Cognitive-behavioral therapy more effective than medication for generalized anxiety disorder

Generalized Anxiety Disorder

Ever since Mick Jagger wrote about "mother's little helpers,' much of the population has viewed medications as the instant cure for such modern-day maladies as Generalized Anxiety Disorder. It is undeniable that the prevalence of GAD is expanding as the world becomes more complex, global, difficult to comprehend and, one might argue, more mechanistic and less humanistic. Recent studies have shown that, despite the current overwhelming allegiance to medication, cognitive-behavioral interventions are more effective for GAD. Several major investigations and a recent small empirical study confirm that cognitive-behavioral counseling works better and more rapidly than medication intervention without attendant therapy.

Introduction

The National Institutes of Mental Health (NIMH) shows that anxiety disorders are the most common mental illnesses in the United States, with more than 23 million people affected each year (Public Health Reports 2005). Within this population, several varieties of anxiety disorder appear, including panic disorder, obsessive-compulsive disorder, phobias, post-traumatic stress disorder and generalized anxiety disorder (GAD). NIMH defines as "chronic or exaggerated worry and tension; almost always anticipating disaster even though nothing seems to provoke it. Worrying is often accompanied by physical symptoms, like trembling, muscle tension, headache and nausea" (Public Health Reports 2005). This is an adequate definition for the current study.

NIMH also notes that there are several forms of effective treatment for anxiety disorder, among them medication, specific forms of psychotherapy known as behavioral therapy and cognitive-behavioral therapy, or a combination of medication and the non-medication therapies.

Medication, for the purposes of this study, will be taken to mean "any psychotropic drug used to treat anxiety or any drug developed for other purposes that has been found useful in treating some psychiatric conditions, such as the antihistamines that have been found useful for some generalized anxiety disorder patients.

Hypothesis: In Maverick County, generalized anxiety disorder patients function better without medication than with it, if medication is the only or main aspect of treatment.

In order to prove the validity of this assertion, two groups were studied. One group was provided with appropriate medication and minimal therapy of any sort; the second group was provided with no medication but did participate in a well-tested cognitive-behavioral regiment based on the Rational-Emotive therapy of Dr. Albert Ellis, as found in his book (which they were asked to read), a Guide to Rational Living.

Review of the Literature

LaTorre (2001) conducted a survey of the possibilities in treating anxiety disorders and concluded that although psychotropic medication often is considered and can be helpful in many cases, it is merely one of a number of interventions possible. Practitioners not limited by this can use equally effective non-pharmacological methods alone or in combination and achieve good results. She noted that studies had shown that cognitive behavioral approaches, similar to the Rational-Emotive therapy described earlier, "allow for an active focus on the client's current problems, while enhancing coping skills" (LaTorre 2001). While La Torre's study did not offer any groundbreaking insights, it is extremely valuable in that it pointed out the advantages not only of combining standard therapeutic techniques, but of using other disciplines as well if they were effective. Among the ones she mentioned were relaxation techniques such as guided imagery and breathing exercises, as well as visualizations and even music therapy to promote change.

Two other interesting studies proceed along similar paths. Nesse (1999) studied the evolution of hope and despair, two emotional conditions that can certainly be considered fellow travelers in respect to generalized anxiety disorder. Nesse wrote:

Events that indicate that our efforts will succeed arouse hope. Events that suggest that our efforts are futile foster despair. We experience hope and despair, not at the beginning or end, but in the midst of our long-term efforts (1999).

While it seems a Pollyanna attitude, Nesse notes that people prefer hope to despair, and also that people prefer it for others (1999), one explanation for people to engage in counseling professions.

Larson and Larson extend beyond hope and despair to investigate the potential of spirituality in emotional health. They suggest that "For a large proportion of either medically ill or mental health patients, spirituality/religion may provide coping resources, enhance pain management, improve surgical outcomes, protect against depression, and reduce risk of substance abuse and suicide" (2003). In other words, it would seem to be possibly highly useful in generalized anxiety disorder treatment, which has elements of depression. They are careful to point out to counselors, however, that "misuse of spirituality/religion to harshly manipulate is linked with mental health harm " (Larson & Larson 2003).

Bowman et al. (1997) investigated the outcomes of adults with generalized anxiety disorder in either self-examination therapy or delayed treatment. "Analyses indicated that participants in self-examination therapy had significantly fewer symptoms of anxiety than did participants in the delayed-treatment group on the outcome measures of this study, which included ratings by trained clinicians and participants" (Bowman et al. 1997).

For the self-examination group, benefits were maintained for three months after the end of treatment. For the delayed-treatment group, significant improvement was shown after they received self-examination therapy. From this study, the LaTorre work and the work of Dia, it is reasonable to conclude that empowerment is conducive to better outcomes in those with generalized anxiety disorder.

Dia (2001) noted that cognitive-behavioral therapy (CBT) is now a respected and proven model of psychotherapy, as noted by a t ask force of the American Psychological Association. In its review, the APA found that CBT "was efficacious for depression, generalized anxiety disorder, social phobia, obsessive compulsive disorder, substance abuse and dependence, agoraphobia, and panic disorder" (Dia 2001).

Kendall and Flannery-Schroeder (2003) examined the issue of treatment for generalized anxiety disorders in youth. Instead of attempting to determine the efficacy of one treatment or another, they wanted instead to determine whether research models were adequate to the task of determining best treatments. They noted that the methodological and design difficulties include procedural matters, as well as, importantly, accurate assessment of anxious distress by researchers and measuring treatment-produced change. Other complicating factors include treatment for comorbid conditions, or even the ingestion of other medications for unrelated medical conditions. In addition, they noted, studies involving children and medications are faced with various ethical guidelines; parents are sometimes hesitant to place their children on medication or, on the other hand, may not be willing to 'risk' having their children in a placebo group. On the other hand, eliminating placebos from studies involving pharmacologicals would also produce a biased result. Studies had shown repeatedly that "anxious adults disproportionately attend to emotionally threatening vs. neutral stimuli. Studies had also shown that among anxious children, the tendency to shift attention to emotionally threatening stimuli and away from neutral ones was present. They had also found evidence that this tendency compromised knowledge and cognitive tasks. "Consistent with previous studies, Martin et al. (1992) found that spider-fearful children were significantly slower to color-name spider-related vs. neutral words while nonfearful children showed no impairment" (Kendall and Flannery-Schroeder 2003).

Kendall and Flannery-Schroeder touched on it, but Ingersoll et al. (2004) took a more extensive look at psychotropic drugs and children in treatment for anxiety disorders. They noted that the paradigm in western medicine is still the alleviation of symptoms using psychotropic medications. They wondered what exactly should be the role of advocacy in that regard vis-a-vis the counseling professions. They were at pains to mention that pharmaceutical companies command a great deal of economic power, a possible prescription for abuse in a "society that overvalues the medical model" (Ingersoll et al. 2004). These researchers examined the possibility that advocacy counseling, which includes social action and social justice-oriented counseling, increases a client's feelings of personal power as well as fostering sociopolitical changes reflecting greater responsiveness to the client's personal needs.

While that sounds a lot like 'pie in the sky,' the authors were interested in the case of children being prescribed psychotropic medications; they found advocacy counseling can help counselors to "critically examine the shortcomings of the medical model and how counseling interventions can address the same symptoms that the medical model claims to treat" (Ingersoll et al. 2004). In short, this process can short-circuit single-minded reliance on medication to solve anxiety problems in children. These researchers also noted that the effectiveness of psychotropic medications used without additional counseling modalities for adults was also an area that would benefit from research.

While much research involves children and anxiety disorders, Myers and Harper (2004) examined a population much less studied, older adults.

They noted that their work was important because an estimated one third of individuals in that population exhibit mental health conditions that require professional intervention, including anxiety. This is an important study for counselors because, given the changes occurring in the structure of society in the United States, that is, the dramatic increase in older citizens, it is more likely than ever that professional counselors will be called on to treat older persons. Myers and Harper also noted that at present, there is a bias against older persons among service providers, compounded by reluctance by older people to seek counseling. It is paramount, then, that counselors become apprised of effective intervention practices for this population group.

Summary

The problem involved the relative merits of treating GAD with medication or counseling. A small experiment revealed that when one group was given appropriate medication but virtually no effective counseling, that group's members were not as successful at combating their GAD as were those who were given no medications but were both counseled and trained in the techniques of Rational-Emotive Therapy, one of the early cognitive-behavioral modalities developed by Dr. Albert Ellis. They were also required to read his book, a Guide to Rational Living. Virtually all of that group made significant progress both in combating their GAD and in beginning to construct a more satisfying life. The findings of the literature review suggest that, in fact, medication is overused and, when used, works more effectively when it is paired with some form of cognitive-behavioral therapy.

Some researchers took the problem even beyond that, and investigated the effects of spirituality on ameliorating GAD. These studies, too, supported the viewpoint that, if one component is to be present, that component ought to be a form of cognitive-behavioral therapy, or even spiritual assistance. Further, one study noted the benefits of sociological frameworks for both counselor and client in coping with the underlying issues of GAD, namely feelings of powerlessness.

It cannot be overemphasized that there has been a bias toward treating all mental disorders with a pill; more than one of the researchers commented upon the inordinate value Americans place on medicine. At the same time, many researchers viewed it as an undesirable practice for a counselor to give in to the search for a pharmacological 'quick fix' when the cognitive-behavioral approaches are almost invariably more effective when used alone, while pharmacological intervention used alone has a very low likelihood of significantly altering the patient's problem.