Drugs or Therapy?

Psychotherapy Superior to Pharmacology for Anxiety

 

Modern life for many is fast-paced and, at times, seemingly replete with existential threats. As such, it is not surprising that anxiety disorders are the most common mental health disorders in Canada and around the world (Katzman et al., 2014, p.1; Craske & Stein, 2016, p. 3049). The disabling nature of these disorders is particularly troublesome because they are at once highly prevalent and highly untreated (Katzman et al., 2014, p.1; Roberge, Fournier, Duhoux, Nguyen, & Smolders, 2011, p. 321). Consequently, anxiety disorders are associated with staggering direct and indirect costs to the Canadian economy (Stonebridge & Sutherland, 2016, p.2). Optimizing treatment is therefore of concern not only to medical professionals and anxiety sufferers but to society at large. Efforts to treat anxiety disorders have led to the emergence of psychotherapeutic and pharmacological interventions (Craske & Stein, 2016, p. 3048; Cuijpers, et al., 2013, p. 137; Katzman et al., 2014). Although both approaches are currently regarded as similarly effective first-line treatments, recent research suggests that psychotherapy offers some distinct advantages (Swift, Greenberg, Tompkins, & Parkin, 2017; Craske & Stein, 2016, p. 3055; Ophuis et al., 2017, p. 11). Despite this, statistics show that pharmacotherapy is currently the de facto first-line approach in Canada (Public Health Agency of Canada, 2015).  While pharmaceuticals can play a role in anxiety disorder treatment, pharmacotherapy should be abandoned as a first-line treatment in favor of psychotherapy. Shifting the focus of first-line treatment towards psychotherapy would improve treatment outcomes and increase treatment rates, easing the burden anxiety disorders place on individual sufferers and society at large.

The first key advantage psychotherapy has over pharmacotherapy is better tolerability with patients, evidenced by lower treatment refusal and premature discontinuation rates (Swift, Greenberg, Tompkins, & Parkin, 2017, p. 48; Payne et al., 2016, p. 397). This means that by comparison, fewer patients refuse to initiate, or prematurely discontinue, psychotherapeutic treatment. Swift, Greenberg, Tompkins, & Parkin’s (2017) meta-analysis of 186 studies demonstrated this, finding that pharmaceutical treatment was associated with treatment refusal rates 1.76 times higher, and premature dropout rates 1.2 times higher, than psychotherapeutic treatment (pp. 51-52). Given the host of side effects associated with pharmacotherapy, which range from nausea and diarrhea to sexual dysfunction and asthenia, these findings are unsurprising (Pittman, 2016). Problematically, these negative treatment outcomes undoubtedly contribute to the high rates of untreated anxiety observed. Research shows that only about one-third, and in some cases fewer than one-fifth, of those impacted by an anxiety disorder, actually receive treatment (Roberge, Fournier, Duhoux, Nguyen, & Smolders, 2011, p. 321; Yuen et al., 2013, p.52). Given that as many as 31% of Canadians are likely to struggle with an anxiety disorder over the course of their lifetime, many millions of Canadians impacted are likely to go untreated. This is substantial because untreated anxiety costs the Canadian economy a staggering $17.3 billion a year in indirect costs associated with things such as absenteeism, reduced work hours and early retirement (Stonebridge & Sutherland, 2016, p.2). By shifting first-line treatment towards psychotherapy, we can expect to lower the rates of untreated anxiety disorders, and therefore lower the immense associated indirect costs. Further, since anxiety disorders are associated with substantially lowered quality of life, improving treatment rates would ease a great deal of human suffering (Oei & Mcalinden, 2014).

Not only is psychotherapy better tolerated than pharmacotherapy, but the benefits it imparts upon patients are more durable and resilient than are those imparted by pharmacotherapy (Craske & Stein, 2016, p. 3055; Payne et al., 2016; Westra, Eastwood, Bouffard, & Gerritsen, 2006, p. 8). While it is true that relapses also occur in patients treated with psychotherapy, rates are generally significantly lower (Craske & Stein, 2016, p. 3055). Since psychotherapy helps patients better understand the sources of their anxiety and equips them with skills to manage their own mental health, the benefits it produces naturally tend to persist longer after treatment cessation (Briers, 2015; Westra, Eastwood, Bouffard, & Gerritsen, 2006, p. 8). Alternatively, pharmacotherapy conditions patients to depend upon a pill to cope with their anxiety, leading to a loss of agency and frequent relapse upon treatment cessation (Westra, Eastwood, Bouffard, & Gerritsen, 2006, p. 8; Craske & Stein, 2016, p. 3055). Because of this, psychotherapy arguably produces not only a better return on investment dollar for dollar than does pharmacotherapy but also yields greater long-term improvements in quality of life for those treated. As such, it should be expected that both direct and indirect costs associated with anxiety disorder treatment would be reduced if more people received psychological rather than pharmacological treatment.

In addition to offering more self-sustaining treatment gains, psychotherapy can be augmented with evidenced-based psychological maintenance approaches. Conversely, despite decades of pharmaceutical research and development, no evidence base for pharmaceutical maintenance strategies exists (Craske & Stein, 2016, p. 3055). Craske & Stein (2016) point out that standard practice when relapse occurs after pharmaceutical treatment cessation is to restart drug treatment, however, this practice is not supported by evidence (p. 3055). Conversely, Craske & Stein point out that simple strategies for maintenance of psychotherapeutic treatment gains do exist and are backed by evidence demonstrating they improve long-term outcomes. These strategies can be as simple as a 20-minute telephone conversation once a month to reinforce skills learned, or a maintenance therapy session once a month for nine months (Craske & Stein, 2016, p. 3055). Ultimately, the existence of evidence-based maintenance strategies which can support psychological treatment gains after treatment completion places psychotherapy at a distinct advantage over pharmacotherapy. This advantage has the potential to offer more anxiety sufferers better long-term outcomes, fewer relapses, and an enhanced quality of life, as well as the potential for reduced direct and indirect costs to society.

Given that psychotherapy is associated with better long-term outcomes and fewer relapses, it comes as no surprise that research shows psychotherapy to be a more cost-effective approach compared to pharmacotherapy (Mavranezouli, et al., 2015; Ophuis, 2017). Since mood and anxiety disorder treatment in Canada is associated with more than $4.5 billion in direct healthcare costs, all Canadians benefit from the utilization of cost-effective anxiety disorder treatment approaches (Government of Canada, 2016). In their economic analysis of 28 different psychological and pharmaceutical treatment approaches, Mavranezouli et al. (2015) found the most cost-effective interventions all to be psychological (p. 12). These results are in line with results of a meta-analysis by Ophuis at el. (2017) which also found that psychotherapy was more cost-effective than pharmacotherapy (p. 10).  Interestingly, studies investigating the comparative cost-effectiveness of the various psychological approaches suggest that a computerized form of psychotherapy known as Internet-based Cognitive Behavioural Therapy may be the most cost-effective delivery format of all (Kumar, Bell & Juusola, 2018, p. 10). Critically, internet-based psychological approaches offer not only potential savings in direct healthcare costs but may also mitigate indirect costs by overcoming many of the barriers to conventional treatment.

Due to the low treatment rates associated with anxiety disorders, overcoming barriers to treatment is crucial to bring down the associated economic and personal costs. Many obstacles to receiving pharmacological treatment and in-person psychotherapy identified in a Canadian study by Perreault et al. (2013) such as physical distance from service sites, lengthy wait times and trouble getting a hold of clinicians by phone could conceivably be overcome through computerized psychotherapy modalities such as Internet-based Cognitive Behavioural Therapy (para. 3). Multiple studies confirm that Internet-based Cognitive Behavioural Therapy, which was first developed over two decades ago, is effective and in many cases can be as effective as in-person treatment (Andersson, Carlbring, & Furmark, 2012, p. 1; Yuen et al., 2013; Andrews, Cuijpers, Craske, McEvoy, & Titov, 2010; Nordgren et al., 2014). Further, the benefits observed in internet-based psychotherapy appear to enjoy the same excellent resiliency as results garnered from in-person therapy. In a study to evaluate the efficacy of Internet-based Cognitive Behavioural Therapy in subjects with social anxiety disorder by Andersson, Carlbring & Furmark (2012), lasting benefits were observed 5 years after treatment (p.1). This is interesting because social anxiety disorders have one of the lowest treatment rates of all the anxiety disorders, with over 80% of sufferers going untreated (Yuen et al., 2013, p.52). Since a major barrier for these patients is their fear of social interaction, and computerized Cognitive Behavioural Therapy can be delivered with minimal to no human interaction, this is a major advantage psychotherapy has over pharmacotherapy, since treatment via pharmaceuticals requires interaction with a prescribing physician.

Psychiatrists, of course, may want to question whether psychotherapy alone could fully replace pharmacotherapy in the first-line treatment of anxiety disorders. They may point out that psychotherapy relies on patient motivation and typically takes longer to show results (Katzman et al., 2014; Davis, 2004). However, meta-analyses show the two approaches share similar effectiveness (Craske & Stein, 2016, p. 3054; Cuijpers, et al., 2013, p. 145). Critically, despite sharing similar efficacies, research shows that psychotherapy does not share many of the problems associated with pharmacotherapy such as issues with side effects, dependence, abuse, and overdose (Farach et al., 2013; Westra, Eastwood, Bouffard, & Gerritsen, 2006). Further, while it is true that treatment gains produced by psychotherapy can be slower to initially emerge than those produced by pharmaceuticals, treatment duration is typically shorter with psychotherapy and by the end of treatment differences in symptom reduction are typically negligible (Briers, 2015). The combination of shorter treatment times, better treatment durability and fewer side effects is a potent recipe for reduced economic costs and an enhanced quality of life for those treated.

Due to the fact that both psychotherapeutic and pharmaceutical treatments have been proven to be effective in reducing anxiety disorder symptoms, some may intuit that combining the two modalities would produce even greater treatment gains. However, this notion is not supported by research which is mixed at best and does not support regularly combining the two treatment approaches. Some studies, such as Fernández-Arias et al.’s (2013) suggest no additive benefit from combination therapy, only increased direct healthcare costs (p. 313). Other research suggests modest short-term benefits in some cases while noting concern that long-term use of pharmaceuticals may interfere with psychological treatment gains (Schmidt, 2005; Otto, Mchugh & Kantak, 2010, p. 91). Indeed, recent studies such as Nordahl et al.’s (2016) suggest that in the long-term, psychotherapy is superior to either pharmacotherapy alone or combination therapy, and that combination therapy can impair long-term outcomes (p. 353). With this in mind, the most reasonable role for pharmaceuticals in anxiety treatment would seem to be one of temporary adjuncts in those individuals who do not initially respond to psychotherapy. This approach would spare many individuals from experiencing unnecessary side effects from pharmaceutical treatment as well as save the economy direct costs associated with inefficient treatment.

Some might argue that one insurmountable obstacle to implementing psychotherapy as the sole first-line approach to treating anxiety is the limited number of psychologists trained to deliver such therapy. Receiving specialized, postgraduate psychological training is a long, arduous process. Therefore, the limited number of professionals available to provide psychotherapy could quickly be overwhelmed with the increased patient load, and new clinicians could not quickly be trained to meet the increased demand. Pharmaceuticals, some might point out, can essentially be manufactured ad infinitum, in ever greater quantities as needed. This objection does not hold water, however, since psychotherapy offers multiple evidence-based solutions to the problem of increased demand. First, group psychotherapy is effective and increases the number of patients a single psychologist can treat (Oei & Mcalinden, 2014). Second, non-expert laypeople with as little as 36 hours of specialized training have been shown to be able to effectively deliver psychological treatments under a psychologist’s supervision (Stanley et al., 2014). This could allow the pool of practitioners to be quickly increased as needed. Third, fully automated internet-delivered psychotherapy approaches have been shown to be capable of producing meaningful symptom reduction (Kallestad, et el., 2018). This means some patients could receive treatment with minimal to no direct clinician involvement. Finally, these aspects have all been effectively combined in internet-based group psychotherapy, guided by inexperienced, non-expert therapists (Andersson, Carlbring, & Furmark, 2012). Clearly, many options exist to meet the increased demand for psychological services that would be expected if psychotherapy were to replace pharmacotherapy as the preferred first-line treatment.

Having come around to the advantageousness and feasibility of psychotherapy as the preferred first-line treatment of anxiety disorders, many might question how best to precipitate this paradigm shift. Since, as Arikian and Gorman (2001) point out, most anxiety disorders are initially treated by primary care physicians, this change could be accomplished by updating the current Canadian treatment guidelines and running education campaigns for both primary care doctors and the public on the advantages of psychotherapy (p. 111). Although current Canadian guidelines give no preference to either psychotherapy or pharmacotherapy for first-line anxiety disorder treatment, statistics reveal that Canadian doctors are currently overwhelmingly suggesting pharmaceuticals to their patients (Katzman et al., 2014, p. 5; Public Health Agency of Canada, 2015, pp. 3-4). It stands to reason that by updating the treatment guidelines clinicians use to guide their decisions and running education campaigns for both doctors and their patients about the advantages of psychotherapy, more anxiety sufferers could reap the advantages of those benefits.

Anxiety disorders have vexed humankind for millennia, evidenced by descriptions of phobias in ancient Greek medical texts dating back to the mid-fifth century BC (Crocq, 2015, p. 320). Modern society is no less susceptible to anxiety now, and it seems likely that for many thousands of years people have borne burdens associated with anxiety disorders. These burdens include substantial personal costs for anxiety sufferers, as well as staggering direct and indirect costs for society (Olatunji, Cisler, & Tolin, 2007, p. 573; Stonebridge & Sutherland, 2016, p.2). Concerningly, research suggests that anxiety disorders are not only highly untreated in Canada but that those cases that are treated are primarily being treated pharmaceutically (Public Health Agency of Canada, 2015, pp. 3-4). Surprisingly, this is the case despite recent research suggesting that psychotherapy is a superior first-line treatment in many ways (Payne et al., 2016, p. 397; Craske & Stein, 2016, p. 3055; Ophuis et al., 2017). The realization of the advantages of psychotherapy at large scale would mean a better quality of life for many Canadians with anxiety disorders and economic benefits for all Canadians from an easing of the burden these disorders place on our society. Direct costs associated with treatment would be reduced freeing up tax dollars for other public expenditures such as education and public infrastructure since, as Ophuis et al. (2017) concluded in their meta-analysis, psychotherapy is more cost-effective than pharmacotherapy (p. 11). Further, the immense indirect costs to the Canadian economy associated with unmet healthcare needs of anxiety sufferers would also be reduced thanks to a more resilient, productive workforce. In this way, adopting psychotherapeutic treatments as the first-line approach of choice for anxiety disorders would benefit all Canadians.

 

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