Effects of concurrent diazepam treatment on the outcome of exposure therapy in agoraphobia

No harmful effect of propranolol administered prior to fear memory extinction in rats and humans

Exposure therapy is an evidence-based treatment option for anxiety-related disorders. Many patients also take medication that could, in principle, affect exposure therapy efficacy. Clinical and laboratory evidence indeed suggests that benzodiazepines may have detrimental effects. Large clinical trials with propranolol, a common beta-blocker, are currently lacking, but several preclinical studies do indicate impaired establishment of safety memories. Here, we investigated the effects of propranolol given prior to extinction training in 9 rat studies (N = 215) and one human study (N = 72). A Bayesian meta-analysis of our rat studies provided strong evidence against propranolol-induced extinction memory impairment during a drug-free test, and the human study found no significant difference with placebo. Two of the rat studies actually suggested a small beneficial effect of propranolol. Lastly, two rat studies with a benzodiazepine (midazolam) group provided some evidence for a harmful effect on extinction memory, i.e., impaired extinction retention. In conclusion, our midazolam findings are in line with prior literature (i.e., an extinction retention impairment), but this is not the case for the 10 studies with propranolol. Our data thus support caution regarding the use of benzodiazepines during exposure therapy, but argue against a harmful effect of propranolol on extinction learning.

Absence of definitive scientific evidence that benzodiazepines could hinder the efficacy of exposure-based interventions in adults with anxiety or posttraumatic stress disorders: A systematic review of randomized clinical trials

BACKGROUND AND OBJECTIVES

Exposure-based interventions (EBIs) are the first-line treatment for anxiety disorders and posttraumatic stress disorder. Although common, the association between EBIs and benzodiazepines is controversial. Therefore, we systematically reviewed the literature to evaluate if benzodiazepines could undermine the efficacy of EBIs in treating these disorders.

METHODS

We conducted a systematic review aiming for randomized clinical trials (RCTs) in ISI Web of Science, Scopus, PubMed/MEDLINE, and PsycINFO databases. We scrutinized the reference list of selected papers and other systematic reviews. Finally, we evaluated the methodological quality and the scientific evidence of the studies.

RESULTS

We screened 1,529 studies and included 12 RCTs in this review (all showing some concerns or high risk of bias). Benzodiazepines did not impact the efficacy of EBIs in nine studies at posttreatment, improved efficacy in two, and reduced it in one. In the follow-up, benzodiazepines (after its discontinuation) did not impact the efficacy in six studies and reduced it in five. The scientific level of evidence achieved was B for both phases.

CONCLUSIONS

Until now there is no definitive evidence that benzodiazepines could hinder the EBIs' efficacy for treating posttraumatic stress disorder and anxiety disorders.

Can Cognitive Behavioral Therapy for Anxiety and Depression Be Improved with Pharmacotherapy? A Meta-analysis

The present meta-analysis examined controlled trials of pharmacologic augmentation of cognitive-behavioral therapy (CBT) for patients with anxiety or depressive disorders. The additive effect of medications was small for both anxiety and depressive disorders at posttreatment, and there was no additive benefit after medications were discontinued. A small body of evidence suggested that antidepressant medications are an efficacious second-line treatment for patients failing to respond to CBT alone. In anxiety disorders, novel agents thought to potentiate the biological mechanisms of CBT showed small effects at posttreatment; after discontinuation, some of these agents were associated with an increasing effect.

Nonpharmacological treatments for anxiety disorders

An evidence-based review of nonpharmacological treatments for anxiety disorders is presented. The vast majority of the controlled research is devoted to cognitive behavior therapy (CBT) and shows its efficiency and effectiveness in all the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) anxiety disorders in meta-analyses. Relaxation, psychoanalytic therapies, Rogerian nondirective therapy, hypnotherapy and supportive therapy were examined in a few controlled studies, which preclude any definite conclusion about their effectiveness in specific phobias, agoraphobia, panic disorder, obsessive-compulsive disorder (OCD), and posttraumatic stress disorder (PTSD), CBT was clearly better than psychoanalytic therapy in generalized anxiety disorder (GAD) and performance anxiety Psychological debriefing for PTSD appeared detrimental to the patients in one high-quality meta-analysis. Uncontrolled studies of psychosurgery techniques for intractable OCD demonstrated a limited success and detrimental side effects. The same was true for sympathectomy in ereutophobia. Transcranial neurostimulation for OCD is under preliminary study. The theoretical and practical problems of CBT dissemination are discussed.

Combined psychotherapy plus benzodiazepines for panic disorder

BACKGROUND

The efficacy of combining psychotherapy and benzodiazepines for panic disorder is unclear, despite widespread use.

OBJECTIVES

To examine the efficacy of the combination compared with either treatment alone.

SEARCH STRATEGY

Randomised trials comparing the combination of psychotherapy and benzodiazepine with either therapy alone for panic disorder were identified. The Cochrane Depression, Anxiety and Neurosis Group Studies and References Registers were searched. References of relevant trials and other reviews were checked. Experts in the field were contacted. Additional unpublished data were sought from authors of the original trials.

SELECTION CRITERIA

Two authors independently checked the records retrieved by the searches to identify randomised trials comparing the combined therapy versus either of the monotherapies, among adults with panic disorder.

DATA COLLECTION AND ANALYSIS

Two authors independently checked eligibility, assessed quality and extracted data from the eligible trials using a standardised data extraction form. The primary outcome was "response" based on global judgement. Random-effects meta-analyses were conducted, combining data from included trials.

MAIN RESULTS

Three trials met eligibility criteria. A 16-week behaviour therapy intervention was used in two trials, and a 12-week cognitive-behaviour therapy intervention in the third. Duration of follow-up varied, ranging from 0 to 12 months. Two trials (total 166 participants) provided data comparing combination with psychotherapy alone (both using behaviour therapy). No statistically significant differences were observed in response during the intervention (relative risk (RR) for combination 1.25, 95% CI 0.78 to 2.03, P = 0.35), at the end of the intervention (RR 0.78, 0.45 to 1.35, P = 0.37), or at the last follow-up time point, although the follow-up data suggested that the combination might be inferior to behaviour therapy alone (RR 0.62, 0.36 to 1.07, P = 0.08). One trial (77 participants) compared combination with a benzodiazepine alone. No differences were found in response during the intervention (RR 1.57, 0.83 to 2.98, P = 0.17). Although the combination appeared to be superior to the benzodiazepine alone at the end of treatment (RR 3.39, 1.03 to 11.21, P = 0.05) the finding was only borderline statistically significant, and no significant differences were observed at the 7-month follow-up (RR 2.31, 0.79 to 6.74, P = 0.12).

AUTHORS' CONCLUSIONS

The review established the paucity of high quality evidence investigating the efficacy of psychotherapy combined with benzodiazepines for panic disorder. Currently, there is inadequate evidence to assess the clinical effects of psychotherapy combined with benzodiazepines for patients who are diagnosed with panic disorder.

Treatment of panic disorder with agoraphobia: randomized placebo-controlled trial of four psychosocial treatments combined with imipramine or placebo

Few randomized controlled trials have included panic disorder patients with moderate to severe agoraphobia. Therefore, this population was studied using pharmacotherapy as well as psychotherapy. At the time of the study, imipramine was widely used as a pharmacological treatment. Also, current practice guidelines for patients with panic disorder find selective serotonin reuptake inhibitors and tricyclic antidepressants roughly comparable in terms of efficacy. Therefore, the main objective of this study is to compare four psychosocial treatments-cognitive and graded in vivo exposure treatments, graded in vivo exposure, cognitive treatment, and supportive therapy-to evaluate the benefits of combining cognitive therapy with exposure in vivo. These treatments were combined with imipramine or placebo for a total of eight experimental conditions. Participants presented moderate to severe agoraphobia. The method involved a randomized, double-blind, placebo-controlled trial with 137 participants who completed a 14-session protocol involving the treatments just mentioned. Measures were taken at baseline and posttreatment and at 3-, 6-, and 12-month follow-up. All treatment conditions were statistically and clinically effective in reducing self-reported panic-agoraphobia symptoms over the 1-year follow-up. No statistical differences were observed between imipramine and placebo conditions. This study found that all treatment modalities helped reduce panic and agoraphobic symptomatology over a 1-year follow-up period. These surprising results support the need to document the relations among the various components of an intervention. This would make it possible to assess the relative efficacy of the treatment components rather than of the intervention as a whole.

Treatment of panic disorder: recent developments and current status

Panic disorder is a commonly encountered condition in general medical practice and in various medical settings. It is important for all medical practitioners to be able to recognize this disorder, provide patients with basic information and medical advice, and depending on the specific circumstances, to refer patients for appropriate treatment by primary care physicians, psychiatrists and/or clinical psychologists. This article reviews the developments in the treatment of panic disorder, focusing on the major treatment modalities of pharmacotherapy and cognitive-behavior therapy, as well as their combinations. In addition to providing information on current treatments for panic disorder and the main underlying treatment issues, the article identifies areas where improvements need to be made and areas where much research has been conducted in recent years. These include simplified modes of delivery of cognitive-behavior therapy, optimal ways of combining medications with cognitive-behavior therapy, and minimizing the risk of recurrence after the cessation of treatment.

Cognitive-behavior therapy for Japanese patients with panic disorder: acute phase and one-year follow-up results

AIM

The aim of this paper is to report the outcomes and follow-up data of our cognitive behavioral therapy program for Japanese patients with panic disorder and to examine the baseline predictors of their outcomes.

METHODS

Seventy outpatients with panic disorder with or without agoraphobia were treated with manualized group cognitive behavioral therapy.

RESULTS

Fourteen patients (20%) did not complete the program. Among the completers, the average Panic Disorder Severity Scale score fell from 12.8 at baseline to 7.1 post-therapy (44.7% reduction). This effectiveness was sustained for 1 year. While controlling for the baseline severity, the duration of illness and the baseline social dysfunction emerged as significant predictors of the outcome.

CONCLUSIONS

Our data suggest that group cognitive behavioral therapy for panic disorder can bring about as much symptom reduction among Japanese patients with panic disorder as among Western patients.

Combination of psychotherapy and benzodiazepines versus either therapy alone for panic disorder: a systematic review

BACKGROUND

The efficacy of combined psychotherapy and benzodiazepine treatment for panic disorder is still unclear despite its widespread use. The present systematic review aims to examine its efficacy compared with either monotherapy alone.

METHODS

All randomised trials comparing combined psychotherapy and benzodiazepine for panic disorder with either therapy alone were identified by comprehensive electronic search on the Cochrane Registers, by checking references of relevant studies and of other reviews, and by contacting experts in the field. Two reviewers independently checked eligibility of trials, assessed quality of trials and extracted data from eligible trials using a standardized data extraction form. Our primary outcome was "response" defined by global judgement. Authors of the original trials were contacted for further unpublished data. Meta-analyses were undertaken synthesizing data from all relevant trials.

RESULTS

Only two studies, which compared the combination with behaviour (exposure) therapy, met our eligibility criteria. Both studies had a 16-week intervention. Unpublished data were retrieved for one study. The relative risk for response for the combination was 1.25 (95%CI: 0.78 to 2.03) during acute phase treatment, 0.78 (0.45 to 1.35) at the end of treatment, and 0.62 (0.36 to 1.07) at 6-12 months follow-up. Some secondary outcomes hinted at superiority of the combination during acute phase treatment. One study was identified comparing the combination to benzodiazepine. The relative risk for response was 1.57 (0.83 to 2.98), 3.39 (1.03 to 11.21, statistically significant) and 2.31 (0.79 to 6.74) respectively. The superiority of the combination was observed on secondary outcomes at all the time points. No sub-group analyses were conducted due to the limited number of included trials.

CONCLUSION

Unlike some narrative reviews in the literature, our systematic search established the paucity of high quality evidence for or against the combined psychotherapy plus benzodiazepine therapy for panic disorder. Based on limited available published and unpublished data, however, the combined therapy is probably to be recommended over benzodiazepine alone for panic disorder with agoraphobia. The combination might be superior to behaviour therapy alone during the acute phase, but afterwards this trend may be reversed. We know little from these trials about their adverse effects.

A meta-analysis of the efficacy of psycho- and pharmacotherapy in panic disorder with and without agoraphobia

The efficacy of (cognitive) behavioural ((C)BT) and pharmacological therapy was investigated using meta-analytic techniques. After a comprehensive review of the literature, the results of 124 studies were included. (C)BT was more effective than a no-treatment control and a placebo control. No difference of efficacy was found when using cognitive elements compared to not using them for anxiety; for associated depressive symptoms, additional cognitive elements seems superior. Pharmacotherapy was more effective than a placebo control; there was no superiority of any drug class. Sample size was related to effect size in pharmacotherapy and publication bias was found. (C)BT was at least as effective as pharmacotherapy and depending on type of analysis even significantly more effective. There were no significant differences between (C)BT alone and a combination approach but characteristics of studies have to be considered.

Naturalistic manner of benzodiazepine use and cognitive behavioral therapy outcome in panic disorder with agoraphobia

Benzodiazepines (BZs) are commonly used in conjunction with cognitive behavioral therapy (CBT) in the treatment of panic disorder with agoraphobia (PDA). However, empirical evidence provides little support for the utility of this combined treatment approach over CBT alone. Westra and Stewart [Clin. Psychol. Rev. 18 (1998) 307] have proposed that pm or as-needed use of BZs may inhibit positive CBT outcome to a greater extent than regularly scheduled BZ use. Using a naturalistic design, the present study investigated the impact of manner of BZ use on treatment outcome from CBT in 43 patients with PDA. Among various BZ parameters (chronicity, frequency, dose, and frequency of prn use), pm use of BZs for coping with anxiety symptoms was a significant negative predictor of degree of change in both anxiety sensitivity and anxious arousal from pre- to post-CBT. Although no significant between-group differences were evident in pre-treatment symptomatology, unmedicated subjects demonstrated the most positive overall CBT outcome, while pm BZ users evidenced the fewest gains. Regular BZ users were generally not significantly differentiated from unmedicated subjects in CBT outcome and both tended to obtain post-treatment scores in the nonclinical range. Implications of these findings for clinical management of BZ use throughout CBT for PDA are discussed.

The psychobiology of anxiolytic drug. Part 2: Pharmacological treatments of anxiety

Benzodiazepines have been the mainstay of pharmacological treatment of anxiety over the last 4 decades. The problems associated with their use prompted the research for alternative agents that would be useful in anxiety conditions. Old classes of antidepressants, such as tricyclic antidepressants and monoamine oxidase inhibitors, showed effectiveness in some anxiety syndromes, even in areas where benzodiazepines were not very effective. Newer antidepressants, the selective serotonin-reuptake inhibitors, also appear very useful in some anxiety states, and their favourable side-effect profile has elevated them to first-line treatment tools in these conditions. However, the ideal anxiolytic does not exist. Research with other new compounds is very active, and some experimental drugs show promise for the future.

Acute and delayed effects of alprazolam on flight phobics during exposure

In order to test if a benzodiazepine would enhance or hinder the therapeutic effects of exposure, immediate and delayed effects of alprazolam on flight phobics were assessed by questionnaires and ambulatory physiological recording. Physiological measures included heart rate, skin conductance level and fluctuations, finger temperature, respiratory sinus arrhythmia, and various respiratory measures derived from two bands calibrated for each subject. Twenty-eight women with flying phobia flew twice at a 1-week interval. One and a half hours before flight 1, 14 randomly assigned phobics received double-blind 1 mg of alprazolam and 14 received placebo. On flight 1, alprazolam reduced self-reported anxiety (5.0 vs 7.4) and symptoms (5.3 vs 3.6) more than placebo, but induced an increase in heart rate (114 vs 105 bpm) and respiratory rate (22.7 vs 18.3 breaths/min). Before flight 2, the alprazolam group did not expect to be more anxious than the placebo group (6.7 vs 6.5), but in fact indicated more anxiety during flight (8.5 vs 5.6), and a substantial increase in panic attacks from flight 1 to flight 2 (7% vs 71%). Heart rates in the alprazolam group increased further (123 bpm). Results indicate that alprazolam increases physiological activation under acute stress conditions and hinders therapeutic effects of exposure in flying phobia.

Causes of Agoraphobia: The Patient's Perspective

Patients' beliefs about the causes of anxiety problems have received comparatively little attention. In the present study, agoraphobic patients rated the contribution of eight factors in causing their condition. They also selected the major cause of their agoraphobia and evaluated that in relation to the elements of attributional style. The most commonly selected major cause was stress, which also attracted the highest average ratings. This was followed in frequency by disposition (being a naturally nervous person), circumstances (staying home too much) and childhood experiences. Depression was associated with stronger beliefs in the contribution of several of the causal factors and with rating the major cause as more stable and global. Anxiety was associated with a stronger belief in medical illness as a cause, and with a lower sense of controllability of the major causes. These results suggest that agoraphobic patients' views of the causes of their condition vary, and could usefully be evaluated in relation to the provision of treatment in order to modify the way treatment options are presented to the patients.

Changes in "withdrawal symptoms" following discontinuation of low-dose diazepam

The intensity of putative benzodiazepine withdrawal symptoms was evaluated as part of a double blind placebo-controlled study of benzodiazepines and behaviour therapy in the management of agoraphobia. During the first phase of that study, some subjects were switched from low dose diazepam to placebo, and others remained on diazepam. Symptoms were evaluated in long-term benzodiazepine users (n = 30) and non-users n = 32) when they first entered the study and 4 weeks later, after both groups had been randomized to either diazepam or placebo, using eight analog rating scales measuring commonly reported withdrawal symptoms. At baseline, both users and non-users reported a substantial number of symptoms, with higher levels in the more anxious patients, but no differences between groups. After the transition to either diazepam or placebo, the users switched to placebo reported significantly higher levels of symptoms than users switched to diazepam and non-users combined. Multiple regression analysis suggested that the increase in symptoms was associated with the increase in anxiety, which was higher in the withdrawing group than the other three groups. These results raise questions concerning the extent to which withdrawal symptoms uniquely characterize benzodiazepine withdrawal. They confirm the common assumption that an increase in symptoms often accompanies withdrawal from benzodiazepines, but suggest that such symptoms are not so intense as to make withdrawal excessively difficult, at least in low-dose users.

A controlled study of cognitive behaviour therapy with buspirone or placebo in panic disorder with agoraphobia

BACKGROUND

This multicentre study compared a 16-week buspirone treatment with placebo in patients presenting with panic disorder with agoraphobia and also receiving cognitive behaviour therapy (CBT).

METHOD

Double-blind testing was maintained until week 68, but not tested; 91 patients were included; 14 placebo-responders excluded; 77 patients randomised; 48 reached week 16 and 41 reached week 68.

RESULTS

At week 16, within-group analysis showed significant improvements in agoraphobia, panic attacks, and depression in both groups. Generalised anxiety improved only in CBT+buspirone. Between-group comparisons showed buspirone to have an effect on generalised anxiety and agoraphobia. Changes in degree of agoraphobia and depression were correlated in subjects on CBT+buspirone only. A significantly higher proportion of women, and of subjects showing high avoidance dropped out. Positive expectations regarding medication predicted success in both groups. At week 68, improvement was retained without significant buspirone effect.

CONCLUSION

Buspirone enhanced the effects of cognitive behaviour therapy on generalised anxiety and agoraphobia in the short term.

Panic disorder. Pathophysiology and drug treatment

Advances over the past 2 decades in our understanding of the biology of panic disorder have paralleled a remarkable increase in the development of new pharmacological agents with antipanic effects. Although we can not presently use biological tests to help with our choice of therapeutic agent for individual patients, we can use this biological understanding in the development of overall pharmaco-therapeutic strategies. Current evidence does not support the hypothesis that panic disorder is associated with a primary disorder in one neurotransmitter system. Rather, the data suggest that the biological aetiology of panic disorder is related to abnormalities in the function of a variety of neurotransmitters including serotonin (5-hydroxytyrptamine; 5-HT), noradrenaline (norepinephrine), gamma-aminobutyric acid (GABA), dopamine, and cholecystokinin. It is likely, however, that panic disorder is a biologically heterogeneous condition and that biological subtypes may exist in which the primary abnormality may involve one or a few neurotransmitter systems. Currently, the data best support the hypothesis that pharmacotherapeutic agents with primary action at sites within the GABA and serotonin systems are the most effective in the treatment of panic disorder. Nevertheless, some patients will respond well to drugs with predominant activity in other systems, or may require pharmacotherapy designed to affect the function of more than 1 neurotransmitter. As our understanding of the biological aetiology of panic disorder evolves, the pharmacotherapeutic agents and strategies used in the treatment of this disorder will continue to evolve as well.