Page 1 of 10http://spider.apa.org/ftdocs/ccp/1999/august/ccp674583.html 8/30/2000Brief Cognitive Therapy for Panic Disorder A Randomized Controlled Trial David M. ClarkDepartment of Psychiatry University of Oxford, Oxford, United Kingdom Paul M. SalkovskisDepartment of Psychiatry University of Oxford, Oxford, United Kingdom Ann HackmannDepartment of Psychiatry University of Oxford, Oxford, United Kingdom Adrian WellsDepartment of Psychiatry University of Oxford, Oxford, United Kingdom John LudgateDepartment of Psychiatry University of Oxford, Oxford, United Kingdom Michael GelderDepartment of Psychiatry University of Oxford, Oxford, United Kingdom ABSTRACTCognitive 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 cost-effective version, a briefer treatment that made extensive use of between-sessions patient self-study 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 [email protected] Received: May 13, 1998 Revised: November 26, 1998 Accepted: November 30, 1998 Journal of Consulting and Clinical Psychology © 1999 by the American Psychological Association August 1999 Vol. 67, No. 4, 583-589 For personal use only--not for distribution.Page 2 of 10http://spider.apa.org/ftdocs/ccp/1999/august/ccp674583.html 8/30/2000During 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, forreviews ). 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 referralsPage 3 of 10http://spider.apa.org/ftdocs/ccp/1999/august/ccp674583.html 8/30/2000for 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 ;
View Full Document
Unlocking...