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CBT and Medication for Panic Disorder

Am Fam Physician. 2005 Nov 15;72(10):2104-2106.

Panic disorder is one of the more common anxiety disorders encountered in the primary care setting. Because patients with panic disorder may present with symptoms consistent with physical disorders, they may receive costly work-ups. One study that assessed a treatment strategy for panic disorders in the primary care setting showed initial benefit, but this effect tended to decrease after nine to 12 months of treatment. The treatment strategy consisted of a psychiatrist with proven expertise in treating anxiety disorders assisting family physicians with prescribing and managing medications without the use of psychotherapy. Roy-Byrne and colleagues evaluated the effectiveness of combined pharmacotherapy and cognitive behavior therapy (CBT) in the treatment of panic disorder in the primary care setting.

The multicenter, randomized, controlled study compared an intervention strategy with usual care. Participants were between 18 and 70 years of age; met criteria for panic disorder described in the Diagnostic and Statistical Manual of Mental Disorders, 4th ed., and had at least one panic attack within one week before the study. The intervention was a collaborative care model with a behavioral health specialist who provided CBT and coordinated care with a family physician. CBT was provided in six sessions and followed up with phone calls for six months afterward. An algorithm-based pharmacotherapy strategy was provided for the family physicians, with assistance provided by a psychiatrist.

Usual care consisted of therapy from the family physician after the physician was informed of the diagnosis of panic disorder. Participants were evaluated every three months during the study with multiple evaluation tools. The main outcomes assessed were the number of patients who remitted and responded. Participants who were classified as remitted had no panic attacks within the previous month, minimal anticipatory anxiety, and a low agoraphobia subscale score. Response was defined as improvement over time in three of the assessment tools but failure to meet the definition for remission.

There were 232 patients who met the inclusion criteria and completed the study. The participants represented a wide range of ages and education and income levels. The intervention group had a better response to treatment in remission and response compared with the usual care group. This improvement was sustained over time, and participants continued to improve gradually. The significantly higher rates of improvement in the intervention group were present at all points of the study. At three months, 20 percent of the intervention group had met the criteria for remission versus 12 percent in the usual care group. At 12 months, 29 percent of the intervention group was in remission compared with 16 percent of the usual care group. At three months, 46 percent of patients in the intervention group had responded to therapy compared with 27 percent of the usual care group; after 12 months, the percentage of responders increased to 63 percent in the intervention group compared with 38 percent of patients receiving usual care.

The authors conclude that patients who receive a combination of CBT and antianxiety medications delivered by a behavioral health specialist in conjunction with a family physician and with the assistance of a psychiatric consultant show significant improvement in their symptoms of panic disorder compared with patients who receive usual care.

Roy-Byrne PP, et al. A randomized effectiveness trial of cognitive-behavioral therapy and medication for primary care panic disorder. Arch Gen Psychiatry. March 2005;62:290-8.


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