Catastrophic Appraisal and Perceived Control as Moderators of Treatment Response in Panic Disorder. One-year follow-up of pharmacotherapy-resistant patients with panic disorder treated with cognitive-behavior therapy: Outcome and predictors of remission. Treating Treatment-Resistant Patients with Panic Disorder and Agoraphobia Using Psychotherapy: A Randomized Controlled Switching Trial A prospective naturalistic study of 326 panic-agoraphobic patients treated with antidepressants. A randomized effectiveness trial of collaborative care for patients with panic disorder in primary care. A 15-year follow-up study of patients with panic disorder. An open study of the effectiveness of Internet treatment for panic disorder delivered in a psychiatric setting Impact of cognitive-behavioral treatment on quality of life in panic disorder patients. Feedback of end-tidal pCO2 as a therapeutic approach for panic disorder. Comparison of cognitive therapy and relaxation training for panic disorder. Next-step strategies for panic disorder refractory to initial pharmacotherapy: a 3-phase randomized clinical trial. Relationship of past depressive episodes to symptom severity and treatment response in panic disorder with agoraphobia. Quality of Life and Treatment Outcome in Panic Disorder: Cognitive Behavior Group Therapy Effects in Patients Refractory to Medication Treatment Randomized controlled trial of a brief intervention for problematic prescription drug use in non-treatment-seeking patients. Clinical experiments in maintenance and discontinuation of imipramine therapy in panic disorder with agoraphobia. Cognitive-behavioral therapy, imipramine, or their combination for panic disorder: A randomized controlled trial. Effect of medication and psychotherapy on heart rate variability in panic disorder.
The purpose of this study was to examine the moderating effects of cognitive risk factors in two mechanistically-distinct interventions . Forty-one patients with panic disorder and agoraphobia were r and omly assigned to receive training aim ed at altering respiration ( Capnometry-assisted respiratory training , CART ) or symptom appraisal ( cognitive skill training , CT ) . Using a mixed effects regression model , we assessed whether reductions in panic symptom severity ( PDSS ) were moderated by the variables of interest . While improvement in PDSS did not differ among treatment modalities , moderating effects emerged . Individuals with greater initial levels of mis appraisal showed smaller reduction in PDSS when receiving CT , but larger reduction when receiving CART . Greater lack of perceived control was predictive of worse outcome in CART , but better outcome in CT . Better homework compliance was related to greater reductions in PDSS irrespective of condition . The findings illustrate the complexity of moderating influences within and between distinct interventions Non-response to pharmacotherapy for panic disorder ( PD ) is a well-documented problem . However , little information exists to guide next-step strategies for these non-responders . In addition to pharmacologic augmentation strategies , several studies support the efficacy of cognitive-behavior therapy ( CBT ) for these patients , although data on long-term outcomes has been lacking . In this study , we provide one-year outcomes on a sample of 63 patients who completed group CBT for PD after failing to respond adequately to previous pharmacotherapy . Sustained significant benefit was found for all dimensional outcome scores , and nearly two-thirds of the sample met remission criteria . This occurred with reductions in medication use over the follow-up period . Negative predictors of remission status included comorbid dysthymia , social phobia , and generalized anxiety disorder . These results provide additional evidence for the efficacy of CBT for medication non-responders with PD Background : Nonresponsiveness to therapy is generally acknowledged , but only a few studies have tested switching to psychotherapy . This study is one of the first to examine the malleability of treatment-resistant patients using acceptance and commitment therapy ( ACT ) .  Methods : This was a r and omized controlled trial that included 43 patients diagnosed with primary panic disorder and /or agoraphobia ( PD/A ) with prior unsuccessful state-of-the-art treatment ( mean number of previous sessions = 42.2 ) . Patients were treated with an ACT manual administered by novice therapists and followed up for 6 months . They were r and omized to immediate treatment ( n = 33 ) or a 4-week waiting list ( n = 10 ) with delayed treatment ( n = 8) . Treatment consisted of eight sessions , implemented twice weekly over 4 weeks . Primary outcomes were measured with the Panic and Agoraphobia Scale ( PAS ) , the Clinical Global Impression ( CGI ) , and the Mobility Inventory ( MI ) . Results : At post-treatment , patients who received ACT reported significantly more improvements on the PAS and CGI ( d = 0.72 and 0.89 , respectively ) than those who were on the waiting list , while improvement on the MI ( d = 0.50 ) was nearly significant . Secondary outcomes were consistent with ACT theory . Follow-up assessment s indicated a stable and continued improvement after treatment . The dropout rate was low ( 9 % ) . Conclusions : Despite a clinical ly challenging sample and brief treatment administered by novice therapists , patients who received ACT reported significantly greater changes in functioning and symptomatology than those on the waiting list , with medium-to-large effect sizes that were maintained for at least 6 months . These proof-of-principle data suggest that ACT is a viable treatment option for treatment-resistant PD/A patients . Further work on switching to psychotherapy for nonresponders is clearly needed OBJECTIVE How far the results of r and omized controlled studies apply to everyday care can not be judged without regular measurements of outcomes in daily practice . We report on systematic data from a 3-year naturalistic prospect i ve study on panic disorder-agoraphobic ( PDA ) patients treated with antidepressants in a setting of routine clinical practice . Our aim is to describe the evolution of PDA in relation to the treatments employed , and to explore demographic and clinical characteristics that might be predictive of outcome . METHODS 326 DSM-III-R PDA patients treated with antidepressants in a setting of routine clinical practice were included in a 3-year naturalistic prospect i ve study . We utilized structured and semi-structures instruments , including the Structured Clinical Interview for Diagnosis and the Longitudinal Interview Follow-up Examination . The main antidepressants used were imipramine ( 39 % ) , clomipramine ( 28.5 % ) and paroxetine ( 23.3 % ) ; only 9 % of patients received other antidepressants . RESULTS 147 patients ( 45.1 % ) stayed on medication throughout the entire period of the follow-up . Of those who interrupted the treatment , 38 % stayed in remission . The probability of achieving at least one remission during the 3-year follow-up period was 96.5 % for PD and 95.9 % for Agoraphobia . Relapses after a period of at least 2 months of complete remission were also common , and the probability of presenting at least one relapse during the 3-years follow-up period was 67.1 % for PD and 39 % for Agoraphobia . The longest period of remission of PD is associated with low severity , medium-lasting course in patients with an onset of the illness in young adulthood . Less severe agoraphobia associated with moderately severe panic attacks appears to confer a better control of phobic behavior . All three major drugs were reasonably well tolerated ( only 9 % dropped out because of side effects ) , with sexual dysfunction and increased appetite being the most common side effects at the last evaluation ; in the first phase of the treatment anticholinergic effects and jitteriness were more common with TCAs . CONCLUSION Both classical antidepressants and paroxetine emerge as a useful treatment in the long-term management of PDA ; paroxetine appears particularly useful in PDA patients because it was significantly less likely to induce jitteriness , thereby reducing barriers to compliance BACKGROUND Effectiveness studies have tested interventions to improve quality of care for depression in primary care , but none , to our knowledge , have been completed for panic disorder ( PD ) in this setting . This study sought to test the clinical effectiveness of PD pharmacotherapy embedded in a disease management framework of " collaborative care " ( CC ) . METHODS One hundred fifteen patients with PD from 3 primary care clinics were r and omized to CC or " usual care " ( UC ) . Patients in CC ( n = 57 ) received educational videotapes and pamphlets ; pharmacotherapy with the selective serotonin reuptake inhibitor paroxetine ; 2 psychiatrist visits and 2 telephone calls in the first 8 weeks ; and up to 5 telephone calls between 3 and 12 months ' follow-up . Usual care patients ( n = 58 ) were treated by their primary care physician . Telephone assessment s of panic , anxiety sensitivity , depression , and disability variables were performed at 3 , 6 , 9 , and 12 months ' follow-up . Adequacy of pharmacotherapy was assessed with an algorithm based on a review of efficacy studies . RESULTS Patients in CC were more likely to receive adequate ( type , dose , duration ) medication and more likely to adhere to this medication at 3 and 6 months . R and om regression analyses showed that CC patients improved significantly more over time compared with UC patients on anxiety , depression , and disability measures , with the greatest effects at 3 and 6 months . CONCLUSIONS Compared with UC , CC interventions significantly improved both quality of care and clinical and functional outcomes in primary care PD patients . Clinical differences were greatest in the first 6 months , corresponding to the greater quality of care and the greater intensity of intervention BACKGROUND Panic disorder ( PD ) is generally regarded as a chronic condition with considerable variation in severity of symptoms . AIMS To describe the long-term outcome of naturalistically treated PD . METHODS Fifty-five out patients with PD , who participated in a placebo-controlled drug trial of the efficacy of alprazolam and imipramine 15 years ago were reassessed with the same instruments used in the original study . RESULTS Complete recovery ( no panic attacks and no longer on medication during the last 10 years ) was seen in 18 % of patients , and an additional 13 % recovered but were still on medication . Fifty-one percent experienced recurrent anxiety attacks whereas 18 % still met diagnostic criteria for PD . The incidence of agoraphobia decreased from 69 % to 20 % . Patients with agoraphobia at admission tended to have a poorer long-term outcome according to daily functioning compared with patients without agoraphobia at admission , although both groups reported improved daily functioning at follow-up . Maintenance medication was common . No benzodiazepine abuse was reported . CONCLUSION PD has a favourable outcome in a substantial proportion of patients . However , the illness is chronic and needs treatment . The short-term treatment given in the drug trial had no influence on the long-term outcome Panic disorder with or without agoraphobia ( PD/A ) is common and can be treated effectively with selective serotonin reuptake inhibitor ( SSRI ) medication or cognitive – behaviour therapy ( CBT ) . However , the lack of access to CBT services has motivated the development of self-help approaches requiring less therapist contact . A novel treatment modality in this field , showing efficacy in several r and omized trials but until now not evaluated within the context of regular psychiatric care , is Internet-based treatment . The aim of the present study was to evaluate the effectiveness of Internet-based CBT  for patients in a psychiatric setting . Twenty consecutively referred patients with PD were included in the study . A structured clinical interview with a psychiatrist was conducted for inclusion , as well as at post-treatment and at the 6-month follow-up . The treatment consisted of a 10-week CBT-based self-help programme , including minimal therapist support by e-mail . At post-treatment , 94 % of patients no longer met DSM-IV criteria for PD ( 82 % at 6-month follow-up ) . The within-group effect sizes ( for the main outcome PDSS ; Panic Disorder Severity Scale ) were Cohen 's d=2.5 ( pre- to post-treatment ) and 2.8 ( pre-treatment to follow-up ) , respectively . The proportion of responders on the PDSS was 75 % at post-treatment and 70 % at 6-month follow-up . The results supports earlier efficacy data on Internet-based CBT for PD and indicates that it is effective also within a regular psychiatric setting . However , a larger r and omized controlled trial should be conducted , directly comparing Internet-based CBT with traditionally administered CBT within such a setting Panic disorder ( PD ) is associated with significant social and health consequences . The present study examined the impact of treatment on PD patients '  quality of life . Patients ( N = 156 ) meeting DSM-III-R ( Diagnostic and Statistical Manual of Mental Disorders [ 3rd ed . , rev . ] ; American Psychiatric Association , 1987 ) criteria for PD with agoraphobia were r and omly assigned to group cognitive-behavioral treatment ( CBT ) or a delayed-treatment control . An assessment battery measuring the major clinical features of PD as well as quality of life was administered at baseline ( Week 0 ) , post-treatment ( Week 9 ) and 6-month follow-up ( Week 35 ) . Consistent with previous studies , PD patients displayed significant impairment in quality of life at intake . Compared with delayed-treatment control participants , CBT-treated participants showed significant reductions in impairment that were maintained at follow-up . Consistent with prediction , anxiety and phobic avoidance were significantly associated with quality of life , whereas frequency of panic attacks was not BACKGROUND Given growing evidence that respiratory dysregulation is a central feature of panic disorder ( PD ) interventions for panic that specifically target respiratory functions could prove clinical ly useful and scientifically informative . We tested the effectiveness of a new , brief , capnometry-assisted breathing therapy ( BRT ) on clinical and respiratory measures in PD . METHODS Thirty-seven participants with PD with or without agoraphobia were r and omly assigned to BRT or to a delayed-treatment control group .  Clinical status , respiration rate , and end-tidal pCO(2 ) were assessed at baseline , post-treatment , 2-month and 12-month follow-up . Respiratory measures were also assessed during homework exercises using a portable capnometer as a feedback device . RESULTS Significant improvements ( in PD severity , agoraphobic avoidance , anxiety sensitivity , disability , and respiratory measures ) were seen in treated , but not untreated patients , with moderate to large effect sizes . Improvements were maintained at follow-up . Treatment compliance was high for session attendance and homework exercises ; dropouts were few . CONCLUSIONS The data provide preliminary evidence that raising end-tidal pCO(2 ) by means of capnometry feedback is therapeutically beneficial for panic patients . Replication and extension will be needed to verify this new treatment 's efficacy and determine its mechanisms Current approaches to the treatment of panic disorder ( PD ) include a treatment package consisting of relaxation training ( RT ) , cognitive therapy ( CT ) , and exposure-based components . In an examination of the separate effects of RT and CT without formally taught exposure of any form , 64 PD patients were assigned r and omly to one of these treatment protocol s or to a minimal-contact control ( MCC ) condition . Both RT and CT were superior to the MCC condition on a variety of measures pertaining to panic , global psychological functioning , agoraphobic fear , and other associated fears . A significantly greater percentage of patients were classified as treatment responders ( based on a composite index ) after CT ( 82 % ) and RT ( 68 % ) , compared with the control group ( 36 % ) . On measures of agoraphobic fear , CT patients fared slightly better than RT patients . Some support was demonstrated for specific cognitive changes after CT , although treatment specificity was not strongly supported overall . These results are discussed in light of current theories of PD and the presumed importance of exposure in its treatment BACKGROUND More data are needed to guide next-step interventions for panic disorder refractory to initial intervention . METHOD This 24-week r and omized 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 r and omization 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 prospect ively 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 clinical trials.gov Identifier : NCT00118417 BACKGROUND Many investigators have reported that panic disorder ( PD ) patients with comorbid major depression ( MD ) have more severe symptoms and a poorer response to treatment than patients with PD alone . It is not known if this is due to a distinct and more serious underlying disorder in these patients or simply a result of the simultaneous presence of the two disorders . METHOD Nondepressed patients presenting for treatment of panic disorder with agoraphobia ( PDA ) were studied before treatment ( N = 180 ) and after 4 weeks of treatment with adinazolam sustained release ( N = 89 ) or placebo ( N = 91 ) . Twenty-nine percent ( N = 53 ) of the patients had a past history of MD .  Symptom severity and treatment outcome were compared in patients with primary , secondary , single , recurrent , or no past MD . RESULTS There were no consistent differences in symptom severity or treatment outcome in patients with a past history of primary , secondary , or single episode MD compared with patients with no history of MD . However , a small number of patients with history of recurrent MD exhibited consistently greater symptom severity and poorer response to treatment than patients with no history of MD . CONCLUSION The greater severity and worse outcome of comorbid PD and MD observed in earlier studies are more likely due to the simultaneous presence of the two disorders than to a more serious and enduring underlying disorder . However , our results suggest that recurrent MD may indicate a more serious condition in patients with PDA . This possibility warrants further study Background : Improvements in quality of life ( QoL ) as well as symptomatic relief are important outcomes for the treatment of panic disorder ( PD ) . The aim of this study is to assess the impact of brief cognitive behavior group therapy ( CBGT ) for panic disorder on QoL and to identify the clinical features associated with these changes . Methods : Thirty-six patients with PD refractory to pharmacological treatment took part in a treatment protocol consisting of 12 sessions of CBGT . To evaluate the changes in QoL , the WHOQOL-bref was administered before and after treatment . Results : Thirty-two patients completed the treatment . Significant improvement in all domains of QoL was observed ( p < 0.001 ) , which was associated with reductions in general and anticipatory anxiety ( p = 0.018 ) and agoraphobic avoidance ( p = 0.046 ) . Consistent with previous findings , associations between QoL and panic-free status did not reach significance in this small study ( p = 0.094 ) . Conclusions : CBGT was efficacious in the treatment of PD ; the symptoms of anticipatory anxiety and avoidance appear to be more important than episodic panic episodes in affecting AIMS Dependence on or problematic use of prescription drugs ( PD ) is estimated to be between 1 and 2 % in the general population . In contrast , the proportion of substance-specific treatment in PD use disorders at 0.5 % is comparatively low . With an estimated prevalence of 4.7 % , PD-specific disorders are widespread in general hospitals compared to the general population . Brief intervention delivered in general hospitals might be useful to promote discontinuation or reduction of problematic prescription drug use . DESIGN A r and omized , controlled clinical trial . SETTING Internal , surgical and gynaecological wards of a general and a university hospital . PARTICIPANTS One hundred and twenty-six patients fulfilling criteria for either regular use of PD ( more than 60 days within the last 3 months ) or dependence on or abuse of PD , respectively , were allocated r and omly to two conditions . INTERVENTION Subjects received two counselling sessions based on Motivational Interviewing plus an individualized written feedback ( intervention group , IG ) or a booklet on health behaviour ( control group , CG ) . MEASUREMENTS The outcome was measured as reduction ( > 25 % ) and discontinuation of PD intake in terms of defined daily dosages ( DDD ) . FINDINGS After 3 months , more participants in the IG reduced their DDD compared to the participants in the CG ( 51.8 % versus 30 % ; chi(2 ) = 6.17 ; P = 0.017 ) . In the IG 17.9 % , in the CG 8.6 % discontinued use of PD ( chi(2 ) = 2.42 ; P = 0.17 ) . Conclusions Brief intervention based on Motivational Interviewing is effective in reducing PD intake in non-treatment-seeking patients Several issues remain to be ascertained beyond the acute response to imipramine hydrochloride in patients with panic disorder . Study 1 consisted of a prospect i ve , systematic characterization of half-dose 12-month maintenance in patients with panic disorder with agoraphobia who had shown marked and stable response to 6 months of acute-phase treatment with imipramine .  Study 2 assessed the 6-month cumulative relapse rate following discontinuation of acute-phase imipramine treatment in a comparable sample of patients . The same assessment battery was used in both studies , and the integrity of experimental drug conditions was verified by plasma drug level determinations . In contrast to the high relapse rate following discontinuation of acute-phase treatment , none of the patients showed relapse or had sustained worsening in panic or phobia measures during the half-dose maintenance period . The results underscore the importance of pharmacological prophylaxis and provide empirical guidelines for a successful low-dose maintenance regimen for patients with panic disorder and agoraphobia who respond markedly to imipramine CONTEXT Panic disorder ( PD ) may be treated with drugs , psychosocial intervention , or both , but the relative and combined efficacies have not been evaluated in an unbiased fashion . OBJECTIVE To evaluate whether drug and psychosocial therapies for PD are each more effective than placebo , whether one treatment is more effective than the other , and whether combined therapy is more effective than either therapy alone . DESIGN AND SETTING R and omized , double-blind , placebo-controlled clinical trial conducted in 4 anxiety research clinics from May 1991 to April 1998 . PATIENTS A total of 312 patients with PD were included in the analysis . INTERVENTIONS Patients were r and omly assigned to receive imipramine , up to 300 mg/d , only ( n=83 ) ; cognitive-behavioral therapy ( CBT ) only ( n=77 ) ; placebo only ( n=24 ) ; CBT plus imipramine ( n=65 ) ; or CBT plus placebo ( n=63 ) . Patients were treated weekly for 3 months ( acute phase ) ; responders were then seen monthly for 6 months ( maintenance phase ) and then followed up for 6 months after treatment discontinuation . MAIN OUTCOME MEASURES Treatment response based on the Panic Disorder Severity Scale ( PDSS ) and the Clinical Global Impression Scale ( CGI ) by treatment group . RESULTS Both imipramine and CBT were significantly superior to placebo for the acute treatment phase as assessed by the PDSS ( response rates for the intent-to-treat [ ITT ] analysis , 45.8 % , 48.7 % , and 21.7 % ; P=.05 and P=.03 , respectively ) , but were not significantly different for the CGI ( 48 . 2 % , 53.9 % , and 37.5 % , respectively ) . After 6 months of maintenance , imipramine and CBT were significantly more effective than placebo for both the PDSS ( response rates , 37.8 % , 39.5 % , and 13.0 % , respectively ; P=.02 for both ) and the CGI ( 37.8 % , 42.1 % , and 13.0 % , respectively ) . Among responders , imipramine produced a response of higher quality . The acute response rate for the combined treatment was 60.3 % for the PDSS and 64.1 % for the CGI ; neither was significantly different from the other groups . The 6-month maintenance response rate for combined therapy was 57.1 % for the PDSS ( P=.04 vs CBT alone and P=.03 vs imipramine alone ) and 56.3 % for the CGI ( P=.03 vs imipramine alone ) , but not significantly better than CBT plus placebo in either analysis . Six months after treatment discontinuation , in the ITT analysis CGI response rates were 41.0 % for CBT plus placebo , 31.9 % for CBT alone , 19.7 % for imipramine alone , 13 % for placebo , and 26.3 % for CBT combined with imipramine . CONCLUSIONS Combining imipramine and CBT appeared to confer limited advantage acutely but more substantial advantage by the end of maintenance . Each treatment worked well immediately following treatment and during maintenance ; CBT appeared durable in follow-up . JAMA . 2000;283:2529 - BACKGROUND Panic disorder ( PD ) patients have been shown to have reduced heart rate variability ( HRV ) . Low HRV has been associated with elevated risk for cardiovascular disease . Our aim was to investigate the effects of treatment on heart rate ( HR ) in patients with PD through a hyperventilation challenge . METHODS We studied 54 participants , 43 with Diagnostic and Statistical Manual of Mental Disorders ( DSM-IV ) PD and 11 controls . Subjects lay supine with their heads in a plastic canopy chamber , resting for 15 min and then breathing at a rate of 30 breaths per minute for 10 min . HRV was sample d for spectral analysis . Clinical and behavioral measures of anxiety were assessed . Treatment was chosen by patients : either 12 weeks of CBT alone or CBT with sertraline . RESULTS All patients showed significant decrease on clinical measures from baseline and 31 were treatment responders , 8 dropped out of the study before completion of the 12-week treatment phase and 4 were deemed nonresponders after 12 weeks of treatment . Although both treatments led to significant clinical improvement , only CBT alone demonstrated a significant reduction in HR and increase in HRV . CONCLUSIONS Our study replicated the finding that increased HR and decreased HRV occur in PD patients . Given the evidence of cardiac risk related to HRV , CBT appears to have additional benefits beyond symptom reduction . The mechanisms of this difference between CBT and sertraline are unclear and require further study
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 .
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 .
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 up date d ( 2015–2017 ) systematic review of pharmacological/non-pharmacological studies , and our personal perspective on this topic .