Psychological therapies for the treatment of panic disorder with or without agoraphobia

Why is this review important?

Many people suffer from panic disorder. Panic disorder can occur on its own or with agoraphobia. People with panic disorder experience recurring panic attacks. During a panic attack people feel the sudden onset of intense fear alongside a series of bodily symptoms such as a racing heart, chest pain, sweating, shaking, dizziness, flushing, stomach churning, faintness and breathlessness. People with agoraphobia feel an intense fear of developing a panic attack in situations where escape might be difficult or embarrassing. This fear often leads to the avoidance of such situations.

There are many different types of talking therapies that are used to treat panic disorder with or without agoraphobia. However it is not clear whether certain talking therapies are more effective than others at treating panic disorder with or without agoraphobia. In this review we compared the effectiveness of different types of talking therapy.

Who will be interested in this review?

People with panic disorder with or without agoraphobia.

Friends and family of people with panic disorder with or without agoraphobia.

General practitioners, psychiatrists and psychologists.

Professionals working in adult mental health services.

What questions does this review aim to answer?

Are any of the included psychological therapies more effective and better tolerated than others in the rapid reduction of panic/agoraphobia symptoms?

Can any of the included psychological therapies guarantee better results one year after termination?

Which studies were included in the review?

We searched medical databases up to 16 March 2015 to find all studies (specifically randomised controlled trials) of talking therapies in the treatment of panic disorder with or without agoraphobia. To be included in the review studies had to include people with a clear diagnosis of panic disorder with or without agoraphobia.

We included 60 studies in the review. Fifty-four of the included studies (involving 3021 participants) were used in numerical analyses. The review authors rated the overall quality of the studies as low to very low.

What does the evidence from the review tell us?

The results of the review show that in general talking therapies are more effective than no treatment. There was no strong evidence to support one talking therapy over the others for the treatment of panic disorder with or without agoraphobia in adults. However, there was some low-quality evidence in favour of cognitive behaviour therapy (CBT), psychodynamic therapy and supportive psychotherapy over other talking therapies for short-term remission and short-term reduction in symptoms. The results concerning supportive psychotherapy should, however, be treated with caution because of the small amount of evidence available about this treatment. On the other hand, beyond the evidence regarding its efficacy, psychodynamic therapy also showed promising results in terms of tolerability: as a way of assessing how well people tolerated the talking therapies, we assessed short-term dropout rates. We found that there were fewer dropouts in psychodynamic therapy and third-wave CBT, suggesting that people tolerate these therapies better than other therapies.

What should happen next?

More high-quality research is needed to be able to fully compare the effectiveness of different talking therapies. In particular, more new studies are needed that compare the specific talking therapies CBT, psychodynamic therapy and supportive psychotherapy for the treatment of panic disorder with or without agoraphobia.

Authors' conclusions: 

There is no high-quality, unequivocal evidence to support one psychological therapy over the others for the treatment of panic disorder with or without agoraphobia in adults. However, the results show that CBT - the most extensively studied among the included psychological therapies - was often superior to other therapies, although the effect size was small and the level of precision was often insufficient or clinically irrelevant. In the only two studies available that explored PD, this treatment showed promising results, although further research is needed in order to better explore the relative efficacy of PD with respect to CBT. Furthermore, PD appeared to be the best tolerated (in terms of ST-dropouts) among psychological treatments. Unexpectedly, we found some evidence in support of the possible viability of non-specific supportive psychotherapy for the treatment of panic disorder; however, the results concerning SP should be interpreted cautiously because of the sparsity of evidence regarding this treatment and, as in the case of PD, further research is needed to explore this issue. Behaviour therapy did not appear to be a valid alternative to CBT as a first-line treatment for patients with panic disorder with or without agoraphobia.

Read the full abstract...
Background: 

Panic disorder is characterised by the presence of recurrent unexpected panic attacks, discrete periods of fear or anxiety that have a rapid onset and include symptoms such as racing heart, chest pain, sweating and shaking. Panic disorder is common in the general population, with a lifetime prevalence of 1% to 4%. A previous Cochrane meta-analysis suggested that psychological therapy (either alone or combined with pharmacotherapy) can be chosen as a first-line treatment for panic disorder with or without agoraphobia. However, it is not yet clear whether certain psychological therapies can be considered superior to others. In order to answer this question, in this review we performed a network meta-analysis (NMA), in which we compared eight different forms of psychological therapy and three forms of a control condition.

Objectives: 

To assess the comparative efficacy and acceptability of different psychological therapies and different control conditions for panic disorder, with or without agoraphobia, in adults.

Search strategy: 

We conducted the main searches in the CCDANCTR electronic databases (studies and references registers), all years to 16 March 2015. We conducted complementary searches in PubMed and trials registries. Supplementary searches included reference lists of included studies, citation indexes, personal communication to the authors of all included studies and grey literature searches in OpenSIGLE. We applied no restrictions on date, language or publication status.

Selection criteria: 

We included all relevant randomised controlled trials (RCTs) focusing on adults with a formal diagnosis of panic disorder with or without agoraphobia. We considered the following psychological therapies: psychoeducation (PE), supportive psychotherapy (SP), physiological therapies (PT), behaviour therapy (BT), cognitive therapy (CT), cognitive behaviour therapy (CBT), third-wave CBT (3W) and psychodynamic therapies (PD). We included both individual and group formats. Therapies had to be administered face-to-face. The comparator interventions considered for this review were: no treatment (NT), wait list (WL) and attention/psychological placebo (APP). For this review we considered four short-term (ST) outcomes (ST-remission, ST-response, ST-dropouts, ST-improvement on a continuous scale) and one long-term (LT) outcome (LT-remission/response).

Data collection and analysis: 

As a first step, we conducted a systematic search of all relevant papers according to the inclusion criteria. For each outcome, we then constructed a treatment network in order to clarify the extent to which each type of therapy and each comparison had been investigated in the available literature. Then, for each available comparison, we conducted a random-effects meta-analysis. Subsequently, we performed a network meta-analysis in order to synthesise the available direct evidence with indirect evidence, and to obtain an overall effect size estimate for each possible pair of therapies in the network. Finally, we calculated a probabilistic ranking of the different psychological therapies and control conditions for each outcome.

Main results: 

We identified 1432 references; after screening, we included 60 studies in the final qualitative analyses. Among these, 54 (including 3021 patients) were also included in the quantitative analyses. With respect to the analyses for the first of our primary outcomes, (short-term remission), the most studied of the included psychological therapies was CBT (32 studies), followed by BT (12 studies), PT (10 studies), CT (three studies), SP (three studies) and PD (two studies).

The quality of the evidence for the entire network was found to be low for all outcomes. The quality of the evidence for CBT vs NT, CBT vs SP and CBT vs PD was low to very low, depending on the outcome. The majority of the included studies were at unclear risk of bias with regard to the randomisation process. We found almost half of the included studies to be at high risk of attrition bias and detection bias. We also found selective outcome reporting bias to be present and we strongly suspected publication bias. Finally, we found almost half of the included studies to be at high risk of researcher allegiance bias.

Overall the networks appeared to be well connected, but were generally underpowered to detect any important disagreement between direct and indirect evidence. The results showed the superiority of psychological therapies over the WL condition, although this finding was amplified by evident small study effects (SSE). The NMAs for ST-remission, ST-response and ST-improvement on a continuous scale showed well-replicated evidence in favour of CBT, as well as some sparse but relevant evidence in favour of PD and SP, over other therapies. In terms of ST-dropouts, PD and 3W showed better tolerability over other psychological therapies in the short term. In the long term, CBT and PD showed the highest level of remission/response, suggesting that the effects of these two treatments may be more stable with respect to other psychological therapies. However, all the mentioned differences among active treatments must be interpreted while taking into account that in most cases the effect sizes were small and/or results were imprecise.

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