- Email: [email protected]
Point-Counter-Point: Psychotherapy in the Age of Pharmacology
P o i n t - C o u n t e r- P o i n t : Psychotherapy in the Age of Pharmacology Helen D. Pratt,
PhD
a,b,
*
KEYWORDS Psychotherapy Pharmacotherapy Evidenced-based and empirically supported treatments Children and adolescents
The long-held view that medicine or therapy is an “art” is quickly becoming obsolete. To procure referrals and reimbursement, clinicians are being forced to be accountable (ie, use empirically supported, effective, reproducible, and efficient treatment interventions) by insurance companies, professional credentialing bodies, and their consumers.1–5 This article focuses on reviews of treatment interventions by scholars, researchers, clinicians, and study groups who have examined multiple databases of published studies, and ongoing treatment protocols. Evidence-based and empirically supported treatments (ESTs) for children and adolescents for treatment of mental and behavioral disorders are reviewed. A LITERATURE REVIEW
Significant controversy continues to exist in the medical and psychological fields surrounding which therapies become designated as evidence based or empiric. Problems in methodology, subject selection, and measures plague most published studies.6 Review articles were drawn from 9 major search engines: 4 where peerreviewed articles on psychopharmacology versus psychotherapy with children and adolescents were the search criteria (First Search, Psych abstracts, Medline, EBSCOhost) and 5 research databases where reviewers had specified specific inclusion criteria, the topic, exclusion criteria, and identified treatment interventions. These databases included (1) National Registry of Evidence-based Programs and Practices (NREPP),7 (2) The Office of Behavioral and Social Sciences Research (OBSSR),8
a
Department of Pediatrics and Human Development, Michigan State University, College of Human Medicine, East Lansing, MI 48824-1317, USA b Behavioral and Developmental Pediatrics, Pediatrics Program, Michigan State University/ Kalamazoo Center for Medical Studies, 1000 Oakland Drive, Kalamazoo, MI 49008, USA * Department of Pediatrics and Human Development, Michigan State University, College of Human Medicine, East Lansing, MI 48824-1317. E-mail address: [email protected] Pediatr Clin N Am 58 (2011) 1–9 doi:10.1016/j.pcl.2010.10.012 pediatric.theclinics.com 0031-3955/11/$ – see front matter Ó 2011 Elsevier Inc. All rights reserved.
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Pratt
(3) Evidence-based Mental Health Treatment for Children and Adolescents,8 (4) National Association of Cognitive-Behavioral Therapists (NACBT),9 and (5) Cochrane Database of Systematic Reviews.6 Four of the 5 databases defined and described criteria for selection of articles and reviews from primarily behavioral and cognitive behavioral resources and were procured from a wide variety of search engines (Box 1).6–10 Criteria for Cochrane Database of Systematic Reviews matched the 4 others but included articles and reviews from a variety of disciplines (eg, psychology, psychiatry, nursing, ambulatory medicine). Keywords used were psychopharmacology versus psychotherapy, mental health 1 psychotherapy, and psychotherapy 1 treatment interventions for children
Box 1 Major databases used for this review Applied Social Sciences Index and Abstracts (ASSIA) British Nursing Index (1994 to 2006) Campbell Library (including SPECTR and CENTRAL) Computer Retrieval of Information on Scientific Projects (CRISP) Cumulative Index to Nursing and Allied Health Literature (CINAHL) Cochrane Depression, Anxiety and Neurosis Trial Register Cochrane Central Register of Controlled Trials Cochrane Depression, Anxiety and Neurosis Group Register Dissertation-Abstracts International EBSCOhost Education Resources Information Center (ERIC) EMBASE is a biomedical database OCLC First Search Latin American and Caribbean Health Sciences Literature (LILACS) MEDLINE MetaRegister of Controlled Trials Ongoing and unpublished trials National Research Register (NRR) Pharmaceutical companies Ongoing and unpublished trials PsycINFO RCN database System for Information on Gray Literature in Europe Archive (SIGLE) Study Reference Lists Sociofile Sociologic Abstracts Sociologic Abstracts Sportdiscus part of Sports Research Intelligence Supportive Web of Science World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP) Note: most of these databases are fee for service.
Psychotherapy in the Age of Pharmacology
and adolescents. Only empiric studies were included and details for the methodology are included on specific Web sites. These databases include a range of reviews and a variety of studies from several disciplines. This search yielded 130 reviews; 22 reviews focused on children or adolescents and also reviews of treatment interventions for mental health disorders.11–23 One review looked at pharmacologic versus psychological treatments for specific diseases and concluded that there were no significant differences between the two types of intervention, although both were effective. The Cochrane reviews also supported the findings from reviews conduced as part of the Evidence-Based Mental Health Treatment for Children and Adolescents group,24–41 Evidence-based Therapy site, and the National Registry of Evidence-based Programs and Practices (NREPP) site. PHARMACOTHERAPY
Empiric evidence supports that a combination of pharmacotherapy and psychotherapy is more beneficial to children and adolescents (attention deficit hyperactivity disorder [ADHD], body dysmorphic disorder, depression, oppositional defiant disorder, and substance abuse).1–3,5,16 The Multimodal Treatment Study of Children with Attention Deficit and Hyperactivity Disorder study comparing pharmacology and psychotherapy in the treatment of children diagnosed with ADHD is the exception; however, these results are highly controversial and contested by several research psychologists.2 For discussion of specific drugs effective in the treatment of mental health disorders outside the scope of practice and training of the current author, readers are referred to an excellent text written for clinicians and edited by Greydaus and colleagues42 entitled Pediatric and Adolescent Psychopharmacology: A Practical Manual for Pediatricians. PSYCHOTHERAPY
Psychotherapy can be a very effective tool for management of mental health disorders with children and adolescents, especially for parents and patients who may object to the use of pharmacotherapy. Some parents may not want their children medicated for a number of reasons. Some children and adolescents do not physiologically tolerate medications used to treat mental and behavioral health disorders. Additional obstacles to prescribing medication are the following: (1) some children reach the maximum dosage of a specific medication and can no longer be given higher dosages; (2) some youth are on multiple medications and are at the point where adding more medications or increasing dosages causes serious neurologic, gastrointestinal, or emotional side effects; and (3) many behavioral problems are not resolved with medication when there is an emotional component or environmental cause for the child’s behavioral responses (eg, family conflict). Table 1 contains a list of evidence- and empirically supported treatments.24–41 Cognitive behavior therapy was the most researched form of psychotherapy and provided the most evidence to support its effectiveness in the treatment of depression, anxiety, disruptive behavior problems, posttraumatic stress disorder (PTSD), and substance abuse in adolescents. Patient referrals for psychotherapy may result in the patient being denied access because of several issues that make access to psychotherapy difficult: Even with current changes in reimbursement rules, many insurance companies do not honor the concept of parity between clinicians who provide mental health and those who provide medical services. Those panels usually do not reimburse for services delivered based on diagnoses of behavioral disorders of childhood
3
4
Pratt
Table 1 Evidence-based mental health treatment for children and adolescents
Anxiety, general symptoms School refusal behavior Child and adolescent OCD
Well-Established
Probably Efficacious
None None None
I CBT None I CBT individual CBT, plus sertraline (Zoloft) CBT CBT None CBT Behavior therapy CBT
Child and adolescent PTSD Social phobia Specific phobia Children
CBT trauma focused CBT None None
Adolescents
IPT Individual IPT
Child and adolescent ADHD
Behavior therapy
N/A
Oppositional defiant disorder Conduct disorder
Behavior therapy
CBT Behavior therapy Multisystemic therapy
Children
CBT
Adolescents
CBT IPT
CBT Behavior therapy CBT IPT
Disruptive behavior problems
Depression
Adolescent Substance abuse
CBT Group CBT Family therapy
Family therapy Multisystemic therapy
Adolescent anorexia nervosa
Family therapy
N/A
Adolescent bulimia nervosa
N/A
N/A
Child and adolescent BPD
N/A
Family therapy N/A
Early autism
Behavior therapy
N/A
Anorexia nervosa Bulimia nervosa Bipolar disorder
Autism
Psychotherapy in the Age of Pharmacology
Abbreviations: ADHD, attention deficit hyperactivity disorder; BPD, bipolar disorder; CBT, cognitive behavior therapy; IPT, interpersonal psychotherapy; N/A, not applicable; OCD, obsessive compulsive disorder; PTSD, posttraumatic stress disorder. Adapted from the Web site of the Association for Behavioral and Cognitive Therapies and the Society of Clinical Child and Adolescent Psychology Evidencebased Mental Health Treatment for Children and Adolescents. Available at: http://www.abct.org/sccap/?m5sPro&fa5pro_ESToptions#sec2. Updated July 30, 2010. Accessed September 4, 2010. Reprinted from Greydaus DE, Calles Jr JL, Patel DR, editors. Pediatric and adolescent psychopharmacology: a practical manual for pediatricians. Cambridge (NY): Cambridge Medical; 2008. p. 12–4; with permission.
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and cap reimbursement for those mental health services they do provide. If services are covered, the reimbursements are at a lower rate than for medical services. These factors make the cost of mental/behavioral health services more burdensome for parents who are responsible for payment. Clinicians trained or credentialed in the treatment of mental/behavioral disorders with infants, children, and adolescents are not always available to provide care. Even fewer of these experts are trained to specifically treat youth with severe metal and behavioral disorders (ie, schizophrenia, or a combination of mental disorders and developmental disabilities, neurologic disorders, or severe mental disorders). Managed care panels limit the numbers of mental health clinicians they will add to their provider panels, thereby limiting their access to reimbursement from those panels for services provided. Parents and youth who are in psychological distress often want immediate relief but this is not generally possible whether the treatment is pharmacotherapy or psychotherapy. Both are time-consuming processes with medicines often advertised as faster acting. Pharmacotherapy requires supervision and sometimes assertiveness by parents to administer the prescribed medication to their child or adolescent. However, parents may falsely believe that they do not have to change to “fix” their child/adolescent because the “medicine” will “fix” the child’s/adolescent’s problem. Psychotherapy often requires daily and/or weekly involvement by the whole family (especially parents) who must devote time, energy, and effort to implementing treatment intervention; youth must be transported to the treating clinician and the process can be disruptive to the family routine. If a patient receives psychosocial treatment, his or her parents are also expected to change their behaviors to support their child’s treatments gains. Referrals: Physicians must have knowledge of other clinicians and their treatment modalities to select appropriate referral resources. They must also maintain collegial relationships with those clinicians to ensure that their patients are receiving care and benefiting from that care. Although parents, teachers, and some adolescents will demand pharmacologic treatment, primary care physicians should consider the use of psychological and psychosocial treatments as a first line of treatment, or in combination with prescribing medicines.
Psychosocial treatments for emotional, behavioral, and mental disorders can be very effective and sufficient in resolving problems. However, in the case of severe or reoccurring emotional, behavioral, and mental disorders, a combination of pharmacotherapy and psychotherapy increases the positive effects of treatment. SUMMARY
Behavioral and cognitive-behavioral therapies were most often identified as wellestablished treatments for specific mental and behavioral health disorders in children and adolescents. Psychotherapy alone or in conjunction with pharmacotherapy can be a powerful tool in helping youth manage or eliminate negative outcomes of mental and behavioral disorders. Youth should receive a comprehensive medical evaluation before being referred for psychosocial treatment. When referring patients for psychotherapy, it is important to maintain contact with the treating therapist and to remember to tell patients and their parents that the process for accessing treatment, evaluation, and the treatment process are often lengthy.
Psychotherapy in the Age of Pharmacology
REFERENCES
1. Sava FA, Brian T, Yates BT, et al. Cost-effectiveness and cost-utility of cognitive therapy, rational emotive behavioral therapy, and Fluoxetine (Prozac) in treating depression: a randomized clinical trial. J Clin Psychol 2009;65(1):36–52. 2. Henggeler SW, Halliday-Boykins CA, Cunningham PB, et al. Juvenile drug court: enhancing outcomes by integrating evidence-based treatments. J Consult Clin Psychol 2006;74(1):42–54. 3. Hinshaw SP, Jensen PS, Kraemer HC, et al. ADHD comorbidity findings from the MTA study: comparing comorbid subgroups. J Am Acad Child Adolesc Psychiatry 2001;40:147–58. 4. Marsh EJ, Barkley RA. Treatment of childhood disorders. 3rd edition. New York (NY): Guilford; 2006. p. 314–5. 5. Clarke G, Debar L, Lynch F, et al. A randomized effectiveness trial of brief cognitive-behavioral therapy for depressed adolescents receiving antidepressant medication. J Am Acad Child Adolesc Psychiatry 2005;44(9):888–98. 6. Cochrane Database of Systematic Reviews. Available at: http://www. thecochranelibrary.com/. Accessed September 4, 2010. 7. SAMHSA’s National Registry of Evidence-based Programs and Practices (NREPP). Substance Abuse and Mental Health Services Administration (SAMHSA). Available at: http://www.nrepp.samhsa.gov/. Accessed September 4, 2010. 8. The Office of Behavioral and Social Sciences Research (OBSSR). Available at: http://obssr.od.nih.gov/index.aspx. Accessed September 4, 2010. 9. National Association of Cognitive-Behavioral Therapists NACBT. Available at: http://nacbt.org/evidenced-based-therapy.htm. Accessed September 4, 2010. 10. The Association for Behavioral and Cognitive Therapies and the Society of Clinical Child and Adolescent Psychology. Evidence-based Mental Health Treatment for Children and Adolescents. Available at: http://www.abct.org/sccap/?m5 sPro&fa5pro_ESToptions#sec2. Accessed September 4, 2010. 11. Bjornstad GJ, Ramchandani P, Montgomery P, et al. Child-focused cognitive behavioural therapy for children who have been physically abused. Cochrane Database Syst Rev 2009;2:CD007838. 12. Barlow J, Parsons J. Group-based parent-training programmes for improving emotional and behavioural adjustment in 0-3 year old children. Cochrane Database Syst Rev 2003;2:CD003680. 13. Barlow J, Johnston I, Kendrick D, et al. Individual and group-based parenting programmes for the treatment of physical child abuse and neglect. Cochrane Database Syst Rev 2006;3:CD005463. 14. Ekeland E, Jamtvedt G, Heian F, et al. Exercise for oppositional defiant disorder and conduct disorder in children and adolescents. Cochrane Database Syst Rev 2006;1:CD005651. 15. Gold C, Wigram T, Elefant C. Music therapy for autistic spectrum disorder. Cochrane Database Syst Rev 2006;2:CD004381. 16. Ipser JC, Sander C, Stein DJ. Pharmacotherapy and psychotherapy for body dysmorphic disorder. Cochrane Database Syst Rev 2009;1:CD005332. 17. James A, Soler A, Weatherall R. Cognitive behavioural therapy for anxiety disorders in children and adolescents. Cochrane Database Syst Rev 2005;4: CD004690. 18. Larun L, Nordheim LV, Ekeland E, et al. Exercise in prevention and treatment of anxiety and depression among children and young people. Cochrane Database Syst Rev 2006;3:CD004691.
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19. Littell JH, Campbell M, Green S, et al. Multisystemic therapy for social, emotional, and behavioral problems in youth aged 10–17. Cochrane Database Syst Rev 2005;4:CD004797. 20. Littell JH, Winsvold A, Bjørndal A, et al. Functional family therapy for families of youth (age 11–18) with behaviour problems. Cochrane Database Syst Rev 2007;2:CD006561. 21. Macdonald G, Higgins JPT, Ramchandani P. Cognitive-behavioural interventions for children who have been sexually abused. Cochrane Database Syst Rev 2006; 4:CD001930. 22. Montgomery P, Bjornstad GJ, Dennis JA. Media-based behavioural treatments for behavioural problems in children. Cochrane Database Syst Rev 2006;1: CD002206. 23. O’Kearney RT, Anstey K, von Sanden C. Behavioural and cognitive behavioural therapy for obsessive compulsive disorder in children and adolescents. Cochrane Database Syst Rev 2006;4:CD004856. 24. Reeves G, Anthony B. Multimodal treatments versus pharmacotherapy alone in children with psychiatric disorders: implications of access, effectiveness, and contextual treatment. Paediatr Drugs 2009;11(3):165–9. 25. David-Ferdon C, Kaslow NJ. Evidence-based psychosocial treatments for child and adolescent depression. J Clin Child Adolesc Psychol 2008;37(1):62–104. 26. Lewinsohn PM, Clarke GN. Psychosocial treatments for adolescent depression. Clin Psychol Rev 1999;19(3):329–42. 27. Michael KD, Crowley SL. How effective are treatments for child and adolescent depression? A meta-analytic review. Clin Psychol Rev 2002;22(2):247–69. 28. Reinecke MA, Ryan NE, DuBois DL. Cognitive-behavioral therapy of depression and depressive symptoms during adolescence: a review and meta-analysis. J Am Acad Child Adolesc Psychiatry 1998;37(1):26–34. 29. Barrett PM, Farrell L, Pina AA, et al. Evidence-based psychosocial treatments for child and adolescent obsessive-compulsive disorder. J Clin Child Adolesc Psychol 2008;37(1):131–55. 30. Eyberg SM, Nelson MM, Boggs SR. Evidence-based psychosocial treatments for children and adolescents with disruptive behavior. J Clin Child Adolesc Psychol 2008;37:215–37. 31. Fristad MA, Verducci JS, Walters K, et al. Impact of multifamily psychoeducational psychotherapy in treating children aged 8 to 12 years with mood disorders. Arch Gen Psychiatry 2009;66(9):1013–21. 32. Goldstein TR, Axelson DA, Birmaher B, et al. Dialectical behavior therapy for adolescents with bipolar disorder: a 1-year open trial. J Am Acad Child Adolesc Psychiatry 2007;46(7):820–30. 33. Keel PK, Haedt A. Evidence-based psychosocial treatments for eating problems and eating disorders. J Clin Child Adolesc Psychol 2008;37:39–61. 34. Miklowitz DJ, Axelson DA, Birmaher B, et al. Family-focused treatment for adolescents with bipolar disorder: results of a 2-year randomized trial. Arch Gen Psychiatry 2008;65(9):1053–61. 35. Pelham WE, Fabiano GA. Evidence-based psychosocial treatments for attentiondeficit/hyperactivity disorder. J Clin Child Adolesc Psychol 2008;37:184–214. 36. Rogers SJ, Vismara LA. Evidence-based comprehensive treatments for early autism. J Clin Child Adolesc Psychol 2008;37:8–38. 37. Silverman WK, Pina AA, Viswesvaran C. Evidence-based psychosocial treatments for phobic and anxiety disorders in children and adolescents: a review and meta-analyses. J Clin Child Adolesc Psychol 2008;37:105–30.
Psychotherapy in the Age of Pharmacology
38. Silverman WK, Ortiz CD, Viswesvaran C, et al. Evidence-based psychosocial treatments for children and adolescents exposed to traumatic events: a review and meta-analysis. J Clin Child Adolesc Psychol 2008;37:156–83. 39. Waldron HB, Turner CW. Evidence-based psychosocial treatments for adolescent substance abuse. J Clin Child Adolesc Psychol 2008;37:238–61. 40. West AE, Jacobs RH, Westerholm R, et al. Child and family-focused cognitive behavioral therapy for pediatric bipolar disorder: pilot study of group treatment format. J Am Acad Child Adolesc Psychiatry 2009;18(3):239–46. 41. Young ME, Fristad MA. Evidence-based treatments for bipolar disorder in children and adolescents. J Contemp Psychother 2007;37:157–64. 42. Greydaus DE, Calles Jr JL, Patel DR, editors. Pediatric and adolescent psychopharmacology: a practical manual for pediatricians. Cambridge (NY): Cambridge Medical; 2008. p. 301.
9
PhD
a,b,
*
KEYWORDS Psychotherapy Pharmacotherapy Evidenced-based and empirically supported treatments Children and adolescents
The long-held view that medicine or therapy is an “art” is quickly becoming obsolete. To procure referrals and reimbursement, clinicians are being forced to be accountable (ie, use empirically supported, effective, reproducible, and efficient treatment interventions) by insurance companies, professional credentialing bodies, and their consumers.1–5 This article focuses on reviews of treatment interventions by scholars, researchers, clinicians, and study groups who have examined multiple databases of published studies, and ongoing treatment protocols. Evidence-based and empirically supported treatments (ESTs) for children and adolescents for treatment of mental and behavioral disorders are reviewed. A LITERATURE REVIEW
Significant controversy continues to exist in the medical and psychological fields surrounding which therapies become designated as evidence based or empiric. Problems in methodology, subject selection, and measures plague most published studies.6 Review articles were drawn from 9 major search engines: 4 where peerreviewed articles on psychopharmacology versus psychotherapy with children and adolescents were the search criteria (First Search, Psych abstracts, Medline, EBSCOhost) and 5 research databases where reviewers had specified specific inclusion criteria, the topic, exclusion criteria, and identified treatment interventions. These databases included (1) National Registry of Evidence-based Programs and Practices (NREPP),7 (2) The Office of Behavioral and Social Sciences Research (OBSSR),8
a
Department of Pediatrics and Human Development, Michigan State University, College of Human Medicine, East Lansing, MI 48824-1317, USA b Behavioral and Developmental Pediatrics, Pediatrics Program, Michigan State University/ Kalamazoo Center for Medical Studies, 1000 Oakland Drive, Kalamazoo, MI 49008, USA * Department of Pediatrics and Human Development, Michigan State University, College of Human Medicine, East Lansing, MI 48824-1317. E-mail address: [email protected] Pediatr Clin N Am 58 (2011) 1–9 doi:10.1016/j.pcl.2010.10.012 pediatric.theclinics.com 0031-3955/11/$ – see front matter Ó 2011 Elsevier Inc. All rights reserved.
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Pratt
(3) Evidence-based Mental Health Treatment for Children and Adolescents,8 (4) National Association of Cognitive-Behavioral Therapists (NACBT),9 and (5) Cochrane Database of Systematic Reviews.6 Four of the 5 databases defined and described criteria for selection of articles and reviews from primarily behavioral and cognitive behavioral resources and were procured from a wide variety of search engines (Box 1).6–10 Criteria for Cochrane Database of Systematic Reviews matched the 4 others but included articles and reviews from a variety of disciplines (eg, psychology, psychiatry, nursing, ambulatory medicine). Keywords used were psychopharmacology versus psychotherapy, mental health 1 psychotherapy, and psychotherapy 1 treatment interventions for children
Box 1 Major databases used for this review Applied Social Sciences Index and Abstracts (ASSIA) British Nursing Index (1994 to 2006) Campbell Library (including SPECTR and CENTRAL) Computer Retrieval of Information on Scientific Projects (CRISP) Cumulative Index to Nursing and Allied Health Literature (CINAHL) Cochrane Depression, Anxiety and Neurosis Trial Register Cochrane Central Register of Controlled Trials Cochrane Depression, Anxiety and Neurosis Group Register Dissertation-Abstracts International EBSCOhost Education Resources Information Center (ERIC) EMBASE is a biomedical database OCLC First Search Latin American and Caribbean Health Sciences Literature (LILACS) MEDLINE MetaRegister of Controlled Trials Ongoing and unpublished trials National Research Register (NRR) Pharmaceutical companies Ongoing and unpublished trials PsycINFO RCN database System for Information on Gray Literature in Europe Archive (SIGLE) Study Reference Lists Sociofile Sociologic Abstracts Sociologic Abstracts Sportdiscus part of Sports Research Intelligence Supportive Web of Science World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP) Note: most of these databases are fee for service.
Psychotherapy in the Age of Pharmacology
and adolescents. Only empiric studies were included and details for the methodology are included on specific Web sites. These databases include a range of reviews and a variety of studies from several disciplines. This search yielded 130 reviews; 22 reviews focused on children or adolescents and also reviews of treatment interventions for mental health disorders.11–23 One review looked at pharmacologic versus psychological treatments for specific diseases and concluded that there were no significant differences between the two types of intervention, although both were effective. The Cochrane reviews also supported the findings from reviews conduced as part of the Evidence-Based Mental Health Treatment for Children and Adolescents group,24–41 Evidence-based Therapy site, and the National Registry of Evidence-based Programs and Practices (NREPP) site. PHARMACOTHERAPY
Empiric evidence supports that a combination of pharmacotherapy and psychotherapy is more beneficial to children and adolescents (attention deficit hyperactivity disorder [ADHD], body dysmorphic disorder, depression, oppositional defiant disorder, and substance abuse).1–3,5,16 The Multimodal Treatment Study of Children with Attention Deficit and Hyperactivity Disorder study comparing pharmacology and psychotherapy in the treatment of children diagnosed with ADHD is the exception; however, these results are highly controversial and contested by several research psychologists.2 For discussion of specific drugs effective in the treatment of mental health disorders outside the scope of practice and training of the current author, readers are referred to an excellent text written for clinicians and edited by Greydaus and colleagues42 entitled Pediatric and Adolescent Psychopharmacology: A Practical Manual for Pediatricians. PSYCHOTHERAPY
Psychotherapy can be a very effective tool for management of mental health disorders with children and adolescents, especially for parents and patients who may object to the use of pharmacotherapy. Some parents may not want their children medicated for a number of reasons. Some children and adolescents do not physiologically tolerate medications used to treat mental and behavioral health disorders. Additional obstacles to prescribing medication are the following: (1) some children reach the maximum dosage of a specific medication and can no longer be given higher dosages; (2) some youth are on multiple medications and are at the point where adding more medications or increasing dosages causes serious neurologic, gastrointestinal, or emotional side effects; and (3) many behavioral problems are not resolved with medication when there is an emotional component or environmental cause for the child’s behavioral responses (eg, family conflict). Table 1 contains a list of evidence- and empirically supported treatments.24–41 Cognitive behavior therapy was the most researched form of psychotherapy and provided the most evidence to support its effectiveness in the treatment of depression, anxiety, disruptive behavior problems, posttraumatic stress disorder (PTSD), and substance abuse in adolescents. Patient referrals for psychotherapy may result in the patient being denied access because of several issues that make access to psychotherapy difficult: Even with current changes in reimbursement rules, many insurance companies do not honor the concept of parity between clinicians who provide mental health and those who provide medical services. Those panels usually do not reimburse for services delivered based on diagnoses of behavioral disorders of childhood
3
4
Pratt
Table 1 Evidence-based mental health treatment for children and adolescents
Anxiety, general symptoms School refusal behavior Child and adolescent OCD
Well-Established
Probably Efficacious
None None None
I CBT None I CBT individual CBT, plus sertraline (Zoloft) CBT CBT None CBT Behavior therapy CBT
Child and adolescent PTSD Social phobia Specific phobia Children
CBT trauma focused CBT None None
Adolescents
IPT Individual IPT
Child and adolescent ADHD
Behavior therapy
N/A
Oppositional defiant disorder Conduct disorder
Behavior therapy
CBT Behavior therapy Multisystemic therapy
Children
CBT
Adolescents
CBT IPT
CBT Behavior therapy CBT IPT
Disruptive behavior problems
Depression
Adolescent Substance abuse
CBT Group CBT Family therapy
Family therapy Multisystemic therapy
Adolescent anorexia nervosa
Family therapy
N/A
Adolescent bulimia nervosa
N/A
N/A
Child and adolescent BPD
N/A
Family therapy N/A
Early autism
Behavior therapy
N/A
Anorexia nervosa Bulimia nervosa Bipolar disorder
Autism
Psychotherapy in the Age of Pharmacology
Abbreviations: ADHD, attention deficit hyperactivity disorder; BPD, bipolar disorder; CBT, cognitive behavior therapy; IPT, interpersonal psychotherapy; N/A, not applicable; OCD, obsessive compulsive disorder; PTSD, posttraumatic stress disorder. Adapted from the Web site of the Association for Behavioral and Cognitive Therapies and the Society of Clinical Child and Adolescent Psychology Evidencebased Mental Health Treatment for Children and Adolescents. Available at: http://www.abct.org/sccap/?m5sPro&fa5pro_ESToptions#sec2. Updated July 30, 2010. Accessed September 4, 2010. Reprinted from Greydaus DE, Calles Jr JL, Patel DR, editors. Pediatric and adolescent psychopharmacology: a practical manual for pediatricians. Cambridge (NY): Cambridge Medical; 2008. p. 12–4; with permission.
5
6
Pratt
and cap reimbursement for those mental health services they do provide. If services are covered, the reimbursements are at a lower rate than for medical services. These factors make the cost of mental/behavioral health services more burdensome for parents who are responsible for payment. Clinicians trained or credentialed in the treatment of mental/behavioral disorders with infants, children, and adolescents are not always available to provide care. Even fewer of these experts are trained to specifically treat youth with severe metal and behavioral disorders (ie, schizophrenia, or a combination of mental disorders and developmental disabilities, neurologic disorders, or severe mental disorders). Managed care panels limit the numbers of mental health clinicians they will add to their provider panels, thereby limiting their access to reimbursement from those panels for services provided. Parents and youth who are in psychological distress often want immediate relief but this is not generally possible whether the treatment is pharmacotherapy or psychotherapy. Both are time-consuming processes with medicines often advertised as faster acting. Pharmacotherapy requires supervision and sometimes assertiveness by parents to administer the prescribed medication to their child or adolescent. However, parents may falsely believe that they do not have to change to “fix” their child/adolescent because the “medicine” will “fix” the child’s/adolescent’s problem. Psychotherapy often requires daily and/or weekly involvement by the whole family (especially parents) who must devote time, energy, and effort to implementing treatment intervention; youth must be transported to the treating clinician and the process can be disruptive to the family routine. If a patient receives psychosocial treatment, his or her parents are also expected to change their behaviors to support their child’s treatments gains. Referrals: Physicians must have knowledge of other clinicians and their treatment modalities to select appropriate referral resources. They must also maintain collegial relationships with those clinicians to ensure that their patients are receiving care and benefiting from that care. Although parents, teachers, and some adolescents will demand pharmacologic treatment, primary care physicians should consider the use of psychological and psychosocial treatments as a first line of treatment, or in combination with prescribing medicines.
Psychosocial treatments for emotional, behavioral, and mental disorders can be very effective and sufficient in resolving problems. However, in the case of severe or reoccurring emotional, behavioral, and mental disorders, a combination of pharmacotherapy and psychotherapy increases the positive effects of treatment. SUMMARY
Behavioral and cognitive-behavioral therapies were most often identified as wellestablished treatments for specific mental and behavioral health disorders in children and adolescents. Psychotherapy alone or in conjunction with pharmacotherapy can be a powerful tool in helping youth manage or eliminate negative outcomes of mental and behavioral disorders. Youth should receive a comprehensive medical evaluation before being referred for psychosocial treatment. When referring patients for psychotherapy, it is important to maintain contact with the treating therapist and to remember to tell patients and their parents that the process for accessing treatment, evaluation, and the treatment process are often lengthy.
Psychotherapy in the Age of Pharmacology
REFERENCES
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