Cognitive Behaviour Therapy for Panic Disorder

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Cognitive Behaviour Therapy for Panic Disorder: Long‐term Follow‐up a

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Justin Kenardy , Susan Robinson & Rian Dob

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Centre of National Research on Disability and Rehabilitation Medicine , University of Queensland , Australia b

Centre of National Research on Disability and Rehabilitation Medicine, School of Medicine , University of Queensland , Herston , Queensland, 4006 , Australia E-mail: Published online: 16 Aug 2006.

To cite this article: Justin Kenardy , Susan Robinson & Rian Dob (2005) Cognitive Behaviour Therapy for Panic Disorder: Long‐term Follow‐up, Cognitive Behaviour Therapy, 34:2, 75-78, DOI: 10.1080/16506070410005410 To link to this article: http://dx.doi.org/10.1080/16506070410005410

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Cognitive Behaviour Therapy Vol 34, No 2, pp. 75–78, 2005

Cognitive Behaviour Therapy for Panic Disorder: Long-term Follow-up Justin Kenardy, Susan Robinson and Rian Dob

Downloaded by [UQ Library] at 17:55 02 July 2013

Centre of National Research on Disability and Rehabilitation Medicine, University of Queensland, Australia Abstract. This paper describes a long-term follow-up of patients with panic disorder who received cognitive behaviour therapy within a randomized controlled trial. Of 89 patients eligible for followup, 28 (31.5%) were reassessed 6–8 years after commencement of treatment in the trial. No differences were found between those who were followed up and those lost to follow-up on most baseline measures including measures of panic-related psychopathology, or depression. Outcomes at long-term follow-up were significantly better than baseline measures of panic, avoidance and depression. In this sub-sample the effect of cognitive behaviour therapy for panic disorder appears to maintain over the long-term. Key words: panic disorder; randomized controlled study; cognitive therapy. Received April 28, 2004; Accepted October 7, 2004 Correspondence address: Justin Kenardy, Centre of National Research on Disability and Rehabilitation Medicine, School of Medicine, University of Queensland, Herston, Queensland, 4006, Australia. E-mail: [email protected]

Cognitive behaviour therapy is widely viewed as the treatment of choice for panic disorder. This is based on the results of outcome studies that have followed treated cases for up to 2 years (e.g. Brown & Barlow, 1995). Shear (1996) has argued that evaluation of longerterm follow-up is urgently needed. There have a number of longer-term follow-up studies reported in the literature. Fava et al. (2001) undertook a naturalistic follow-up of exposure treated patients with agoraphobia, the median follow-up was 8 years. Of those followed-up at 10 years, 62% were in remission. O’Rourke et al. (1996) found good outcomes for 80% of patients with panic disorder following treatment with antidepressants and behavioural counselling. Long-term follow-up of patients with panic disorder treated with medication has had mixed results. For example Andersch and Hetta (2003) found that after 15 years 31% of patients treated with alprazolam or imipramine were panic-free. Katschnig et al. (1995) followed up patients with panic disorder treated at 1 site of # 2005 Taylor & Francis Ltd ISSN 1650-6073 DOI 10.1080/16506070410005410

a multi-site outcome study for alprazolam vs imiprimine. In this study 39% of patients were found to be panic-free at 2–6 years follow-up. In contrast Swoboda et al. (2003) also followed up patients who were part of the same multi-site trial, but at a different site. At 11 years post-treatment 87.5% were panic-free. To date there are no reports of longer-term follow-up after cognitive behaviour therapy for panic disorder. The aim of this study is to examine longer-term outcomes in patients treated for panic disorder using cognitive behaviour therapy. Patients were originally from 1 site of an international multi-site trial of cognitive behaviour therapy for panic disorder (Kenardy et al., 2003). The followup was naturalistic and was over a median of 6 years after completion of treatment.

Method The sample for this study came from 89 panic disorder patients who received cognitive


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behaviour therapy within a treatment outcome study (Kenardy et al., 2003.) In order to improve external validity the original study had limited exclusion criteria. Thus the sample had more co-morbidity and was more representative of a clinical population. These patients were all recruited at Brisbane, Australia and received 1 of 3 variations of cognitive behaviour therapy, a 12 weekly session ‘‘standard’’ treatment (CBT12), a 6 weekly session ‘‘brief ’’ treatment (CBT6) and a 6 weekly session treatment augmented by patient access to a palm-top computer (CBT6CA). All patients were sent consent forms and a pre-paid envelope to return prior to participation in the follow-up. The initial letter encouraged patients to return the consent form unsigned if they did not wish to participate. Those who returned the signed consent form were then sent the questionnaire package. Where there was no response to the initial letter 2 reminder letters were sent. In the event of the letter being returned to sender, any other new address was sought through the government electoral rolls and if found another letter was sent. Of the 89 initial letters sent, 15 were returned to sender, for 45 there was no response. One patient refused consent.

not differ between those followed up (M538.30, SD512.20) and those who were not (M538.28, SD510.02), however there were significantly more women followed up (n525, 89.3%) than not (n541, 67.2%, X254.88, p50.03). No difference was found in the proportion of patients with agoraphobia in those followed-up (n525, 89.3%) and those not (n547, 77.0%). No difference was found in duration of the disorder between those followed-up (M510.39 years, SD58.82) and those not (M511.82 years, SD510.45). No relationship was found between numbers in each treatment condition and follow-up (CBT12, n510, 35.7%; CBT6, n510, 35.7%; CBT6CA, n58, 28.6%) vs those not followed up (CBT12, n518, 29.5%; CBT6, n518, 29.5%; CBT6CA, n525, 41.0%.) Also no difference was found between patients followed up and those not, on initial severity of the disorder (pre-treatment: F/U M50.68, SD50.58; No F/U M50.66, SD50.56, ES50.01) or on treatment response (Pre-Post change: F/U M520.88, SD50.70; No F/U M520.88, SD50.72, ES50.01) as assessed using a panic-related composite measure (Kenardy et al., 2003.)

Measures

At baseline no patients were panic free, but at follow-up 57.1% (n516) were panic-free. Panic frequency reduced significantly from baseline (M52.39, SD50.87) to follow-up (M51.11, SD51.47; t[27]54.50, pv0.001, ES52.02). In those patients who reported having panic attacks, the rated severity did not change significantly from baseline (M54.75, SD51.76) to follow-up (M53.50, SD52.11; t[11]51.42, p50.18, ES50.71)

The baseline assessment was carried out using the Structured Clinical Interview for DSM-IV Axis I Disorders (SCID-I, First, Spitzer, Gibbon & Williams, 1997.) Other baseline measures included self-reported frequency of panic attacks over the last 2 weeks; panicrelated distress/disability rated on a 9-point scale, where 0 represented ‘‘not at all disturbing and/or disabling’’, 2 ‘‘slightly’’, 4 ‘‘definitely’’, 6 ‘‘markedly’’ and 8 ‘‘very disturbing/ disabling’’; phobic avoidance was assessed by the Fear Questionnaire (Marks & Mathews, 1979); and depression was assessed by the Beck Depression Inventory (BDI; Beck, Steer & Garbin, 1988). These self-report measures were all included in the follow-up.

Results Twenty-eight (31%) of the original 89 patients were reassessed between 5 and 7 years (M574.4 months, SD57.6, range564–90 months) after entry to the study. Age did

Panic

Avoidance The Total Score on the Fear Questionnaire reduced significantly from baseline (M546.93, SD522.30) to follow-up (M522.81, SD5 24.13; t[27]54.63, pv0.001, ES51.08). This was also the case for the Agoraphobia (baseline M515.25, SD58.61; follow-up M57.60, SD510.91; t[27]53.60, pv0.001, ES50.89), Social Phobia (baseline M517.57, SD510.11; follow-up M58.07, SD59.49; t[27]54.35, pv0.001, ES50.94) and Blood-Injury Phobia (baseline M514.82, SD58.68; follow-up M57.14, SD58.73; t[27]54.61,

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pv0.001, ES50.88) subscales of the Fear Questionnaire.

Depression The Beck Depression Inventory reduced significantly from baseline (M522.46, SD5 12.01) to follow-up (M59.86, SD512.28; t[27]54.49, pv0.001, ES51.05). At baseline 53.6% (n515) exceeded a total score of 18, and indicator of clinical depression (Beck et al., 1988). This reduced significantly to 10.7% (n53) at follow-up (Wilcoxon signed ranks test Z53.46, pv.001).


Outcome prediction Using a series of regression analyses baseline avoidance (Fear Questionnaire), panic frequency, depression (Beck Depression Inventory) and duration of disorder were used to predict follow-up scores. In each case baseline values were controlled for by entering them first into the regression equation. No significant predictor was found. Using analysis of covariance controlling for pre-treatment value no relationship was found between original treatment condition and outcome on Fear Questionnaire, Beck Depression Inventory or panic frequency. Gender comparisons could not be made due to the small number of males (n53).

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different picture of patients’ status. In the original study between 63% and 67% of patients were panic-free at 6-month followup (Kenardy et al., 2003). This compares reasonably well with the 57.1% found at the long-term follow-up. Furthermore there is also evidence from all outcome measures that patients continue to remain improved on measures of avoidance and depression. This suggests that there is a degree of maintenance of treatment outcome following cognitive behaviour therapy for panic disorder, although this must be tempered with the likelihood that other influences will have had an impact over the follow-up period. The finding that type of original treatment did not predict outcome is consistent with the finding for 6-month follow-up outcome in the original study (Kenardy et al., 2003.) Therefore confirming the finding that long-term outcome is not necessarily dependent on length of initial treatment (Clark et al., 1999). Further work is required on longer-term outcomes of cognitive behaviour therapy with larger more complete samples. Also, whilst outcomes from this study are promising, there is still a significant proportion of patients who have not recovered, and this suggests that we still have room for improvement in the psychological treatment of panic disorder.

Treatment Only 3 patients reported ongoing treatment for their panic disorder, 1 on medication, 1 receiving psychological care and 1 from an alternative healthcare provider.

Discussion This is the longest duration of follow-up of a group of patients with panic disorder treated with cognitive behaviour therapy. The strengths of the study are that it has used measures that overlap with the original study, and that the sample appears to be largely representative of the original sample, however it is quite possible that those lost to follow-up had relapsed following treatment. The limitations of the study are that the sample size is relatively small and that the follow-up is of only one-third of the original sample. Also the study only employed self-report measures, interview measures may have provided a

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