The American Psychiatric Association Practice Guideline for the Treatment of Patients With Panic Disorder: Recommendations and Controversies

Fredric N. Busch, MD and Barbara L. Milrod, MD

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In This Article

Evidence Used in Making Treatment Recommendations

The guideline makes a series of recommendations which are coded as to level of clinical confidence; these are either substantial (I), moderate (II), or on the basis of individual circumstances (III). Cognitive behavioral therapy (CBT) and pharmacotherapy are recommended with substantial confidence. Psychodynamic psychotherapy is suggested with moderate confidence, although only in conjunction with cognitive behavioral treatment or pharmacotherapy. Psychotherapy without medication other than CBT is considered on the basis of individual circumstances.

The criteria for determining what is recommended with these varying levels of confidence are unclear. It is implied that randomized controlled trials are used for making these recommendations, but this standard of evidence is not applied consistently. In some places within the document, strong recommendations are made where there are no systematic data, and at other points, clinically derived data are minimized because they were not systematically collected.

For example, ". . . educating family members and enlisting their help when appropriate" (p 2) is recommended at level I, but there are no systematic data to support this conclusion. The guideline suggests that "there is evidence that group [CBT] treatments may be equally effective" (p 9) as individual CBT, but there is no reference to actual randomized, controlled comparisons between group CBT and individual CBT. In other instances, the tone of the guideline implies that if a treatment is not systematically studied, it is not effective. There is variability within the guideline as to the value of case reports. Many published case reports exist showing successful psychodynamic treatment of panic. These are minimized in the guideline as "reports of isolated cases rather than systematic consecutive case series" (p 10), whereas four case reports of treatment of panic patients with venlafaxine are cited as indications that the medication "may be effective and well tolerated" (p 17).

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