Is a combined therapy more effective than either CBT or SSRI alone? Results of a multicenter trial on panic disorder with or without agoraphobia

Enhanced interhemispheric resting-state functional connectivity of the visual network is an early treatment response of paroxetine in patients with panic disorder

This study aimed to detect alterations in interhemispheric interactions in patients with panic disorder (PD), determine whether such alterations could serve as biomarkers for the diagnosis and prediction of therapeutic outcomes, and map dynamic changes in interhemispheric interactions in patients with PD after treatment. Fifty-four patients with PD and 54 healthy controls (HCs) were enrolled in this study. All participants underwent clinical assessment and a resting-state functional magnetic resonance imaging scan at (i) baseline and (ii) after paroxetine treatment for 4 weeks. A voxel-mirrored homotopic connectivity (VMHC) indicator, support vector machine (SVM), and support vector regression (SVR) were used in this study. Patients with PD showed reduced VMHC in the fusiform, middle temporal/occipital, and postcentral/precentral gyri, relative to those of HCs. After treatment, the patients exhibited enhanced VMHC in the lingual gyrus, relative to the baseline data. The VMHC of the fusiform and postcentral/precentral gyri contributed most to the classification (accuracy = 87.04%). The predicted changes were accessed from the SVR using the aberrant VMHC as features. Positive correlations (p < 0.001) were indicated between the actual and predicted changes in the severity of anxiety. These findings suggest that impaired interhemispheric coordination in the cognitive-sensory network characterized PD and that VMHC can serve as biomarkers and predictors of the efficiency of PD treatment. Enhanced VMHC in the lingual gyrus of patients with PD after treatment implied that pharmacotherapy recruited the visual network in the early stages.

Pharmacological treatments in panic disorder in adults: a network meta-analysis

BACKGROUND

A panic attack is a discrete period of fear or anxiety that has a rapid onset and reaches a peak within 10 minutes. The main symptoms involve bodily systems, such as racing heart, chest pain, sweating, shaking, dizziness, flushing, churning stomach, faintness and breathlessness. Other recognised panic attack symptoms involve fearful cognitions, such as the fear of collapse, going mad or dying, and derealisation (the sensation that the world is unreal). Panic disorder is common in the general population with a prevalence of 1% to 4%. The treatment of panic disorder includes psychological and pharmacological interventions, including antidepressants and benzodiazepines.

OBJECTIVES

To compare, via network meta-analysis, individual drugs (antidepressants and benzodiazepines) or placebo in terms of efficacy and acceptability in the acute treatment of panic disorder, with or without agoraphobia. To rank individual active drugs for panic disorder (antidepressants, benzodiazepines and placebo) according to their effectiveness and acceptability. To rank drug classes for panic disorder (selective serotonin reuptake inhibitors (SSRIs), serotonin-norepinephrine reuptake inhibitors (SNRIs), tricyclic antidepressants (TCAs), mono-amine oxidase inhibitors (MAOIs) and benzodiazepines (BDZs) and placebo) according to their effectiveness and acceptability. To explore heterogeneity and inconsistency between direct and indirect evidence in a network meta-analysis.

SEARCH METHODS

We searched the Cochrane Common Mental Disorders Specialised Register, CENTRAL, CDSR, MEDLINE, Ovid Embase and PsycINFO to 26 May 2022.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) of people aged 18 years or older of either sex and any ethnicity with clinically diagnosed panic disorder, with or without agoraphobia. We included trials that compared the effectiveness of antidepressants and benzodiazepines with each other or with a placebo.

DATA COLLECTION AND ANALYSIS

Two authors independently screened titles/abstracts and full texts, extracted data and assessed risk of bias. We analysed dichotomous data and continuous data as risk ratios (RRs), mean differences (MD) or standardised mean differences (SMD): response to treatment (i.e. substantial improvement from baseline as defined by the original investigators: dichotomous outcome), total number of dropouts due to any reason (as a proxy measure of treatment acceptability: dichotomous outcome), remission (i.e. satisfactory end state as defined by global judgement of the original investigators: dichotomous outcome), panic symptom scales and global judgement (continuous outcome), frequency of panic attacks (as recorded, for example, by a panic diary; continuous outcome), agoraphobia (dichotomous outcome). We assessed the certainty of evidence using threshold analyses.

MAIN RESULTS

Overall, we included 70 trials in this review. Sample sizes ranged between 5 and 445 participants in each arm, and the total sample size per study ranged from 10 to 1168. Thirty-five studies included sample sizes of over 100 participants. There is evidence from 48 RCTs (N = 10,118) that most medications are more effective in the response outcome than placebo. In particular, diazepam, alprazolam, clonazepam, paroxetine, venlafaxine, clomipramine, fluoxetine and adinazolam showed the strongest effect, with diazepam, alprazolam and clonazepam ranking as the most effective. We found heterogeneity in most of the comparisons, but our threshold analyses suggest that this is unlikely to impact the findings of the network meta-analysis. Results from 64 RCTs (N = 12,310) suggest that most medications are associated with either a reduced or similar risk of dropouts to placebo. Alprazolam and diazepam were associated with a lower dropout rate compared to placebo and were ranked as the most tolerated of all the medications examined. Thirty-two RCTs (N = 8569) were included in the remission outcome. Most medications were more effective than placebo, namely desipramine, fluoxetine, clonazepam, diazepam, fluvoxamine, imipramine, venlafaxine and paroxetine, and their effects were clinically meaningful. Amongst these medications, desipramine and alprazolam were ranked highest. Thirty-five RCTs (N = 8826) are included in the continuous outcome reduction in panic scale scores. Brofaromine, clonazepam and reboxetine had the strongest reductions in panic symptoms compared to placebo, but results were based on either one trial or very small trials. Forty-one RCTs (N = 7853) are included in the frequency of panic attack outcome. Only clonazepam and alprazolam showed a strong reduction in the frequency of panic attacks compared to placebo, and were ranked highest. Twenty-six RCTs (N = 7044) provided data for agoraphobia. The strongest reductions in agoraphobia symptoms were found for citalopram, reboxetine, escitalopram, clomipramine and diazepam, compared to placebo. For the pooled intervention classes, we examined the two primary outcomes (response and dropout). The classes of medication were: SSRIs, SNRIs, TCAs, MAOIs and BDZs. For the response outcome, all classes of medications examined were more effective than placebo. TCAs as a class ranked as the most effective, followed by BDZs and MAOIs. SSRIs as a class ranked fifth on average, while SNRIs were ranked lowest. When we compared classes of medication with each other for the response outcome, we found no difference between classes. Comparisons between MAOIs and TCAs and between BDZs and TCAs also suggested no differences between these medications, but the results were imprecise. For the dropout outcome, BDZs were the only class associated with a lower dropout compared to placebo and were ranked first in terms of tolerability. The other classes did not show any difference in dropouts compared to placebo. In terms of ranking, TCAs are on average second to BDZs, followed by SNRIs, then by SSRIs and lastly by MAOIs. BDZs were associated with lower dropout rates compared to SSRIs, SNRIs and TCAs. The quality of the studies comparing antidepressants with placebo was moderate, while the quality of the studies comparing BDZs with placebo and antidepressants was low.

AUTHORS' CONCLUSIONS

In terms of efficacy, SSRIs, SNRIs (venlafaxine), TCAs, MAOIs and BDZs may be effective, with little difference between classes. However, it is important to note that the reliability of these findings may be limited due to the overall low quality of the studies, with all having unclear or high risk of bias across multiple domains. Within classes, some differences emerged. For example, amongst the SSRIs paroxetine and fluoxetine seem to have stronger evidence of efficacy than sertraline. Benzodiazepines appear to have a small but significant advantage in terms of tolerability (incidence of dropouts) over other classes.

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.

Valproate Adjuvant Cognitive Behavioral Therapy in Panic Disorder Patients With Comorbid Bipolar Disorder: Case Series and Review of the Literature

Anxiety disorders are the most common comorbid psychiatric disorders in patients with bipolar disorder. Managing anxiety symptoms in comorbid conditions is challenging and has received little research interest. The findings from preclinical research on fear conditioning, an animal model of anxiety disorder, have suggested that memory reconsolidation updating (exposure-based therapy) combined with valproate might facilitate the amelioration of fear memories. Here, three cases of successful amelioration of agoraphobia and panic symptoms through valproate adjuvant therapy for cognitive behavioral therapy in patients who failed to respond to two to three consecutive standard pharmacotherapy trials over several years are described. To the best of the author's knowledge, this is the first attempt to combine CBT with valproate in patients with panic disorder, agoraphobia, and comorbid bipolar disorder. Additionally, the background preclinical research on this combination therapy based on the reconsolidation-updating mechanism, the inhibition of histone deacetylase 2, and critical period reopening, off-label use of valproate in panic disorder, plasticity-augmented psychotherapy, and how to combine valproate with CBT is discussed.

Objective Assessments in Diagnoses and Treatment: A Proposed Change in Paradigm

For patients with psychiatric disorders, current diagnostic and treatment approaches are far from optimal. The clinical interview drives the standard approach-matching symptoms to diagnostic criteria-and results in standardized pharmacological and behavioral treatments, often, with inadequate outcome; but now, recent imaging advances can correlate behavioral assessments with brain function and measure them against normative databases to provide data critical for the reevaluation of patient diagnosis and treatment. This article addresses the data that support a redefinition of our current paradigm. We believe a neurobehavioral approach provides for more personalized treatment approaches unbound from classically defined diagnostic biases.

Adapting cognitive-behavioral therapy for a Malaysian muslim

Background: Over the years, cognitive-behavioural therapy (CBT) has gained momentum because of its robust evidence in the treatment of several disorders. However, there is an issue of religious and cultural appropriateness as CBT principles are based on Western conceptualization. This single-case study (N = 1) implements a culturally and religiously adapted CBT on a 34-year-old male with panic disorder with agoraphobia in Malaysia. The client had symptoms comprising various episodes of sudden onset of breathlessness, accelerated heart rate, and fear of dying for the last 14 years. The CBT was culturally and religiously adapted based on (1) A CBT manual in Bahasa Malaysia that was previously modified and adjusted according to the norms of the Malaysian society and (2) General guidelines in "Religious-Cultural Psychotherapy in the Management of Anxiety Patients" by Razali et al in 2002. The present modified CBT had 3 assessments formulation sessions and 12 intervention sessions. Methods: The first 6 sessions were based on the behaviour component of CBT (ie, a relaxation technique using Islamic prayer, reciting verses from the Holy Quran, slow breathing exercise, body scan, and progressive muscular relaxation). However, sessions 7 to 12 were focused on cognitive restructuring and exercises, such as identification of negative automatic thoughts, cognitive distortions, dysfunctional thought records, vertical arrow technique, and the coping statement was practised through collaborative empiricism, while implementing Islamic and cultural elements. The focus of termination sessions was on interoceptive exposure, cognitive rehearsal, and in vivo situational exposure. Results: Beck Anxiety Inventory (BAI) was administered at regular intervals. BAI scores revealed the effectiveness of adapting the intervention. Conclusion: Panic attacks, worry about panic attacks, and anxiety scores reduced remarkably and the client was able to go out of the house, travel independently, and pursue religious/social activities.

Evidence-Based Brief Psychological Treatment for Emotional Disorders in Primary and Specialized Care: Study Protocol of a Randomized Controlled Trial

Emotional Disorders (EDs) are very prevalent in Primary Care (PC). However, general practitioners (GPs) have difficulties to make the diagnosis and the treatment of this disorders that are usually treated with drugs. Brief psychological therapies may be a new option to treat EDs in a PC context. This article aims to present a study protocol to evaluate the effectiveness and the efficiency of an adaptation to brief format of the "Unified Protocol (UP) for the transdiagnostic treatment of EDs." This is a single-blinded RCT among 165 patients with EDs. Patients will be randomly assigned to receive brief psychological treatment based on UP, conventional psychological treatment, conventional psychological treatment plus pharmacological treatment, minimum intervention based on basic psychoeducational information, or pharmacological treatment only. Outcome measure will be the following: GAD-7, STAI, PHQ-9, BDI-II, PHQ-15, PHQ-PD, and BSI-18. Assessments will be carried out by blinded raters at baseline, after the treatment and 6-month follow-up. The findings of this RCT may encourage the implementation of brief therapies in the PC context, what would lead to the decongestion of the public health system, the treatment of a greater number of people with EDs in a shorter time, the reduction of the side effects of pharmacological treatment and a possible economic savings for public purse. Clinical Trial Registration: ClinicalTrial.gov, identifier NCT03286881. Registered September 19, 2017.

Royal Australian and New Zealand College of Psychiatrists clinical practice guidelines for the treatment of panic disorder, social anxiety disorder and generalised anxiety disorder

Objective:

To provide practical clinical guidance for the treatment of adults with panic disorder, social anxiety disorder and generalised anxiety disorder in Australia and New Zealand.

Method:

Relevant systematic reviews and meta-analyses of clinical trials were identified by searching PsycINFO, Medline, Embase and Cochrane databases. Additional relevant studies were identified from reference lists of identified articles, grey literature and literature known to the working group. Evidence-based and consensus-based recommendations were formulated by synthesising the evidence from efficacy studies, considering effectiveness in routine practice, accessibility and availability of treatment options in Australia and New Zealand, fidelity, acceptability to patients, safety and costs. The draft guidelines were reviewed by expert and clinical advisors, key stakeholders, professional bodies, and specialist groups with interest and expertise in anxiety disorders.

Results:

The guidelines recommend a pragmatic approach beginning with psychoeducation and advice on lifestyle factors, followed by initial treatment selected in collaboration with the patient from evidence-based options, taking into account symptom severity, patient preference, accessibility and cost. Recommended initial treatment options for all three anxiety disorders are cognitive–behavioural therapy (face-to-face or delivered by computer, tablet or smartphone application), pharmacotherapy (a selective serotonin reuptake inhibitor or serotonin and noradrenaline reuptake inhibitor together with advice about graded exposure to anxiety triggers), or the combination of cognitive–behavioural therapy and pharmacotherapy.

Conclusion:

The Royal Australian and New Zealand College of Psychiatrists clinical practice guidelines for the treatment of panic disorder, social anxiety disorder and generalised anxiety disorder provide up-to-date guidance and advice on the management of these disorders for use by health professionals in Australia and New Zealand.

Management of Treatment-Resistant Panic Disorder

PURPOSE OF REVIEW

Purpose of Review Management of treatment-resistant (TR) panic disorder (PD) is an unresolved issue. In this paper, we provide a brief summary of previous findings, an updated (2015-2017) systematic review of pharmacological/non-pharmacological studies, and our personal perspective on this topic.

RECENT FINDINGS

Recent Findings We found a very limited number of recent findings. Quetiapine extended-release augmentation has not been found to be beneficial, in comparison to placebo, in non-responders to previously recommended pharmacotherapy. In non-responders to cognitive behavioral therapy (CBT), switching to paroxetine/citalopram has been found to be more effective than continuing CBT. Acceptance and commitment therapy (ACT) has shown some improvement in patients' resistance to previous psychological/pharmacological interventions compared with a waiting-list condition.

SUMMARY

Summary Previous and recent findings regarding the treatment of TR PD suffer from several methodological limitations. Available studies provide insufficient evidence to support the use of medications alternative to the recommended medications; the efficacy of ACT needs confirmation with more rigorous methodology. Prolonged pharmacotherapy may produce significant improvement in patients with unsatisfactory response to short-term pharmacotherapy, while switching to pharmacotherapy may help non-responders to CBT. We discuss our personal perspective on the definition of "treatment resistance" as it relates to PD and provide personalized intervention strategies to increase favorable clinical outcomes based on our clinical expertise and review of experimental studies on the pathophysiology of PD.

Serotonin and brain function: a tale of two receptors

Previous attempts to identify a unified theory of brain serotonin function have largely failed to achieve consensus. In this present synthesis, we integrate previous perspectives with new and older data to create a novel bipartite model centred on the view that serotonin neurotransmission enhances two distinct adaptive responses to adversity, mediated in large part by its two most prevalent and researched brain receptors: the 5-HT1A and 5-HT2A receptors. We propose that passive coping (i.e. tolerating a source of stress) is mediated by postsynaptic 5-HT1AR signalling and characterised by stress moderation. Conversely, we argue that active coping (i.e. actively addressing a source of stress) is mediated by 5-HT2AR signalling and characterised by enhanced plasticity (defined as capacity for change). We propose that 5-HT1AR-mediated stress moderation may be the brain's default response to adversity but that an improved ability to change one's situation and/or relationship to it via 5-HT2AR-mediated plasticity may also be important - and increasingly so as the level of adversity reaches a critical point. We propose that the 5-HT1AR pathway is enhanced by conventional 5-HT reuptake blocking antidepressants such as the selective serotonin reuptake inhibitors (SSRIs), whereas the 5-HT2AR pathway is enhanced by 5-HT2AR-agonist psychedelics. This bipartite model purports to explain how different drugs (SSRIs and psychedelics) that modulate the serotonergic system in different ways, can achieve complementary adaptive and potentially therapeutic outcomes.

Psychological therapies versus pharmacological interventions for panic disorder with or without agoraphobia in adults

BACKGROUND

Panic disorder is common and deleterious to mental well-being. Psychological therapies and pharmacological interventions are both used as treatments for panic disorder with and without agoraphobia. However, there are no up-to-date reviews on the comparative efficacy and acceptability of the two treatment modalities, and such a review is necessary for improved treatment planning for this disorder.

OBJECTIVES

To assess the efficacy and acceptability of psychological therapies versus pharmacological interventions for panic disorder, with or without agoraphobia, in adults.

SEARCH METHODS

We searched the Cochrane Common Mental Disorders Group Specialised Register on 11 September 2015. This register contains reports of relevant randomised controlled trials from the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE (1950 to present), Embase (1974 to present), and PsycINFO (1967 to present). We cross-checked reference lists of relevant papers and systematic reviews. We did not apply any restrictions on date, language, or publication status.

SELECTION CRITERIA

We included all randomised controlled trials comparing psychological therapies with pharmacological interventions for panic disorder with or without agoraphobia as diagnosed by operationalised criteria in adults.

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted data and resolved any disagreements in consultation with a third review author. For dichotomous data, we calculated risk ratios (RR) with 95% confidence intervals (CI). We analysed continuous data using standardised mean differences (with 95% CI). We used the random-effects model throughout.

MAIN RESULTS

We included 16 studies with a total of 966 participants in the present review. Eight of the studies were conducted in Europe, four in the USA, two in the Middle East, and one in Southeast Asia.None of the studies reported long-term remission/response (long term being six months or longer from treatment commencement).There was no evidence of a difference between psychological therapies and selective serotonin reuptake inhibitors (SSRIs) in terms of short-term remission (RR 0.85, 95% CI 0.62 to 1.17; 6 studies; 334 participants) or short-term response (RR 0.97, 95% CI 0.51 to 1.86; 5 studies; 277 participants) (very low-quality evidence), and no evidence of a difference between psychological therapies and SSRIs in treatment acceptability as measured using dropouts for any reason (RR 1.33, 95% CI 0.80 to 2.22; 6 studies; 334 participants; low-quality evidence).There was no evidence of a difference between psychological therapies and tricyclic antidepressants in terms of short-term remission (RR 0.82, 95% CI 0.62 to 1.09; 3 studies; 229 participants), short-term response (RR 0.75, 95% CI 0.51 to 1.10; 4 studies; 270 participants), or dropouts for any reason (RR 0.83, 95% CI 0.53 to 1.30; 5 studies; 430 participants) (low-quality evidence).There was no evidence of a difference between psychological therapies and other antidepressants in terms of short-term remission (RR 0.90, 95% CI 0.48 to 1.67; 3 studies; 135 participants; very low-quality evidence) and evidence that psychological therapies did not significantly increase or decrease the short-term response over other antidepressants (RR 0.96, 95% CI 0.67 to 1.37; 3 studies; 128 participants) or dropouts for any reason (RR 1.55, 95% CI 0.91 to 2.65; 3 studies; 180 participants) (low-quality evidence).There was no evidence of a difference between psychological therapies and benzodiazepines in terms of short-term remission (RR 1.08, 95% CI 0.70 to 1.65; 3 studies; 95 participants), short-term response (RR 1.58, 95% CI 0.70 to 3.58; 2 studies; 69 participants), or dropouts for any reason (RR 1.12, 95% CI 0.54 to 2.36; 3 studies; 116 participants) (very low-quality evidence).There was no evidence of a difference between psychological therapies and either antidepressant alone or antidepressants plus benzodiazepines in terms of short-term remission (RR 0.86, 95% CI 0.71 to 1.05; 11 studies; 663 participants) and short-term response (RR 0.95, 95% CI 0.76 to 1.18; 12 studies; 800 participants) (low-quality evidence), and there was no evidence of a difference between psychological therapies and either antidepressants alone or antidepressants plus benzodiazepines in terms of treatment acceptability as measured by dropouts for any reason (RR 1.08, 95% CI 0.77 to 1.51; 13 studies; 909 participants; very low-quality evidence). The risk of selection bias and reporting bias was largely unclear. Preplanned subgroup and sensitivity analyses limited to trials with longer-term, quality-controlled, or individual psychological therapies suggested that antidepressants might be more effective than psychological therapies for some outcomes.There were no data to contribute to a comparison between psychological therapies and serotonin-norepinephrine reuptake inhibitors (SNRIs) and subsequent adverse effects.

AUTHORS' CONCLUSIONS

The evidence in this review was often imprecise. The superiority of either therapy over the other is uncertain due to the low and very low quality of the evidence with regard to short-term efficacy and treatment acceptability, and no data were available regarding adverse effects.The sensitivity analysis and investigation of the sources of heterogeneity indicated three possible influential factors: quality control of psychological therapies, the length of intervention, and the individual modality of psychological therapies.Future studies should examine the long-term effects after intervention or treatment continuation and should provide information on risk of bias, especially with regard to selection and reporting biases.

Antidepressants and benzodiazepines for panic disorder in adults

BACKGROUND

A panic attack is a discrete period of fear or anxiety that has a rapid onset, reaches a peak within 10 minutes and in which at least four of 13 characteristic symptoms are experienced, including racing heart, chest pain, sweating, shaking, dizziness, flushing, stomach churning, faintness and breathlessness. Panic disorder is common in the general population with a lifetime prevalence of 1% to 4%. The treatment of panic disorder includes psychological and pharmacological interventions. Amongst pharmacological agents, antidepressants and benzodiazepines are the mainstay of treatment for panic disorder. Different classes of antidepressants have been compared; and the British Association for Psychopharmacology, and National Institute for Health and Care Excellence (NICE) consider antidepressants (mainly selective serotonin reuptake inhibitors (SSRIs)) as the first-line treatment for panic disorder, due to their more favourable adverse effect profile over monoamine oxidase inhibitors (MAOIs) and tricyclic antidepressants (TCAs). In addition to antidepressants, benzodiazepines are widely prescribed for the treatment of panic disorder.

OBJECTIVES

To assess the evidence for the effects of antidepressants and benzodiazepines for panic disorder in adults.

SEARCH METHODS

The Specialised Register of the Cochrane Common Mental Disorders Group (CCMDCTR) to 11 September 2015. This register includes relevant randomised controlled trials from the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE (1950-), Embase (1974-) and PsycINFO (1967-). Reference lists of relevant papers and previous systematic reviews were handsearched. We contacted experts in this field for supplemental data.

SELECTION CRITERIA

All double-blind randomised controlled trials allocating adult patients with panic disorder to antidepressants or benzodiazepines versus any other active treatment with antidepressants or benzodiazepines.

DATA COLLECTION AND ANALYSIS

Two review authors independently checked eligibility and extracted data using a standard form. Data were entered in RevMan 5.3 using a double-check procedure. Information extracted included study characteristics, participant characteristics, intervention details, settings and outcome measures in terms of efficacy, acceptability and tolerability.

MAIN RESULTS

Thirty-five studies, including 6785 participants overall (of which 5365 in the arms of interest (antidepressant and benzodiazepines as monotherapy)) were included in this review; however, since studies addressed many different comparisons, only a few trials provided data for primary outcomes. We found low-quality evidence suggesting no difference between antidepressants and benzodiazepines in terms of response rate (risk ratio (RR) 0.99, 95% confidence interval (CI) 0.67 to 1.47; participants = 215; studies = 2). Very low-quality evidence suggested a benefit for benzodiazepines compared to antidepressants in terms of dropouts due to any cause, even if confidence interval (CI) ranges from almost no difference to benefit with benzodiazepines (RR 1.64, 95% CI 1.03 to 2.63; participants = 1449; studies = 7). We found some evidence suggesting that serotonin reuptake inhibitors (SSRIs) are better tolerated than TCAs (when looking at the number of patients experiencing adverse effects). We failed to find clinically significant differences between individual benzodiazepines. The majority of studies did not report details on random sequence generation and allocation concealment; similarly, no details were provided about strategies to ensure blinding. The study protocol was not available for almost all studies so it is difficult to make a judgment on the possibility of outcome reporting bias. Information on adverse effects was very limited.

AUTHORS' CONCLUSIONS

The identified studies are not sufficient to comprehensively address the objectives of the present review. The majority of studies enrolled a small number of participants and did not provide data for all the outcomes specified in the protocol. For these reasons most of the analyses were underpowered and this limits the overall completeness of evidence. In general, based on the results of the current review, the possible role of antidepressants and benzodiazepines should be assessed by the clinician on an individual basis. The choice of which antidepressant and/or benzodiazepine is prescribed can not be made on the basis of this review only, and should be based on evidence of antidepressants and benzodiazepines efficacy and tolerability, including data from placebo-controlled studies, as a whole. Data on long-term tolerability issues associated with antidepressants and benzodiazepines exposure should also be carefully considered.The present review highlights the need for further higher-quality studies comparing antidepressants with benzodiazepines, which should be conducted with high-methodological standards and including pragmatic outcome measures to provide clinicians with useful and practical data. Data from the present review will be included in a network meta-analysis of psychopharmacological treatment in panic disorder, which will hopefully provide further useful information on this issue.

Reconsolidation versus retrieval competition: Rival hypotheses to explain memory change in psychotherapy

I suggest it is premature to assume memory reconsolidation provides a unifying model of psychotherapeutic change given our current state of knowledge, and that other basic memory mechanisms, also supported by neuroscience, have a stronger claim at present. In particular, I propose that retrieval competition provides a more plausible alternative to memory reconsolidation.

Is There Room for Second-Generation Antipsychotics in the Pharmacotherapy of Panic Disorder? A Systematic Review Based on PRISMA Guidelines

A role for second-generation antipsychotics (SGAs) in the treatment of panic disorders (PD) has been proposed, but the actual usefulness of SGAs in this disorder is unclear. According to the PRISMA guidelines, we undertook an updated systematic review of all of the studies that have examined, in randomized controlled trials, the efficacy and tolerability of SGAs (as either monotherapy or augmentation) in the treatment of PD, with or without other comorbid psychiatric disorders. Studies until 31 December 2015 were identified through PubMed, PsycINFO, Embase, Cochrane Library and Clinical trials.gov. Among 210 studies, five were included (two involving patients with a principal diagnosis of PD and three involving patients with bipolar disorder with comorbid PD or generalized anxiety disorder). All were eight-week trials and involved treatments with quetiapine extended release, risperidone and ziprasidone. Overall, a general lack of efficacy of SGAs on panic symptoms was observed. Some preliminary indications of the antipanic effectiveness of risperidone are insufficient to support its use in PD, primarily due to major limitations of the study. However, several methodological limitations may have negatively affected all of these studies, decreasing the validity of the results and making it difficult to draw reliable conclusions. Except for ziprasidone, SGAs were well tolerated in these short-term trials.

Efficacité de la psychothérapie comparativement à la pharmacothérapie dans le traitement des troubles anxieux et dépressifs chez l’adulte : une revue de la littérature

Dans l’optique de l’amélioration d’une couverture de la psychothérapie au Québec, le ministère de la Santé et des Services sociaux a confié à l’Institut national d’excellence en santé et en services sociaux le mandat d’évaluer l’efficacité de la psychothérapie comparée à la pharmacothérapie dans le traitement des adultes souffrant de troubles anxieux et dépressifs. Une mise à jour d’une revue de la littérature récente et de bonne qualité a été effectuée grâce à une revue des revues systématiques traitant de la psychothérapie comparée à la pharmacothérapie dans le traitement des adultes anxieux et dépressifs avec un horizon temporel compris entre 2009 et 2013. Le niveau de l’ensemble de la preuve scientifique permet de dire que de manière générale, il n’y a pas de différence significative entre la psychothérapie et la pharmacothérapie sur le plan de la réduction des symptômes des patients souffrant de troubles anxieux ou dépressifs modérés, ce qui indique une efficacité comparable de ces deux modes de traitement. Cependant, les avantages de la psychothérapie sont maintenus plus longtemps après la fin du traitement que ceux des médicaments. La psychothérapie offre donc une meilleure protection contre la rechute. Par ailleurs, la combinaison de la psychothérapie et de la pharmacothérapie présente une efficacité supérieure à celle de la psychothérapie seule dans les cas chroniques ou graves.

An Overview of Translationally Informed Treatments for Posttraumatic Stress Disorder: Animal Models of Pavlovian Fear Conditioning to Human Clinical Trials

Posttraumatic stress disorder manifests after exposure to a traumatic event and is characterized by avoidance/numbing, intrusive symptoms and flashbacks, mood and cognitive disruptions, and hyperarousal/reactivity symptoms. These symptoms reflect dysregulation of the fear system likely caused by poor fear inhibition/extinction, increased generalization, and/or enhanced consolidation or acquisition of fear. These phenotypes can be modeled in animal subjects using Pavlovian fear conditioning, allowing investigation of the underlying neurobiology of normative and pathological fear. Preclinical studies reveal a number of neurotransmitter systems and circuits critical for aversive learning and memory that have informed the development of therapies used in human clinical trials. In this review, we discuss the evidence for a number of established and emerging pharmacotherapies and device-based treatments for posttraumatic stress disorder that have been developed via a bench to bedside translational model.

Efficacy of treatments for anxiety disorders: a meta-analysis

To our knowledge, no previous meta-analysis has attempted to compare the efficacy of pharmacological, psychological and combined treatments for the three main anxiety disorders (panic disorder, generalized anxiety disorder and social phobia). Pre-post and treated versus control effect sizes (ES) were calculated for all evaluable randomized-controlled studies (n = 234), involving 37,333 patients. Medications were associated with a significantly higher average pre-post ES [Cohen's d = 2.02 (1.90-2.15); 28,051 patients] than psychotherapies [1.22 (1.14-1.30); 6992 patients; P < 0.0001]. ES were 2.25 for serotonin-noradrenaline reuptake inhibitors (n = 23 study arms), 2.15 for benzodiazepines (n = 42), 2.09 for selective serotonin reuptake inhibitors (n = 62) and 1.83 for tricyclic antidepressants (n = 15). ES for psychotherapies were mindfulness therapies, 1.56 (n = 4); relaxation, 1.36 (n = 17); individual cognitive behavioural/exposure therapy (CBT), 1.30 (n = 93); group CBT, 1.22 (n = 18); psychodynamic therapy 1.17 (n = 5); therapies without face-to-face contact (e.g. Internet therapies), 1.11 (n = 34); eye movement desensitization reprocessing, 1.03 (n = 3); and interpersonal therapy 0.78 (n = 4). The ES was 2.12 (n = 16) for CBT/drug combinations. Exercise had an ES of 1.23 (n = 3). For control groups, ES were 1.29 for placebo pills (n = 111), 0.83 for psychological placebos (n = 16) and 0.20 for waitlists (n = 50). In direct comparisons with control groups, all investigated drugs, except for citalopram, opipramol and moclobemide, were significantly more effective than placebo. Individual CBT was more effective than waiting list, psychological placebo and pill placebo. When looking at the average pre-post ES, medications were more effective than psychotherapies. Pre-post ES for psychotherapies did not differ from pill placebos; this finding cannot be explained by heterogeneity, publication bias or allegiance effects. However, the decision on whether to choose psychotherapy, medications or a combination of the two should be left to the patient as drugs may have side effects, interactions and contraindications.

Lifestyle Behaviours Add to the Armoury of Treatment Options for Panic Disorder: An Evidence-Based Reasoning

This article presents an evidence-based reasoning, focusing on evidence of an Occupational Therapy input to lifestyle behaviour influences on panic disorder that also provides potentially broader application across other mental health problems (MHP). The article begins from the premise that we are all different. It then follows through a sequence of questions, examining incrementally how MHPs are experienced and classified. It analyses the impact of individual sensitivity at different levels of analysis, from genetic and epigenetic individuality, through neurotransmitter and body system sensitivity. Examples are given demonstrating the evidence base behind the logical sequence of investigation. The paper considers the evidence of how everyday routine lifestyle behaviour impacts on occupational function at all levels, and how these behaviours link to individual sensitivity to influence the level of exposure required to elicit symptomatic responses. Occupational Therapists can help patients by adequately assessing individual sensitivity, and through promoting understanding and a sense of control over their own symptoms. It concludes that present clinical guidelines should be expanded to incorporate knowledge of individual sensitivities to environmental exposures and lifestyle behaviours at an early stage.

Empirically supported treatments for panic disorder with agoraphobia in a Spanish psychology clinic

The aim of this work is to study the sociodemographic and clinical characteristics of patients diagnosed with Panic Disorder with Agoraphobia (PD/Ag), as well as the characteristics of the treatment and its results and cost in a University Psychology Clinic. Fifty patients demanded psychological assistance for PD/Ag; 80% were women, with an average age of 29.22 years (SD = 9.03). Mean number of evaluation sessions was 3.26 (SD = 1.03), and of treatment sessions, 13.39 (SD = 9.237). Of the patients, 83.33% were discharged (that is, questionnaire scores were below the cut-off point indicated by the authors, and no PD/Ag was observed at readministration of the semistructured interview), 5.5% refused treatment, and 11% were dropouts. The average number of treatment sessions of patients who achieved therapeutic success was 15.13 (SD = 8.98). Effect sizes (d) greater than 1 were obtained in all the scales. Changes in all scales were significant (p < .05). The estimated cost of treatment for patients who achieved therapeutic success was 945.12€. The treatment results are at least similar to those of studies of efficacy and effectiveness for PD/Ag. The utility of generalizing treatments developed in research settings to a welfare clinic is discussed.

Cost-effectiveness of CBT, SSRI, and CBT+SSRI in the treatment for panic disorder

OBJECTIVE

The objective of this study was to assess the cost-effectiveness of three empirically supported treatments for panic disorder with or without agoraphobia: cognitive behavioral therapy (CBT), pharmacotherapy using a selective serotonin reuptake inhibitor (SSRI), or the combination of both (CBT+SSRI).

METHOD

Cost-effectiveness was examined based on the data from a multicenter randomized controlled trial. The Hamilton Anxiety Rating Scale was selected as a primary health outcome measure. Data on costs from a societal perspective (i.e., direct medical, direct non-medical, and indirect non-medical costs) were collected in the study sample (N=150) throughout a 24-month period in which patients received active treatment during the first twelve months and were seen twice for follow-up in the next twelve months.

RESULTS

Total costs were largely influenced by costs of the interventions and productivity losses. The mean total societal costs were lower for CBT as compared to SSRI and CBT+SSRI. Costs of medication use were substantial for both SSRI and CBT+SSRI. When examining the balance between costs and health outcomes, both CBT and CBT+SSRI led to more positive outcomes than SSRI.

CONCLUSION

Cognitive behavioral therapy is associated with the lowest societal costs. Cognitive behavioral therapy and CBT+SSRI are more cost-effective treatments for panic disorder with or without agoraphobia as compared to SSRI only.

Adding psychotherapy to antidepressant medication in depression and anxiety disorders: a meta-analysis

We conducted a meta-analysis of randomized trials in which the effects of treatment with antidepressant medication were compared to the effects of combined pharmacotherapy and psychotherapy in adults with a diagnosed depressive or anxiety disorder. A total of 52 studies (with 3,623 patients) met inclusion criteria, 32 on depressive disorders and 21 on anxiety disorders (one on both depressive and anxiety disorders). The overall difference between pharmacotherapy and combined treatment was Hedges' g = 0.43 (95% CI: 0.31-0.56), indicating a moderately large effect and clinically meaningful difference in favor of combined treatment, which corresponds to a number needed to treat (NNT) of 4.20. There was sufficient evidence that combined treatment is superior for major depression, panic disorder, and obsessive-compulsive disorder (OCD). The effects of combined treatment compared with placebo only were about twice as large as those of pharmacotherapy compared with placebo only, underscoring the clinical advantage of combined treatment. The results also suggest that the effects of pharmacotherapy and those of psychotherapy are largely independent from each other, with both contributing about equally to the effects of combined treatment. We conclude that combined treatment appears to be more effective than treatment with antidepressant medication alone in major depression, panic disorder, and OCD. These effects remain strong and significant up to two years after treatment. Monotherapy with psychotropic medication may not constitute optimal care for common mental disorders.

Rate of improvement during and across three treatments for panic disorder with or without agoraphobia: cognitive behavioral therapy, selective serotonin reuptake inhibitor or both combined

BACKGROUND

Existing literature on panic disorder (PD) yields no data regarding the differential rates of improvement during Cognitive Behavioral Therapy (CBT), Selective Serotonin Reuptake Inhibitor (SSRI) or both combined (CBT+SSRI).

METHOD

Patients were randomized to CBT, SSRI or CBT+SSRI which each lasted one year including three months of medication taper. Participating patients kept record of the frequency of panic attacks throughout the full year of treatment. Rate of improvement on panic frequency and the relationship between rate of improvement and baseline agoraphobia (AG) were examined.

RESULTS

A significant decline in frequency of panic attacks was observed for each treatment modality. SSRI and CBT+SSRI were associated with a significant faster rate of improvement as compared to CBT. Gains were maintained after tapering medication. For patients with moderate or severe AG, CBT+SSRI was associated with a more rapid improvement on panic frequency as compared to patients receiving either mono-treatment.

LIMITATIONS

Frequency of panic attacks was not assessed beyond the full year of treatment. Second, only one process variable was used.

CONCLUSIONS

Patients with PD respond well to each treatment as indicated by a significant decline in panic attacks. CBT is associated with a slower rate of improvement as compared to SSRI and CBT+SSRI. Discontinuation of SSRI treatment does not result in a revival of frequency of panic attacks. Our data suggest that for patients without or with only mild AG, SSRI-only will suffice. For patients with moderate or severe AG, the combined CBT+SSRI treatment is recommended.

The efficacy of psychotherapy and pharmacotherapy in treating depressive and anxiety disorders: a meta-analysis of direct comparisons

Although psychotherapy and antidepressant medication are efficacious in the treatment of depressive and anxiety disorders, it is not known whether they are equally efficacious for all types of disorders, and whether all types of psychotherapy and antidepressants are equally efficacious for each disorder. We conducted a meta-analysis of studies in which psychotherapy and antidepressant medication were directly compared in the treatment of depressive and anxiety disorders. Systematic searches in bibliographical databases resulted in 67 randomized trials, including 5,993 patients that met inclusion criteria, 40 studies focusing on depressive disorders and 27 focusing on anxiety disorders. The overall effect size indicating the difference between psychotherapy and pharmacotherapy after treatment in all disorders was g=0.02 (95% CI: -0.07 to 0.10), which was not statistically significant. Pharmacotherapy was significantly more efficacious than psychotherapy in dysthymia (g=0.30), and psychotherapy was significantly more efficacious than pharmacotherapy in obsessive-compulsive disorder (g=0.64). Furthermore, pharmacotherapy was significantly more efficacious than non-directive counseling (g=0.33), and psychotherapy was significantly more efficacious than pharmacotherapy with tricyclic antidepressants (g=0.21). These results remained significant when we controlled for other characteristics of the studies in multivariate meta-regression analysis, except for the differential effects in dysthymia, which were no longer statistically significant.

Chronic antidepressant treatment impairs the acquisition of fear extinction

BACKGROUND

Like fear conditioning, the acquisition phase of extinction involves new learning that is mediated by the amygdala. During extinction training, the conditioned stimulus is repeatedly presented in the absence of the unconditioned stimulus, and the expression of previously learned fear gradually becomes suppressed. Our previous study revealed that chronic treatment with a selective serotonin reuptake inhibitor (SSRI) impairs the acquisition of auditory fear conditioning. To gain further insight into how SSRIs affect fear learning, we tested the effects of chronic SSRI treatment on the acquisition of extinction.

METHODS

Rats were treated chronically (22 days) or subchronically (9 days) with the SSRI citalopram (10 mg/kg/day) before extinction training. The results were compared with those after chronic and subchronic treatment with tianeptine (10 mg/kg/day), an antidepressant with a different method of action. The expression of the NR2B subunit of the N-methyl-D-aspartate receptor in the amygdala was examined after behavioral testing.

RESULTS

Chronic but not subchronic administration of citalopram impaired the acquisition of extinction and downregulated the NR2B subunit of the N-methyl-D-aspartate receptor in the lateral and basal nuclei of the amygdala. Similar behavioral and molecular changes were found with tianeptine treatment.

CONCLUSIONS

These results provide further evidence that chronic antidepressant treatment can impair amygdala-dependent learning. Our findings are consistent with a role for glutamatergic neurotransmission in the final common pathway of antidepressant treatment.

Antianxiety medications for the treatment of complex agoraphobia: pharmacological interventions for a behavioral condition

BACKGROUND

Although there are controversial issues (the "American view" and the "European view") regarding the construct and definition of agoraphobia (AG), this syndrome is well recognized and it is a burden in the lives of millions of people worldwide. To better clarify the role of drug therapy in AG, the authors summarized and discussed recent evidence on pharmacological treatments, based on clinical trials available from 2000, with the aim of highlighting pharmacotherapies that may improve this complex syndrome.

METHODS

A systematic review of the literature regarding the pharmacological treatment of AG was carried out using MEDLINE, EBSCO, and Cochrane databases, with keywords individuated by MeSH research. Only randomized, placebo-controlled studies or comparative clinical trials were included.

RESULTS

After selection, 25 studies were included. All the selected studies included patients with AG associated with panic disorder. Effective compounds included selective serotonin reuptake inhibitors, serotonin-norepinephrine reuptake inhibitors, tricyclic antidepressants, selective noradrenergic reuptake inhibitors, and benzodiazepines. Paroxetine, sertraline, citalopram, escitalopram, and clomipramine showed the most consistent results, while fluvoxamine, fluoxetine, and imipramine showed limited efficacy. Preliminary results suggested the potential efficacy of inositol; D-cycloserine showed mixed results for its ability to improve the outcome of exposure-based cognitive behavioral therapy. More studies with the latter compounds are needed before drawing definitive conclusions.

CONCLUSION

No studies have been specifically oriented toward evaluating the effect of drugs on AG; in the available studies, the improvement of AG might have been the consequence of the reduction of panic attacks. Before developing a "true" psychopharmacology of AG it is crucial to clarify its definition. There may be several potential mechanisms involved, including fear-learning processes, balance system dysfunction, high light sensitivity, and impaired visuospatial abilities, but further studies are warranted.

Patterns of psychiatric and physical comorbidities associated with panic disorder in a nationwide population-based study in Taiwan

OBJECTIVE

This study aims to document a range of risk of psychiatric and physical comorbidities among PD patients using a nationwide population-based dataset in Taiwan.

METHOD

A total of 3672 patients with at least three consensus diagnoses with PD were included, together with 18 360 matched controls without PD. Logistic regression analyses were performed after adjusting for sociodemographic characteristics.

RESULTS

After adjusting for the patients' sex, age and geographic region, patients with PD were more likely to have major depressive disorder (OR = 23.45), bipolar disorder (OR = 15.54), cardiac dysrhythmia (OR = 15.12), coronary heart disease (OR = 7.69), myocardial infarction (OR = 6.55), irritable bowel syndrome (OR = 4.82), peptic ulcers (OR = 4.30), cerebrovascular disease (OR = 3.61), hypertension (OR = 3.31), epilepsy (OR = 3.07), hepatitis (OR = 2.70), hyperlipidemia (OR = 2.20), asthma (OR = 2.17), schizophrenia (OR = 2.14), neoplasms (OR = 2.02), renal disease (OR = 1.89) and diabetes (OR = 1.26), compared to patients in the comparison cohort.

CONCLUSION

We conclude that PD is associated with an array of psychiatric and physical illnesses.

Advances in molecular genetics of panic disorder

The molecular genetic research on panic disorder (PD) has grown tremendously in the past decade. Although the data from twin and family studies suggest an involvement of genetic factors in the familial transmission of PD with the heritability estimate near 40%, the genetic substrate underlying panicogenesis is not yet understood. The linkage studies so far have suggested that chromosomal regions 13q, 14q, 22q, 4q31-q34, and probably 9q31 are associated with the transmission of PD phenotypes. To date, more than 350 candidate genes have been examined in association studies of PD, but most of these results remain inconsistent, negative, or not clearly replicated. Only Val158Met polymorphism of the catechol-O-methyltransferase gene has been implicated in susceptibility to PD by several studies in independent samples and confirmed in a recent meta-analysis. However, the specific role of this genetic variation in PD requires additional analysis considering its gender- and ethnicity-dependent effect and putative impact on cognitive functions. The recent advantages in bioinformatics and genotyping technologies, including genome-wide association and gene expression methods, provide the means for far more comprehensive discovery in PD. The progress in clinical and neurobiological concepts of PD may further guide genetic research through the current controversies to more definitive findings.

A randomized controlled study of paroxetine and cognitive-behavioural therapy for late-life panic disorder

OBJECTIVE

To examine the effectiveness of paroxetine and cognitive-behavioural therapy (CBT) in elderly patients suffering from panic disorder with or without agoraphobia (PD(A)).

METHOD

Forty-nine patients aged 60+ years with confirmed PD(A) were randomly assigned to 40 mg paroxetine, individual CBT, or to a 14-week waiting list. Outcomes, with avoidance behaviour and agoraphobic cognitions being the primary measures, were assessed at baseline and at weeks 8, 14 (conclusion CBT/waiting list), and at week 26 (treated patients only) and analysed using mixed models.

RESULTS

All outcome measures showed that the patients having received CBT and those treated with paroxetine had significantly better improvement compared with those in the waiting-list condition. With one patient (1/20, 5%) in the CBT and three (3/14, 17.6%) in the paroxetine condition dropping out, attrition rates were low.

CONCLUSION

Patients with late-life panic disorder respond well to both paroxetine and CBT. Although promising, the outcomes warrant replication in larger study groups.

Next-step strategies for panic disorder refractory to initial pharmacotherapy: a 3-phase randomized clinical trial

BACKGROUND

More data are needed to guide next-step interventions for panic disorder refractory to initial intervention.

METHOD

This 24-week randomized clinical trial (RCT) enrolled 46 patients with DSM-IV-defined panic disorder from November 2000 to April 2005 and consisted of 3 phases. Patients who failed to meet remission criteria were eligible for randomization in the next treatment phase. Phase 1 was a 6-week lead-in with open-label sertraline flexibly dosed to 100 mg (or escitalopram equivalent) to prospectively define treatment refractoriness (lack of remission). Phase 2 was a 6-week double-blind RCT of (1) increased-dose selective serotonin reuptake inhibitor (SSRI) versus (2) continued SSRI plus placebo. Phase 3 was a 12-week RCT of added cognitive-behavioral therapy (CBT) compared to "medication optimization" with SSRI plus clonazepam. Primary endpoints were remission and change in Panic Disorder Severity Scale (PDSS) score in the intent-to-treat sample in each phase.

RESULTS

In phase 1, 20.5% (8/39) of the patients achieved remission, and only baseline severity predicted endpoint PDSS score (beta [SE] = 1.04 [0.15], t = 6.76, P < .001). In phase 2, increasing the SSRI dose did not result in greater improvement or remission rates (placebo 15% [n = 2] vs increased dose 9% [n = 1]: Fisher exact test P = NS). In phase 3, remission was minimal (medication optimization = 11% [n = 1]; CBT = 10% [n = 1]), with a lack of group difference in PDSS score reduction (t(17) = 0.51, P > .60) consistent with a small effect size (d = 0.24).

CONCLUSIONS

Although power was limited and larger studies are needed, we failed to find evidence for greater benefit of increased SSRI dose versus continuation of current dose for panic disorder symptomatic after 6 weeks at moderate dose. Further, augmentation with CBT or medication optimization with clonazepam augmentation in nonremitted panic after 12 weeks of an SSRI did not differ, suggesting that both are reasonable next-step options. However, low overall remission rates in this comorbid refractory population suggest that better predictors of response to specific treatments over time and additional interventions are needed.

TRIAL REGISTRATION

clinicaltrials.gov Identifier: NCT00118417.

Cognitive behavior therapy in the treatment of panic disorder

BACKGROUND

Comprehensive cognitive behavior therapies have been proved to be more effective than behavioral interventions. However, the efficacy of CBT is not studied in the Indian context and also, the amount of change brought about by CBT is not known.

AIMS

This study aims to examine the efficacy of cognitive behavioral intervention (CBI) in the treatment of panic disorder. Our specific objectives were to assess the effectiveness of CBI in reducing symptom severity as well as cognitions related to panic and panic-related behaviors.

DESIGN

The study adopted a two-group comparison with pre- and postassessments design.

MATERIALS AND METHODS

The sample consisted of 30 patients sequentially allotted to the CBI (n = 15) and behavioral intervention (BI, n = 15) groups. Assessment was done using a semistructured interview schedule, panic disorder severity scale, Texas panic attack record form, Anxiety Sensitivity Index, Agoraphobic cognitions questionnaire, Behavioral avoidance checklist, and Panic appraisal inventory. The CBI group was provided with comprehensive cognitive behavior therapy and the BI group with psycho-education and applied relaxation.

RESULTS

CBI was found to be superior to BI in the reduction of panic symptoms, behavioral avoidance, safety behaviors, and cognitions. A large percentage of the CBI group patients met the criteria for clinically significant change with a large magnitude of change.

CONCLUSION

Multicomponent CBI is superior to BI in terms of the amount of change it brings about with respect to panic symptoms, avoidance, safety behaviors, and cognitions.

Treatment of panic disorder: recent developments and current status

Panic disorder is a commonly encountered condition in general medical practice and in various medical settings. It is important for all medical practitioners to be able to recognize this disorder, provide patients with basic information and medical advice, and depending on the specific circumstances, to refer patients for appropriate treatment by primary care physicians, psychiatrists and/or clinical psychologists. This article reviews the developments in the treatment of panic disorder, focusing on the major treatment modalities of pharmacotherapy and cognitive-behavior therapy, as well as their combinations. In addition to providing information on current treatments for panic disorder and the main underlying treatment issues, the article identifies areas where improvements need to be made and areas where much research has been conducted in recent years. These include simplified modes of delivery of cognitive-behavior therapy, optimal ways of combining medications with cognitive-behavior therapy, and minimizing the risk of recurrence after the cessation of treatment.