Page 1 of 10 Journal of Consulting and Clinical Psychology August 1999 Vol 67 No 4 583 589 1999 by the American Psychological Association For personal use only not for distribution Brief Cognitive Therapy for Panic Disorder A Randomized Controlled Trial David M Clark Department of Psychiatry University of Oxford Oxford United Kingdom Paul M Salkovskis Department of Psychiatry University of Oxford Oxford United Kingdom Ann Hackmann Department of Psychiatry University of Oxford Oxford United Kingdom Adrian Wells Department of Psychiatry University of Oxford Oxford United Kingdom John Ludgate Department of Psychiatry University of Oxford Oxford United Kingdom Michael Gelder Department of Psychiatry University of Oxford Oxford United Kingdom ABSTRACT Cognitive therapy CT is a specific and highly effective treatment for panic disorder PD Treatment normally involves 12 15 1 hr sessions In an attempt to produce a more costeffective version a briefer treatment that made extensive use of between sessions patient selfstudy modules was created Forty three PD patients were randomly allocated to full CT FCT brief CT BCT or a 3 month wait list FCT and BCT were superior to wait list on all measures and the gains obtained in treatment were maintained at 12 month follow up There were no significant differences between FCT and BCT Both treatments had large approximately 3 0 and essentially identical effect sizes BCT required 6 5 hr of therapist time including booster sessions Patients initial expectation of therapy success was negatively correlated with posttreatment panic anxiety Cognitive measures at the end of treatment predicted panic anxiety at 12 month follow up Adrian Wells is now at the Department of Clinical Psychology Manchester University Manchester United Kingdom This research was funded by grants from the Medical Research Council of the United Kingdom and the Wellcome Trust We are grateful to Hester Barrington Ward Sarah Durbin Anke Ehlers Melanie Fennell Carolyn Fordham Walker Freda McManus Anthony Morrison and Christina Suraway for their assistance Correspondence may be addressed to David M Clark Department of Psychiatry University of Oxford Warneford Hospital Oxford United Kingdom OX3 7JX Electronic mail may be sent to David Clark psych ox ac uk Received May 13 1998 Revised November 26 1998 Accepted November 30 1998 http spider apa org ftdocs ccp 1999 august ccp674583 html 8 30 2000 Page 2 of 10 During the 1980s several effective cognitive behavioral treatments for panic disorder were developed The two that have been most extensively evaluated are the panic control treatment PCT developed by Barlow Craske and colleagues and the cognitive therapy program developed by Clark Salkovskis Beck and colleagues Although the two treatments differ in emphasis they have many common ingredients and appear to be similarly effective Originally they involved 12 to 15 one hour sessions In this format one or both have been shown to be superior to equally credible relaxation based treatment supportive psychotherapy alprazolam imipramine and placebo medication see Barlow Lehman 1996 and Clark 1996 for reviews Recently researchers have started to investigate whether it might be possible to obtain similarly good results with briefer forms of the treatments If so scarce health care resources could be used to provide effective treatment for a larger number of patients Two studies have investigated briefer forms of panic control therapy Craske Maidenberg and Bystritsky 1995 found that a four session version of PCT was more effective than four sessions of nondirective supportive therapy However the authors commented that the overall clinical outcome of the four session version was considerably less than the outcome typically achieved with full PCT Newman Kenardy Herman and Taylor 1997 reported a small scale pilot study in which full PCT was compared with 6 hr of palmtop computer assisted PCT Both treatments produced significant improvement However at the end of treatment but not at follow up a significantly greater proportion of patients were panic free after full PCT than after computer assisted PCT One study has attempted to abbreviate cognitive therapy Black Wesner Bowers and Gabel 1993 devised a shortened eight session version of cognitive therapy which included additional psychological procedures that they developed This abbreviated version of cognitive therapy was not significantly different from placebo medication and achieved a panic free rate 32 of the intention to treat sample which is less than half the rate obtained in any other study of cognitive therapy see Clark 1996 for a review The present study represents a further attempt to develop a brief version of cognitive therapy To maximize the amount of change achieved in each therapy session we developed a set of self study modules covering the main aspects of therapy and asked patients to complete the modules prior to therapy sessions Method Design Patients were initially assigned to full cognitive therapy FCT brief cognitive therapy BCT or a wait list control condition Patients in FCT had up to 12 one hour sessions in the first 3 months whereas BCT patients had 5 sessions Both groups had up to 2 booster sessions in the next 3 months Patients on the wait list received no treatment for 3 months after which they were assigned randomly to one of the two forms of cognitive therapy Assessments which included ratings completed by an independent assessor who was unaware of treatment allocation were at pretreatment wait list posttreatment wait list 3 month posttreatment follow up and 12 month posttreatment follow up Patients All Oxfordshire general practitioners psychiatrists and psychologists were sent a letter requesting referrals http spider apa org ftdocs ccp 1999 august ccp674583 html 8 30 2000 Page 3 of 10 for a study of psychological treatments for panic disorder Referred patients were assessed by trained clinical psychologists using the Structured Clinical Interview for DSM III R Spitzer Williams 1986 Acceptance criteria which were the same as in our previous trial of FCT Clark et al 1994 were a Diagnostic and Statistical Manual of Mental Disorders 3rd ed rev DSM III R American Psychiatric Association 1987 criteria for panic disorder with no mild or moderate agoraphobic avoidance b duration of current episode of at least 6 months c at least three panic attacks in the 3 weeks prior to interview d panic considered as the patient s main problem e
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