Panic Disorder: Combining CBT with Pharmacotherapies

Combining CBT with Pharmacotherapies

Simultaneous Treatments

Many clinicians believe the optimal treatment consists of drugs combined with some form of psychosocial intervention. This view arose from observations that even the most effective drugs and the most effective psychosocial interventions do not elimi-nate panic disorder in all cases. It was thought that combination treatments might be a way to improve treatment outcome. The available evidence provides mixed support for this view. Evi-dence suggests that the efficacy of CBT is not improved when it is combined with either diazepam or alprazolam. In fact, some studies have found that the efficacy of situational exposure is worsened when alprazolam is added.

Several studies have compared CBT with CBT combined with imipramine. These results have also been mixed. Adding imipramine in the range of 150–300 mg/day to either situational exposure or CBT sometimes improves treatment outcome in the short term, provided that patients are able to tolerate the dose. Any advantage of combined treatment tends to be lost at follow-up. Similarly, studies of combining CBT with SSRIs (fluvox-amine or paroxetine) have produced mixed results, with some studies finding the combination is no better than CBT.

It remains unclear whether treatment outcome is enhanced by combining CBT with SSRIs. The neuroanatomical model with its dual emphasis on cortical and serotonergic mechanisms suggests that this combined treatment might be superior to CBT alone and to SSRIs alone. On the other hand, pharmacothera-pies such as SSRIs might undermine the patient’s confidence in implementing CBT, particularly if they attribute their gains to medications rather than to their own efforts at using the skills learned in CBT. Large, well-designed studies are needed to ex-plore these important issues.

Sequential Treatments

A more promising type of combined therapy is a sequential ap-proach, where patients are treated with pharmacotherapy during the acute phase, and then are treated with CBT as the medication is phased out. Several studies have shown that adding CBT dur-ing the tapering period for alprazolam and clonazepam reduces the relapse rate associated with these drugs. It remains to be dem-onstrated that CBT can reduce relapse when patients are tapered off other antipanic drugs such as SSRIs. However, there is no reason to expect that CBT would not be helpful in these cases.