Cognitive behavioural therapy and pharmacotherapy: complementary or contradictory approaches to the treatment of anxiety?

Considerable controversy exists regarding the practice of combining Cognitive Behavioural Therapy (CBT) with Pharmacotherapy (PT) in the management of anxiety. This paper considers whether these two forms of treating anxiety disorders can be effectively combined to enhance treatment outcome. Despite the theoretical appeal of a combined approach, a critical review of treatment outcome findings across CBT and various anxiolytic medications and their combination, suggests a failure of these treatments to operate in a complementary fashion. A detrimental impact of anxiolytic medication on CBT outcome is particularly salient for high potency benzodiazepines. Low potency benzodiazepines and antidepressants generally have a negligible impact with no clear evidence of treatment enhancement and some negative combined treatment effects on medication withdrawal and at long-term follow-up. Thus, we address potential mechanisms that may explain this treatment noncomplementarity and in some cases, treatment incompatibility. Cognitive factors influencing treatment outcome (catastrophic beliefs, self-efficacy, selective attention, and memory) are highlighted in view of the empirically supported mediating role of these variables in accounting for treatment responsiveness. Potential effects of anxiolytic medication on cognitive change in CBT are postulated. A number of suggestions for future research and clinical practice are proposed on the basis of this review.