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Psychotherapy plus antidepressant for panic disorder with or without agoraphobia: Systematic review

  • Toshi A. Furukawa (a1), Norio Watanabe (a1) and Rachel Churchill (a2)

Abstract

Background

Panic disorder can be treated with psychotherapy, pharmacotherapy or a combination of both.

Aims

To summarise the evidence concerning the short- and long-term benefits and adverse effects of a combination of psychotherapy and antidepressant treatment.

Method

Meta-analyses and meta-regressions were undertaken using data from all relevant randomised controlled trials identified by a comprehensive literature search. The primary outcome was relative risk (RR) of response.

Results

We identified 23 randomised comparisons (21 trials involving a total of 1709 patients). In the acute-phase treatment, the combined therapy was superior to antidepressant pharmacotherapy (RR=1.24, 95% CI 1.02–1.52) or psychotherapy (RR=1.16, 95%CI 1.03–1.30). After termination of the acute-phase treatment, the combined therapy was more effective than pharmacotherapy alone (RR=1.61, 95% CI 1.23–2.11) and was as effective as psychotherapy (RR=0.96, 95% CI 0.79–1.16).

Conclusions

Either combined therapy or psychotherapy alone may be chosen as first-line treatment for panic disorder with or without agoraphobia, depending on the patient's preferences.

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Copyright

Corresponding author

Professor Toshi A. Furukawa, Department of Psychiatry and Cognitive–Behavioural Medicine, Nagoya City University Graduate School of Medical Sciences, Nagoya City University Medical School, Mizuho-cho, Mizuho-ku, Nagoya 467-8601, Japan. Tel: +81 52 853 8271; fax: +81 52 8520837; e-mail: furukawa@med.nagoya-cu.ac.jp

Footnotes

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Declaration of interest

T.A.F. has received research grants and fees for speaking from several pharmaceutical companies. These companies did not provide funding for the current study (see Acknowledgements).

Footnotes

References

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Alderson, P., Green, S. & Higgins, J. P. T. (eds) (2004) Cochrane Reviewers' Handbook 4.2.2. Chichester: John Wiley & Sons.
American Psychiatric Association (1998) Practice guideline for the treatment of patients with panic disorder. American Journal of Psychiatry, 155, 134.
Azhar, M. Z. (2000) Comparison of fluvoxamine alone, fluvoxamine and cognitive psychotherapy and psychotherapy alone in the treatment of panic disorder in Kelantan – implications for management by family doctors. Medical Journal of Malaysia, 55, 402408.
Barlow, D. H., Gorman, J. M., Shear, M. K., et al (2000) Cognitive–behavioral therapy, imipramine, or their combination for panic disorder: a randomized controlled trial. JAMA, 283, 25292536.
Berger, P., Sachs, G., Amering, M., et al (2004) Personality disorder and social anxiety predict delayed response in drug and behavioral treatment of panic disorder. Journal of Affective Disorders, 80, 7578.
de Beurs, E., van Balkom, A. J., Lange, A., et al (1995) Treatment of panic disorder with agoraphobia: comparison of fluvoxamine, placebo, and psychological panic management combined with exposure and of exposure in vivo alone. American Journal of Psychiatry, 152, 683691.
Fahy, T. J., O'Rourke, D., Brophy, J., et al (1992) The Galway Study of Panic Disorder, I. Clomipramine and lofepramine in DSM–111–R panic disorder: a placebo-controlled trial. Journal of Affective Disorders, 25, 6375.
Fava, G. A., Savron, G., Zielezny, M., et al (1997) Overcoming resistance to exposure in panic disorder with agoraphobia. Acta Psychiatrica Scandinavica, 95, 306312.
Fava, G. A., Rafanelli, C., Grandi, S., et al (2001) Long-term outcome of panic disorder with agoraphobia treated by exposure. Psychological Medicine, 31, 891898.
Foa, E. B., Franklin, M. E. & Moser, J. (2002) Context in the clinic: how well do cognitive–behavioral therapies and medications work in combination? Biological Psychiatry, 52, 987997.
Furukawa, T. A., Guyatt, G. H. & Griffith, L. E. (2002) Can we individualize the ‘number needed to treat’? An empirical study of summary effect measures in meta-analyses. International Journal of Epidemiology, 31, 7276.
Gould, R. A., Otto, M. W. & Pollack, M. H. (1995) A meta-analysis of treatment outcome for panic disorder. Clinical Psychology Review, 15, 819844.
Guy, W. (1976) ECDEU Assessment Manual for Psychopharmacology. Rockville, MD: US Department of Health and Human Services.
Higgins, J. P., Thompson, S. G., Deeks, J. J., et al (2003) Measuring inconsistency in meta-analyses. BMJ, 327, 557560.
Hollon, S. D. & DeRubeis, R. J. (1981) Placebo–psychotherapy combinations: inappropriate representations of psychotherapy in drug–psychotherapy comparative trials. Psychological Bulletin, 90, 467477.
Johnston, D. G., Troyer, I. E., Whitsett, S. F., et al (1995) Clomipramine treatment and behaviour therapy with agoraphobic women. Canadian Journal of Psychiatry, 40, 192199.
Kampman, M., Keijsers, G. P., Hoogduin, C. A., et al (2002) A randomized, double-blind, placebo-controlled study of the effects of adjunctive paroxetine in panic disorder patients unsuccessfully treated with cognitive–behavioral therapy alone. Journal of Clinical Psychiatry, 63, 772777.
Loerch, B., Graf-Morgenstern, M., Hautzinger, M., et al (1999) Randomised placebo-controlled trial of moclobemide, cognitive–behavioural therapy and their combination in panic disorder with agoraphobia. British Journal of Psychiatry, 174, 205212.
Marks, I. M. & Mathews, A. M. (1979) Brief standard self-rating for phobic patients. Behavior Research and Therapy, 17, 263267.
Marks, I. M., Gray, S., Cohen, D., et al (1983) Imipramine and brief therapists-aided exposure in agoraphobics having self-exposure homework. Archives of General Psychiatry, 40, 153162.
Marshall, M., Lockwood, A., Bradley, C., et al (2000) Unpublished rating scales: a major source of bias in randomised controlled trials of treatments for schizophrenia. British Journal of Psychiatry, 176, 249252.
Mattick, R. P., Andrews, G., Hadzi-Pavlovic, D., et al (1990) Treatment of panic and agoraphobia. An integrative review. Journal of Nervous and Mental Disease, 178, 567576.
Mavissakalian, M. & Michelson, L. (1986) Agoraphobia: relative and combined effectiveness of therapist-assisted in vivo exposure and imipramine. Journal of Clinical Psychiatry, 47, 117122.
Mavissakalian, M. R. & Perel, J. M. (2002) Duration of imipramine therapy and relapse in panic disorder with agoraphobia. Journal of Clinical Psychopharmacology, 22, 294299.
Mavissakalian, M., Michelson, L. & Dealy, R. S. (1983) Pharmacological treatment of agoraphobia: imipramine versus imipramine with programmed practice. British Journal of Psychiatry, 143, 348355.
Nathan, P. E. & Gorman, J. M. (2002) A Guide to Treatments That Work (2nd edn). New York: Oxford University Press.
Oehrberg, S., Christiansen, P. E., Behnke, K., et al (1995) Paroxetine in the treatment of panic disorder. A randomised, double-blind, placebo-controlled study. British Journal of Psychiatry, 167, 374379.
Otto, M. W., Pollack, M. H. & Maki, K. M. (2000) Empirically supported treatments for panic disorder: costs, benefits and stepped care. Journal of Consulting and Clinical Psychology, 68, 556563.
Schmidt, N. B., Koselka, M. & Woolaway-Bickel, K. (2001) Combined treatments for phobic anxiety disorders. In Combined Treatments for Mental Disorders (eds Sammons, M. T. & Schmidt, N. B.), pp. 81110. Washington, DC: American Psychological Association.
Sharp, D. M., Power, K. G., Simpson, R. J., et al (1996) Fluvoxamine, placebo, and cognitive–behaviour therapy used alone and in combination in the treatment of panic disorder and agoraphobia. Journal of Anxiety Disorders, 10, 219242.
Shear, M. K., Brown, T. A., Barlow, D. H., et al (1997) Multicenter collaborative panic disorder severity scale. American Journal of Psychiatry, 154, 15711575.
Sheehan, D. V., Ballenger, J. & Jacobsen, G. (1980) Treatment of endogenous anxiety with phobic, hysterical and hypochondriacal symptoms. Archives of General Psychiatry, 37, 5159.
Simon, N. M., Safren, S. A., Otto, M. W., et al (2002) Longitudinal outcome with pharmacotherapy in a naturalistic study of panic disorder. Journal of Affective Disorders, 69, 201208.
Song, F., Altman, D. G., Glenny, A. M., et al (2003) Validity of indirect comparison for estimating efficacy of competing interventions: empirical evidence from published meta-analyses. BMJ, 326, 472476.
Spinhoven, P., Onstein, E. J., Klinkhamer, R. A., et al (1996) Panic management, trazodone and a combination of both in the treatment of panic disorder. Clinical Psychology and Psychotherapy, 3, 8692.
Stein, M. B., Ron Norton, G., Walker, J. R., et al (2000) Do selective serotonin re-uptake inhibitors enhance the efficacy of very brief cognitive–behavioral therapy for panic disorder? A pilot study. Psychiatry Research, 94, 191200.
Taylor, S. (2000) Understanding and Treating Panic Disorder. Chichester: John Wiley & Sons.
Telch, M. J., Agras, W. S., Taylor, C. B., et al (1985) Combined pharmacological and behavioral treatment for agoraphobia. Behavior Research and Therapy, 23, 325335.
Thompson, S. G. & Sharp, S. J. (1999) Explaining heterogeneity in meta-analysis: acomparison of methods. Statistics in Medicine, 18, 26932708.
van Balkom, A. J., Bakker, A., Spinhoven, P., et al (1997) A meta-analysis of the treatment of panic disorder with or without agoraphobia: acomparison of psychopharmacological, cognitive–behavioral and combination treatments. Journal of Nervous and Mental Disease, 185, 510516.
Wiborg, I. M. & Dahl, A. A. (1996) Does brief dynamic psychotherapy reduce the relapse rate of panic disorder? Archives of General Psychiatry, 53, 689694.
Zitrin, C. M., Klein, D. F. & Woerner, M. G. (1980) Treatment of agoraphobia with group exposure in vivo and imipramine. Archives of General Psychiatry, 37, 6372.
Zitrin, C. M., Klein, D. F., Woerner, M. G., et al (1983) Treatment of phobias. I. Comparison of imipramine hydrochloride and placebo. Archives of General Psychiatry, 40, 125138.
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Psychotherapy plus antidepressant for panic disorder with or without agoraphobia: Systematic review

  • Toshi A. Furukawa (a1), Norio Watanabe (a1) and Rachel Churchill (a2)
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eLetters

Psychotherapy plus antidepressant for panic disorder with or without agoraphobia

Dr Grace Ghunang, Professor Of Physchiatry
21 June 2006

Panic disorder with or without agoraphobia is a highly prevalent psychiatric disorder. As shown by the results of the National Comorbidity Survey Replication (1),life-time prevalence for panic disorder with agoraphobia is 1.1 and 3.7 for panic disorder without agoraphobia.

Both pharmacotherapy, especially using antidepressants, and psychotherapy, especially cognitive-behavioral psychotherapy or CBT have been shown to be effective in treating the disorder. It is all the more striking that most current treatment fails to meet basic treatment guidelines (2).

The question concerning combined pharmacotherapy and psychotherapy versus either one of the monotherapies has remained controversial. Conclusions of recent reviews have been variable, with some favouring the combination, some favouring monotherapy, some drawing mixed conclusions.

The present study is important in that it makes two unambiguous statements:

1.The treatment combining antidepressants and psychotherapy is more effective than either monotherapy in the acute phase of the treatment and as long as treatment is continued 2.At follow-up, after discontinuation of treatment, the combination is still more effective than pharmacotherapy alone, but not more effective than psychotherapy alone In comparison with previous reviews, the present one has several strengths. First, it relies on the findings of systematic and comprehensive searches for relevant trials. Second, the meta-analyses performed in the study applied the intention-to-treat principle, with drop-outs being counted as non-responders.3.Heterogeneity and sensitivity analyses indicated that the results of theanalyses were quite robust.

The study has some limitations. In particular, the nature of follow-up after termination of treatment is described as “naturalistic”, meaning that participants were usually free to seek further treatment between the termination of treatment and the follow-up assessments. In fact, 30-70% ofthe participants received additional treatment.

Another limitation of the study is that it does not address the relative merits of combination therapy compared with sequential treatments.

Additional studies are needed to confirm the results of the present review and to investigate the potential benefit of sequential versus combined treatments.

References:

1. Kessler RC, Chiu WT, Jin R, Ruscio AM, Shear K and Walters EE. Theepidemiology of panic attacks, panic disorder, and agoraphobia in the National Comorbidity Survey Replication. Archives of General Psychiatry 2006; 63; 415-424

2. Wang PS, Lane M, Olfson M, Pincus HA, Wells KB and Kessler RC. Twelve-month use of mental health services in the United States: results from the National Comorbidity Survey Replication. Archives of General Psychiatry 2005; 62 (6); 629-40
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Conflict of interest: None Declared

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