Ordering Treatment

In addition to maximizing the common application of component interventions that are useful in both anxiety and depressive disorders, the therapist must decide how to order their treatment. Should the anxiety disorder or the depression be targeted first? Compared to the anxiety literature, the depression literature does not provide much empirical guidance other than to document a poorer outcome for pharmacological and cognitive-behavioral treatment when comorbid anxiety is present (e.g., Brown et al., 1996; Gaynes et al., 1999). In contrast, a growing body of research suggests that CBT for anxiety disorders is fairly resilient with respect to the effects of depression. These data, presented in some detail below, have been influential at the clinical level to motivate us frequently to target anxiety disorders rather than depression as the first phase of treatment. Accordingly, we provide in these sections more details on issues of attending to comorbid depression rather than the reverse when treating anxiety disorders. However, we realize that such general guidance is challenging given the complexity of individual cases; hence, we also offer the following considerations on the ordering of treatment (see Table 8.1).

First, because research indicates that a match between the patient's expectations and treatment methods is important for treatment adherence (Eisenthal, Emery, Lazare, & Udin, 1979; Grilo, Money, Barlow, Goddard, Gorman, et al., 1998; Schulberg et al., 1996), treatment selection should be informed by both the patient's primary areas of distress and his/her beliefs about what is needed in therapy. These considerations on the patient's side should be complemented on the therapist's side by a functional analysis of the controlling relations between the anxiety and depression. Does the situa-

TABLE 8.1. Considerations in the Ordering of Treatment Interventions


Ensure that treatment offers a match with patient expectations.

Ensure that the ordering of treatment makes sense relative to a functional analysis of the links between the patient's anxiety, depression, and avoidance.

Beware of overattending to in-session distress relative to maintaining a step-by-step focus on core maladaptive patterns.

Attend to early gains as a strategy to promote motivation for treatment.


In addition to eliciting the patient's sense of which symptom clusters are the primary source of distress and disability, devote effort to helping the patient see controlling relations between the symptoms.

Patient expectations need to be balanced against the therapist's analysis of how one set of symptoms may limit progress on other sets of symptoms.

Ensure that progress from the last session is consistently reviewed, and that any new distress is integrated within the general model of change to help the therapy stay on track.

At every stage of treatment, help the patient see the links between his/her efforts in and out of therapy, and changes in symptoms and disability.

tional distress and avoidance from the anxiety disorder limit the affective benefit that a patient may derive from a more primary focus on depressed mood? Are the anxiety, avoidance, and dysfunction from the anxiety disorder used as evidence for core beliefs underlying depression? Alternatively, is the depressed mood strong enough to compromise the patient's motivation or willingness to complete exposure exercises, or his/her ability to judge or utilize the success of these exercises?

In completing this functional analysis, we caution therapists against overattention to insession, weekly depressive distress to the exclusion of out-of-session dysfunctional patterns. Depressive symptoms, particularly insession sadness and tearfulness, are often more salient to clinicians than the anxiety and avoidance symptoms that tend to occur outside rather than inside the clinician's office. Indeed, treatment of the anxiety disorder in patients with comorbid depression requires that the clinician focus on what is most useful to the patient over the interval between sessions instead on what is most obviously comforting within the session. This difficult process requires the clinician to judge what is in the patient's best interest—whether to focus on the affective distress of the moment or on a broader agenda that may offer earlier relief from punishing anxiety that may be fueling affective distress more broadly. Certainly the clinician is aided in this process by the collaborative relationship with the patient, balancing the patient's own sense of which disorder deserves primary attention and the clinician's perspective on which affective patterns appear to be most central to maintenance of the disorders.

As a final point on the ordering of interventions, we also encourage therapists to provide patients with early evidence that treatment can lead to beneficial change; that is, the most central problem does not always need to be the first treatment target. Research suggests that early gains in treatment can boost motivation and therapeutic alliance (see Tang & DeRubeis, 1999). Accordingly, we encourage therapists to focus attention on the interventions that might offer the earliest, noticeable benefit to the patient, using initial treatment gains as (1) a way to boost the patient's momentum in therapy, and (2) establish efficacy with a therapeutic strategy that can be applied to other problem areas.

Nonetheless, the outcome literature suggests that treatment of comor-bid conditions may need a longer course of treatment, and we encourage clinicians to be resilient in pursuing full remission of mood and anxiety disorders. Treatment of comorbid anxiety and depression may require more sessions of treatment, because (1) some patients may require additional treatment to reach remission given their greater illness severity; (2) the comorbid condition may not resolve, and may require additional treatment once the other disorder has been treated; or (3) the selected treatment may fail outright. Residual symptoms tend to be predictors of relapse; hence, additional treatment targeting full remission offers not only the short-term benefits of better quality of life but also a better long-term outcome.

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