Does Maintenance CBT Contribute to Long-Term Treatment Response of Panic Disorder With or Without Agoraphobia? A Randomized Controlled Clinical Trial

Journal of Consulting and Clinical Psychology (Impact Factor: 4.85). 11/2012; 81(1). DOI: 10.1037/a0030666
Source: PubMed


We examined the possibility that maintenance cognitive behavior therapy (M-CBT) may improve the likelihood of sustained improvement and reduced relapse in a multi-site randomized controlled clinical trial of patients who met criteria for panic disorder with or without agoraphobia.

Participants were all patients (N = 379) who first began an open trial of acute-phase CBT. Patients completing and responding to acute-phase treatment were randomized to receive either 9 monthly sessions of M-CBT (n = 79) or assessment only (n = 78) and were then followed for an additional 12 months without treatment.

M-CBT produced significantly lower relapse rates (5.2%) and reduced work and social impairment compared to the assessment only condition (18.4%) at a 21-month follow-up. Multivariate Cox proportional hazards models showed that residual symptoms of agoraphobia at the end of acute-phase treatment were independently predictive of time to relapse during 21-month follow-up (hazards ratio = 1.15, p < .01).

M-CBT aimed at reinforcing acute treatment gains to prevent relapse and offset disorder recurrence may improve long-term outcome for panic disorder with and without agoraphobia.

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Available from: Kamila White, Jun 11, 2014
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    • "Primary outcomes from this trial (e.g., number of responders and nonresponders, attrition/dropout) were reported in Aaronson et al. (2008) and White et al. (2010), respectively (see Grilo et al., 1998; Hofmann et al., 1998, for similar reports on previous trials examining this treatment approach for panic disorder ). Additionally, White et al. (2013) recently reported the primary outcomes for the study of acute treatment responders who were randomized to receive maintenance CBT or no maintenance. "
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    ABSTRACT: Objective: Recently, innovative statistical tools have been used to model patterns of change in psychological treatments. These tools can detect patterns of change in patient progress early in treatment and allow for the prediction of treatment outcomes and treatment length. Method: We used growth mixture modeling to identify different latent classes of early change in patients with panic disorder (N = 326) who underwent a manualized cognitive-behavioral treatment. Results: Four latent subgroups were identified, showing clusters of change trajectories over the first 5 sessions. One of the subgroups consisted of patients whose symptoms rapidly decreased and also showed the best outcomes. This information improved treatment prediction by 16.1% over patient intake characteristics. Early change patterns also significantly predicted patients' early treatment termination. Patient intake characteristics that significantly predicted class membership included functional impairment and separation anxiety. Conclusions: These findings suggest that early treatment changes are uniquely predictive of treatment outcome.
    Journal of Consulting and Clinical Psychology 01/2014; 82(2). DOI:10.1037/a0035535 · 4.85 Impact Factor
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    • "Patients were then triaged into two clinical trials according to response status. Responders were randomized to booster sessions or no booster sessions (White et al., 2013) while non-responders were randomized to either continued CBT or to paroxetine (Payne et al., 2013). In this study, data were analyzed from the initial treatment phase only where all patients (n ¼ 379) received CBT from 23 therapists. "
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    ABSTRACT: Although the alliance-outcome correlation is well established, no published studies to date have separated between therapists' and patients' contributions while controlling for early symptom change. In this study, we examined therapist effects in two trials of CBT for panic disorder with agoraphobia (PDA) and the impact of therapists' and patients' contribution to the alliance on outcome and attrition in one trial. Alliance ratings were obtained from patients and therapists early and late in treatment (n = 133). Data were analyzed using multi-level modeling controlling for early symptom change. No therapist effects were found. The patients' contribution to the alliance predicted outcome (in both panic severity and anxiety sensitivity) and attrition. The therapists' contribution to the alliance predicted attrition but not outcome. Results suggest that the patient's contribution to the alliance plays an important role in CBT for PDA and that including common factors into research on CBT may help elucidate treatment processes.
    Behaviour Research and Therapy 11/2013; 52C(1):26-34. DOI:10.1016/j.brat.2013.11.001 · 3.85 Impact Factor
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    ABSTRACT: Although associations with outcome have been inconsistent, therapist adherence and competence continues to garner attention, particularly within the context of increasing interest in the dissemination, implementation, and sustainability of evidence-based treatments. To date, research on therapist adherence and competence has focused on average levels across therapists. With a few exceptions, research has failed to address multiple sources of variability in adherence and competence, identify important factors that might account for variability, or take these sources of variability into account when examining associations with symptom change. Objective: (a) statistically demonstrate between-and within-therapist variability in adherence and competence ratings and examine patient characteristics as predictors of this variability and (b) examine the relationship between adherence/competence and symptom change. Method: Randomly selected audiotaped sessions from a randomized controlled trial of cognitive-behavioral therapy for panic disorder were rated for therapist adherence and competence. Patients completed a self-report measure of panic symptom severity prior to each session and the Inventory of Interpersonal Problems-Personality Disorder Scale prior to the start of treatment. Results: Significant between-and within-therapist variability in adherence and competence were observed. Adherence and competence deteriorated significantly over the course of treatment. Higher patient interpersonal aggression was associated with decrements in both adherence and competence. Neither adherence nor competence predicted subsequent panic severity. Conclusions: Variability and "drift" in adherence and competence can be observed in controlled trials. Training and implementation efforts should involve continued consultation over multiple cases in order to account for relevant patient factors and promote sustainability across sessions and patients.
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