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What is the long-term effectiveness of cognitive behavioural therapy (CBT), pharmacotherapy using a selective serotonin reuptake inhibitor (SSRI) or the combination of both for panic disorder with or without agoraphobia?
150 adults with a primary diagnosis of DSM-IV panic disorder with or without DSM-III-R agoraphobia (based on Mini-International Neuropsychiatric Interview). The study excluded people who were pregnant, lactating, suicidal, psychotic or severely depressed.
11 treatment centres in the Netherlands; enrolment April 2001 to September 2003.
CBT, SSRI or both for 1 year. CBT consisted of up to 21 sessions lasting 50 min. Participants receiving SSRIs had up to 12 sessions with their therapist and tapered their medication over 3 months at the end of treatment. Participants were classed as completers, dropouts or no-tapers. Those who received a minimum of 15 CBT sessions and/or eight SSRI sessions and ended treatment with therapist consent were considered completers. Dropouts received less than 1 year's treatment. No-tapers did not taper off their SSRI medication.
General aspects of anxiety (Hamilton Anxiety Rating Scale score range 0–56, higher score indicating greater anxiety), confidence in coping with future panic attacks (coping scale of the Panic Appraisal Inventory, PAI, score range 0–100, higher score indicating better coping), remission (defined as no panic attacks in the 2 weeks after treatment discontinuation, minimal anticipatory anxiety on the PAI and Fear Questionnaire agoraphobia subscale score ≤10). Patients were assessed at baseline, after 9 months of treatment (post-test 1), immediately after treatment discontinuation (post-test 2) and 6 and 12 months after treatment discontinuation (follow-up 1 and follow-up 2).
55% were completers.
Randomised controlled trial.
12 months (post-treatment follow-up).
CBT completers received an average of 19.0 sessions; SSRI completers received an average of 11.6 sessions; and CBT plus SSRI completers received an average of 18.6 CBT sessions and an average of 11.8 SSRI sessions. After 9 months' treatment, all groups had improved significantly in general anxiety, but both SSRI alone and CBT plus SSRI improved anxiety more than CBT alone (p<0.05 vs SSRI alone; p<0.001 vs combination treatment). However, between post-test 1 and post-test 2 CBT alone improved anxiety more than CBT plus SSRI or SSRI alone (p<0.01 for both comparisons). All treatment groups showed an improvement in confidence in their ability to cope with subsequent panic attacks between baseline and post-test 1 (p<0.001), and this effect was sustained at 1-year post-treatment follow-up. See online table for proportion of completer participants who remitted at each time Point”
At the end of follow-up, all treatments showed similar improvements in participants' general anxiety and confidence in ability to cope with subsequent panic attacks and in the proportion of remitters.
Cognitive behavioural therapy (CBT) and selective serotonin reuptake inhibitors (SSRIs) are now widely accepted as the gold standard for the treatment of panic disorder. However, long-term follow-up studies on the relative effectiveness of either treatment or a combined treatment of both are still scarce. Findings from the present study indicate that although a combined treatment may be more effective from a short-term perspective, long-term effectiveness of the combined treatment is equal to treatment with either CBT or an SSRI. These results are largely in concordance with findings from a recent meta-analysis, with the exception that antidepressants alone were found to be less effective than either CBT or a combined treatment.1
Surprisingly, the present study provides no indication for a higher rate of relapse in either the SSRI or combined treatment group even though medication use was tapered off. In a recent revision of the Dutch guidelines for the treatment of anxiety disorders pertaining to panic disorder, it is stated that research has shown a greater relapse of panic symptoms in patients receiving a pharmacological or combined treatment versus patients receiving CBT. However, such research has mostly involved tricyclic antidepressants and not SSRIs.2
Replication studies and meta-analyses are needed to firmly establish whether the ‘greater relapse after discontinuation of SSRI’ hypothesis can truly be refuted. One study indicated that attribution phenomena play an important mediating role in relapse; patients who attribute their progress to medication were found to be more prone to relapse after discontinuation of medication than patients who attribute their progress to their own achievements.3 As our present knowledge indicates that CBT, SSRIs and a combined treatment are effective for panic disorder patients, the patient's preference and treatment history are probably the most decisive factors in choosing a specific treatment. After reading the present study, I would still advocate the use of CBT alone as a first choice, as it constitutes the least invasive procedure, it is equally effective from a long-term perspective and probably more cost-effective than a combined approach, and progress may be more durable as it is more likely to be attributed to one's own achievements.
Source of funding The Dutch Health Insurance Board.
Competing interests None.
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