Psychotherapies for Panic Disorder: Which Is Best?

Sharyn Alden

June 23, 2015

Cognitive-behavioral therapy (CBT) has a consistent track record in the treatment of panic disorder, but psychodynamic psychotherapy shows new promise, new research suggests.

Results from the first large panic disorder trial to compare CBT, panic-focused psychodynamic psychotherapy (PFPP), and applied relaxation training (ART) showed that although all treatments improved panic disorder, CBT performed most consistently. PFPP also demonstrated efficacy.

"All treatments showed improvements in patients with panic disorder, but it was noteworthy that psychodynamic psychotherapy showed promise in treating this disorder," lead investigator Barbara Milrod, MD, professor, Department of Psychiatry, Weill Cornell Medical College, New York City, told Medscape Medical News.

The study was published online June 9 in the Journal of Clinical Psychiatry.

Prevalent, Disabling, Costly

Panic disorder is "prevalent, disabling and costly" and linked to "poor emotional and physical health, comorbid substance abuse and suicide," the authors note. Effective treatments include CBT and/or pharmacotherapy. However, the investigators point out that in general, patients with panic disorder prefer psychotherapy to medication.

Previous research into effective psychotherapies has largely focused on CBT, although one small, randomized trial suggested that PFPP was effective compared with ART.

The new randomized controlled trial compared CBT, PFPP, and ART at Weill Medical College and at the University of Pennsylvania, in Philadelphia. It included 200 patients aged 18 to 70 years with primary panic disorder, diagnosed on the basis of DSM-IV criteria, with or without agoraphobia. Study participants were randomly assigned to receive CBT (n = 81), PFPP (n = 80), or ART (n = 39).

Thirty therapists participated in the study, with each one delivering one modality. Eleven of the therapists were physicians, 17 held PhD degrees, one held an MSW degree, and one held a PsyD degree. Patients received treatments two times a week in 45- to 50-minute sessions for 19 to 24 sessions during a period of 12 to 14 weeks.

The study's primary outcome measure was improvement over time in scores on the Panic Disorder Severity Scale (PDSS); additionally, "response rates," defined as a 40% reduction in PDSS scores, were reported.

There was a site-by-treatment interaction when outcomes were evaluated by both methods. At Cornell, patients in all therapy groups improved at the same rate over time using a mixed models, shared parameters approach. At the University of Pennsylvania, patients receiving CBT and ART improved faster than those receiving PFPP, and at 12 weeks, patients were less symptomatic with these two interventions.

It is noteworthy that attrition did not differ between sites and was significantly higher among patients receiving ART at both sites. With combined randomization of only half the number of patients receiving ART, this data-analytic approach yields more accurate estimates for CBT and PFPP. Evaluation of response rates, on the other hand, showed that both PFPP and CBT significantly outperformed ART at Cornell, whereas there were no significant differences between response rates at Penn between the treatments.

CBT did well at both sites, but PFPP performed better at Cornell, where the modality has a strong history.

Attrition rates across both sites were 41% for ART, 25% for CBT, and 22% for PFPP. Results showed that the most symptomatic patients were more likely to drop out of ART compared with CBT or PFPP (P = .013). In the most impaired patients, the attrition rate for patients receiving ART was 69%.

Patients who completed the 3-month course of therapy, regardless of treatment group, were more likely to improve.

Dr Milrod noted that this finding highlights the importance of completing a course of psychotherapy in achieving optimal outcomes. "Patients who do so," she said, "have a much better chance of getting better."

The researchers concluded that both CBT and PFPP were more appealing treatments for patients with panic disorder than ART at both Cornell and Penn, regardless of how well trained the therapists were in that modality. But for some patients, ART may still be an effective approach.

"The idea behind this research is how we can best treat this disorder and practice better medicine," said Dr Milrod. "If one treatment doesn't benefit the patient, another one probably will. The point is, all three approaches helped people to get better. There is hope."

Novel Finding

Commenting on the study for Medscape Medical News, Eric Hollander, MD, director, Autism and Obsessive Compulsive Spectrum Program and Anxiety and Depression Program at Albert Einstein College of Medicine, in New York City, said "the study is important because it incorporates psychodynamic psychotherapies for treatment of panic disorder. This hasn’t been shown before."

"The multisite component also makes the study interesting. What a clinician believes can play a role in how well panic disorder patients do. For example, how strongly a clinician believes in a treatment can be well received by patients," said Dr. Hollander.

Although the study showed that patients who completed a course of treatment, albeit brief, improved during the multisite trial, Dr Hollander said it is important to consider the generalizability of a given treatment.

"Results may not translate the same as it becomes widely available. Still, the study is helpful because it shines a light on new types of approaches for patients with panic disorder," he said.

The authors and Dr Hollander report no relevant financial relationships.

J Clin Psychiatry. Published online June, 9 2015. Abstract

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