The implementation of guided Internet-based cognitive behaviour therapy for panic disorder in a routine-care setting: effectiveness and implementation efforts

Panic disorder is a common mental disorder. Guided Internet-based cognitive behavioural therapy (Guided Internet-based cognitive behaviour therapy (ICBT)) is a promising approach to reach more people in need of help. In the present effectiveness study, we investigated the outcome of guided ICBT for panic disorder after implementation in routine care. A total of 124 patients were included in the study, of which 114 started the treatment. Large within-group effect sizes were observed on the primary panic disorder symptoms (post-treatment: d = 1.24; 6-month follow-up: d = 1.39) and moderate and large effects on secondary panic disorder symptoms and depressive symptoms at post-treatment and follow-up (d = .55–1.13). More than half (56.1%) of the patients who started treatment recovered or improved at post-treatment. Among treatment takers (completed at least five of the nine modules), 69.9% recovered or improved. The effectiveness reported in the present trial is in line with previous effectiveness and efficacy trials of guided ICBT for panic disorder. This provides additional support for guided ICBT as a treatment alternative in routine care.     

Attentional fixation in panic disorder

According to Beck's (1988) clinical observations, patients with panic disorder describe a fixation on their distressing physical and psychological symptoms and an inability to access corrective information during panic attacks. The present study sought to evaluate empirically the notion that attentional fixation is characteristic of these patients. A subset of panic patients participating in 3 cognitive therapy clinical trials completed the Attentional Fixation Questionnaire (AFQ) at intake, during treatment and at termination. The AFQ had adequate internal consistency at all time intervals, and it correlated positively with measures of depression, anxiety and distorted cognitive content. At termination, the AFQ total score and nearly all single items decreased significantly, and patients who continued to meet diagnostic criteria for panic disorder scored higher on most items than patients who no longer met diagnostic criteria for panic disorder. These preliminary data suggest that attentional fixation is an important dimension of cognition relevant to panic disorder.     

Predicting who benefits from psychoeducation and self help for panic attacks

Self-help and psychoeducation have been identified as effective methods for delivering treatment, yet not everyone benefits from these brief interventions. Therefore it is clinically and economically useful to identify who is likely to require more intensive assistance. This paper develops a prognostic scale which predicts who will recover from panic attacks and who will require more assistance. Method: Random regression models were used to evaluate the relationship between predictive variables, baseline severity, and the rate of improvement in 117 people with DSMIV panic attacks who participated in a trial of a psycho-educational booklet, a self-help workbook, and brief group CBT over a 9-month period. ROC analysis was used to choose cut-off points on a scale made up of significant predictors. Results: Panic disorder and agoraphobia symptom measures were predicted by baseline social anxiety, and general mental health. There was no significant effect on the outcome for baseline depression or anxiety sensitivity. While general mental health (SF12 Mental Component scores) was predicted by the age at first panic attack, neuroticism, panic disorder and/or agoraphobia symptoms and a positive screen for alcohol use disorders. A prognostic scale based on simple additive scoring was equivalent to standard scores and significantly better than chance at predicting who would recover and who required face-to-face therapy. Conclusions: The prognostic scale may be used to guide the choice of psychoeducation, self-help or face-to-face therapy as the first step in stepped care.     

Treatment of panic disorder with agoraphobia: randomized placebo-controlled trial of four psychosocial treatments combined with imipramine or placebo

Few randomized 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 graded in vivo exposure treatments, graded 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 randomized, 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 clinically 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.     

Comorbidity and Internet-Delivered Transdiagnostic Cognitive Behavioural Therapy for Anxiety Disorders

Internet-delivered transdiagnostic anxiety interventions aim to reduce symptoms across several anxiety disorders using one treatment protocol. However, it is unclear whether comorbidity affects outcomes of such treatment. This study re-examined data from a recent randomised controlled trial (N = 129) that evaluated the efficacy of an Internet-delivered transdiagnostic cognitive behavioural therapy (iCBT) intervention for participants with principal diagnoses of generalised anxiety disorder (GAD), social phobia (SP) panic disorder and agoraphobia (PDA), of whom 72% met criteria for a comorbid anxiety disorder or depression. Participants were divided into two groups based on whether or not they had a comorbid disorder before treatment. Participants with comorbid conditions reported higher symptom levels at pre-treatment, post-treatment, and follow-up across a range of measures. Both groups showed significant reductions in symptoms over treatment; however, participants with comorbid disorders showed greater reductions in measures of GAD, PDA, SP, depression, and neuroticism. In addition, treatment significantly reduced the number of comorbid diagnoses at follow-up. These results indicate transdiagnostic iCBT protocols have the potential to reduce comorbidity.     

Cognitive Behaviour Therapy for Schizophrenia in Patients with Mild to Moderate Substance Misuse Problems

Rates of substance misuse are high among patients with schizophrenia. Cognitive therapies have been developed separately for both problems but little is known about outcome for this group of dual diagnosed patients. Data from a major trial of cognitive behaviour therapy for psychosis was therefore sub‐analysed to determine whether this therapy is effective in those with schizophrenia and mild to moderate substance misuse. During the original study patients received a brief cognitive behaviour therapy‐based intervention for schizophrenia delivered by trained and supervised nurses. The control group received care as usual. The outcome measures included: total psychopathology using the Comprehensive Psychopathological Rating Scale (CPRS) and Health of the Nation Outcome Scale (HoNOS), change in schizophrenic positive symptoms using Schizophrenia Change Scale (SCR), anxiety using the Brief Scale for Anxiety (BAS), depression using the Montgomery‐Asberg Depression Rating Scale (MADRS) and insight using the Assessment of Insight Scale, at baseline and end of therapy. In the original study, patients who received cognitive behaviour therapy showed improvement in overall symptomatology (p = 0.01), insight (p = 0.00) and depression (p = 0.00) compared with the control group. In the present sub‐analysis, no interaction was found between treatment group and presence or absence of substance misuse. There was a reduction in substance misuse after treatment in both the cognitive behaviour therapy and control groups but this did not differ between them. It appears that mild to moderate degrees of substance misuse did not change the outcome of cognitive behaviour therapy for psychosis in this sub‐analysis.     

Panic disorder: A cognitive-behavioural approach to treatment

The present study investigated the relationship between panic disorder and cognitive-behavioural therapy in a sample of 27 panic disorder patients who were randomly assigned to either a Treatment (six weeks of cognitive-behavioural therapy) or a Control group. Panic disorder was operationalized using three subjective and three physiologic indices. Results indicated that six weeks of cognitive-behavioural therapy were effective in decreasing panic disorder, as measured by three report measures: the Anxiety Sensitivity Index (catastrophic thoughts), State-Trait Anxiety Inventory (trait anxiety), and number of panic attacks, for the Treatment group relative to the Control group. In contrast, cognitive—behavioural therapy was ineffective in decreasing physiologic arousal as defined by blood pressure, pulse rate, and finger temperature. Implications of these results are discussed.     

Cognitive behavior therapy vs exposure in vivo in the treatment of panic disorder with agoraphobia (corrected from agrophobia)

Seventy-three psychiatric outpatients 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 randomly 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 clinically 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.     

Panic disorder and depression: A psychodynamic exploration of comorbidity

Eight of twenty-one patients presenting for treatment in an open trial of brief psychodynamic psychotherapy for panic disorder also carried the diagnosis of major depression. For the patients who completed the study, depression remitted as well as panic disorder. The authors highlight psychodynamic factors that they hypothesize may contribute to the significant overlap between panic disorder and depression, and describe three videotaped cases to illustrate these points.     

Cognitive-Behavior Therapy (CBT) for Panic Disorder: Relationship of Anxiety and Depression Comorbidity with Treatment Outcome

Research evaluating the relationship of comorbidity to treatment outcome for panic disorder has produced mixed results. The current study examined the relationship of comorbid depression and anxiety to treatment outcome in a large-scale, multi-site clinical trial for cognitive-behavior therapy (CBT) for panic disorder. Comorbidity was associated with more severe panic disorder symptoms, although comorbid diagnoses were not associated with treatment response. Comorbid generalized anxiety disorder (GAD) and major depressive disorder (MDD) were not associated with differential improvement on a measure of panic disorder severity, although only rates of comorbid GAD were significantly lower at posttreatment. Treatment responders showed greater reductions on measures of anxiety and depressive symptoms. These data suggest that comorbid anxiety and depression are not an impediment to treatment response, and successful treatment of panic disorder is associated with reductions of comorbid anxiety and depressive symptoms. Implications for treatment specificity and conceptual understandings of comorbidity are discussed.     

Dysfunctional beliefs in panic disorder: The Panic Belief Inventory

The Panic Belief Inventory (PBI) was developed to assess beliefs that increase the likelihood of catastrophic reactions to physical and emotional experiences in panic disorder. In the first stage of scale development, 197 panic disorder patients completed the PBI and standard self-report inventories of psychiatric symptomatology. An exploratory factor analysis yielded a 4-factor solution from which a 35-item instrument with 4 scales was constructed. The shortened measure and its scales had good internal consistency and convergent validity and moderate discriminant validity. Subsequently, 22 panic disorder patients who received cognitive therapy completed the PBI and other self-report inventories of dysfunctional cognitions at intake, 4 weeks, 8 weeks, termination, and several follow-up intervals. Results indicated that the PBI decreased significantly across treatment, with the largest decline occurring between intake and 4 weeks into treatment. The PBI correlated more strongly with dysfunctional cognitions associated with anxiety than dysfunctional cognitions associated with depression. These results provide preliminary evidence that the PBI has adequate psychometric characteristics, is useful to assess change in dysfunctional beliefs during treatment, and has the potential to advance cognitive theories of panic.     

Role of cognitive appraisal in panic-related avoidance

The present study examined several dimensions of panic cognitions to test whether panic appraisals predict phobicity among panic sufferers. Thirty-five patients meeting DSM-III-R criteria for panic disorder with minimal or no phobic avoidance were compared to 40 patients meeting DSM-III-R criteria for panic disorder with agoraphobia (severe). The two groups looked strikingly similar on measures of panic symptoms, panic frequency and panic severity. As expected, patients diagnosed as having panic disorder with agoraphobia reported significantly more depression and phobic avoidance than patients with PD. Striking differences emerged on each of the following panic appraisal dimensions: (a) anticipated panic, (b) perceived consequences of panic, and (c) perceived self-efficacy in coping with panic. In each case, patients with panic disorder and agoraphobia reported significantly more dysfunctional panic appraisals than patients with panic disorder and no avoidance. Of those panic appraisal dimensions studied, anticipated panic emerged as the most potent correlate of agoraphobic avoidance. These findings support the hypothesis that cognitive appraisal factors may play an important role in the genesis or maintenance of phobic avoidance among panic patients.     

CBT intensity and outcome for panic disorder in a primary care setting

A hybrid efficacy-effectiveness design in which participants (n = 91/93) were retained in the study regardless of whether or not they received treatment enabled evaluation of CBT intensity in relation to panic disorder in the primary care setting. CBT intensity was operationalized as number of cognitive-behavioral therapy sessions, number of follow-up booster phone calls, and secondarily, as number of cognitive behavioral coping and exposure strategies. Baseline psychosocial and demographic predictors of CBT intensity were analyzed first. Severity of anxiety sensitivity predicted number of cognitive behavioral sessions, but no baseline variables predicted number of follow-up booster phone calls or number of coping and exposure strategies. Multivariate logistic and linear regressions were used to evaluate the degree to which treatment intensity predicted 3-month and 12-month outcomes (anxiety sensitivity, phobic avoidance, depressive symptoms, disability, and medical and mental health functioning) after controlling for potential confounding baseline variables. Number of cognitive behavioral therapy sessions predicted lower anxiety sensitivity at 3 and 12 months, and number of follow-up booster phone calls predicted lower anxiety sensitivity, less phobic avoidance, and less depression at 12 months. These findings indicate that "dose" of psychotherapy was an important predictor of outcome. The significance of follow-up booster phone contact is discussed as an index of continued self-management of panic and anxiety following acute treatment.     

Treatment of Panic Disorder with Agoraphobia: Randomized Placebo‐Controlled Trial of Four Psychosocial Treatments Combined with Imipramine or Placebo

Few randomized 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 graded in vivo exposure treatments, graded 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 randomized, 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 clinically 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.     

Comparison between REBT and Visual/Kinaesthetic Dissociation in the Treatment of Panic Disorder: An Empirical Study

The aim of this study was to test the efficacy of two brief treatment methods for panic disorder: Rational Emotive Behaviour Therapy (REBT) and Visual/Kinaesthetic Dissociation (VKD), neither of which have been the object of scientific enquiry. The study is a two-way between-groups pre-test/post-test experimental design with baseline and follow-up measures. An innovative four-session treatment protocol was developed for each treatment method. Eighteen participants in North-East Surrey, England, who responded to media advertisements for cognitive-behavioural treatment for panic disorder and who met Diagnostic and Statistical Manual of Mental Disorders criteria for panic disorder with or without agoraphobia were randomly assigned to either REBT or VKD. Pre-test/post-test changes in panic were measured using the ACQ, PASQ, and HADS scales and a global panic rating measure. At post-test there was a statistically significant improvement on all measures for both groups, which was maintained at one-month follow-up. Taking into consideration limitations such as the small sample size and a short follow-up period, implications of this study and recommendations for future research are discussed.     

Treatment of panic disorder: live therapy vs. self-help via the Internet

A randomized trial was conducted comparing 10 individual weekly sessions of cognitive behaviour therapy for panic disorder (PD) with or without agoraphobia with a 10-module self-help program on the Internet. After confirming the PD diagnosis with an in-person structured clinical interview (SCID) 49 participants were randomized. Overall, the results suggest that Internet-administered self-help plus minimal therapist contact via e-mail can be equally effective as traditional individual cognitive behaviour therapy. Composite within-group effect sizes were high in both groups, while the between-group effect size was small (Cohen's d=16). One-year follow-up confirmed the results, with a within-group effect size of Cohen's d=0.80 for the Internet group and d=0.93 for the live group. The results from this study generally provide evidence to support the continued use and development of Internet-distributed self-help programs.     

Cognitive behavioral therapy for panic disorder and comorbidity: more of the same or less of more?

This study compared the effects of a higher dose of cognitive behavioral therapy (CBT) for panic disorder versus CBT for panic disorder combined with "straying" to CBT for comorbid disorders in individuals with a principal diagnosis of panic disorder with or without agoraphobia. Sixty-five participants were randomly assigned to one of two treatment conditions, either CBT focused solely upon panic disorder and agoraphobia or CBT that simultaneously addressed panic disorder and agoraphobia and, to a lesser degree, the most severe comorbid condition. Results indicated a significant reduction in panic disorder severity and a decline in severity of comorbid diagnoses across both treatment conditions. However, individuals receiving CBT focused only on panic disorder were more likely to meet high end-state functioning at post-treatment, even in intent-to-treat analyses, and report zero panic attacks at the 1-year follow-up, although this effect was not retained in intent-to-treat analyses. At follow-up, CBT focused only on panic disorder yielded more substantial improvement in the most severe baseline comorbid condition, although not in intent-to-treat analyses, and a greater proportion of individuals in this treatment condition were rated as having no comorbid diagnoses, even in intent-to-treat analyses. These findings raise the possibility that remaining focused on CBT for panic disorder may be more beneficial for both principal and comorbid diagnoses than combining CBT for panic disorder with 'straying' to CBT for comorbid disorders.     

The Interaction of Motivation and Therapist Adherence Predicts Outcome in Cognitive Behavioral Therapy for Panic Disorder: Preliminary Findings

This report is a post-hoc, exploratory examination of the relationships among patient motivation, therapist protocol adherence, and panic disorder outcome in patients treated with cognitive behavioral therapy within the context of a randomized clinical trial for the treatment of panic disorder (Barlow, Gorman, Shear, & Woods, 2000). Results suggested that motivation and adherence interacted to predict change in panic severity. Among patients rated as less motivated, greater therapist protocol adherence was associated with poorer outcome. Among patients rated as more motivated, adherence was not significantly associated with outcome. Further process research is needed to confirm these preliminary results and to understand the interactions of patient and therapist factors and how they are related to outcome in standardized protocols such as cognitive behavioral therapy for panic disorder.     

Telephone-administered cognitive behavior therapy for obsessive-compulsive disorder

Exposure with response prevention and cognitive behavior therapy are widely recognized as effective treatments for obsessive-compulsive disorder. Unfortunately, many people with obsessive-compulsive disorder--particularly those living in rural areas--do not have access to therapists providing these treatments. Accordingly, we investigated the efficacy of telephone-administered cognitive behavior therapy for obsessive-compulsive disorder. Two open trials are reported, for a total of 33 people with obsessive-compulsive disorder (without major depression). The first trial consisted of 12 weeks on a waiting list followed by 12 weeks of treatment (delayed treatment). The second trial consisted of 12 weeks of immediate treatment. Obsessive-compulsive symptoms did not change during the waiting period. Symptoms declined from pre- to post-treatment, with gains maintained at 12-week follow-up. For the pooled sample our pre-to-post-treatment effect size was as large or larger than those obtained in other studies of reduced contact treatment, and similar to those of face-to-face exposure with response prevention. Our proportion of treatment dropouts tended to be lower than those of other reduced contact interventions. The results suggest that telephone-administered cognitive behavior therapy is effective and well-tolerated, at least for people with obsessive-compulsive disorder without major depression. It remains to be seen whether this treatment is safe and effective when comorbid major depression is present.