Therapy for panic disorder that combines an evidence-based cognitive behavioral therapy (CBT) with medication may be more effective than the usual care offered to these patients in a primary care setting, according to an article in the March issue of Archives of General Psychiatry.
Panic disorder is one of the most disabling and costly anxiety disorders and is commonly treated in primary care settings, according to background information in the article. This randomized, controlled trial assesses the extent to which the benefits of evidence-based, specialist-delivered, panic disorder interventions can be generalized to primary care settings with non-specialist therapists and more diverse patient populations.
Peter P. Roy-Bryne, M.D., of the University of Washington School of Medicine at Harborview Medical Center, Seattle, and colleagues randomly assigned 232 primary-care patients meeting the Diagnostic and Statistical Manual of Mental Disorders - Fourth Edition (DSM-IV) criteria for panic disorder to receive treatment as usual (medication and counseling from the physician on recognition and treatment of panic disorder) or to receive an intervention consisting of up to six sessions in the course of three months of CBT, with up to six follow-up telephone contacts during the next nine months, and medications provided by the primary care physician with guidance from a psychiatrist. The patients were selected from six primary care clinics associated with three university medical schools, serving a diverse patient population.
"The combined cognitive-behavioral and pharmacotherapeutic [medications] intervention resulted in sustained and gradually increasing improvement relative to treatment as usual," the authors state. The proportion of patients who remitted, defined as patients who had had no panic attacks in the past month, minimal anticipatory anxiety about panic and a low score on a measure of agoraphobia [fear of going out], was significantly higher than those receiving usual care at all points--at three months, 20 percent versus 12 percent and at 12 months, 29 percent versus 16 percent. The proportion of patients who responded, defined by a low score on a test for anxiety level, was also significantly higher than those receiving usual care at all points--at three months, 46 percent versus 27 percent, and at 12 months, 63 percent versus 38 percent.
The patients receiving the CBT and medication intervention also made significantly greater improvements on two standard measures of mental health functioning. "These effects were obtained in spite of similar rates of delivery of guideline-concordant [appropriate, taken as directed] pharmacotherapy to the two groups," the authors write.
"We also learned that many patients did not adhere to the entire CBT program, even though it was brief and delivered with considerable flexibility of scheduling," the authors conclude. "This finding suggests the need for qualitative research to elucidate the reasons for nonadherence in these patients. A major goal of future work in this area should be to develop, implement, and disseminate approaches to treatment of anxiety disorders that are maximally acceptable to patients, physicians, and payers."