treatments, for all major mental conditions that are seen in behavioral health and general medical settings. The last chapter by Dr. Muse provides an innovative perspective on integrating behavioral perspectives and the science of prescribing with psychopharmacology. This book will serve as an important reference for a variety of healthcare providers. All of the many authors who collaborated on this project are to be congratulated for developing a framework on integrating behavioral therapies with psychopharmacology. This integration fits well with the move toward an integrated healthcare system in the United States.

Cognitive Behavioral Psychopharmacology: The Clinical Practice of Evidence-Based Biopsychosocial Integration is an important collaborative step in the push toward a clearer understanding of the interplay between psychopharmacology and psychotherapy, with an ever-diligent eye toward evidence-based decision-making. The chapters follow the format of reviewing the literature concerning effective psychotherapies, psychopharmacological interventions, and combinations of both for each diagnostic category, managing to include the relevant meta-analyses and randomized clinical trials down to case reports, rounded out by discussions of available published clinical guidelines. Outstanding chapters, able to stand alone as definitive reviews for all providers, are those addressing insomnia, attention deficit hyperactivity disorder (ADHD) and disruptive disorders in childhood and adolescence, chronic nonmalignant pain, and depression and dementia-related disorders in the elderly. This book is an important milestone in the quest to better predict and achieve therapeutic outcomes in the management of mental illness with well-studied medication and behavioral interventions. It will be exciting to see where the second edition of this important first round will lead us.

James H. Bray, PhD
Former President of the American Psychological Association and American Society for Advancement of Pharmacotherapy.

Kelly L. Cozza, MD, DFAPA, FAPM1
Associate Professor, Department of Psychiatry
Director, Psychiatry Clinical Clerkship
Scientist, Center for the Study of Traumatic Stress
Uniformed Services University of the Health Sciences
Bethesda, Maryland

References

  1. Agency for Healthcare Research and Quality (AHRQ) (2017). Behavioral and mental health. Retrieved from http://www.ahrq.gov/professionals/prevention-chronic-care/improve/mental/index.html
  2. American Psychological Association (APA) (2016). Data on behavioral health in the United States. Retrieved from http://www.apa.org/helpcenter/data-behavioral-health.aspx
  3. Dunlop, B. W., Rajendra, J. K., Craighead, W. E., Kelley, M. E., McGrath, C. L., . . . & Mayberg, H. S. (2017). Functional connectivity of the subcallosal cingulate cortex and differential outcomes to treatment with cognitive-behavioral therapy or antidepressant medication for major depressive disorder. AJP in Advance, 1–13. doi:10.1176/appi.ajp.2016.16050518
  4. Kessler, R. C., Angermeyer, M., Anthony, J. C., De Graff, R., Demyttenaere, K., Gasquet, I., . . . & WHO World Mental Health Survey Consortium (2007). Lifetime prevalence and age of onset distributions of mental disorders in the World Health Organization's World Mental health Survey Initiative. Word Psychiatry, 6, 168–176.
  5. Library of Congress (2000). Project on the decade of the brain. Retrieved from http://www.loc.gov/loc/brain/
  6. Morris, K. (2000). Advances in “brain decade” bring new challenges. Lancet, 355, 45. doi:10.1016/S0140-6736(99)90222-2
  7. Phelps, R., Bray, J. H., & Kearney, L. K. (in press, 2017). A quarter century of psychological practice. American Psychologist.
  8. Regier, D. A., Hirschfeld, R. M., Goodwin, F. K., Burke, J. D., Lazar, J. B., & Judd, L. L. (1988). The NIMH depression awareness, recognition, and treatment program: Structure, aims, and scientific basis. American Journal of Psychiatry, 145, 135101357. doi:10.1176/ajp.145.11.1351
  9. Sackett, D., Rosenberg, W., Gray, J., Haynes, R. B., & Richardson, W. S. (1996). Evidence based medicine: What it is and what it isn't. British Journal of Medicine, 312, 71.
  10. Wang, P. S., Lane, M., Olfson, M., Pincus, H. A., Wells, K. B., & Kessler, R. C. (2005). Twelve-month use of mental health services in the United States: Results from the National Comorbidity Survey Replication. Archives of General Psychiatry, 62, 629–640. doi:10.1001/archpsyc.62.6.629
  11. Wang, P. S., Demler, O., Olfson, M., Pincus, H. A., Wells, K. B., & Kessler, R. C. (2006). Changing profiles of service sectors used for mental health care in the United States. American Journal of Psychiatry, 163, 1187–1198. doi:10.1176/appi.ajp.163.7.1187

Note

Preface

The present volume has had to wait until now to be written because a truly unbiased, evidence-based look at the weighted value of treatments and combinations of treatments within behavioral health has required time to mature while evidence slowly amassed and practitioners' acceptance of the integrated biopsychosocial paradigm increased. We now know, more than ever, that the biopsychosocial model is strongly supported by the data. Indeed, it would be remiss at this stage of our understanding to exclude a priori either medications or psychotherapies when evaluating the effectiveness of the entire array of treatment approaches available for any given condition or patient.

This book brings together experts of renown who have made exhaustive searches of evidence-based studies within their respective specialties, and weighed their findings according to the quality of each study to be able to present to you summaries of their investigations as well as practice recommendations based upon the evidence. In analyzing the data, authors were encouraged to use a system of classification in which each article reviewed was rated according to its strength of design and clarity of findings.

Chapter 1 summarizes all major findings of the individual chapters that comprise this volume, and it culminates in a single table that specifies first-line, integrated approaches for each major diagnosis. Each of the following chapters, authored in large part by teams made up of both prescriber and therapist, targets a specific diagnostic area, and also generates a concise table of detailed findings for its respective domain; within each chapter the reader will find a summary table with not only the first-line treatments for the condition under study, but also alternative treatments that may be indicated for particular nuances of the presenting problem, or because the condition has proved resistant to first-line approaches for a given patient.

The final chapter, Chapter 13, presents a new conceptualization for the integration of pharmacotherapy and psychosocial therapies through behaviorally managed medications. The final chapter departures from the rigorous substantiation of recommendations based on randomized clinical trials and metanalyses found in the previous chapters, as there simply is not, at this juncture, a body of controlled clinical studies investigating the systematic application of behavioral principals of learning in the integration of pharmacotherapy with psychotherapy. Notwithstanding this limitation, the chapter, while falling short of authoritative best-practice recommendations, presents numerous possibilities for innovative prescribing within the cognitive behavioral approach, and presents nine case studies to illustrate the potential of prescribing medications from the cognitive-behavioral paradigm.

The idea of behaviorally prescribed medication as an interface that overarches the integration of pharmacotherapy with psychotherapy provides a new direction of inquiry from which clinical trials might eventually substantiate the basic tenant that learning is the basis of therapeutic change, and that learning can be enhanced by employing conditioning contingencies, based on cognitive-behavioral methods, when prescribing medications.

I am grateful to each and every contributor to this volume. It has been a rare privilege to work with some of the world's sharpest minds, and to learn how they view the practice of integrated biopsychosocial diagnosis and treatment within their specialties. I have received a great deal of support in preparing this book, and my gratitude extends especially to Wiley-Blackwell for believing in the value and uniqueness of the project, and to my colleagues at the Maryland Academy of Medical Psychologists, who provided moral as well as intellectual support.

Special thanks is due Professor Robert McGrath, past president of the American Society for the Advancement of Pharmacotherapy, for reviewing and encouraging Chapter 13.

Mark Dana Muse