Well, JAMA decided not to publish the letter that Barbara and I wrote in response to the CBT-slanted commentary there. I thought I would publish it here instead:
Really Treating Anxiety in 2017
John C. Markowitz, M.D. and Barbara Milrod, M.D.
To the Editor:
In “Treating Anxiety in 2017,” Drs. Stein and Craske outline management of anxiety treatment for non-psychiatric clinicians.1 They strongly endorse pharmacotherapy and cognitive behavioral therapy (CBT) “by a qualified therapist,” both of which are evidence-based anxiolytic treatments. They further emphasize that “not all therapy or counseling is CBT,” as if to warn the non-psychiatrist against referring patients to Brand X talking therapies.
The authors’ suggestions are useful as far as they go, but they hardly go far enough. If the advisory about non-CBT counseling is a caution against non-evidence-based, free form therapies, we concur. But Drs. Stein and Craske, two anxiety experts from specialized treatment backgrounds, surely know that a state of the art view of treating anxiety in 2017 encompasses more than medications and CBT: growing evidence supports targeted, time-limited psychodynamic therapy2,3and interpersonal psychotherapy (IPT)4,5 for patients with panic, PTSD, and other anxiety disorders. CBT indeed has “the most empirical support,” as they state, but readers should not misunderstand this to mean that CBT has the only empirical support or outperforms viable alternatives. Because no treatment benefits all patients, it is good that an array of available, effective treatments exists, and all physicians should know about them. The field of psychotherapy needs to move beyond sectarian guild struggles to observe what really works for whom.
Drs. Markowitz and Milrod acknowledge conflicts of interest in that they receive minor royalties from treatment manuals of the psychotherapies they mention.
- Stein MB, Craske MG. Treating anxiety in 2017: optimizing care to improve outcomes. [published online July 5, 2017.] JAMA doi:10.1001/jama.2017.6996.
- Milrod B, Leon AC, Busch F, et al. A randomized controlled clinical trial of psychoanalytic psychotherapy for panic disorder. Am J Psychiatry 2007;164(2):265-272.
- Milrod B, Chambless DL, Gallop R, et al. Psychotherapies for panic disorder: a tale of two sites. J Clin Psychiatry 2016;77(7):927-935.
- Markowitz JC, Lipsitz J, Milrod BL. A critical review of outcome research on interpersonal psychotherapy for anxiety disorders. Depress Anxiety 2014; 31(4):316-325.
- Markowitz JC, Petkova E, Neria Y, et al. Is exposure necessary? A randomized clinical trial of interpersonal psychotherapy for PTSD. Am J Psychiatry 2015;172(5):430-440.
John C. Markowitz, M.D.
New York State Psychiatric Institute
Professor of Clinical Psychiatry
Columbia University College of Physicians & Surgeons
1051 Riverside Drive, Unit #129
New York, NY 10032