- Email: [email protected]
S.26.03 Benzodiazepines and psychotherapy in panic disorder
S216
S.26 Drugs facilitation of psychotherapy in anxiety related disorders
Forty years on, there is now a re-interest in these drugs. And with the development of the newer drug MDMA, there are further therapeutic possibilities to re-visit the thousands of case reports from the 50s and 60s, using modern research methods. Trials are now underway testing whether psychedelic drugs could assist psychotherapy and offer new treatments for mental illness once again. References [1] Sessa B, 2005, Can psychedelics have a role in psychiatry again? Br J Psychiatry 186, 457–458. [2] Sessa B, 2007, Is there a role for MDMA-assisted psychotherapy in the UK? J Psychopharmacol 21(2), 220–224.
S.26.02 MDMA facilitated treatment of PTSD M. Mithoefer ° . Private practice clinical research, Psychiatry, Mount Pleasant, USA A phase II clinical trial of MDMA-assisted psychotherapy for treatment resistant Posttraumatic Stress Disorder was begun in the United States in March, 2004 [1]. It is a double-blind, placebo controlled trial involving the administration of MDMA or inactive placebo on two or three occasions under the direct supervision of a male/female therapist team. During these eight-hour experimental sessions vital signs are monitored as subjects revisit their trauma with minimally directive guidance and support from the therapists. Preceding these sessions are two non-drug preparatory sessions and at least nine non-drug follow up psychotherapy sessions aimed at integrating the MDMA experience. Subjects with significant medical problems or some psychiatric disorders such as active substance abuse, psychosis or bipolar disorder type II are excluded. The hypothesis being tested is that MDMA will catalyze the psychotherapeutic process by decreasing levels of fear and defensiveness, which are often obstacles to effective therapy for PTSD. The primary outcome measure is the Clinician Administered PTSD Scale [2]. Neuropsychological function is also measured before and after two MDMA or placebo. At the time of this writing 15 of the 20 subjects have completed the study. Preliminary results suggest that the effect of MDMA- assisted therapy on PTSD symptoms in this treatment resistant population is quite robust compared to the same therapy with placebo. There is no evidence for a decline in neuropsychological function after MDMA in these subjects, most of whom are MDMA-na¨ıve. References [1] Mithoefer MC, 2003, Study Protocol Phase II clinical trial testing the safety and efficacy of 3,4-methylenedioxymethamphetamine (MDMA)assisted psychotherapy in subjects with chronic posttraumatic stress disorder. Available online from: http://www.maps.org/mdma/protocol/ index.html [cited 24 March 2007]. [2] Blake DD, et al, 1995, The development of a clinician administered PTSD scale. J Traumatic Stress 8(1), 75−90.
S.26.03 Benzodiazepines and psychotherapy in panic disorder C. Allgulander ° . Karolinska Institutet, Department of Clinical Neuroscience, Stockholm, Sweden The relative merits of psychotherapy versus pharmacotherapy have been debated by proponents of opposing schools of thought. Clinicians pragmatically do not hesitate to combine the two as
it seems to make sense. Donald F. Klein in 1980 assumed that benzodiazepines and psychotherapy could be useful in addressing the complications of spontaneous panic attacks: anticipatory anxiety and phobic avoidance. Another rationale for combining treatments is to facilitiate psychotherapy through pharmacotherapy, by allowing a short-acting benzodiazepine or other anxiolytic to enable exposure. Or, vice versa, psychotherapy may have an adjunctive effect in pharmacotherapy to ameliorate common fears of medicating for emotional disorders, or to deal with fears of stopping such medications. One may consider benefit of combined treatments in patients with comorbid panic and personality disorders. The patient who fails to respond to one treatment or the other may be a candidate for add-on therapy. One may have to distinguish the merits of short-term from long-term combination therapy, short-acting versus long-acting drugs, and regular versus prn dosing. One may argue that benzodiazepines impede statedependent learning during CBT. The 1991 NIH/NIMH Consensus Development Conference on the Treatment of Panic Disorder concluded that “in the years to come depolarization between the two disciplines will occur and and with it a deeper understanding of combined treatments.” Gerald L. Klerman pointed to the need for a four-cell design for evaluating two combined treatments, but no such studies have been reported. Naturalistic long-term studies find a small proportion (15%) of panic disorder patients using benzodiazepines. References [1] Wolfe BE, Maser JD (editors), 1994, Treatment of Panic Disorder. A Consensus Development Conference. Washington DC: American Psychiatric Press. [2] Andersch S, Hetta J, 2003, A 15-year follow-up study of patients with panic disorder. Eur Psychiatry 18, 401−8. [3] Swoboda H, Amering M, Windhaber J, Katschnig H, 2003, The longterm follow-up of patients with panic disorder. J Anxiety Disord 17, 223−32.
S.26.04 Is the combination of SSRIs with cognitive behavioural therapy the best treatment option for patients with anxiety disorders? A.J.L.M. van Balkom ° . VU-University Medical Center and GGZ Buitenamstel, Department of Psychiatry and Institute for Research in Extramural Medicine, Amsterdam, The Netherlands Background: In an effort to maximise treatment effect, patients with anxiety disorders are frequently treated with a combination of antidepressants and cognitive-behavioural therapy (CBT). This clinical practice is based on common knowledge that combining two effective treatment methods must be superior to each of these treatments given alone. The scientific grounds for this practice, however, are surprisingly small. Objective: To give an overview of outcome studies in anxiety disorders comparing the effectiveness of the combination of CBT with antidepressants versus each of these treatments given alone. Method: Update of published meta-analyses by means of a systematic review. Results: In the greater part of the anxiety disorders virtually no research has been done on this subject. Most of the available research has been performed in patients with obsessive compulsive disorder (OCD) and panic disorder with or without agoraphobia (PA). In OCD the combination treatment is not superior to CBT alone, but it is superior to antidepressants alone. In PA with moderate or severe agoraphobia the combination of antidepressants with exposure is superior over antidepressants of exposure alone.
S.26 Drugs facilitation of psychotherapy in anxiety related disorders
Forty years on, there is now a re-interest in these drugs. And with the development of the newer drug MDMA, there are further therapeutic possibilities to re-visit the thousands of case reports from the 50s and 60s, using modern research methods. Trials are now underway testing whether psychedelic drugs could assist psychotherapy and offer new treatments for mental illness once again. References [1] Sessa B, 2005, Can psychedelics have a role in psychiatry again? Br J Psychiatry 186, 457–458. [2] Sessa B, 2007, Is there a role for MDMA-assisted psychotherapy in the UK? J Psychopharmacol 21(2), 220–224.
S.26.02 MDMA facilitated treatment of PTSD M. Mithoefer ° . Private practice clinical research, Psychiatry, Mount Pleasant, USA A phase II clinical trial of MDMA-assisted psychotherapy for treatment resistant Posttraumatic Stress Disorder was begun in the United States in March, 2004 [1]. It is a double-blind, placebo controlled trial involving the administration of MDMA or inactive placebo on two or three occasions under the direct supervision of a male/female therapist team. During these eight-hour experimental sessions vital signs are monitored as subjects revisit their trauma with minimally directive guidance and support from the therapists. Preceding these sessions are two non-drug preparatory sessions and at least nine non-drug follow up psychotherapy sessions aimed at integrating the MDMA experience. Subjects with significant medical problems or some psychiatric disorders such as active substance abuse, psychosis or bipolar disorder type II are excluded. The hypothesis being tested is that MDMA will catalyze the psychotherapeutic process by decreasing levels of fear and defensiveness, which are often obstacles to effective therapy for PTSD. The primary outcome measure is the Clinician Administered PTSD Scale [2]. Neuropsychological function is also measured before and after two MDMA or placebo. At the time of this writing 15 of the 20 subjects have completed the study. Preliminary results suggest that the effect of MDMA- assisted therapy on PTSD symptoms in this treatment resistant population is quite robust compared to the same therapy with placebo. There is no evidence for a decline in neuropsychological function after MDMA in these subjects, most of whom are MDMA-na¨ıve. References [1] Mithoefer MC, 2003, Study Protocol Phase II clinical trial testing the safety and efficacy of 3,4-methylenedioxymethamphetamine (MDMA)assisted psychotherapy in subjects with chronic posttraumatic stress disorder. Available online from: http://www.maps.org/mdma/protocol/ index.html [cited 24 March 2007]. [2] Blake DD, et al, 1995, The development of a clinician administered PTSD scale. J Traumatic Stress 8(1), 75−90.
S.26.03 Benzodiazepines and psychotherapy in panic disorder C. Allgulander ° . Karolinska Institutet, Department of Clinical Neuroscience, Stockholm, Sweden The relative merits of psychotherapy versus pharmacotherapy have been debated by proponents of opposing schools of thought. Clinicians pragmatically do not hesitate to combine the two as
it seems to make sense. Donald F. Klein in 1980 assumed that benzodiazepines and psychotherapy could be useful in addressing the complications of spontaneous panic attacks: anticipatory anxiety and phobic avoidance. Another rationale for combining treatments is to facilitiate psychotherapy through pharmacotherapy, by allowing a short-acting benzodiazepine or other anxiolytic to enable exposure. Or, vice versa, psychotherapy may have an adjunctive effect in pharmacotherapy to ameliorate common fears of medicating for emotional disorders, or to deal with fears of stopping such medications. One may consider benefit of combined treatments in patients with comorbid panic and personality disorders. The patient who fails to respond to one treatment or the other may be a candidate for add-on therapy. One may have to distinguish the merits of short-term from long-term combination therapy, short-acting versus long-acting drugs, and regular versus prn dosing. One may argue that benzodiazepines impede statedependent learning during CBT. The 1991 NIH/NIMH Consensus Development Conference on the Treatment of Panic Disorder concluded that “in the years to come depolarization between the two disciplines will occur and and with it a deeper understanding of combined treatments.” Gerald L. Klerman pointed to the need for a four-cell design for evaluating two combined treatments, but no such studies have been reported. Naturalistic long-term studies find a small proportion (15%) of panic disorder patients using benzodiazepines. References [1] Wolfe BE, Maser JD (editors), 1994, Treatment of Panic Disorder. A Consensus Development Conference. Washington DC: American Psychiatric Press. [2] Andersch S, Hetta J, 2003, A 15-year follow-up study of patients with panic disorder. Eur Psychiatry 18, 401−8. [3] Swoboda H, Amering M, Windhaber J, Katschnig H, 2003, The longterm follow-up of patients with panic disorder. J Anxiety Disord 17, 223−32.
S.26.04 Is the combination of SSRIs with cognitive behavioural therapy the best treatment option for patients with anxiety disorders? A.J.L.M. van Balkom ° . VU-University Medical Center and GGZ Buitenamstel, Department of Psychiatry and Institute for Research in Extramural Medicine, Amsterdam, The Netherlands Background: In an effort to maximise treatment effect, patients with anxiety disorders are frequently treated with a combination of antidepressants and cognitive-behavioural therapy (CBT). This clinical practice is based on common knowledge that combining two effective treatment methods must be superior to each of these treatments given alone. The scientific grounds for this practice, however, are surprisingly small. Objective: To give an overview of outcome studies in anxiety disorders comparing the effectiveness of the combination of CBT with antidepressants versus each of these treatments given alone. Method: Update of published meta-analyses by means of a systematic review. Results: In the greater part of the anxiety disorders virtually no research has been done on this subject. Most of the available research has been performed in patients with obsessive compulsive disorder (OCD) and panic disorder with or without agoraphobia (PA). In OCD the combination treatment is not superior to CBT alone, but it is superior to antidepressants alone. In PA with moderate or severe agoraphobia the combination of antidepressants with exposure is superior over antidepressants of exposure alone.