«RUNNING HEAD: DAVID BARLOW AND PANIC DISORDER The Contribution of David Barlow to the Understanding and Treatment of Panic Disorder Brett J. Deacon, ...»
Patients were assessed by independent evaluators at pre-treatment and after acute treatment, after six months of maintenance treatment, and six months after treatment discontinuation.
Following acute and maintenance treatment, PCT and imipramine were equally effective, while patients receiving the combination of PCT and imipramine had significantly better outcomes than those receiving PCT alone. However, the opposite pattern emerged six months after treatment was discontinued: patients receiving combined treatment had the worst outcomes of patients in any active intervention, while PCT without imipramine proved most beneficial.
Taken together, these findings demonstrate that adding imipramine to PCT may improve shortterm efficacy but impedes the durability of therapeutic gains after medication is discontinued.
Moreover, PCT appears to be as effective as imipramine in the short-term and more effective after treatment discontinuation. An important take-home message of this study is that when longterm outcomes are considered, PCT alone appears to be the treatment of choice for PD.
A third generalization supported by the treatment outcome literature is that PCT is effective across many different methods of delivery. PCT administered in group format appears to be both highly efficacious (e.g., Telch et al., 1993; Schmidt et al., 2000) and particularly costeffective (Gould, Otto, & Pollack, 1995). Efforts to increase the dissemination and accessibility
examining bibliotherapy (e.g., Gould, Clum, & Shapiro, 1993), computer-guided self-exposure (Marks, Kenwright, McDonough, Whittaker, & Mataix-Cols, 2004), palmtop-computer assisted PCT (Kenardy et al., 2003), internet-based treatment (e.g., Carlbring, Westling, Ljungstrand, Ekselius, & Andersson, 2001), and teletherapy (e.g., Swinson, Fergus, Cox, & Wickwire, 1995) indicate that brief, reduced therapist contact interventions may be viable options for many individuals with PD. Notably, several studies indicate that very brief, intensive PCT produces outcomes comparable to standard-length PCT in a matter of weeks (Westling & Ost, 1999) or even days (Evans et al., 1991).
A final generalization about PCT concerns its real-world effectiveness. Numerous studies indicate that the beneficial effects of PCT demonstrated in highly controlled clinical trials generalize to real-world settings in which complex patients are treated in a less structured manner by non-expert therapists. For example, Wade, Treat, and Stuart (1998) found that 87% of PD patients who received PCT from master’s level clinicians in a community mental health center were panic-free at the end of treatment. A follow-up study of these patients indicated that the vast majority had maintained or improved upon their gains one year later (Stuart, Treat, & Wade, 2000). More recently, Addis et al. (2004) reported that PCT delivered by minimally trained therapists was more effective than treatment-as-usual in a managed care setting. These studies indicate that PCT can be effectively transported to real-world settings in which it is administered to complex patients by therapists with only minimal training in the cognitivebehavioral treatment of anxiety.
Despite his seminal contributions to the conceptualization and treatment of PD, Dr.
Barlow’s efforts to increase the scientific rigor of clinical practice may eventually prove to have
effective treatments like PCT, the failure of most clinicians in the community to provide such treatments to eligible patients (Goisman, Warshaw, & Keller, 1999) represents an important public health problem. Dr. Barlow has been a key figure in the movement to address this problem by identifying and disseminating empirically supported psychological treatments. His writings on this topic (e.g., Barlow, 1996; Barlow, Levitt, & Bufka, 1999) have focused on reviewing research methods used to evaluate treatments, highlighting treatments that work, discussing how to implement these treatments in the community, and debunking myths that prevent clinicians from adopting empirically supported treatments. By spreading the word that treatments like PCT are uniquely effective, transportable to different settings, and easily adopted by non-expert clinicians, Dr. Barlow has been instrumental in the ongoing struggle to adopt evidence-based standards of practice in clinical psychology.
Consistent with psychology’s growing status as a health care profession, Barlow (2004) recently argued for the adoption of an important change in the language used to describe its treatments. Rather than characterizing all psychological interventions with the term “psychotherapy,” Barlow suggested that the label of “psychological treatments” be used to describe specific interventions developed for specific disorders (e.g., PCT for PD). By adopting this new terminology, psychologists (and the public) can distinguish the more generic “psychotherapy,” which consists of treatments often applied outside of health care systems, from empirically supported psychological treatments that have been developed to target the specific pathological processes associated with specific psychological problems. If psychology comes to adopt this proposed terminological change, an important step will be taken in the effort to
Addis, M. E., Hatgis, C., Krasnow, A. D., Jacob, K., Bourne, L., Mansfield, A. (2004).
Effectiveness of cognitive-behavioral treatment for panic disorder versus treatment as usual in a managed care setting. Journal of Consulting & Clinical Psychology, 72, 625American Psychiatric Association (1998). Practice guideline for the treatment of patients with panic disorder. Washington, DC: Author.
American Psychological Association. (2000). Diagnostic and statistical manual of mental disorders (4th edition, text revision). Washington DC: Author.
Barlow, D. H. (1996). Health care policy, psychotherapy research, and the future of psychotherapy. American Psychologist, 51, 1050-1058.
Barlow, D. H. (2002). Anxiety and its disorders: The nature and treatment of anxiety and panic.
Barlow, D. H. (2004). Psychological treatments. American Psychologist, 59, 869-878.
Barlow, D. H., & Craske, M. G. (2000). Mastery of Your Anxiety and Panic (3rd ed.). San Antonio, TX: Graywind Publications Inc/The Psychological Corporation.
Barlow, D. H., Craske, M. G., Cerny, J. A., & Klosko, J. S. (1989). Behavioral treatment of panic disorder. Behavior Therapy, 20, 261-282.
Barlow, D. H., Gorman, J. M., Shear, M. K., & Woods, S. W. (2000). Cognitive-behavioral therapy, imipramine, or their combination for panic disorder: A randomized controlled trial. Journal of the American Medical Association, 283, 2529-2536.
Barlow, D. H., Levitt, J. T., & Bufka, L. F. (1999). The dissemination of empirically supported
Beck, A. T., Sokol, L., Clark, D. A., Berchick, R., & Wright, F. (1992). A crossover study of focused cognitive therapy for panic disorder. American Journal of Psychiatry, 149, 778Bouton, M. E., Mineka, S., & Barlow, D. H. (2001). A modern learning theory perspective on the etiology of panic disorder. Psychological Review, 108, 4-32.
Boyd, J. H. (1986). Use of mental health services for the treatment of panic disorder. American Journal of Psychiatry, 143, 1569-1574.
Carlbring, P. Westling, B. E., Ljungstrand, P., Ekselius, L., & Andersson, G. (2001). Treatment of panic disorder via the internet: A randomized trial of a self-help program. Behavior
Chambless, D. L., & Ollendick, T. H. (2001). Empirically supported psychological interventions:
Controversies and evidence. Annual Review of Psychology, 52, 685-716.
Clark, D. M., Salkovskis, P. M., Hackmann, A., Middleton, H., Anastasiades, P., & Gelder, M.
(1994). A comparison of cognitive therapy, applied relaxation and impiramine in the treatment of panic disorder. British Journal of Psychiatry, 164, 759-769.
Clark, D. M. (1986). A cognitive approach to panic. Behaviour Research and Therapy, 24, 461Craske, M. G., Brown, T. A., & Barlow, D. H. (1991). Behavioral treatment of panic disorder: A two-year follow-up. Behavior Therapy, 22, 289-304.
Deacon, B. J., & Abramowitz, J. S. (2005). Patients’ perceptions of pharmacological and
Evans, L., Holt, C., & Oei, T. P. S. (1991). Long term follow-up of agoraphobics treated by brief, intensive group cognitive behavioural therapy. Australian and New Zealand Journal of Psychiatry, 25, 343-349.
Goisman, R. M., Warshaw, M. G., & Keller, M. B. (1999). Psychosocial treatment prescriptions for generalized anxiety disorder, panic disorder, and social phobia, 1991-1996. American Journal of Psychiatry, 156, 1819-1821.
Goldstein, A. J., & Chambless, D. L. (1978). A reanalysis of agoraphobia. Behavior Therapy, 9, 47-59.
Gould, R. A., Clum, G. A., & Shapiro, D. (1993). The use of bibliotherapy in the treatment of panic disorder: A preliminary investigation. Behavior Therapy, 24, 241-252.
Gould, R. A., Otto, M. W., & Pollack, M. H. (1995). A meta-analysis of treatment outcome for panic disorder. Clinical Psychology Review, 8, 819-844.
Heuzenroeder. L., Donnelly, M., Haby, M. M., Mihalopoulos, C., Rossell, R., Carter, R., Andrews, G., & Vos, T. (2004). Cost-effectiveness of psychological and pharmacological interventions for generalized anxiety disorder and panic disorder. Australian and New Zealand Journal of Psychiatry, 38, 602-612.
Hofmann, S. G., Barlow, D. H., Papp, L. A., Detweiler, M. F., Ray, S. E., Shear, M. K., Woods, S. W., & Gorman, J. M. (1998). Pretreatment attrition in a comparative outcome study in panic disorder. American Journal of Psychiatry, 155, 43-47.
Huppert, J. D., & Baker-Morissette, S. L. (2003). Beyond the manual: The insider’s guide to
Kenardy, J. A., Dow, M. G., Johnston, D. W., Newman, M. G., Thomson, A., & Taylor, C. B.
(2003). A comparison of delivery methods of cognitive-behavioral therapy for panic disorder: An international multicenter trial. Journal of Consulting and Clinical Psychology, 71, 1068-1075.
Kessler, R. C., Berglund, P., Demler, O., Jin, R., & Walters, E. E. (2005). Lifetime prevalence and age-of-onset distributions of DSM-IV disorders in the national comorbidity survey replication. Archives of general Psychiatry, 62, 593-602.
Leon, A. C., Portera, L., & Weissman, M. M. (1995). The social costs of anxiety disorders.
British Journal of Psychiatry, 166 (suppl. 27), 19-22.
Marks, I. M., Kenwright, M., McDonough, M., Whittaker, M., & Mataix-Cols, D. (2004). Saving clinicians' time by delegating routine aspects of therapy to a computer: A randomized controlled trial in phobia/panic disorder. Psychological Medicine, 34, 9-17.
McNally, R. J. (1990). Psychological approaches to panic disorder. Psychological Bulletin, 108, 403-419.
Michelson, L., Mavissakalian, M., & Marchione, K. (1985). Cognitive-behavioral treatments of agoraphobia: Clinical, behavioral, and psychophysiological outcome. Journal of Consulting and Clinical Psychology, 53, 913-925.
Raffa, S. D., White, K. S., & Barlow, D. H. (2004). Feared consequences of panic attacks in panic disorder: A qualitative and quantitative analysis. Cognitive Behaviour Therapy, 33,
Schmidt, N. B., Woolaway-Bickel, K., Trakowski, J., Santiago, H., Storey, J., Koselka, & M.,
Cook, J. (2000). Dismantling cognitive-behavioral treatment for panic disorder:
questioning the utility of breathing retraining. Journal of Consulting and Clinical Psychology, 68, 417-424.
Stein, M. B., Sherbourne, C. D., Craske, M. G., Means-Christensen, A., Bystritsky, A., Katon, W., Sullivan, G., & Roy-Byrne, P. P. (2004). Quality of care for primary care patients with anxiety disorders. American Journal of Psychiatry, 161, 2230-2237.
Stuart, G. L., Treat, T. A., & Wade, W. A. (2000). Effectiveness of an empirically based treatment for panic disorder delivered in a service clinic setting: 1-year follow-up.
Journal of Consulting and Clinical Psychology, 68, 506-512.
Swinson, R. P., Fergus, K. D., Cox, B. J., & Wickwire, K. (1995). Efficacy of telephoneadministered behavioral therapy for panic disorder with agoraphobia. Behaviour Research and Therapy, 33, 465-469.
Taylor, S. (2000). Understanding and treating panic disorder: Cognitive-behavioural approaches. New York: Wiley.
Telch, M. J., Lucas, J. A., Schmidt, N. B., Hanna, H. H., LaNae, J. T., & Lucas, R. A. (1993).
Group cognitive-behavioral treatment of panic disorder. Behaviour Research and
Wade, W. A., Treat, T. A., & Stuart, G. L. (1998). Transporting an empirically supported treatment for panic disorder to a service clinic setting: A benchmarking strategy. Journal of Consulting & Clinical Psychology, 66, 231-239.
Westling, B. E., & Ost, L.-G. (1999). Brief cognitive behaviour therapy of panic disorder. Scandinavian
Journal of Behavior Therapy, 28, 49-57.