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Therapy or Medication?

Cognitive and behavior therapies (CBT) have been shown to work for a broad range of mental health disorders, as well as for many life problems not typically classified as disorders in both children and adults. The same can be said, however, for the effectiveness of several psychoactive medications. The information below is intended to help parents/caregivers choose between these two treatment options for their child or adolescent or decide when they should be combined.

This section offers information on:

A. CBT or medication for non-psychotic and psychotic disorders
B. What if my child just has a minor or specific problem?
C. Types of medications
D. Some limitations of CBT
E. Navigating recent treatment controversies
F. Additional reading

A. CBT or Medication for Non-psychotic and Psychotic Disorders

Non-psychotic Disorders (e.g., Disorders NOT involving a loss of contact with reality, such as schizophrenic or manic disorders)

  • As a general rule, findings suggest that CBT with children and adolescents can do anything that medications can do in the treatment of the nonpsychotic disorders and it can do so without causing problematic side effects.
  • Research suggests that pediatric medications often work but they do so only IF or for as long as your child keeps taking them. The reason for this is psychiatric medications typically treat the symptoms but do not cure the disorders.
  • CBT, on the other hand, can address symptoms on a more enduring basis by teaching children and adolescents valuable skills that may reduce the risk for subsequent symptom return long after treatment is over.
  • Young people with more severe symptoms may benefit from taking psychoactive medications-either alone or in conjunction with CBT treatment-particularly among disorders like depression, obsessive-compulsive disorder, and attention-deficit hyperactivity disorder. For the less severe instances of these disorders, however, the evidence for CBT is at least as strong as that for medications and for some disorders it is even stronger.
  • Medications tend to work a little faster than CBT (by a matter of weeks) and there are sometimes benefits from using the two in combination or in sequence. Currently, the best research evidence indicates that, for most children and adolescents, some combination of medication and CBT is the "gold standard" treatment for clinical symptoms of anxiety, depression, and attention-deficit hyperactivity disorder.
  • As a caveat, however, there are indications that taking medications may undermine the enduring effects of CBT in some patients.
  • Findings regarding the effectiveness of child/adolescent psychotherapy as an alternative to medication use are mostly available for CBT therapy. While there are many other approaches to psychotherapy, data indicating whether these other approaches are effective are still emerging.

Psychotic Disorders

A different rule applies for the psychotic disorders (those involving a loss of contact with reality, such as schizophrenia or mania). For these disorders, medication treatment has the best empirical support and represents the current standard of treatment.

  • The parents of young people with psychotic disorders are advised to seek good psychiatric treatment for their children and to keep them on their prescribed medication.
  • CBT and certain family focused interventions often can play a useful adjunctive role in these disorders but they should not be used instead of medications.

 

B. What if my child just has a minor or specific problem?

Many children and adolescents have certain life problems not typically classified as psychiatric disorders which may benefit from CBT.

  • Young people who have trouble standing up for themselves or who are prone to anger or acting in an aggressive fashion often benefit from CBT.
  • Children/adolescents who are experiencing difficulties in their relationships with family members, peers, romantic partners, or people at school often benefit from CBT.
  • There is nothing that medications can do for the everyday problems of childhood or adolescence that could not also be addressed by the skillful application of cognitive and behavioral principles. Often, CBT treatment results in these situations are better and longer-lasting!
  • When considering how to deal with long-standing child or adolescent difficulties such as temperament or everyday problems in living, it is important to keep in mind that some of the most widely prescribed medications can be addictive and have a number of unwanted or harmful side-effects.

Most children see a pediatrician on a regular basis, whereas few will ever see a psychotherapist. With the advent of newer and safer medications like the SSRIs (selective serotonin reuptake inhibitors), more children and adolescents are getting medicated than ever before for problems like depression and anxiety. On the one hand this may be good, since these problems might be causing a young person significant distress and/or impairment and may have otherwise gone untreated. On the other hand, this could represent a lost opportunity; these drugs do nothing to resolve the underlying propensity for these young people to get anxious or depressed.

Given current trends in medical practice, many children grow up to face a lifetime of more or less continuous reliance on medications when equally efficacious and longer lasting alternatives are available. It is not that pediatricians or primary care physicians do not want to help-they do-but often the only way that they know how to help is by prescribing medications. Your child's pediatrician will likely refer you to a psychiatrist if he or she has a more severe disorder (as they should) but many young people with nonpsychotic disorders or problems (e.g., depression, anxiety, everyday stress, etc.) would benefit as much or more from receiving CBT. With our growing reliance on the internet as a source for valuable information related to mental health treatment it is increasingly possible to educate yourself as a parent (and your child's pediatrician) about the possible alternatives.

 

C. Types of Medications

There are several different types of psychiatric medications:

  • Antipsychotics are used in the treatment of schizophrenia and other psychotic disorders like mania. They include the typical antipsychotics like chlorpromazine or haloperidol and the newer atypical antipsychotics like aripiprazole or olanzapine. These are powerful medications that are intended to treat serious disorders and they can sometimes have serious side effects or complications; they typically require close psychiatric management.
  • Mood stabilizers like lithium and the anticonvulsants are used to reduce the risk for mania and depression in bipolar patients and, like the antipsychotics, typically require psychiatric management.
  • Antidepressants are widely used in the treatment of depression and anxiety. The newer SSRIs are relatively safe and widely prescribed in primary care settings; older types of antidepressants like the tricyclic antidepressants (TCAs) and monoamine oxidase inhibitors (MAOIs) work at least as well but are more difficult to manage.
  • Stimulants like methylphenidate and dextroamphetamine are commonly used in the treatment of attention-deficit disorder (with or without hyperactivity) in children and adolescents and are sometimes used to augment other medications in the treatment of depression. Stimulants can be addictive and there are ongoing concerns about their effects on growth and development in young people, but they appear to have an important role in the treatment of more severe instances of ADHD (together with careful CBT behavior management strategies).
  • Anxiolytics include benzodiazepines like diazepam and chlordiazepoxide and are used to treat anxiety and stress-related disorders. Although widely prescribed and providing very rapid symptom relief, they can be addictive if used for too long (especially the high-potency benzodiazapines like alprazolam). CBT sometimes is used to help children and adolescents withdraw from these medications and many psychiatrists now prefer to treat these disorders with the slower acting but nonaddictive antidepressants.
  • Hypnotics include medications like zolpidem that are widely used to treat insomnia but also can be addictive if taken for too long. Once again, CBT has been shown to provide comparable and more lasting relief of pediatric insomnia without the risks associated with medication.

Each of these medication classes has its uses and its contraindications. To summarize: CBT is largely adjunctive to the antipsychotics and mood stabilizers in the treatment of patients with psychotic and bipolar disorders, a viable alternative to the antidepressants and stimulants for less severe nonpsychotic disorders and best used in combination with medication for more severe nonpsychotic disorders, and generally superior over time to the anxiolytics and hypnotics for the anxiety and sleep disorders.

 

D. Some Limitations of CBT

  • It can sometimes be hard to find a good CBT therapist. The Association for Behavioral and Cognitive Therapies (ABCT) maintains a website to help in that regard.
  • It has become fashionable for therapists to describe themselves as offering CBT even when they do something quite different; it is perfectly appropriate to ask what kind of training your potential therapist has received.
  • It still may be hard to find a well-trained CBT therapist in some communities. In this case, medications may represent the best available option.
  • CBT will not work for everyone and if it does not work for your child within a reasonable period of time then it might be wise to consider adding or switching to medications.
  • It also may help to add medications if CBT produces some relief but, after a time, does not fully resolve the problems that brought you to first bring your child into treatment.

Some parents, or even the children or adolescents themselves, may prefer medications to CBT, since medications typically work a little faster and may involve less time and effort. That is perfectly alright; it is good to live in an age in which there are multiple efficacious treatment options. But remember- just as adding medications can sometimes help when CBT alone is not enough, adding CBT to medications can often help when drugs alone are not enough.

 

E. Navigating Recent Treatment Controversies

There are several recent controversies that deserve to be addressed.

  • Recent studies suggest that some antidepressant medications such as the SSRIs may actually increase the risk of suicidal thoughts and behaviors in children and adolescents (and perhaps young adults under the age of 25). Although these findings and their implications remain controversial (i.e., suicide rates have increased among young people in recent years as the number of prescriptions written have declined), CBT may provide a particularly valuable alternative intervention.
  • There has been a striking increase in the rate at which children and adolescents have been diagnosed with bipolar disorders including mania. This has led in turn to a marked increase in the numbers of prescriptions written for mood stabilizers and antipsychotic medications. This, too, remains controversial and parents are strongly advised to secure a second opinion when starting treatment on such medications.
  • It remains controversial whether children with attention-deficit hyperactivity disorder (ADHD) truly benefit from being placed on stimulant medications. The current literature would appear to suggest that cognitive and especially behavioral interventions may produce comparable benefits to medications without their risks in less severe cases, but that CBT and medication may need to be combined when symptoms are more severe.

 

F. Additional Reading

Chambless, D. L., & Ollendick, T. H. (2001). Empirically supported psychological interventions: Controversies and evidence. Annual Review of Psychology, 52, 685-716.

Hollon, S. D., Stewart, M. O., & Strunk, D. (2006). Cognitive behavior therapy has enduring effects in the treatment of depression and anxiety. Annual Review of Psychology, 57, 285-315.

Roth, A. R., & Fonagy, P. (2005). What works for whom? A critical review of psychotherapy research (2nd ed.). New York: Guilford press.

Thase, M. E., & Jindal, R. D. (2004). Combining psychotherapy and psychopharmacology for treatment of mental disorders. In M. J. Lambert (Ed.), Bergin and Garfield's Handbook of Psychotherapy and Behavior Change (5th ed., pp. 743-766). New York: Wiley.

See also Wikipedia for reference

 
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