Adding Psychotherapy to Medication in Depression and Anxiety
Dr Christian Jonathan Haverkampf, M.D.
The effects of combined treatment compared with placebo are usually larger than those of medication only compared with placebo, underscoring the clinical advantage of combined treatment. Combined treatment appears to be more effective than treatment with antidepressant medication alone in major depression, panic disorder, and OCD. Thus, adding psychotherapy to medication is, in the large majority of cases, necessary for optimum treatment.
Keywords: psychotherapy, medication, psychiatry
Table of Contents
Medication and Psychotherapy. 4
Communication between Psychotherapist and Prescriber. 5
Introduction
Psychotherapy and medication both affect how information is transmitted and processed within a person and between the person and the environment. Given the high plasticity and connectivity of the brain, information flows determine to a large extent the morphological and physiological network of neurons within the brain. Both, medication and psychotherapy, affect these information flows and thus also the neural networks within the brain.
Medication and psychotherapy affect the neural networks in different ways but lead to similar results in relieving symptoms. Their timing can be quite different. Medication may in some cases provide faster relied. While psychotherapy can take longer. However, it may also be the other way around, when only the prospect of help can bring changes in psychotherapy early on.
Due to the plasticity of the brain, psychotherapy can medication can bring about lasting changes. However, since psychotherapy changes information content and flows more selectively, and more specifically also to situations and events in the environment, can lead to better fine-tuned and more specific changes in the individual. This could at least in theory lead to longer lasting changes.
Anxiety and Depression
Anxiety and depressive disorders are highly prevalent and are associated with a substantial loss of quality of life for patients and stress for relatives and friends. They cause high substantial economic costs, and a considerable disease burden for public health. Effective treatments are available for these disorders, including several types of psychotherapy and antidepressant medication.
Medication and Psychotherapy
Although psychotherapy and antidepressants are about equally effective for most anxiety and depressive disorders, there is some evidence that combined treatments may be more effective than each of these treatments alone. At the same time, however, an increasing proportion of patients with mental disorders in the past decade have received psychotropic medication without psychotherapy.
Psychotherapy as a treatment option, and as a general approach to mental health using communication as the basic tool, should always be the starting point when it comes to treating a mental health problem. Medication is less specific than psychotherapy from an information and communication perspective but can be a very valuable support in many cases and gains significant relevance in more severe mental health conditions, particularly those which have primarily a biological explanation.
Communication
The detrimental effects of anxiety and depression come mostly from the impact they have on internal and external communication. Whether it is a greater disconnectedness from oneself or from the world, which are usually present in both anxiety and depression, developing better communication patterns with oneself and others is an important piece towards recovery in moat mental health conditions, particularly in anxiety and depression. (Haverkampf, 2010) Various techniques can be helpful in this regard, including also body focused work, but a communication-oriented psychotherapy is probably the most direct way of working with communication patterns that have become maladaptive and unhelpful to the individual.
Understanding
One of the main problems if medication is not working or compliance is low is that patients do not understand what the medication does and how it does it. The same applies also to psychotherapy. An understanding for how things work is an important element to make something work. The more a patient understands about how a medication or a psychotherapeutic technique works, the easier it is for the patient to see how they can fit together. This increases the effectiveness of both and the compliance.
Language
Understanding requires that the other person can encode a message in such a way that the meaning of it can be accurately decoded by the other person. This requires that the therapist, for example, uses words that can be easily understood by the patient. On the other side, it is important that the patient can communicate his or her thoughts about the medication. This requires a setting that conveys a sense of safety and openness. A communication-oriented psychotherapeutic approach can provide this.
Communication between Psychotherapist and Prescriber
If the psychotherapist is not also the prescriber, the communication between psychotherapist and prescriber is important. This communication can determine how effective the medication and the psychotherapy eventually will be. Regarding psychotherapy and medication as equally important instruments can be helpful in this communication. Information from a psychotherapeutic perspective helps the prescriber, while information from the medical perspective helps the psychotherapist.
Empirical studies
Since scientific journals are specialized in fields and their readership and editors usually practice in that field, whether medication or a specific brand of psychotherapy, there is, of course, a risk that a journal will publish reports that interest its readership, that is things that work than things that so not work. The publication bias is probably large when two approaches, medication and psychotherapy, are contrasted, in which one side often has incomplete knowledge about the other. This can lead to misunderstandings and dogmatic viewpoints.
At least one study showed that even after adjusting for publication bias, the superiority of combined treatment was still statistically significant. The researchers also found some indications that the difference between pharmacotherapy and combined treatment was especially high in clinical samples compared with samples that were (in part) recruited from the community. It may suggest that patients actively seeking treatment may benefit more from combined treatment than people who are recruited from the community.
Synergies
Studies have found indications that the effects of combined treatment compared with placebo only were about twice as large as those of pharmacotherapy compared with placebo only. This would imply that the effects of psychotherapy and pharmacotherapy may be largely independent from each other and additive, not interfering with each other, and both contribute about equally to the effects of combined treatment. However, this probably depends on the type of psychotherapy used. Since better communication is an important part of therapy, and it has been shown that better communication increases the effectiveness and compliance of medication, possible synergies are probably greater with a therapeutic approach that focuses on communication rather than a predominantly manualized technical approach.
Most patients receive either pharmacotherapy or psychotherapy, and only a minority receives combined therapy. The synergistic effect does not seem to depend on the severity of the condition in both anxiety and depression. Efforts should thus be increased to make both approaches available to patients, which does not mean both are always needed or recommended. However, open communication with the aim of mutual understanding between therapist and patient and a better understanding of the underlying condition should always be pursued.
Communication
Both therapies may be helped by the other. In clinical practice, medication seems to facilitate psychotherapy, and psychotherapy can raise the compliance and possibly the tolerance for medication. (Haverkampf, 2018) They thus work well together, and both can lead to enduring effects after treatment has ended. It is, however, the better communication with oneself and the world to be gained on the psychotherapeutic side which can lead to life-long effects. Improvements and more flexibility in internal and external communication patterns is a major part of it. (Haverkampf, 2017a) But even here medication can, if used correctly, be a helpful support in facilitating this.
Conclusion
It is important to use what achieves the greatest effect consistently and with the lowest risk. Communication plays here an important role on both the medication and the psychotherapy sides. Better ways of communicating help on the psychotherapy and the medication side, while both together in clinical practice often work synergistically. However, this combined effect often also depends on the type of psychotherapy used. For anxiety and depression a more communication focused therapy shows to be helpful. (Haverkampf, 2013, 2017b, 2017c, 2017d)
Dr Jonathan Haverkampf, M.D. MLA (Harvard) LL.M. trained in medicine, psychiatry and psychotherapy and works in private practice for psychotherapy, counselling and psychiatric medication in Dublin, Ireland. The author can be reached by email at
jo****************@gm***.com
or on the websites www.jonathanhaverkampf.com and www.jonathanhaverkampf.ie.
References
Haverkampf, C. J. (2010). Communication and Therapy (3rd ed.). Dublin: Psychiatry Psychotherapy Communication Publishing Ltd.
Haverkampf, C. J. (2013). A Case of Depression. J Psychiatry Psychotherapy Communication, 2(3), 88–90.
Haverkampf, C. J. (2017a). Communication-Focused Therapy (CFT) (2nd ed.). Dublin: Psychiatry Psychotherapy Communication Publishing Ltd.
Haverkampf, C. J. (2017b). Communication-Focused Therapy (CFT) for Anxiety and Panic Attacks. J Psychiatry Psychotherapy Communication, 6(4), 91–95.
Haverkampf, C. J. (2017c). Communication-Focused Therapy (CFT) for Depression. J Psychiatry Psychotherapy Communication, 6(4), 101–104.
Haverkampf, C. J. (2017d). Treatment-Resistant Anxiety. J Psychiatry Psychotherapy Communication, 6(3), 60–67.
Haverkampf, C. J. (2018). An Overview of Psychiatric Medication (3rd ed.). Dublin: Psychiatry Psychotherapy Communication Publishing Ltd.
Kessler RC, Berglund P, Demler O et al. National Comorbidity Survey Replication. The epidemiology of major depressive disorder: results from the National Comorbidity Survey Replication (NCS-R). JAMA 2003;289:3095-105.
Kessler RC, Berglund P, Demler O et al. Lifetime prevalence and age-of-onset distributions of DSM-IV disorders in the National Comorbidity Survey Replication. Arch Gen Psychiatry 2005;62:593-602.
Ustun TB, Ayuso-Mateos JL, Chatterji S et al. Global burden of depressive disorders in the year 2000. Br J Psychiatry 2004;184:386-92.
Saarni SI, Suvisaari J, Sintonen H et al. Impact of psychiatric disorders on health-related quality of life: general population survey. Br J Psychiatry 2007;190:326-32.
Berto P, D’Ilario D, Ruffo P et al. Depression: cost-of-illness studies in the international literature: a review. J Ment Health Policy Econ 2000;3:3-10.
Greenberg PE, Birnbaum HG. The economic burden of depression in the US: societal and patient perspectives. Exp Opin Pharmacother 2005;6:369-76.
Smit F, Cuijpers P, Oostenbrink J et al. Excess costs of common mental disorders: population based cohort study. J Ment Health Policy Econ 2006;9:193-200.
Mathers CD, Loncar D. Projections of global mortality and burden of disease from 2002 to 2030. PLoS Med 2006;3:e442.
National Institute for Health and Clinical Excellence (NICE). Depression; the treatment and management of depression in adults. Holborn: NICE, 2009.
Bauer M, Bschor T, Pfennig A et al. World Federation of Societies of Biological Psychiatry (WFSBP) guidelines for biological treatment of unipolar depressive disorders in primary care. World J Biol Psychiatry 2007;8:67-104.
Bandelow B, Sher L, Bunevicius R et al. Guidelines for the pharmacological treatment of anxiety disorders, obsessive-compulsive disorder and posttraumatic stress disorder in primary care. Int J Psychiatry Clin Pract 2012;16:77-84.
Cuijpers P, Sijbrandij M, Koole SL et al. The efficacy of psychotherapy and pharmacotherapy in treating depressive and anxiety disorders: a meta-analysis of direct comparisons. World Psychiatry 2013;12:137-48.
Cuijpers P, Dekker J, Hollon SD et al. Adding psychotherapy to pharmacotherapy in the treatment of depressive disorders in adults: a meta-analysis. J Clin Psychiatry 2009;70:1219-29.
Cuijpers P, van Straten A, Warmerdam L et al. Psychological treatment versus combined treatment of depression: a meta-analysis. Depress Anx 2009;26:279-88.
de Maat SM, Dekker J, Schoevers RA et al. Relative efficacy of psychotherapy and combined therapy in the treatment of depression: a meta-analysis. Eur Psychiatry 2007;22:1-8.
Olfson M, Marcus SC. National trends in outpatient psychotherapy. Am J Psychiatry 2010;167:1456-63.
Marcus SC, Olfson M. National trends in the treatment for depression from 1998 to 2007. Arch Gen Psychiatry 2010;67:1265-73.
Furukawa TA, Watanabe N, Churchill R. Combined psychotherapy plus antidepressants for panic disorder with or without agoraphobia. Cochrane Database of Systematic Reviews 2007 (1):CD004364.
Hofmann SG, Sawyer AT, Korte KJ et al. Is it beneficial to add pharmacotherapy to cognitive-behavioral therapy when treating anxiety disorders? A meta-analytic review. Int J Cogn Ther 2009;2:160-75.
Higgins JPT, Green S (eds). Cochrane handbook for systematic reviews of interventions. Version 5.0.1. Oxford: Cochrane Collaboration, 2008.
Hedges LV, Olkin I. Statistical methods for meta-analysis. San Diego: Academic Press, 1985.
Kraemer HC, Kupfer DJ. Size of treatment effects and their importance to clinical research and practice. Biol Psychiatry 2006;59:990-6.
Laupacis A, Sackett DL, Roberts RS. An assessment of clinically useful measures of the consequences of treatment. N Engl J Med 1988;318:1728-33.
Higgins JP, Thompson SG, Deeks JJ et al. Measuring inconsistency in meta-analyses. BMJ 2003;327:557-60.
Ioannidis JPA, Patsopoulos NA, Evangelou E. Uncertainty in heterogeneity estimates in meta-analyses. BMJ 2007;335:914-6.
Orsini N, Higgins J, Bottai M et al. Heterogi: Stata module to quantify heterogeneity in a meta-analysis. Boston: Boston College Department of Economics, 2005.
Duval S, Tweedie R. Trim and fill: a simple funnel-plot-based method of testing and adjusting for publication bias in meta-analysis. Biometrics 2000;56:455-63.
Azhar MZ. Comparison of Fluvoxamine alone, Fluvoxamine and cognitive psychotherapy and psychotherapy alone in the treatment of panic disorder in Kelantan – implications for management by family doctors. Med J Malaysia 2000;55:402-8.
Barlow DH, Gorman JM, Shear MK et al. Cognitive-behavioral therapy, imipramine, or their combination for panic disorder: a randomized controlled trial. JAMA 2000;283:2529-36.
Bellack AS, Hersen M, Himmelhoch J. Social skills training compared with pharmacotherapy and psychotherapy in the treatment of unipolar depression. Am J Psychiatry 1981;138:1562-67.
Bellino S, Zizza M, Camilla R et al. Combined treatment of major depression in patients with borderline personality disorder: a comparison with pharmacotherapy. Can J Psychiatry 2006;51:253-60.
Berger P, Sachs G, Amering M et al. Personality disorder and social anxiety predict delayed response in drug and behavioral treatment of panic disorder. J Affect Disord 2004;80:75-8.
Blackburn IM, Bishop S, Glen AI et al. The efficacy of cognitive therapy in depression: a treatment trial using cognitive therapy and pharmacotherapy, each alone and in combination. Br J Psychiatry 1981;139:181-9.
Blanco C, Heimberg RG, Schneier FR et al. A placebo-controlled trial of phenelzine, cognitive behavioral group therapy, and their combination for social anxiety disorder. Arch Gen Psychiatry 2010;67:286-95.
Blom MB, Spinhoven P, Hoffman T et al. Severity and duration of depression, not personality factors, predict short term outcome in the treatment of major depression. J Affect Disord 2007;104:119-26.
Blomhoff S, Haug TT, Hellström K et al. Randomised controlled general practice trial of sertraline, exposure therapy and combined treatment in generalised social phobia. Br J Psychiatry 2001;179:23-30.
Browne G, Steiner M, Roberts J et al. Sertraline and/or interpersonal psychotherapy for patients with dysthymic disorder in primary care: 6-month comparison with longitudinal 2-year follow-up of effectiveness and costs. J Affect Disord 2002;68:317-30.
Burnand Y, Andreoli A, Kolatte E et al. Psychodynamic psychotherapy and clomipramine in the treatment of major depression. Psychiatr Serv 2002;53:585-90.
Crits-Christoph P, Newman MG, Rickels K et al. Combined medication and cognitive therapy for generalized anxiety disorder. J Anxiety Disord 2011;25:1087-94.
Davidson JRT, Foa EB, Huppert JD et al. Fluoxetine, comprehensive cognitive behavioral therapy, and placebo in generalized social phobia. Arch Gen Psychiatry 2004;61:1005-13.
de Jonghe F, Kool S, van Aalst G et al. Combining psychotherapy and antidepressants in the treatment of depression. J Affect Disord 2001;64:217-29.
de Mello MF, Myczcowisk LM, Menezes PR. A randomized controlled trial comparing moclobemide and moclobemide plus interpersonal psychotherapy in the treatment of dysthymic disorder. J Psychother Pract Res 2001;10:117-23.
Dozois DJA, Bieling PJ, Patelis-Siotis I et al. Changes in self-schema structure in cognitive therapy for major depressive disorder: a randomized clinical trial. J Consult Clin Psychol 2009;77:1078-88.
Finkenzeller W, Zobel I, Rietz S et al. Interpersonal psychotherapy and pharmacotherapy for post-stroke depression. Feasibility and effectiveness. Nervenarzt 2009;80:805-12.
Foa EB, Liebowitz MR, Kozak MJ et al. Randomized, placebo-controlled trial of exposure and ritual prevention, clomipramine, and their combination in the treatment of obsessive-compulsive disorder. Am J Psychiatry 2005;162:151-61.
Hautzinger M, de Jong-Meyer R, Treiber R et al. Wirksamkeit Kognitiever Verhaltenstherapie, Pharmacotherapie und deren Kombination bei nicht-endogenen, unipolaren Depressionen. Zeitschr Klin Psychol 1996;25:130-45.
Hellerstein DJ, Little SAS, Samstag LW et al. Adding group psychotherapy to medication treatment in dysthymia: a randomized prospective pilot study. J Psychother Pract Res 2001;10:93-103.
Hollon SD, DeRubeis RJ, Evans MD et al. Cognitive therapy and pharmacotherapy for depression: singly and in combination. Arch Gen Psychiatry 1992;49:774-81.
Hsiao FH, Jow GM, Lai YM et al. The long-term effects of psychotherapy added to pharmacotherapy on morning to evening diurnal cortisol patterns in outpatients with major depression. Psychother Psychosom 2011;80:166-72.
Keller MB, McCullough JP, Klein DN et al. A comparison of nefazodone, the cognitive behavioral-analysis system of psychotherapy, and their combination for the treatment of chronic depression. N Engl J Med 2000;342:1462-70.
King ALS, Valenca AM, de Melo-Neto VL et al. Efficacy of a specific model for cognitive-behavioral therapy among panic disorder patients with agoraphobia: a randomized clinical trial. Sao Paulo Med J 2011;129:325-34.
Koszycki D, Taljaard M, Segal Z et al. A randomized trial of sertraline, self-administered cognitive behavior therapy, and their combination for panic disorder. Psychol Med 2011;41:373-83.
Lesperance F, Frasure-Smith N, Koszycki D et al. Effects of citalopram and interpersonal psychotherapy on depression in patients with coronary artery disease: the Canadian Cardiac Randomized Evaluation of Antidepressant and Psychotherapy Efficacy (CREATE) trial. JAMA 2007;297:367-79.
Loerch B, Graf-Morgenstern M, Hautzinger M et al. Randomised placebo-controlled trial of moclobemide, cognitive-behavioural therapy and their combination in panic disorder with agoraphobia. Br J Psychiatry 1999;174:205-12.
Lynch TR, Morse JQ, Mendelson T et al. Dialectical behavior therapy for depressed older adults: a randomized pilot study. Am J Geriatr 2003;11:33-45.
Macaskill ND, Macaskill A. Rational-emotive therapy plus pharmacotherapy vs. pharmacotherapy alone in the treatment of high cognitive dysfunction depression. Cogn Ther Res 1996;20:575-92.
Maina G, Rosso G, Rigardetto S et al. No effect of adding brief dynamic therapy to pharmacotherapy in the treatment of obsessive-compulsive disorder with concurrent major depression. Psychother Psychosom 2010;79:295-302.
Markowitz JC, Kocsis JH, Bleiberg KL et al. A comparative trial of psychotherapy and pharmacotherapy for “pure” dysthymic patients. J Affect Disord 2005;89:167-75.
Misri S, Reebye P, Corral M et al. The use of paroxetine and cognitive-behavioral therapy in postpartum depression and anxiety: a randomized controlled trial. J Clin Psychiatry 2004;65:1236-41.
Mitchell PH, Veith RC, Becker KJ et al. Brief psychosocial-behavioral intervention with antidepressant reduces poststroke depression significantly more than usual care with antidepressant: living well with stroke: randomized, controlled trial. Stroke 2009;40:3073-8.
Murphy GE, Simons AD, Wetzel RD et al. Cognitive therapy and pharmacotherapy. Singly and together in the treatment of depression. Arch Gen Psychiatry 1984;41:33-41.
Mynors-Wallis LM, Gath DH, Day A et al. Randomised controlled trial of problem solving treatment, antidepressant medication, and combined treatment for major depression in primary care. BMJ 2000;320:26-30.
Naeem F, Waheed W, Gobbi M et al. Preliminary evaluation of culturally sensitive CBT for depression in Pakistan: findings from Developing Culturally-sensitive CBT Project (DCCP). Behav Cogn Psychother 2011;39:165-73.
Otto MW, Hinton D, Korbly NB et al. Treatment of pharmacotherapy-refractory posttraumatic stress disorder among Cambodian refugees: a pilot study of combination treatment with cognitive-behavior therapy vs sertraline alone. Behav Res Ther 2003;41:1271-6.
Prasko J, Dockery C, Horacek J et al. Moclobemide and cognitive behavioral therapy in the treatment of social phobia. A six-month controlled study and 24 months follow up. Neuroendocrinol Lett 2006;27:473-81.
Ravindran AV, Anisman H, Merali Z et al. Treatment of primary dysthymia with group cognitive therapy and pharmacotherapy: clinical symptoms and functional impairments. Am J Psychiatry 1999;156:1608-17.
Reynolds CF 3rd, Miller MD, Pasternak RE et al. Treatment of bereavement-related major depressive episodes in later life: a controlled study of acute and continuation treatment with nortriptyline and interpersonal psychotherapy. Am J Psychiatry 1999;156:202-8.
Rothbaum BO, Cahill SP, Foa EB et al. Augmentation of sertraline with prolonged exposure in the treatment of posttraumatic stress disorder. J Trauma Stress 2006;19:625-38.
Shamsaei F, Rahimi A, Zarabian MK et al. Efficacy of pharmacotherapy and cognitive therapy, alone and in combination in major depressive disorder. Hong Kong J Psychiatry 2008;18:76-80.
Shareh H, Gharraee B, Atef-Vahid MK et al. Metacognitive Therapy (MCT), fluvoxamine, and combined treatment in improving obsessive-compulsive, depressive and anxiety symptoms in patients with Obsessive-Compulsive Disorder (OCD). Iran J Psychiatry Behav Sci 2010;4:17-25.
Sharp DM, Power KG, Simpson RJ et al. Fluvoxamine, placebo, and cognitive behaviour therapy used alone and in combination in the treatment of panic disorder and agoraphobia. J Anxiety Dis 1996;10:219-42.
Sirey JA, Bruce ML, Alexopoulos GS. The Treatment Initiation Program: an intervention to improve depression outcomes in older adults. Am J Psychiatry 2005;162:184-6.
Spinhoven P, Onstein EJ, Klinkhamer RA et al. Panic management, trazodone and a combination of both in the treatment of panic disorder. Clin Psychol Psychother 1996;3:86-92.
Tenneij NH, Megen HJ, Denys DAJP et al. Behavior therapy augments response of patients with obsessive-compulsive disorder responding to drug treatment. J Clin Psychiatry 2005;66:1169-75.
Thompson LW, Coon DW, Gallagher-Thompson D et al. Comparison of desipramine and cognitive/behavioral therapy in the treatment of elderly outpatients with mild-to-moderate depression. Am J Geriatr Psychiatry 2001;9:225-40.
van Apeldoorn FJ, van Hout WJPJ, Huisman M et al. Is a combined therapy more effective than either CBT or SSRI alone? Results of a multicenter trial on panic disorder with or without agoraphobia. Acta Psychiatr Scand 2008;17:260-70.
Weissman MM, Prusoff BA, Dimascio A et al. The efficacy of drugs and psychotherapy in the treatment of acute depressive episodes. Am J Psychiatry 1979;136:555-8.
Wiborg IM, Dahl AA. Does brief dynamic psychotherapy reduce the relapse rate of panic disorder? Arch Gen Psychiatry 1996;53:689-94.
Wiles NJ, Hollinghurst S, Mason V et al. A randomized controlled trial of cognitive behavioural therapy as an adjunct to pharmacotherapy in primary care based patients with treatment resistant depression: a pilot study. Behav Cogn Psychother 2008;36:21-33.
Katz R, Shaw BF, Vallis TM et al. The assessment of severity and symptom patterns in depression. In: Beckham EE, Leber WR (eds). Handbook of depression, 2nd ed. New York: Guilford, 1995:61-85.
Turner EH, Matthews AM, Linardatos E et al. Selective publication of antidepressant trials and its influence on apparent efficacy. N Engl J Med 2008;358:252-60.
Cuijpers P, Smit F, Bohlmeijer et al. Is the efficacy of cognitive behaviour therapy and other psychological treatments for adult depression overestimated? A meta-analytic study of publication bias. Br J Psychiatry 2010;196:173-8.
Friedman MA, Detweiler-Bedell JB, Leventhal HE et al. Combined psychotherapy and pharmacotherapy for the treatment of major depressive disorder. Clin Psychol Sci Pract 2004;11:47-68.
Otto MW, Smits JAJ, Reese HE. Combined psychotherapy and pharmacotherapy for mood and anxiety disorders in adults: review and analysis. Clin Psychol Sci Pract 2005;12:72-86.
This article is solely a basis for academic discussion and no medical advice can be given in this article, nor should anything herein be construed as advice. Always consult a professional if you believe you might suffer from a physical or mental health condition. Neither author nor publisher can assume any responsibility for using the information herein.
Trademarks belong to their respective owners. No checks have been made.
This article has been registered with the U.S. Copyright Office. Unauthorized reproduction and/or publication in any form is prohibited. Copyright will be enforced.
© 2017-2018 Christian Jonathan Haverkampf. All Rights Reserved
Unauthorized reproduction and/or publication in any form is prohibited.