Long‐term outcome of pharmacological and psychological treatment for panic disorder with agoraphobia: a 2‐year naturalistic follow‐up Treatment of Panic Disorder with Agoraphobia: Randomized Placebo‐Controlled Trial of Four Psychosocial Treatments Combined with Imipramine or Placebo Treatment of panic disorder with agoraphobia: comparison of fluvoxamine, placebo, and psychological panic management combined with exposure and of exposure in vivo alone. A 15-year follow-up study of patients with panic disorder. Cognitive therapy versus interoceptive exposure as treatment of panic disorder without agoraphobia. SECOND-STAGE TREATMENTS FOR RELATIVE NONRESPONDERS TO COGNITIVE BEHAVIORAL THERAPY (CBT) FOR PANIC DISORDER WITH OR WITHOUT AGORAPHOBIA-CONTINUED CBT VERSUS SSRI: A RANDOMIZED CONTROLLED TRIAL. The benefit of an insight-oriented and experiential approach on panic and agoraphobia symptoms. Results of a controlled comparison of client-centered therapy alone and in combination with behavioral exposure. A randomized effectiveness trial of cognitive-behavioral therapy and medication for primary care panic disorder. A randomized clinical trial of cognitive behavioral therapy and interpersonal psychotherapy for panic disorder with agoraphobia. 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. Group cognitive-behavioral treatment of panic disorder. Does concurrent drug intake affect the long-term outcome of group cognitive behaviour therapy in panic disorder with or without agoraphobia? Cognitive behavior therapy vs exposure in vivo in the treatment of panic disorder with agoraphobia (corrected from agrophobia). Study and course of the psychological profile in 77 patients expressing panic disorder with agoraphobia after cognitive behaviour therapy with or without buspirone. A prospective naturalistic study of 326 panic-agoraphobic patients treated with antidepressants. Overcoming resistance to exposure in panic disorder with agoraphobia Cognitive and performance-based treatments for panic attacks in people with varying degrees of agoraphobic disability.
Two years after completion of a controlled outcome study of treatments for panic disorder with agoraphobia , patients were revisited and interviewed about their complaints . In the initial study , four treatments had been compared : ( i ) fluvoxamine combined with exposure ; ( ii ) placebo medication plus exposure ; ( iii ) psychological panic management plus exposure : and ( iv ) exposure alone . Comparison of the results at post‐test had revealed superior efficacy of fluvoxamine combined with exposure over the other three treatments in reducing agoraphobic avoidance . The current naturalistic follow‐up study investigated the long‐term efficacy of the treatments with regard to abatement of complaints and reduced dem and for further treatment . In addition , we examined whether patients were able to taper off the study medication without a recurrence of complaints . In total , 71 of the 76 patients of the original trial ( 93 % ) were interviewed . Comparison of the mean level of psychopathology at follow‐up revealed no difference between the original treatment groups . The effect in the fluvoxamine plus exposure group was maintained , but was no longer superior , due to further improvements in the other treatment groups . Most patients received additional treatment during the follow‐up period , usually because the 12 treatment sessions in the controlled study had yielded insufficient improvement . There was a trend for patients who received the fluvoxamine plus exposure treatment to require less aftercare than those who received the other treatments . Finally , almost 50 % of the patients who had received medication in the original trial were able to taper off the use of fluvoxamine without a recurrence of complaints Few r and omized controlled trials have included panic disorder patients with moderate to severe agoraphobia . Therefore , this population was studied using pharmacotherapy as well as psychotherapy . At the time of the study , imipramine was widely used as a pharmacological treatment . Also , current practice guidelines for patients with panic disorder find selective serotonin reuptake inhibitors and tricyclic antidepressants roughly comparable in terms of efficacy . Therefore , the main objective of this study is to compare four psychosocial treatments — cognitive and grade d in vivo exposure treatments , grade d in vivo exposure , cognitive treatment , and supportive therapy — to evaluate the benefits of combining cognitive therapy with exposure in vivo . These treatments were combined with imipramine or placebo for a total of eight experimental conditions . Participants presented moderate to severe agoraphobia . The method involved a r and omized , double‐blind , placebo‐controlled trial with 137 participants who completed a 14‐session protocol involving the treatments just mentioned . Measures were taken at baseline and posttreatment and at 3‐ , 6‐ , and 12‐month follow‐up . All treatment conditions were statistically and clinical ly effective in reducing self‐reported panic – agoraphobia symptoms over the 1‐year follow‐up . No statistical differences were observed between imipramine and placebo conditions . This study found that all treatment modalities helped reduce panic and agoraphobic symptomatology over a 1‐year follow‐up period . These surprising results support the need to document the relations among the various components of an intervention . This would make it possible to assess the relative efficacy of the treatment components rather than of the intervention as a whole OBJECTIVE The purpose of this comparative outcome study was to investigate whether the effects of exposure in vivo treatment for panic disorder with agoraphobia could be enhanced by adding interventions specifically for panic attacks before the start of exposure treatment . The additional effect of two types of treatment for panic attacks -- pharmacological ( fluvoxamine ) and psychological ( repeated hyperventilation provocations and respiratory training)--was examined . Thus , the combined treatment of panic interventions with exposure in vivo could be compared to exposure in vivo alone . METHOD Ninety-six patients were r and omly assigned to four treatment conditions : double-blind , placebo-controlled fluvoxamine followed by exposure in vivo , psychological panic management followed by exposure , and exposure in vivo alone . Outcome was assessed by self-report measures , a st and ardized multitask behavioral avoidance test , and continuous monitoring of panic attacks .  Seventy-six patients completed the study . RESULTS All four treatments were effective and result ed in a significant decrease of agoraphobic avoidance . Moreover , the combination of fluvoxamine and exposure in vivo demonstrated efficacy superior to that of the other treatments and had twice as large an effect size ( difference between pre- and posttreatment scores ) on self-reported agoraphobic avoidance . The other treatments did not differ among each other in effectiveness . CONCLUSIONS Results of the study indicate that the short-term outcome of exposure in vivo treatment can be enhanced by adding fluvoxamine treatment . Psychological panic management combined with exposure was not superior to exposure alone of equal duration 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 Cognitive therapy ( CT ) and interoceptive exposure ( IE ) as treatments of panic disorder without agoraphobia were compared in a sample of 69 patients , r and omly allocated to condition . There were no significant differences between treatments as to reductions in panic frequency , daily anxiety levels and a composite question naire score , at posttest after the 12-session treatment , and at both follow-ups ( 4 weeks , 6 months ) . In both conditions , high percentages of patients were panic free at post and follow-up tests ( range 75 - 92 % ) . Although the reduction in idiosyncratic beliefs about the catastrophic nature of bodily sensations was equally strong in both conditions , post-treatment beliefs correlated strongly with symptoms at post and follow-up tests in the CT condition , but not in the IE condition . Reduction of beliefs may be essential in CT , but not in IE . This suggests that the two treatments utilize different change mechanisms BACKGROUND Cognitive behavioral therapy ( CBT ) and pharmacotherapy are efficacious for the short-term treatment of panic disorder . Less is known about the efficacy of these therapies for individuals who do not respond fully to short-term CBT .  METHOD The current trial is a second-step stratified r and omized design comparing two treatment conditions-selective serotonin reuptake inhibitor ( SSRI ; paroxetine or citalopram ; n = 34 ) and continued CBT  ( n = 24)-in a sample of individuals classified as treatment nonresponders to an initial course of CBT for panic disorder . Participants were r and omized to 3 months of treatment and then followed for an additional 9 months . Only treatment responders after 3 months were maintained on the treatment until 12-month follow-up . Data analysis focused on panic disorder symptoms and achievement of response status across the first 3 months of treatment . Final follow-up data are presented descriptively . RESULTS Participants in the SSRI condition showed significantly lower panic disorder symptoms as compared to continued CBT at 3 months . Results were similar when excluding individuals with comorbid major depression or analyzing the entire intent-to-treat sample . Group differences disappeared during 9-month naturalistic follow-up , although there was significant attrition and use of non study therapies in both arms . CONCLUSIONS These data suggest greater improvement in panic disorder symptoms when switching to SSRI after failure to fully respond to an initial course of CBT . Future studies should further investigate relapse following treatment discontinuation for nonresponders who became responders . Clinical trials.gov Identifier : NCT00000368 ; https:// clinical trials.gov/show/NCT00000368 BACKGROUND It is a common view that psychodynamic treatment does not help much to ameliorate the symptoms of panic and agoraphobia . The effects of an insight-oriented treatment on central anxiety symptoms are the subject of the present controlled study . METHODS Forty patients with severe panic and agoraphobia were admitted to an inpatient anxiety treatment program . Most of the patients had been treated by pharmacological means unsuccessfully . The patients were r and omly assigned to pure client-centered therapy or to additional behavioral exposure treatment . Client-centered and behavioral agoraphobia manuals were used . The patients were examined on admission , at discharge and at 3 , 6 , and 12 months follow-up for panic ( Structured Clinical Interview for DSM III-R -- SCID ) , anxiety ( Hamilton Anxiety Scale ) , agoraphobia ( SCID , Fear Survey Schedule ) , and depressive ( Hamilton Depression Scale ) symptoms . RESULTS Both client-centered treatment and a combination with exposure treatment reduced panic , avoidance and depressive symptoms significantly . For a short period the combined treatment was superior in patients ' coping actively with anxiety and improving agoraphobic symptoms . However , at 1-year follow-up there was no further difference in the reduction of anxiety and depressive symptoms . CONCLUSIONS The results are discussed with regard to the combination of these forms of therapy and to widespread skepticism about the efficacy of insight-oriented treatment BACKGROUND Panic disorder is a prevalent , often disabling condition among patients in the primary care setting . Although numerous studies have assessed the effectiveness of treatments for depression in primary care , few such studies have been conducted for panic disorder . OBJECTIVE To implement and test the effectiveness of a combined pharmacotherapy and cognitive-behavioral intervention for panic disorder tailored to the primary care setting . DESIGN R and omized , controlled study comparing intervention to treatment as usual . SETTING Six primary care clinics associated with 3 university medical schools , serving an ethnically and socioeconomically diverse patient population . PARTICIPANTS Two hundred thirty-two primary care patients meeting DSM-IV criteria for panic disorder . Comorbid mental and physical disorders were permitted , provided these did not contraindicate the treatment to be provided and were not acutely life threatening . INTERVENTION Patients were r and omized to receive either treatment as usual or an intervention consisting of a combination of up to 6 sessions ( across 12 weeks ) of cognitive-behavioral therapy ( CBT ) modified for the primary care setting , with up to 6 follow-up telephone contacts during the next 9 months , and algorithm-based pharmacotherapy provided by the primary care physician with guidance from a psychiatrist . Behavioral health specialists , the majority inexperienced in CBT for panic disorder , were trained to deliver the CBT and coordinated overall care , including pharmacotherapy . MAIN OUTCOMES MEASURES Proportion of subjects remitted ( no panic attacks in the past month , minimal anticipatory anxiety , and agoraphobia subscale score < 10 on Fear Question naire ) and responding ( Anxiety Sensitivity Index score < 20 ) and change over time in World Health Organization Disability Scale and short form 12 scores . RESULTS The combined cognitive-behavioral and pharmacotherapeutic intervention result ed in sustained and gradually increasing improvement relative to treatment as usual , with significantly higher rates at all points of both the proportion of subjects remitted ( 3 months , 20 % vs 12 % ; 12 months , 29 % vs 16 % ) and responding ( 3 months , 46 % vs 27 % ; 12 months , 63 % vs 38 % ) and significantly greater improvements in World Health Organization Disability Scale ( all points ) and short form 12 mental health functioning ( 3 and 6 months ) scores . These effects were obtained in spite of similar rates of delivery of guideline -concordant pharmacotherapy to the 2 groups . CONCLUSION Delivery of evidence -based CBT and medication using the collaborative care model and a CBT-naive , midlevel behavioral health specialist is feasible and significantly more effective than usual care for primary care panic disorder BACKGROUND Interpersonal psychotherapy ( IPT ) seems to be as effective as cognitive behavioral therapy ( CBT ) in the treatment of major depression . Because the onset of panic attacks is often related to increased interpersonal life stress , IPT has the potential to also treat panic disorder . To date , a preliminary open trial yielded promising results but there have been no r and omized controlled trials directly comparing CBT and IPT for panic disorder . METHOD This study aim ed to directly compare the effects of CBT versus IPT for the treatment of panic disorder with agoraphobia . Ninety-one adult patients with a primary diagnosis of DSM-III or DSM-IV panic disorder with agoraphobia were r and omized . Primary outcomes were panic attack frequency and an idiosyncratic behavioral test . Secondary outcomes were panic and agoraphobia severity , panic-related cognitions , interpersonal functioning and general psychopathology . Measures were taken at 0 , 3 and 4 months ( baseline , end of treatment and follow-up ) . RESULTS Intention-to-treat ( ITT ) analyses on the primary outcomes indicated superior effects for CBT in treating panic disorder with agoraphobia . Per- protocol analyses emphasized the differences between treatments and yielded larger effect sizes . Reductions in the secondary outcomes were equal for both treatments , except for agoraphobic complaints and behavior and the credibility ratings of negative interpretations of bodily sensations , all of which decreased more in CBT . CONCLUSIONS CBT is the preferred treatment for panic disorder with agoraphobia compared to IPT . Mechanisms of change should be investigated further , along with long-term outcomes 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 r and omized 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 present study examined the efficacy of an 8-wk , cognitive-behavioral group treatment for panic disorder . Patients meeting DSM-III-R criteria for panic disorder with or without agoraphobia were r and omly assigned to treatment ( N = 34 ) or delayed treatment control ( N = 33 ) . The treatment consisted of : ( a ) education and corrective information ; ( b ) cognitive therapy ; ( c ) training in diaphragmatic breathing ; and ( d ) interoceptive exposure . At posttreatment , 85 % of treated Ss were panic free , compared to 30 % of controls . Treated Ss also showed clinical ly significant improvement on indices of anxiety , agoraphobia , depression and fear of fear . Recovery , as estimated conservatively by the attainment of normal levels of functioning on each of the major clinical dimensions of the disorder ( i.e. panic , anxiety and avoidance ) , was achieved in 64 % of the treated Ss and 9 % of the controls . At the 6 month follow-up , 63 % of the treated patients met criteria for recovery . These findings mirror those from recently-completed trials of individually-administered cognitive-behavioral treatment , and suggest that CBT is a viable alternative to pharmacotherapy in the treatment of panic disorder The present study investigated the impact of pre-existing pharmacotherapy regimes on the long-term outcome of brief intensive group cognitive-behavioural therapy ( BIGCBT ) in the treatment of panic disorder with or without agoraphobia in 106 patients ( 74 females ) . Forty patients were allocated to BIGCBT without medication , 40 to BIGCBT plus anti-anxiety medication , 10 to BIGCBT plus anti-depressant medication and 16 to BIGCBT plus combined anti-anxiety and anti-depressant medications . The mean follow-up period was 3.2 yr and ranged from 1.1 to 6.2 yr . The results demonstrated that patients who received BIGCBT concurrent with pre-existing medication regimes did not differ significantly ( P > 0.001 ) from each other or from patients who underwent BIGCBT without medication on any of the dependent measures either at pre-treatment assessment or long-term follow-up . However , BIGCBT ( with or without pharmacotherapy ) was associated with significant ( P < 0.001 ) long-term improvements in frequency of panic attacks , avoidance behaviour and question naire measures of anxiety , depression and agoraphobia . Furthermore , the large majority ( 80 % ) of patients in the BIGCBT without medication group remained medication-free at long-term follow-up . Of those patients who underwent BIGCBT concurrent with pre-existing pharmacotherapy , a large percentage ( 44 % ) reported no longer taking medication for their condition at long-term follow-up . Overall , it is concluded that pre-existing medication regimes ( anti-anxiety , anti-depressant or combinations of these ) do not significantly enhance or detract from the long-term outcome of a BIGCBT program used in the treatment of panic disorder and agoraphobia Seventy-three psychiatric out patients with DSM-IV diagnosis of panic disorder with agoraphobia were assessed with a battery of independent assessor , self-observation , self-report and behavioral measures before and after therapy , and at a 1-yr follow-up . They were r and omly assigned to Exposure in vivo ( E ; n = 25 ) , Cognitive Behavior Therapy ( CBT ; n = 26 ) , or a Wait-list control ( WLC ; n = 22 ) and received 12 - 16 individual therapy sessions , once weekly . The treatments yielded significant improvements , both on panic/agoraphobia measures and on measures of general anxiety , depression , social adjustment and quality of life , which were maintained at follow-up . However , there were no significant differences between E and CBT . The three criteria of clinical ly significant improvement were achieved by 67 % of the E- patients and 79 % of the CBT- patients at post-treatment , and 74 % and 76 % , respectively , at follow-up . The conclusion that can be drawn is that adding cognitive therapy to exposure did not yield significantly better results than for exposure alone BACKGROUND The change of psychopathological dimensions during treatment of panic disorder is attracting increasing interest . METHODS A population of subjects experiencing panic disorder with agoraphobia is evaluated with the French version of the factor structure of the Symptom Checklist 90 R ( SCL 90 R ) . Two groups of patients are compared : a group receiving cognitive behaviour therapy ( CBT ) combined with buspirone and a group receiving cognitive behaviour therapy combined with placebo .  RESULTS Comparative analysis of pre- and post-test changes between both groups completing treatment showed that the combination cognitive behaviour therapy plus buspirone provided better results than those in patients who had received cognitive behaviour therapy plus placebo . This difference between treatments did not persist at the 1-year follow-up , since , while results had been effectively maintained in the CBT plus buspirone group , the CBT plus placebo group continued to improve significantly for the target dimensions of treatment . CONCLUSIONS Psychopathological dimensions on the SCL 90 R show that combination of buspirone and cognitive behaviour therapy accelerates the behaviour modification process only in the short term 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 The issue of panic disorder resistant to treatment ( whether pharmacological or psychological ) has attracted little research attention , despite its clinical frequency and importance . The aim of this study was to compare three treatment modalities , namely exposure alone ( E ) , exposure associated with imipramine ( EI ) and cognitive therapy supplementing exposure ( EC ) , in a sample of 21 patients with DSM‐IV panic disorder and agoraphobia , who failed to respond to a first st and ard course of individual behavioural treatment based on exposure in vivo . Treatments were administered according to a cross‐over , controlled design ( E‐EI‐EC , EI‐EC‐E , EC‐E‐EI ) . Twelve of the 21 patients  achieved remission ( panic‐free status ) during the trial . In 8 cases this occurred after exposure alone ( E ) and in two cases each after the other treatments ( EI and EC ) . The results revealed a significant effect of the factor time on a number of variables , and the superiority of exposure alone compared to other treatment modalities with regard to some variables . These findings suggest that long‐term behavioural treatment based on exposure may be necessary in some patients , and may induce clinical remission . However , patients who do not respond to exposure show poor tolerance of and compliance with pharmacological treatment , and are unlikely to achieve remission  with imipramine or cognitive therapy , even though this may occur in individual cases Compared the effectiveness of cognitive therapy and performance-based exposure as treatments for panic attacks . Subjects were 48 panicky individuals selected without regard to agoraphobic disability , and who varied widely in that respect . Subjects were assigned r and omly to either cognitive treatment , performance-based exposure treatment , a combined cognitive/performance treatment , or a no-treatment control condition . All three treatments led to marked and enduring improvements in panic , and did not differ from one another in effectiveness , whereas the control condition produced little benefit . However , on several measures of phobia and panic-related cognitions , performance exposure was significantly more effective than cognitive therapy . Degree of agoraphobic disability had a significant bearing on panic treatment effectiveness . Whereas 94 % of the low agoraphobia Ss were free of panic after treatment , only 52 % of the high agoraphobia Ss became panic-free . The findings suggest that when panic treatment research excludes people with serious phobias , as it has routinely done in recent years , an overly positive estimate of panic treatment effectiveness can result
After the acute phase treatment , as long as the drug was continued , the superiority of the combination over either monotherapy appeared to persist .
BACKGROUND Panic disorder can be treated with pharmacotherapy , psychotherapy or in combination , but the relative merits of combined therapy have not been well established .
OBJECTIVES To review evidence concerning short- and long-term advantages and disadvantages of combined psychotherapy plus antidepressant treatment for panic disorder with or without agoraphobia , in comparison with either therapy alone .