Effectiveness of Cognitive-Behavioral Treatment for Panic Disorder Versus Treatment as Usual in a Managed Care Setting.

Eighty clients enrolled in a managed care health plan who identified panic disorder as their primary presenting problem were randomly assigned to treatment by a therapist recently trained in a manual-based empirically supported psychotherapy (M. G. Craske, E. Meadows, & D. H. Barlow, 1994) or a therapist conducting treatment as usual (TAU). Participants in both conditions showed significant change from pre- to posttreatment on a number of measures. Those receiving panic control therapy (PCT) showed greater levels of change than those receiving TAU. Among treatment completers, an average of 42.9% of those in PCT and 18.8% in TAU achieved clinically significant change across measures. The results are discussed with reference to the dissemination of PCT and other evidence-based psychotherapies to clinical practice settings. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Therapists, therapist variables, and cognitive-behavioral therapy outcome in a multicenter trial for panic disorder.

The relationship between therapists and treatment outcome was examined in 14 highly trained therapists who participated in the Multicenter Collaborative Study for the Treatment of Panic Disorder. Overall, therapists yielded positive outcomes in their caseloads; yet, therapists significantly differed in the magnitude of change among caseloads. Effect sizes for therapist impact on outcome measures varied from 0% to 18%. Overall experience in conducting psychotherapy was related to outcome on some measures, whereas age, gender, gender match, and experience with cognitive-behavioral therapy (CBT) were not. Therapists with above- and below-average outcomes were rated similarly on measures of adherence and competency. The results suggest that therapists make a contribution to outcome in CBT for panic disorder, even when patients are relatively uniform, treatment is structured, and outcome is positive. Implications for future clinical outcome studies and for training clinicians are discussed. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Comment: The evidence-based treatment debate: Toward a dialectical rapprochement.

In this commentary on Zeldow's (2009) “In Defense of Clinical Judgment, Credentialed Clinicians, and Reflective Practice,” the dialectical method is presented as a conceptual model and strategy for reconciling the division between clinical practitioners and clinical scientists in their acceptance of the need for empirically based psychological treatments and practices. Recommendations are made for (a) better integrating practitioners in the conduct of science, (b) confronting unhelpful attitudes of scientific chauvinism and imperialism, and (c) recognizing the contributions of both microlevel (process) and macrolevel (outcome) phenomena in psychotherapeutic practice and its scientific investigation. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Preliminary evidence for cognitive mediation during cognitive-behavioral therapy of panic disorder.

Cognitive-behavioral therapy (CBT) and pharmacotherapy are similarly effective for treating panic disorder with mild or no agoraphobia, but little is known about the mechanism through which these treatments work. The present study examined some of the criteria for cognitive mediation of treatment change in CBT alone, imipramine alone, CBT plus imipramine, and CBT plus placebo. Ninety-one individuals who received 1 of these interventions were assessed before and after acute treatment, and after a 6-month maintenance period. Multilevel moderated mediation analyses provided preliminary support for the notion that changes in panic-related cognitions mediate changes in panic severity only in treatments that include CBT. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Benchmarking the effectiveness of psychotherapy treatment for adult depression in a managed care environment: A preliminary study.

This preliminary study evaluated the effectiveness of psychotherapy treatment for adult clinical depression provided in a natural setting by benchmarking the clinical outcomes in a managed care environment against effect size estimates observed in published clinical trials. Overall results suggest that effect size estimates of effectiveness in a managed care context were comparable to effect size estimates of efficacy observed in clinical trials. Relative to the 1-tailed 95th-percentile critical effect size estimates, effectiveness of treatment provided in this setting was observed to be between 80% (patients with comorbidity and without antidepressants) and 112% (patients without comorbidity concurrently on antidepressants) as compared to the benchmarks. Because the nature of the treatments delivered in the managed care environment were unknown, it was not possible to make conclusions about treatments. However, while replications are warranted, concerns that psychotherapy delivered in a naturalistic setting is inferior to treatments delivered in clinical trials appear unjustified. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Effectiveness of cognitive-behavioral therapy with adult ethnic minority clients: A review.

Practicing psychologists may question the relevance of cognitive- behavioral treatments for their ethnic minority clients. Many cognitive- behavioral treatments are listed as empirically supported treatments by the Task Force on the Promotion and Dissemination of Psychological Procedures (D. L. Chambless et al., 1998). However, the samples in these effectiveness studies are composed primarily of White European American individuals. There is a paucity of research examining the effectiveness of cognitive- behavioral therapy (CBT) for ethnic minority clients. The author reviews the current literature on the use of CBT with ethnic minority clients living in the United States, specifically those of African, Asian, and Hispanic/Latino descent. Twelve studies are reviewed that examined the effectiveness of CBT for ethnic minority participants with a variety of psychological disorders. Recommendations for conducting and evaluating clinical outcome research that includes ethnic minority participants are provided. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Youth psychotherapy change trajectories and outcomes in usual care: Community mental health versus managed care settings.

Objective: The authors compared symptom change trajectories and treatment outcome categories in children and adolescents receiving routine outpatient mental health services in a public community mental health system and a private managed care organization. Method: Archival longitudinal outcome data from parents completing the Youth Outcome Questionnaire (Y-OQ) were retrieved for children and adolescents (4–17 years old) served in a community mental health system (n = 936, mean age = 12 years, 40% girls or young women, 28% from families of color) and a managed care organization (n = 3,075, mean age = 13 years, 45% girls or young women, race and ethnicity not reported). The authors analyzed Y-OQ data using multilevel modeling and partial proportional odds modeling to test for differences in change trajectories and final outcomes across the 2 service settings. Results: Although initial symptom level was comparable across the 2 settings, the rate of change was significantly steeper for cases in the managed care setting. In addition, 24% of cases in the community mental health setting demonstrated a significant increase in symptoms over the course of treatment, compared with 14% of cases in the managed care setting. Conclusions: These results emphasize the need for increased attention to negative outcomes in routine mental health services and provide a stronger foundation for identifying youth cases at risk for treatment failure. In addition, given the overall differences observed across treatment settings for average rate of change and deterioration rates, results suggest that setting-specific model heuristics should be used for identifying cases at risk for negative outcomes. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Catastrophic misinterpretations as a predictor of symptom change during treatment for panic disorder.

Objective: Cognitive models of panic disorder suggest that change in catastrophic misinterpretations of bodily sensations will predict symptom reduction. To examine change processes, we used a repeated measures design to evaluate whether the trajectory of change in misinterpretations over the course of 12-week cognitive behavior therapy is related to the trajectory of change in a variety of panic-relevant outcomes. Method: Participants had a primary diagnosis of panic disorder (N = 43; 70% female; mean age = 40.14 years). Race or ethnicity was reported as 91% Caucasian, 5% African American, 2.3% biracial, and 2.3% “other.” Change in catastrophic misinterpretations (assessed with the Brief Body Sensations Interpretation Questionnaire; Clark et al., 1997) was used to predict a variety of treatment outcomes, including overall panic symptom severity (assessed with the Panic Disorder Severity Scale [PDSS]; Shear et al., 1997), panic attack frequency (assessed with the relevant PDSS item), panic-related distress/apprehension (assessed by a latent factor, including peak anxiety in response to a panic-relevant stressor—a straw breathing task), and avoidance (assessed by a latent factor, which included the Fear Questionnaire–Agoraphobic Avoidance subscale; Marks & Mathews, 1979). Results: Bivariate latent difference score modeling indicated that, as expected, change in catastrophic misinterpretations predicted subsequent reductions in overall symptom severity, panic attack frequency, distress/apprehension, and avoidance behavior. However, change in the various symptom domains was not typically a significant predictor of later interpretation change (except for the distress/apprehension factor). Conclusions: These results provide considerable support for the cognitive model of panic and speak to the temporal sequence of change processes during therapy. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Specificity of treatment effects: Cognitive therapy and relaxation for generalized anxiety and panic disorders.

[Correction Notice: An erratum for this article was reported in Vol 76(5) of Journal of Consulting and Clinical Psychology (see record 2008-13625-021). In the article, "Specificity of Treatment Effects: Cognitive Therapy and Relaxation for Generalized Anxiety and Panic Disorders," by Jedidiah Siev and Dianne L. Chambless (Journal of Consulting and Clinical Psychology, 2007, Vol. 75, No. 4, pp. 513-522), the individual measures were not listed in the domains labeled "Panic" and "Cognitive" for the ?st and Westling (1995) citation in Table 3. The corrected table is included, with the added text appearing in bold font.] The aim of this study was to address claims that among bona fide treatments no one is more efficacious than another by comparing the relative efficacy of cognitive therapy (CT) and relaxation therapy (RT) in the treatment of generalized anxiety disorder (GAD) and panic disorder without agoraphobia (PD). Two fixed-effects meta-analyses were conducted, for GAD and PD separately, to review the treatment outcome literature directly comparing CT with RT in the treatment of those disorders. For GAD, CT and RT were equivalent. For PD, CT, which included interoceptive exposure, outperformed RT on all panic-related measures, as well as on indices of clinically significant change. There is ample evidence that both CT and RT qualify as bona fide treatments for GAD and PD, for which they are efficacious and intended to be so. Therefore, the finding that CT and RT do not differ in the treatment of GAD, but do for PD, is evidence for the specificity of treatment to disorder, even for 2 treatments within a CBT class, and 2 disorders within an anxiety class. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Automatic associations and panic disorder: Trajectories of change over the course of treatment.

Cognitive models of anxiety and panic suggest that symptom reduction during treatment should be preceded by changes in cognitive processing, including modifying the anxious schema. The current study tested these hypotheses by using a repeated measures design to evaluate whether the trajectory of change in automatic panic associations over a 12-week course of cognitive behavior therapy (CBT) is related to the trajectory of change in panic symptoms. Individuals with panic disorder (N = 43) completed a measure of automatic panic associations--the Implicit Association Test (A. G. Greenwald, D. E. McGhee, & J. L. K. Schwartz, 1998), which reflects elements of the schema construct--every 3 weeks over the course of therapy and measures of panic symptoms each week. Dynamic bivariate latent difference score modeling not only indicated that automatic panic associations changed over the course of CBT for panic disorder but showed these changes were correlated with symptom reduction. Moreover, change in automatic panic associations was a significant predictor of change in panic symptom severity. These findings permit inferences about the temporality of change, suggesting that cognitive change does in fact precede and contribute to symptom change. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Hypnotic enhancement of cognitive-behavioral interventions for pain: An analogue treatment study.

Recent meta-analyses have shown that adding hypnosis enhances the effectiveness of cognitive behavioral psychotherapy. This hypnotic enhancement effect was evaluated in the analogue treatment of pain. Individuals scoring in the high (n=135) and low (n=150) ranges of hypnotic suggestibility were randomly assigned to 1 of 6 conditions: Stress Inoculation Training, the same treatment provided hypnotically, nonhypnotic analgesia suggestions, hypnotic analgesia suggestions, a hypnotic induction treatment, or a control condition. The 5 analogue treatments reduced experimental pain more than the control condition, but were not different from one another. Under circumstances optimized to detect an enhancement effect, neither Stress Inoculation Training nor analgesia suggestions produced more relief when delivered in a hypnotic context than identical treatments provided nonhypnotically. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

"Specificity of treatment effects: Cognitive therapy and relaxation for generalized anxiety and panic disorders": Correction.

Reports an error in "Specificity of treatment effects: Cognitive therapy and relaxation for generalized anxiety and panic disorders" by Jedidiah Siev and Dianne L. Chambless (Journal of Consulting and Clinical Psychology, 2007[Aug], Vol 75[4], 513-522). The individual measures were not listed in the domains labeled "Panic" and "Cognitive" for the ?st and Westling (1995) citation in Table 3. The corrected table is included, with the added text appearing in bold font. (The following abstract of the original article appeared in record 2007-11558-001.) The aim of this study was to address claims that among bona fide treatments no one is more efficacious than another by comparing the relative efficacy of cognitive therapy (CT) and relaxation therapy (RT) in the treatment of generalized anxiety disorder (GAD) and panic disorder without agoraphobia (PD). Two fixed-effects meta-analyses were conducted, for GAD and PD separately, to review the treatment outcome literature directly comparing CT with RT in the treatment of those disorders. For GAD, CT and RT were equivalent. For PD, CT, which included interoceptive exposure, outperformed RT on all panic-related measures, as well as on indices of clinically significant change. There is ample evidence that both CT and RT qualify as bona fide treatments for GAD and PD, for which they are efficacious and intended to be so. Therefore, the finding that CT and RT do not differ in the treatment of GAD, but do for PD, is evidence for the specificity of treatment to disorder, even for 2 treatments within a CBT class, and 2 disorders within an anxiety class. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Respiratory and cognitive mediators of treatment change in panic disorder: Evidence for intervention specificity.

Objective: There are numerous theories of panic disorder, each proposing a unique pathway of change leading to treatment success. However, little is known about whether improvements in proposed mediators are indeed associated with treatment outcomes and whether these mediators are specific to particular treatment modalities. Our purpose in this study was to analyze pathways of change in theoretically distinct interventions using longitudinal, moderated mediation analyses. Method: Forty-one patients with panic disorder and agoraphobia were randomly assigned to receive 4 weeks of training aimed at altering either respiration (capnometry-assisted respiratory training) or panic-related cognitions (cognitive training). Changes in respiration (PCO?, respiration rate), symptom appraisal, and a modality-nonspecific mediator (perceived control) were considered as possible mediators. Results: The reductions in panic symptom severity and panic-related cognitions and the improvements in perceived control were significant and comparable in both treatment groups. Capnometry-assisted respiratory training, but not cognitive training, led to corrections from initially hypocapnic to normocapnic levels. Moderated mediation and temporal analyses suggested that in capnometry-assisted respiratory training, PCO? unidirectionally mediated and preceded changes in symptom appraisal and perceived control and was unidirectionally associated with changes in panic symptom severity. In cognitive training, reductions in symptom appraisal were bidirectionally associated with perceived control and panic symptom severity. In addition, perceived control was bidirectionally related to panic symptom severity in both treatment conditions. Conclusion: The findings suggest that reductions in panic symptom severity can be achieved through different pathways, consistent with the underlying models. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Psychological treatment for panic disorder with agoraphobia: A randomized controlled trial to examine the role of therapist-guided exposure in situ in CBT.

[Correction Notice: An erratum for this article was reported in Vol 79(5) of Journal of Consulting and Clinical Psychology (see record 2011-21293-002). In the article, the name of author Georg W. Alpers was misspelled as George W. Alpers. In Table 2, in the footnote, line two, the criteria should read “MI≤1.8”. The online versions of this article have been corrected.] Objective: Cognitive–behavioral therapy (CBT) is a first-line treatment for panic disorder with agoraphobia (PD/AG). Nevertheless, an understanding of its mechanisms and particularly the role of therapist-guided exposure is lacking. This study was aimed to evaluate whether therapist-guided exposure in situ is associated with more pervasive and long-lasting effects than therapist-prescribed exposure in situ. Method: A multicenter randomized controlled trial, in which 369 PD/AG patients were treated and followed up for 6 months. Patients were randomized to 2 manual-based variants of CBT (T+/T?) or a wait-list control group (WL; n = 68) and were treated twice weekly for 12 sessions. CBT variants were identical in content, structure, and length, except for implementation of exposure in situ: In the T+ variant (n = 163), therapists planned and supervised exposure in situ exercises outside the therapy room; in the T? group (n = 138), therapists planned and discussed patients' in situ exposure exercises but did not accompany them. Primary outcome measures were (a) Hamilton Anxiety Scale, (b) Clinical Global Impression, (c) number of panic attacks, and (d) agoraphobic avoidance (Mobility Inventory). Results: For T+ and T? compared with WL, all outcome measures improved significantly with large effect sizes from baseline to post (range = ?0.5 to ?2.5) and from post to follow-up (range = ?0.02 to ?1.0). T+ improved more than T? on the Clinical Global Impression and Mobility Inventory at post and follow-up and had greater reduction in panic attacks during the follow-up period. Reduction in agoraphobic avoidance accelerated after exposure was introduced. A dose–response relation was found for Time × Frequency of Exposure and reduction in agoraphobic avoidance. Conclusions: Therapist-guided exposure is more effective for agoraphobic avoidance, overall functioning, and panic attacks in the follow-up period than is CBT without therapist-guided exposure. Therapist-guided exposure promotes additional therapeutic improvement—possibly mediated by increased physical engagement in feared situations—beyond the effects of a CBT treatment in which exposure is simply instructed. (PsycINFO Database Record (c) 2011 APA, all rights reserved)     

Review of Breaking free of managed care: A step-by-step guide to regaining control of your practice.

Reviews the book, Breaking free of managed care: A step-by-step guide to regaining control of your practice by Dana C. Ackley (see record 1997-97500-000). This book provides a practitioner's blueprint for moving from dependent (on managed care) to independent practice. It is organized around three major themes: 1) dealing with managed care; 2) the business of managed care-free therapy; and 3) the array of psychotherapists' services. The reviewer points out that the author tends to overlook some problem areas in psychotherapy. In addition, he takes some of his own skills as a doctoral-level clinical psychologist for granted and fails to appeal to practitioners with minimal training or expertise. However, overall, the reviewer believes that this is a highly enjoyable and practically useful book which provides some guidance to practitioners wanting to "break free from managed care." (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Effectiveness of an empirically based treatment for panic disorder delivered in a service clinic setting: 1-year follow-up.

The transportability of cognitive–behavioral therapy (CBT) for panic disorder to a community mental health center (CMHC) setting at 1-year follow-up was examined by comparing CMHC treatment outcome data with results obtained in controlled efficacy studies. Participants were 81 CMHC clients with a primary diagnosis of panic disorder with or without agoraphobia who completed CBT for panic disorder. Despite differences in settings, clients, and treatment providers, both the magnitude of change from pretreatment to follow-up and the maintenance of change from posttreatment to follow-up in the CMHC sample were comparable with the parallel findings in the efficacy studies. At follow-up, 89% of the CMHC clients were panic free and a substantial proportion of the sample successfully discontinued benzodiazepine use. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Attachment as moderator of treatment outcome in major depression: A randomized control trial of interpersonal psychotherapy versus cognitive behavior therapy.

Anxiety and avoidance dimensions of adult attachment insecurity were tested as moderators of treatment outcome for interpersonal psychotherapy (IPT) and cognitive- behavioral therapy (CBT). Fifty-six participants with major depression were randomly assigned to these treatment conditions. Beck Depression Inventory-II, Six-Item Hamilton Rating Scale for Depression scores, and remission status served as outcome measures. Patients higher on attachment avoidance showed significantly greater reduction in depression severity and greater likelihood of symptom remission with CBT as compared with IPT, even after controlling for obsessive-compulsive and avoidant personality disorder symptoms. Results were replicated across treatment completers and intent-to-treat samples. These results suggest that it is important to consider the interaction between attachment insecurity and treatment type when comparing efficacy of treatments. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Computerized cognitive-behavioral therapy in a stepped care model of treatment.

A growing body of literature suggests that computerized cognitive-behavioral therapies (CCBT) are effective in community settings in terms of symptom reduction, favorable client satisfaction, attrition comparable to standard cognitive-behavioral therapy, reduced clinician time, high cost-effectiveness, and ease of integration into community clinics. Clinicians report lack of knowledge about computerized programs as the main reason that they have not used CCBT in their practice. To mitigate this disconnect between empirical evidence and dissemination, this article first reviews empirical studies focusing on the efficacy of CCBT for specific psychological disorders, followed by a review of research on the effectiveness of CCBT in community settings. Next, issues related to dissemination and barriers to CCBT adoption by clinicians are discussed. Finally, the implications of CCBT for research and practice and the possible role of CCBT in a stepped care model of treatment is discussed in terms of cost-effectiveness, standards of care, and implications for public policy. (PsycINFO Database Record (c) 2010 APA, all rights reserved)