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Comparing Pharmocological Interventions and Psychological Therapy for Anxiety Disorders

Paper Type: Free Essay Subject: Psychology
Wordcount: 2391 words Published: 8th Feb 2020

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Pharmacological intervention or psychological therapy for the management of anxiety disorders?  Discuss.


Anxiety disorders such as generalised anxiety disorders (GAD), social phobia, obsessive-compulsive disorders (OCD) or post-traumatic stress disorders (PTSD) place a large financial burden on society as well as providers in the healthcare system. If not treated effectively, anxiety can lead to associated mental health problems e.g. insomnia and depression.2  These condition can then lead to inpatient stays in mental health units putting more strain on NHS resources.

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Anxiety disorders are classed as some of the most prevalent psychiatric disorders and once diagnosed, treatment is recommended based on a patient’s preference. Factors that may complicate the treatment pathway could be a history of substance misuse. This would limit the use of benzodiazepines as a treatment option if abuse of them in the past had been identified. The treatment a patient undertakes could also purely be based on what has been tried in the past and either been successful or failed. The side effect profile of most medications can lead patients to seek alternative psychological therapies in the first instance as they may be more tolerable and with limited adverse effects affecting the patient after the treatment period has finished.

During this review the different treatment methods were explored and included, solely pharmacological interventions, psychological treatments or programmes and then combined therapies.

Searches of the major databases such as PubMed, psycINFO, Science direct, JAMA and Wiley were conducted using the key words: Cognitive behaviour therapy, evidence based guidelines, generalised anxiety disorder, anxiety disorders, pharmacological treatment, psychological treatment, PTSD, Social Phobia, OCD, benzodiazepines, anxiolytics, antipsychotics, antidepressants.

The different approaches or pathways to treating anxiety disorders are all clearly outlined in key guidelines used by practitioners including The British Association for Psychopharmacology (BAPs) and the National Institute for Health and Clinical Excellence (NICE). The British Association for Psychopharmacology guidelines cover the range and aims of treatment for anxiety disorders. The guidelines are based on the available evidence and are presented as recommendations to aid clinical decision making.3 The guidelines cover the diagnosis of anxiety disorders and key steps in clinical management, including acute treatment, relapse prevention and approaches for patients who do not respond to first-line treatments.

NICE recommends that first-line treatments should always consist of psychological therapies ahead of pharmacological interventions because they are less intrusive and most effective when used in a step wised approach to anxiety.4

There are many drug treatments also available to treat an anxiety disorder; these can include anxiolytics, antidepressants and antipsychotics. Benzodiazepines were initially considered to be first line agent in treating anxiety mainly because of their similar efficacy to tricyclic antidepressants but were more acceptable by patients with the side effects. Benzodiazepines are now primarily prescribed by practitioners when there has been a sub-therapeutic response to antidepressants.

The current recommendation by NICE for management for anxiety using medication is to prescribe a selective serotonin reuptake inhibitor (SSRI) or serotonin norepinephrine reuptake inhibitors (SNRI) NICE. This is due to their side effect profiles being more tolerable for patients compared to older antidepressants such as tricyclic antidepressants. They are also associated with a low potential for abuse and safer if taken in overdose. Across most studies, lower dosages of SSRIs are often as effective to treat anxiety disorders as higher dosages.5 However, in OCD, higher dosages are associated with better response.6 Benzodiazepines were no longer clinically indicated as a first line choice for anxiety mainly due to their risk of potential dependence and the cognitive and psychomotor impairment patients can suffer both as a consequence of chronic use.7 Patients also are at risk of suffering from rebound anxiety when they are withdrawn after a prolonged period of use and so generally they would be tapered down and withdrawn slowly over a period of a couple of months. During this time period the patient would start either another medication with a lower dependence potential or CBT to help patients to focus on the situation causing the anxiety and looking at the possible negative or positive outcomes. Modifying behaviour and developing a more balanced perspective allows patients to decide how to handle the situation.8

The actual choice though between deciding whether to use pharmacological therapies over psychological interventions such as CBT can be dictated by a number of factors that may include, the patient’s own preference to which treatment they would like to undertake and  in the case of psychological therapies, whether the treatment is available in the area the patient lives. Another factor that may be considered before treatment options are offered to a patient may be their availability to undertake a weekly session with a qualified professional and the level of commitment which they display towards wanting to improve their condition.

Gould and Otto found in their meta-analytic review of controlled trials that CBT was associated with greater effects on the severity of depression and had clear maintenance of treatment gains compared to trials involving medication where the efficacy was lessened after the treatment was discontinued demonstrating the influence that behaviour modifying techniques can have in the longer term in dealing with anxieties rather than relying on medication alone which only provided short term benefit.2

In GAD evidence suggests that increasing the dose of the medication has very little beneficial effect and instead switching to an alternative treatment may be more beneficial to the patient.9 During the acute phase of the illness and in the shorter term, most research has shown that a minimum of 3 months is needed to assess if drug treatment such as with a SSRI has proved efficacious. But longer term incorporating this drug therapy with CBT has reduced the chances of relapse than with using medication alone as a treatment pathway.9 More recently NICE have recommended that talking therapies for GAD are offered to patients.

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In PTSD, there was little research in which therapy pathway showed higher efficacy in both the short and long term. One small study found that utilising drug treatment such as paroxetine alongside trauma focused CBT resulted in an advantageous outcome of reducing the depressive symptoms in the patient in the longer term. The weakness of this study though was that the participant size was very small and the study was unblinded over a short period of time of only 12 weeks leading it open to researcher bias with not enough subjects to generalise the results.10

Researchers in one comparative study found that in patients who were suffering from PTSD there was a high amount of strength of evidence supporting that exposure therapy improved the symptoms that the patients with PTSD were experiencing.1 Whereas the strength of the evidence presented using other psychological therapies such as cognitive therapy or cognitive behavioural therapy (CBT – mixed therapies) was more of moderate nature for achieving symptom control in patients with PTSD.1 When  drug therapies were examined in the same research the strength of the evidence regardless of what drug type was being looked at was moderate in alleviating any symptoms of functional impairment or bringing on remission.1 The different classes of drug therapies examined included antidepressants, antipsychotic as well as antiepileptic medications.

There is some evidence that combination therapy in OCD can be beneficial but as with other anxiety disorders the research has proven to be inconsistent. The recommendation if initial treatment with a medication fails, is to consider combining this drug therapy with exposure therapy or CBT and in refractory or resistant cases to refer them to a national specialist OCD service.3

New initiatives designed to increase the uptake of psychological interventions in patients with anxiety disorders include the Improving Access to Psychological Therapies programme (IAPT). 12, 13 This therapy programme provides specific evidence based psychological therapies for patients who specifically suffer from anxiety disorders. It offers digitally enabled therapy meaning that, the therapy itself is delivered through online resources or applications allowing patients to take a self-directed approach to their therapy but at the same time is supported by trained therapists. 9 Unfortunately in the UK, IAPT has not been evaluated through any formal randomised controlled trials and so patients undertaking this therapy need to be reminded that the response is not immediate and that a prolonged course of therapy is usually needed to maintain the initial response.9

Most patients who suffer from an anxiety related condition will always require support when they are in a heightened emotional state as this emotional stress can cloud their problem solving abilities which in turn can affect their quality of life.


From all the literature that was compared there is not enough clear evidence to prove whether one treatment method, pharmacological or physiological is more effective than the other when treating patients with anxiety disorders. What is clear is that if combination treatment is initiated from the outset by the practitioner then there is a higher degree of success in controlling the symptoms associated with the disorders as well as improving the quality of life of the patient. First line agents  SSRIs and SNRIs outlined in guidance by NICE and BAPs work reasonably well to reduce the physiological symptoms of anxiety but their main drawbacks are that they act slowly (at least 4-6 weeks) leading patients to believing that the medication is not working for them and also they do not lead to continuous remission.

The downside to a lot of the studies that were looked at was that the follow up end point was up to or less than 1 year which may not have been a sufficient period of time to assess any efficacy of interventions adequately.

In the future research could focus more on comparisons between psychological treatments with the best evidence of efficacy such as, exposure therapy compared to cognitive processing therapy and pharmacological therapies that have a moderate to high strength of evidence behind them supporting their efficacy.


  1. Jonas DE, Cusack K, Forneris CA, et al. Psychological and Pharmacological Treatments for Adults with Posttraumatic Stress Disorder (PTSD) [Internet]. Rockville (MD): Agency for Healthcare Research and Quality (US); 2013 Apr. (Comparative Effectiveness Reviews, No. 92.)
  2. Gould RA, Otto MW, Pollack MH, LiangYap. Cognitive behavioural and pharmacological treatment of generalized anxiety disorder: A preliminary meta-analysis. Behaviour Therapy Volume 28, Issue 2, 1997, Pages 285-305
  3. Baldwin, D. S. et al. (2005) ‘Evidence-based guidelines for the pharmacological treatment of anxiety disorders: recommendations from the British Association for Psychopharmacology’, Journal of Psychopharmacology, 19(6), pp. 567–596
  4. NICE Guidance Quality standard [QS53] Anxiety Disorders. Published February 2014
  5. Marshall RD, Beebe KL, Oldham M, Zaninelli R. Efficacy and safety of paroxetine treatment for chronic PTSD: a fixed-dose, placebo-controlled study. American Journal of Psychiatry. 2001; 158:1982–1988.
  6. Bloch MH, McGuire J, Landeros-Weisenberger A, Leckman JF, Pittenger C. Meta-analysis of the dose–response relationship of SSRI in obsessive–compulsive disorder. Molecular Psychiatry. 2009; 15:850–855.
  7. Otto MW, McHugh RK, Simon NM, Farach FJ, Worthington JJ, Pollack MH. Efficacy of CBT for benzodiazepine discontinuation in patients with panic disorder: further evaluation. Behaviour Research and Therapy. 2010; 48:720–727.
  8. McDermott SP. Treating Anxiety Disorders Using Cognitive Therapy Techniques. Psychiatric Annals. 2004;34(11):858-872 (Abstract only)
  9. NICE Clinical Guideline [CG113] Generalised anxiety disorder and panic disorder in adults: management, published January 2011 reviewed and updated in June 2018
  10. Frommberger U, Stieglitz RD, Nyberg E. Comparison between paroxetine and behaviour therapy in patients with posttraumatic stress disorder (PTSD): A pilot study. International Journal of Psychiatry and Clinical Practice, 2004, 8: 19–23.
  11. Simpson HB, Foa EB, Liebowitz MR. A randomized, controlled trial of cognitive-behavioural therapy for augmenting pharmacotherapy in obsessive-compulsive disorder. American Journal of Psychiatry, 2008, 165: 621–630.
  12. Brown JSL, Boardman J, Whittinger N. Can a self-referral system help improve access to psychological treatments? British Journal of General Practice, 2010,  60: 365–371
  13. Clark DM. Implementing NICE guidelines for the psychological treatment of depression and anxiety disorders: The IAPT experience. International Review of Psychiatry, 2011, 23: 318–327.


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