It's time to relegate prescription medications for anxiety and depression to last resort treatment
I recently wrote a book on treating anxiety disorders, Anxiety Protocol, and asked a psychiatrist colleague to review the book. He stated he liked the book very much, and was in full agreement with the recommendation of cognitive behavioral therapy (CBT) as first-line treatment for anxiety disorders. However, he disagreed initially with my recommendation that prescription medication for anxiety disorder should be last resort treatment, and only then should be prescribed for severe cases or for psychotherapy-resistant cases. My colleague went on to opine that in moderate to severe cases, he saw the use of prescription medication “in association” with CBT, or as an adjunct to CBT, not as a “last resort.” Otherwise, he found contents of the book very useful.
I thanked my colleague for the comment on prescription medication as a last resort treatment. When I wrote the book, it was intended for end-users to help and educate themselves about anxiety. I worded it so, about pharmacotherapy being “last resort,” as there is such a focus on prescription medications as first-line treatment for anxiety- I had to emphasize this point with such language. Both patients and physicians overtly favor medication treatment…it seems easy, convenient, and good results are to be had in just a few weeks of treatment. But this is not an infection that needs an antibiotic. Anxiety and depression are still psychological disturbances, requiring psychosocial interventions to address them. Sure, the biological aspects of severe cases of anxiety and depression are there for psychiatrists to treat with their vast knowledge of pharmacotherapy and psychopathology. But for the vast majority of people with anxiety and depression, what they really need is to adjust their maladaptive coping styles, address their distorted thoughts and attributions, and address their behaviors which serve to perpetuate and maintain the vicious, negative cycles of anxiety and depression.
While primary care physicians are responsible for most of the prescribing of medication for anxiety and depression before considering CBT, I have also witnessed psychiatrists prescribing medication before fully implementing CBT. I should know…I have done that in the past… psychiatrists just mentioning as an after-thought some behavioral work to their depressed and anxious patients, some recommendations for relaxation, then onto the prescription pad. So what is the person with anxiety and depression supposed to do in the face of such bias in practice towards prescribing medications for even mild cases, and before CBT? My use of the word "last resort" is a backlash to the prominent prescription of medications before CBT is fully implemented for anxiety disorders and depression.
When you look at the treatment guidelines for anxiety and depression from the American Psychiatric Association (APA), you see contradictory findings with regards to pharmacotherapy versus psychotherapy. For the APA major depressive disorder guidelines, it states on page 17: “An antidepressant medication is recommended as an initial treatment choice for patients with mild to moderate major depressive disorder,” while in another section, it also states on page 17: “Use of a depression-focused psychotherapy alone is recommended as an initial treatment choice for patients with mild to moderate major depressive disorder,” and these two statements seem to contradict each other (APA, 2010). The APA panic disorder guidelines state the following on page 11: “The use of a selective serotonin reuptake inhibitor (SSRI), serotonin-norepinephrine reuptake inhibitor (SNRI), tricyclic antidepressant (TCA), benzodiazepine (appropriate as monotherapy only in the absence of a co-occurring mood disorder), or cognitive-behavioral therapy (CBT) as the initial treatment for panic disorder is strongly supported by demonstrated efficacy in numerous randomized controlled trials,” so this states that medication or CBT is first-line treatment for panic disorder (APA, 2009a). For the APA post-traumatic stress disorder (PTSD) guidelines, it states on page 13: “SSRIs are recommended as first-line medication treatment for PTSD,” while it states on page 14: “For patients with a diagnosis of ASD or PTSD, available evidence and clinical experience suggest that a number of psychotherapeutic interventions may be useful. Patients with ASD may be helped by cognitive behavior therapy and other exposure-based therapies,” failing to mention in what order or combination to use pharmacotherapy versus psychotherapy (APA, 2004). And with the updated APA PTSD guidelines, it has further evidence that SSRIs may not be effective for combat-related PTSD (APA, 2009b). For the APA obsessive compulsive disorder (OCD) guidelines, it states on page 4: “The guideline recommends CBT or a serotonin reuptake inhibitor (SRI; i.e., SSRIs or clomipramine) as first-line treatments for OCD” (APA, 2013). There are no APA treatment guidelines for generalized anxiety disorder (GAD), social phobia, and specific phobia.
The APA treatment guidelines for anxiety and depression seem contradictory, and even recommend pharmacotherapy as monotherapy as first-line treatment for mild to moderate cases of depression, and pharmacotherapy as monotherapy as first-line treatment for panic disorder, PTSD, and OCD. Again, there are no APA treatment guidelines on GAD, social phobia, and specific phobia.
It seems counterintuitive to even rely on pharmacotherapy as a first-line treatment for mild to moderate cases of anxiety and depression, given the significant side effect profiles of antidepressants and benzodiazepines. For all anxiety disorders, CBT has higher level of evidence of effectiveness than any other type of psychotherapy, and for depression, CBT and other psychotherapeutic modalities have been shown to be effective (Clark, 2011).
Given that CBT is effective as first line treatment for all anxiety disorders, and that CBT and other psychotherapeutic modalities are effective as first line treatment for major depressive disorder, it seems logical to start with the most benign treatment modality, especially for mild to moderate cases. There has been “treatment creep” with prescription medications, to the point where treatment guidelines from the APA are suggesting prescription medications as monotherapy even for mild cases. No wonder, given that the majority of the thought leaders in psychiatry have direct connections to the pharmaceutical industry that has profited immensely off the backs of psychiatric patients.
It’s time to relegate prescription medications as “last resort treatment” for anxiety and depression- reserved only for the most severe cases or for those who have failed psychotherapy. This may sound controversial to those who consider medication in association with or as an adjunct to psychotherapy. This statement, “last resort treatment,” may be controversial to many clinicians, but it is meant to educate, raise awareness, and encourage physicians to avoid the indiscriminate use of psychotropic medications for anxiety and depression before even trying other strategies, such as CBT, which has evidence to back its position as first line treatment. Psychotherapy also has longer lasting, beneficial effects for anxiety and depression than any medication, especially CBT. In addition, there are self–help and/or alternative interventions which are effective for milder cases of anxiety and depression, such as on AnxietyBoss.com, and do not have the need to rely on pharmacotherapy.
The take home message of this article is for clinicians and patients to think about CBT, self-help, and/or alternative interventions for milder cases of anxiety and depression, before resorting too quickly to medication. After much discussion with my colleague who reviewed my book, he finally conceded and agreed that recommending psychotropic medications as “last resort” for anxiety and depression is not so controversial after all.
- American Psychiatric Association. (2010). Practice guideline for the treatment of patients with major depressive disorder. Amer Psychiatric Pub Incorporated. Retrieved online April 18, 2015.
- American Psychiatric Association. (2009a). Practice guideline for the treatment of patients with panic disorder. Amer Psychiatric Pub Incorporated. Retrieved online April 18, 2015.
- American Psychiatric Association. (2004). Practice guideline for the treatment of patients with acute stress disorder and posttraumatic stress disorder. Amer Psychiatric Pub Incorporated. Retrieved online April 18, 2015.
- American Psychiatric Association. (2009b). Guideline watch (March 2009): Practice guideline for the treatment of patients with acute stress disorder and posttraumatic stress disorder. Amer Psychiatric Pub Incorporated. Retrieved online April 18, 2015.
- American Psychiatric Association (2013). Guideline watch (March 2013): Practice guideline for the treatment of patients with obsessive-compulsive disorder. Amer Psychiatric Pub Incorporated. Retrieved online April 18, 2015.
- Clark, D. M. (2011). Implementing NICE guidelines for the psychological treatment of depression and anxiety disorders: the IAPT experience. International Review of Psychiatry, 23(4), 318-327.