The Effect of Comorbidity on the Process and Outcome of Cognitive Therapy

Most of the literature regarding cognitive therapy (CT) of GAD, OCD, and PTSD describes treatments in which the disorders are considered in isolation. Most well-controlled, randomized clinical trials have focused on "pure" cases of anxiety or depression and have shown promising outcomes in the treatment of these conditions (Chambless & Ollendick, 2001). Yet the samples utilized in the empirically supported treatment literature include few (if any) participants who have comorbid depression and anxiety (e.g., Ladouceur et al., 2000).

Few researchers have examined the impact of coexisting anxiety disorders on CT for depression, and studies that do exist have yielded conflicting results (Rowa et al.,2005). Some studies have investigated the general role of comorbid anxiety disorders in treatment outcome in depression. In a study of a manualized group therapy, in comparison to patients without comorbid disorders, depressed individuals with comorbid anxiety presented with more severe depression at pretest and continued to exhibit residual symptoms at posttest, suggesting that comorbidity contributed to poorer therapeutic effectiveness (Gelhart & King, 2001).

In a study of an individualized case formulation approach to CT, Persons, Roberts, and Zalecki (2003) investigated whether both anxiety and depressive symptoms would improve over the course of treatment. Both anxious and depressive symptoms improved by at least 50% or more in 31.6% of patients. However, less optimistic results were that 35.1% of patients showed improvement on only one set of symptoms, and 33.3% of patients showed no improvement on either anxiety or depression.

There is some preliminary research on the impact of depression in the treatment of specific anxiety disorders. In one study, patients with OCD, who were initially in the severe range of depression, showed significantly lower rates of improvement with standard treatment for OCD (exposure and response prevention), than did individuals with no, mild, or moderate depression (Abramowitz, Franklin, Street, Kozak, & Foa, 2000). Other studies indicate that nontargeted depressive symptoms improve as a result oftreatment aimed at GAD and PTSD. Meta-analytic data indicate that depressive symptoms also improve with CT aimed at treating GAD (cf. Chambless & Gillis, 1993). In addition, depressive symptoms appear to improve following CT for PTSD (Ehlers, Clark, Hackmann, McManus, & Fennell, 2005).

Given that comorbid depression and anxiety is associated with increased symptom severity and functional impairment, treatment of the comorbid patient is especially challenging. As such, we contend that the strategy for CT of comorbid conditions should involve a comprehensive and idiographic approach to assessment, followed by a case conceptualization that is tailored to the individual patient.

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