A randomized clinical trial of cognitive behavioral therapy and interpersonal psychotherapy for panic disorder with agoraphobia

Interpersonal Psychotherapy: A Review of Theory, History, and Evidence of Efficacy

Interpersonal psychotherapy (IPT) is an empirically validated treatment for mood disorders, anxiety disorders, eating disorders, and trauma. IPT is based on the concept of "relational frame"-that an individual's experience of psychological distress impacts those around them, and that their social support network impacts the distressed individual. This concept, along with the specific techniques and tools that flow from it and the theoretical bases of IPT (attachment and interpersonal theory) make IPT unique. In this article we review the theoretical bases of IPT (attachment and communication) and provide a brief history of IPT, as well as the evidence supporting its use for a variety of disorders. We also describe its application to groups, adolescents, and other diverse populations. Future directions for research and treatment development are proposed, particularly research in the area of combining IPT with other psychotherapeutic modalities.

Hypnotherapy for agoraphobia-Feasibility and efficacy investigated in a pilot study

A number of case studies describing hypnotherapy in the treatment of anxiety disorder patients have already been published. Only a few randomized controlled trials (RCTs) investigated the efficacy of hypnotherapy but focused mainly on symptoms rather than specific mental disorders. The goal of this study was to investigate whether hypnotherapy (HT) was superior to a waitlist control group (WL) in the reduction of agoraphobia-related symptoms. Further goals were to report the feasibility of hypnotherapy as well as attrition and completion rates and detect (epi-)genetic variables, which might play a role in treatment outcome. This pilot study was based on a monocentric two-armed randomized controlled rater-blind clinical trial that was conducted between 2018 and 2020 with a waitlist control group. A total of 36 patients diagnosed with agoraphobia were randomized to either HT or WL. Patients in HT received individual outpatient treatment with hypnotherapy with 8 to 12 sessions for a period of 3 months. Patients in WL received HT after 3 months. Agoraphobia-related symptoms were assessed at baseline, after the treatment, and 3 months later in both groups with a clinician rating. The primary hypothesis concerning the difference between groups in the individual percentage symptom reduction could be confirmed in the intention-to-treat, not the per-protocol sample. Additionally, we applied repeated-measures analyses of variance and found a higher symptom decrease in HT compared with WL patients in three of the five imputed datasets. The dropout rate was low, and satisfaction with the treatment was high. HT patients experienced a strong symptom reduction after receiving hypnotherapy. WL patients improved slightly during the waiting period. The COMT Val108/158Met genotype had an effect on the agoraphobia-related symptoms as well as on COMT DNA methylation levels. This is the first study to indicate that hypnotherapy performed better than a waitlist control group regarding the reduction in anxiety symptoms in an RCT. Future studies should confirm the efficacy of hypnotherapy and compare the treatment with a standard treatment for anxiety disorders in a larger trial. Future studies should also investigate whether hypnotic susceptibility is associated with COMT Val108/158Met genotype and could predict treatment success for HT.

Clinical trial registration

https://classic.clinicaltrials.gov/ct2/show/NCT03684577, identifier: NCT03684577.

Comparative efficacy and acceptability of psychotherapies for panic disorder with or without agoraphobia: systematic review and network meta-analysis of randomised controlled trials

BACKGROUND

Psychotherapies are the treatment of choice for panic disorder, but which should be considered as first-line treatment is yet to be substantiated by evidence.

AIMS

To examine the most effective and accepted psychotherapy for the acute phase of panic disorder with or without agoraphobia via a network meta-analysis.

METHOD

We conducted a systematic review and network meta-analysis of randomised controlled trials (RCTs) to examine the most effective and accepted psychotherapy for the acute phase of panic disorder. We searched MEDLINE, Embase, PsycInfo and CENTRAL, from inception to 1 Jan 2021 for RCTs. Cochrane and PRISMA guidelines were used. Pairwise and network meta-analyses were conducted using a random-effects model. Confidence in the evidence was assessed using Confidence in Network Meta-Analysis (CINeMA). The protocol was published in a peer-reviewed journal and in PROSPERO (CRD42020206258).

RESULTS

We included 136 RCTs in the systematic review. Taking into consideration efficacy (7352 participants), acceptability (6862 participants) and the CINeMA confidence in evidence appraisal, the best interventions in comparison with treatment as usual (TAU) were cognitive-behavioural therapy (CBT) (for efficacy: standardised mean differences s.m.d. = -0.67, 95% CI -0.95 to -0.39; CINeMA: moderate; for acceptability: relative risk RR = 1.21, 95% CI -0.94 to 1.56; CINeMA: moderate) and short-term psychodynamic therapy (for efficacy: s.m.d. = -0.61, 95% CI -1.15 to -0.07; CINeMA: low; for acceptability: RR = 0.92, 95% CI 0.54-1.54; CINeMA: moderate). After removing RCTs at high risk of bias only CBT remained more efficacious than TAU.

CONCLUSIONS

CBT and short-term psychodynamic therapy are reasonable first-line choices. Studies with high risk of bias tend to inflate the overall efficacy of treatments. Results from this systematic review and network meta-analysis should inform clinicians and guidelines.

Remote cognitive behavioral therapy for panic disorder: A meta-analysis

Cognitive behavioral therapy (CBT) is an established treatment for panic disorder (PD). Remote CBT (RCBT) is becoming increasingly popular and has the potential to enhance access to this treatment. The aim of this study was to examine the efficacy of RCBT for PD using a meta-analytic approach. An electronic database search was used to identify relevant articles and the references of previously completed reviews. Twenty-one studies (n = 1,604; mean age range: 31.9-43.9; mean female representation = 71 %) were included in the meta-analysis. 14/21 (67 %; n = 817 of the included studies were randomised controlled trials and 7/21 (33 %; n = 787) were open trials or non-randomised controlled trials. Pooled within-group effect sizes across all remote treatments for PD symptoms were large from pre-treatment to post-treatment (Hedges' g = 1.18; 95 % CI: 0.99-1.36) and pre-treatment to follow-up (Hedges' g = 1.51; 95 % CI: 1.22-1.79). Pooled between-group findings indicate that remote CBT treatments are more effective than passive control (Hedges' g = 1.17; 95 % CI: 0.85-1.50), but are similar to other active treatments on measures of PD symptoms (e.g., face-to-face CBT) (Hedges' g = 0.02; 95 % CI: -0.43 to 0.48). Internet-delivered CBT (Hedges' g = 1.10, 95 % CI: 0.91-1.30), videoconferencing-delivered CBT (Hedges' g = 1.40, 95 % CI: 0.85-1.95) and bibliotherapy-delivered CBT (Hedges' g = 1.51, 95 % CI: 0.95-2.06) each produce large effect sizes on measures of PD symptoms. The results have important implications for the dissemination of entirely remote stepped-care treatments for PD.

Interpersonal Psychotherapy: A Scoping Review and Historical Perspective (1974-2017)

BACKGROUND

Interpersonal Psychotherapy (IPT) is an affect- and relationally focused, time-limited treatment supported by research spanning >4 decades. IPT focuses on stressful interpersonal experiences of loss, life changes, disputes, and social isolation. It emphasizes the role of relationships in recovery. This scoping review describes, within a historical perspective, IPT's evolution as an evidence-supported treatment of psychiatric disorders.

METHODS

English-language publications (n = 1119) identified via EMBASE, MEDLINE, PsycINFO, and Web of Science databases (1974-2017), augmented with manual reference searches, were coded for clinical focus, population demographics, format, setting, publication type, and research type. Quantitative and qualitative analyses identified IPT publications' characteristics and trends over four epochs of psychotherapy research.

RESULTS

IPT literature primarily focused on depression (n = 772 articles; 69%), eating disorders (n = 135; 12%), anxiety disorders (n = 68; 6%), and bipolar disorder (n = 44; 4%), with rising publication rates and numbers of well-conducted randomized, controlled trials over time, justifying inclusion in consensus treatment guidelines. Research trends shifted from efficacy trials to effectiveness studies and population-based dissemination initiatives. Process research examined correlates of improvement and efficacy moderators. Innovations included global initiatives, prevention trials, and digital, web-based training and treatment.

CONCLUSION

Sparked by clinical innovations and scientific advances, IPT has evolved as an effective treatment of psychiatric disorders across the lifespan for diverse patients, including underserved clinical populations. Future research to elucidate mechanisms of change, improve access, and adapt to changing frameworks of psychopathology and treatment planning is needed. IPT addresses the universal centrality of relationships to mental health, which is as relevant today as it was over 40 years ago.

On the Road to Personalized Psychotherapy: A Research Agenda Based on Cognitive Behavior Therapy for Depression

In this conceptual paper, we outline the many challenges on the road to personalized psychotherapy, using the example of cognitive behavior therapy (CBT) for depression. To optimize psychotherapy for the individual patient, we need to find out how therapy works (identification of mechanisms of change) and for whom it works (identification of moderators). To date, psychotherapy research has not resulted in compelling evidence for or against common or specific factors that have been proposed as mechanisms of change. Our central proposition is that we need to combine the "how does it work?"-question with the "for whom does it work?"-question in order to advance the field. We introduce the personalized causal pathway hypothesis that emphasizes the links and distinction between individual patient differences, therapeutic procedures and therapy processes as a paradigm to facilitate und understand the concept of personalized psychotherapy. We review the mechanism of change literature for CBT for depression to see what we have learned so far, and describe preliminary observational evidence supporting the personalized causal pathway hypothesis. We then propose a research agenda to push the ball forward: exploratory studies into the links between individual differences, therapeutic procedures, therapy processes and outcome that constitute a potential causal pathway, making use of experience sampling, network theory, observer ratings of therapy sessions, and moderated mediation analysis; testing and isolation of CBT procedures in experiments; and testing identified causal pathways of change as part of a personalized CBT package against regular CBT, in order to advance the application of personalized psychotherapy.

The influence of comorbid anxiety on the effectiveness of Cognitive Therapy and Interpersonal Psychotherapy for Major Depressive Disorder

BACKGROUND

Anxious depression is an important subtype of Major Depressive Disorder (MDD) defined by both syndromal (anxiety disorders) and dimensional (anxiety symptoms) criteria. A debated question is how anxiety affects MDD treatment. This study examined the impact of comorbid anxiety disorders and symptoms on the effectiveness of and dropout during Cognitive Therapy (CT) and Interpersonal Psychotherapy (IPT) for MDD.

METHODS

Depressed individuals were randomized to CT (n = 76) or IPT (n = 75). Outcome was depression severity measured with the Beck Depression Inventory-II (BDI-II) at the start of each therapy session, post treatment, and monthly up to five months follow-up. Anxiety disorders were assessed with the Structured Clinical Interview for DSM-IV Axis I disorders, (phobic) anxiety symptoms were assessed with Brief Symptom Inventory subscales.

RESULTS

Approximately one third of participants had a comorbid anxiety disorder. Comorbid anxiety disorders and anxiety symptoms were associated with less favorable depression change during IPT as compared to CT in the treatment phase, but not in the trial follow-up phase. Individuals with a comorbid anxiety disorder had significantly higher treatment dropout during both treatments.

LIMITATIONS

Not all therapists and participants were blind to the assessment of comorbid anxiety disorders and the assessments were performed by one rater.

CONCLUSIONS

A preference for CT over IPT for MDD is justifiable when comorbid anxiety is present, although long-term differences are not established and replication of this finding is needed. Clinicians should be aware of the risk of dropout for depressed individuals with an anxiety disorder.

Two Novel Cognitive Behavioral Therapy-Based Mobile Apps for Agoraphobia: Randomized Controlled Trial

Background

Despite the large body of literature demonstrating the effectiveness of cognitive behavioral treatments for agoraphobia, many patients remain untreated because of various barriers to treatment. Web-based and mobile-based interventions targeting agoraphobia may provide a solution to this problem, but there is a lack of research investigating the efficacy of such interventions.

Objective

The objective of our study was to evaluate for the first time the effectiveness of a self-guided mobile-based intervention primarily targeting agoraphobic symptoms, with respect to a generic mobile app targeting anxiety.

Methods

A Web-based randomized controlled trial (RCT) compared a novel mobile app designed to target agoraphobia (called Agoraphobia Free) with a mobile app designed to help with symptoms of anxiety in general (called Stress Free). Both interventions were based on established cognitive behavioral principles. We recruited participants (N=170) who self-identified as having agoraphobia and assessed them online at baseline, midpoint, and end point (posttreatment) over a period of 12 weeks. The primary outcome was symptom severity measured by the Panic and Agoraphobia Scale.

Results

Both groups had statistically significant improvements in symptom severity over time (difference –5.97, 95% CI –8.49 to –3.44, P<.001 for Agoraphobia Free and –6.35, 95% CI –8.82 to –3.87, P<.001 for Stress Free), but there were no significant between-group differences on the primary outcome (difference 0.38, 95% CI –1.96 to 3.20, P=.64).

Conclusions

This is, to our knowledge, the first RCT to provide evidence that people who identify as having agoraphobia may equally benefit from a diagnosis-specific and a transdiagnostic mobile-based intervention. We also discuss clinical and research implications for the development and dissemination of mobile mental health apps.

Trial Registration

International Standard Randomized Controlled Trial Number (ISRCTN): 98453199; http://www.isrctn.com /ISRCTN98453199 (Archived by WebCite at http://www.webcitation.org/6uR5vsdZw)

Anxiety disorders

Anxiety disorders constitute the largest group of mental disorders in most western societies and are a leading cause of disability. The essential features of anxiety disorders are excessive and enduring fear, anxiety or avoidance of perceived threats, and can also include panic attacks. Although the neurobiology of individual anxiety disorders is largely unknown, some generalizations have been identified for most disorders, such as alterations in the limbic system, dysfunction of the hypothalamic-pituitary-adrenal axis and genetic factors. In addition, general risk factors for anxiety disorders include female sex and a family history of anxiety, although disorder-specific risk factors have also been identified. The diagnostic criteria for anxiety disorders varies for the individual disorders, but are generally similar across the two most common classification systems: the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) and the International Classification of Diseases, Tenth Edition (ICD-10). Despite their public health significance, the vast majority of anxiety disorders remain undetected and untreated by health care systems, even in economically advanced countries. If untreated, these disorders are usually chronic with waxing and waning symptoms. Impairments associated with anxiety disorders range from limitations in role functioning to severe disabilities, such as the patient being unable to leave their home.

Efficacy of a Transdiagnostic internet-based treatment for emotional disorders with a specific component to address positive affect: Study protocol for a randomized controlled trial

BACKGROUND

Emotional disorders (ED) are among the most prevalent mental disorders. However, less than 50% of people suffering from ED receive the appropriate treatment. This situation has led to the development of new intervention proposals based on the transdiagnostic perspective, which tries to address the underlying processes common to ED. Most of these programs focus primarily on down-regulating negative affectivity, rather than increasing strengths and up-regulating positive affectivity. The data suggest the existence of disturbances in positive affectivity in these disorders, and so new interventions focusing on these problems are greatly needed. It is also essential to provide assistance to all the people in need. Information and Communication Technologies can be very useful. This study aims to evaluate the efficacy of a transdiagnostic Internet-based treatment for ED in a community sample. The protocol includes traditional CBT components, as well as a specific component to address positive affect. We intend to test this protocol, including this specific component or not, versus a waiting list control group. Moreover, we aim to test the differential effect of this specific component, and study the effectiveness (in terms of patients' acceptance) of using a self-applied Internet-based program. This paper presents the study protocol.

METHODS

The study is a randomized controlled trial. 207 participants will be randomly assigned to: a)Transdiagnostic Internet-based protocol (TIBP), b)Transdiagnostic Internet-based protocol + positive affect component (TIBP + PA), or c)a Waiting List control group (WL). Primary outcomes measures will be the BDI-II, the BAI, and the PANAS. Secondary outcomes will include diagnosis-specific measures of the principal disorder. Participants' treatment acceptance will also be measured. Participants will be assessed at pre-, post-treatment, and 3- and 12- month follow-ups. The data will be analyzed based on the Intention-to-treat principle. Per protocol analyses will also be performed.

DISCUSSION

To the best of our knowledge, this is the first study of a transdiagnostic Internet-based treatment for ED with a specific component to up-regulate positive affectivity. This intervention could contribute to improve the efficiency and effectiveness of current treatment programs for ED, promote the dissemination of EBTs, and help to decrease the high prevalence of ED.

TRIAL REGISTRATION

ClinicalTrial.gov: NCT02578758 . Registered 15 October 2015.

Anxiety

Anxiety disorders (separation anxiety disorder, selective mutism, specific phobias, social anxiety disorder, panic disorder, agoraphobia, and generalised anxiety disorder) are common and disabling conditions that mostly begin during childhood, adolescence, and early adulthood. They differ from developmentally normative or stress-induced transient anxiety by being marked (ie, out of proportion to the actual threat present) and persistent, and by impairing daily functioning. Most anxiety disorders affect almost twice as many women as men. They often co-occur with major depression, alcohol and other substance-use disorders, and personality disorders. Differential diagnosis from physical conditions-including thyroid, cardiac, and respiratory disorders, and substance intoxication and withdrawal-is imperative. If untreated, anxiety disorders tend to recur chronically. Psychological treatments, particularly cognitive behavioural therapy, and pharmacological treatments, particularly selective serotonin-reuptake inhibitors and serotonin-noradrenaline-reuptake inhibitors, are effective, and their combination could be more effective than is treatment with either individually. More research is needed to increase access to and to develop personalised treatments.

Relative effects of cognitive and behavioral therapies on generalized anxiety disorder, social anxiety disorder and panic disorder: A meta-analysis

Although cognitive and behavioral therapies are effective in the treatment of anxiety disorders, it is not clear what the relative effects of these treatments are. We conducted a meta-analysis of trials comparing cognitive and behavioral therapies with a control condition, in patients with social anxiety disorder (SAD), generalized anxiety disorder (GAD) and panic disorder. We included 42 studies in which generic measures of anxiety were used (BAI, HAMA, STAI-State and Trait). Only the effects of treatment for panic disorder as measured on the BAI (13.33 points; 95% CI: 10.58-16.07) were significantly (p=0.001) larger than the effect sizes on GAD (6.06 points; 95% CI: 3.96-8.16) and SAD (5.92 points; 95% CI: 4.64-7.20). The effects remained significant after adjusting for baseline severity and other major characteristics of the trials. The results should be considered with caution because of the small number of studies in many subgroups and the high risk of bias in most studies.

Is Interpersonal Psychotherapy Infinitely Adaptable? A Compendium of the Multiple Modifications of IPT

We employed standard literature search techniques and surveyed participants on the International Society for Interpersonal Psychotherapy listserve (isiptlist@googlegroups.com) to catalogue the multiple and highly creative ways in which Klerman's and Weissman's original concept of interpersonal psychotherapy (IPT) has been modified to meet the needs of a vast range of patient populations. Focusing first on adaptations of the individual treatment model for subgroups of adult patients, we next describe further adaptations of four major off-shoots of IPT: interpersonal counseling (IPC), IPT for adolescents (IPT-A), group IPT (IPT-G) and most recently, brief IPT (IPT-B). We then discuss IPT "in-laws," those treatments that have married IPT with of other forms of psychotherapy for patients with bipolar disorder, panic symptomatology, and substance abuse. We conclude with that although there have been myriad successful adaptations of IPT, there remain some conditions for which IPT adaptations have not been found to be efficacious.

Critical review of outcome research on interpersonal psychotherapy for anxiety disorders

BACKGROUND

Interpersonal psychotherapy (IPT) has demonstrated efficacy in treating mood and eating disorders. This article critically reviews outcome research testing IPT for anxiety disorders, a diagnostic area where cognitive behavioral therapy (CBT) has dominated research and treatment.

METHODS

A literature search identified six open and five controlled trials of IPT for social anxiety disorder (SAD), panic disorder, and posttraumatic stress disorder.

RESULTS

Studies were generally small, underpowered, and sometimes methodologically compromised. Nonetheless, minimally adapted from its standard depression strategies, IPT for anxiety disorders yielded positive results in open trials for the three diagnoses. In controlled trials, IPT fared better than waiting list (N = 2), was equipotent to supportive psychodynamic psychotherapy (N = 1), but less efficacious than CBT for SAD (N = 1), and CBT for panic disorder (N = 1) in a methodologically complicated study. IPT equaled CBT in a group residential format (N = 1).

CONCLUSIONS

IPT shows some promise for anxiety disorders but has thus far shown no advantages in controlled trials relative to other therapies. Methodological and ecological issues have complicated testing of IPT for anxiety disorders, clouding some findings. The authors discuss difficulties of conducting non-CBT research in a CBT-dominated area, investigator bias, and the probable need to further modify IPT for anxiety disorders. Untested therapies deserve the fairest possible testing.

Advancing psychotherapy and evidence-based psychological interventions

Psychological models of mental disorders guide research into psychological and environmental factors that elicit and maintain mental disorders as well as interventions to reduce them. This paper addresses four areas. (1) Psychological models of mental disorders have become increasingly transdiagnostic, focusing on core cognitive endophenotypes of psychopathology from an integrative cognitive psychology perspective rather than offering explanations for unitary mental disorders. It is argued that psychological interventions for mental disorders will increasingly target specific cognitive dysfunctions rather than symptom-based mental disorders as a result. (2) Psychotherapy research still lacks a comprehensive conceptual framework that brings together the wide variety of findings, models and perspectives. Analysing the state-of-the-art in psychotherapy treatment research, "component analyses" aiming at an optimal identification of core ingredients and the mechanisms of change is highlighted as the core need towards improved efficacy and effectiveness of psychotherapy, and improved translation to routine care. (3) In order to provide more effective psychological interventions to children and adolescents, there is a need to develop new and/or improved psychotherapeutic interventions on the basis of developmental psychopathology research taking into account knowledge of mediators and moderators. Developmental neuroscience research might be instrumental to uncover associated aberrant brain processes in children and adolescents with mental health problems and to better examine mechanisms of their correction by means of psychotherapy and psychological interventions. (4) Psychotherapy research needs to broaden in terms of adoption of large-scale public health strategies and treatments that can be applied to more patients in a simpler and cost-effective way. Increased research on efficacy and moderators of Internet-based treatments and e-mental health tools (e.g. to support "real time" clinical decision-making to prevent treatment failure or relapse) might be one promising way forward.