CBT Outperforms IPT in Social Phobia Trial
Cognitive-behavioral therapy (CBT) works better than placebo and as well or better than fluoxetine for social anxiety disorder (SAD) (Davidson JR et al, Arch Gen Psychiatry;61:1005–1013). (CBT has not been compared with SSRIs that are FDA-approved for SAD, such as Zoloft and Paxil.)
However, few other psychotherapies have been tested for SAD and none have been compared to CBT. A recent trial randomly assigned 117 SAD patients to CBT, interpersonal therapy (IPT), and a waiting-list control group. Patients with comorbid substance abuse, severe depression, or acute suicidality were excluded and psychiatric medications were not allowed during the trial. Psychologists or psychiatrists delivered psychotherapy according to manualized guidelines for up to 16 weekly sessions.
On the primary outcome, the Clinical Global Impressions-Improvement scale, CBT resulted in a significantly higher response rate (66%) than either IPT (42%) or waiting-list (7%). These differences persisted at one-year followup (CBT: 68% vs IPT: 32%) (Stangier U et al, Arch Gen Psychiatry 2011;68:692– 700).
TCPR’s Take: The exclusion of comorbid substance abuse affects the generalizability of these results, because about 25% of SAD patients also have alcohol dependence (Schneier FR et al, Psychol Med 2010;40:977–988). Nonetheless, for relatively “pure” SAD patients, this trial implies that CBT works better than IPT. For more details on CBT for SAD, see the July 2010 issue of TCPR.
Is One Antipsychotic Just as Effective as Two?
Using combination antipsychotic treatment has become more common over the years, presumably reflecting a common sense theory that in refractory patients, two medications might be more effective than one. But studies thus far of the practice have been small and inconclusive.
In this new multi-site, six-month study, 127 patients with schizophrenia who were currently taking two antipsychotics were randomized to either stay on polypharmacy or switch to monotherapy by discontinuing one of their meds. Nearly every typical and atypical antipsychotic was represented in the study. Medication dosages were at the discretion of the prescribing doctors, and patients were permitted to take other psychiatric drugs other than other antipsychotics. Outcomes measured were time to discontinuation (for any reason), psychiatric symptoms, hospitalizations, and side effects.
By the end of the trial, 86% of the polypharmacy patients were still on their assigned meds, vs 69% of the monotherapy patients. The majority of the monotherapy patients who discontinued their regime did so to return to polypharmacy, and reasons for discontinuation ranged from patient and/or physician dissatisfaction to side effects.
There were no significant differences in psychiatric symptoms or hospitalizations between the two groups. Body mass index (BMI) decreased an average of 0.50 points in the monotherapy group and increased an average of 0.28 points in the polypharmacy group (Essock SM et al, Am J Psychiatry 2011;168:702–708).
TCPR’s Take: The results provide evidence for both those who favor polypharmacy and for others favoring monotherapy. Patients lasted longer on their meds when taking two drugs, though actually symptoms didn’t differ between groups. Also, polypharmacy led to significant weight gain, while monotherapy led to weight loss. Bottom line is that weaning patients down to one drug is often feasible, as long as you closely monitor their symptoms and stand ready to reintroduce drug #2 quickly if needed.