PrintthispageReturntopreviouspage

AVAILABLEEFFECTIVETREATMENTS
FORPANICDISORDERANDAGORAPHOBIA
ANDSATISFACTIONWITHTREATMENT
B.Bandelow,P.D.Dr.,Dipl.Psych.,
ConsultantPsychiatrist,K.Sievert,Dr.M.Rthemeyer,G.Hajak,P.D.Dr.,ConsultantPsychiatrist,L.Adler,Dr.,Consultant
Psychiatrist,andE.Rther,Prof.Dr.,Gttingen,Germany.

Correspondence:
PDDr.B.Bandelow,Dept.ofPsychiatry,TheUniversityofGttingen,Germany

Abstract
Inordertocomparethecurrentstateoftreatmentofpanicdisorderandagoraphobia(PDA)withtherecommendationsderivedfrom
controlledstudies,100PDApatientsand103physicians,psychologistsandpsychotherapistswereinterviewedbymeansofstructured
interviewsaboutthepsychologicalandpsychopharmacologicaltreatmentsusedinpanicdisorder.Bothinvestigationsrevealedthat
psychologicalandpharmacologicaltreatmentmodalitieswithprovenefficacyarebeingunderutilized(e.g.cognitivebehaviortherapy,
exposuretherapy,tricyclicantidepressants,benzodiazepinesorselectiveserotoninreuptakeinhibitors).Ontheotherhand,methods
whoseefficacyhasnotbeenprovenarebeingwidelyapplied.Theretrospectiveinterviewswiththepatientsrevealedthattheyweremost
satisfiedwithtreatmentsthathavebeenproveneffectiveincontrolledstudies.Reasonsfortheinadequateuseofproventreatment
modalitiescouldbeinsufficientknowledge,ideologicalissuesorthefactthat40percentofthehealthprofessionalsdidnotaccepttheterm
"panicdisorder"asdefinedbyDSMIII.Treatmentofpanicdisordermightbeimprovedifmoreheedweretakenoftheresultsofclinical
studies.
Keywords:PanicDisorderAgoraphobiaDrugtreatment,Psychologicaltreatment

Introduction
Patientswithpanicdisorderwithorwithoutagoraphobia(PDA)asdefinedbyDSMIIIRcanbeeffectivelytreatedwithpsychologicaland
psychopharmacologicaltreatmentmodalities.Foranoverview,all77PDAstudiesthatcouldbetracedbycomputeraidedliteraturesearch
wereevaluated(updateofstudy[2]).InTable1andTable2,theresultsofcontrolledstudiesarelisted.Asummaryoftheseresultsis
presentedinTable3.Asplacebotreatmentsareusuallyhighlyeffectiveinpanicdisorder[1],onlystudiesshouldbetakenintoaccountthat
usedadrugplacebo,a"psychologicalplacebo"ora"waitinglist"conditionasacontrolgroup.Treatmentsthathaveproveneffectivein
suchcomparisonsinclude:benzodiazepines(e.g.alprazolam[1]),tricyclicantidepressants(e.g.imipramine[7]orclomipramine[12]),
irreversibleMAOinhibitors(e.g.phenelzine[22]),andserotoninreuptakeinhibitors(e.g.fluvoxamine[4]orparoxetine[19]).Aconsensus
conferenceoftheNationalInstituteofMentalHealthhasrecommendedthesedrugsfortreatmentofPDA[17].Neurolepticsarebeing
widelyappliedinanxietydisordersinEurope,thoughtheirefficacyhasnotbeenshowninPDAtrials.Treatmentstudieswithbetablockers
haveshownconflictingresultsinsummary,convincingproofofefficacyismissing.Propranololwasnotbetterthanplaceboandless
effectivethanalprazolam[16].Inanotherstudy,itwaslesseffectivethandiazepam[18].Herbalpreparationsorhomoeopathicformulations
havenotbeeninvestigated.
Psychologicalmethodswithprovenefficacyincludebehavioraltherapieslikeexposureorcognitivetherapy[36].Otherbehavioral
techniqueslikesystematicdesensitization[26]orprogressiverelaxation[11]werelesseffectivethanexposuretherapy[1315].
PsychodynamicpsychotherapywasonlyinvestigatedonceinPDApatients:inthatstudy,acombinationofpsychodynamictherapyand
exposurewassuperiortopurepsychodynamictherapy[10].Otherpsychologicaltherapies,e.g.clientcenteredtherapy[20],autogenic
training[21]orbiofeedback[9]haveneverbeeninvestigatedinPDApatients.

ComparisonsofpsychologicalandpsychopharmacologicaltherapieshavebeendiscussedindetailbyBandelowetal.[2].Thenumberof
suchcomparisonsislow,andtheirresultsareconflicting.Insummary,nomajoradvantageofeithermethodcanbefound.Becauseofthe
lownumbersoffollowupinvestigations,thewidelyheldopinionthatpsychologicaltherapiesaremoreeffectiveatfollowupwhen
comparedtodrugtherapycannotbeproved.Thoughitissometimesemphasizedthatsimultaneousapplicationofpsychopharmacological
drugscouldinhibitpsychologicaltherapy,studieshaveshownthatacombinationofbothmodalitiesseemstobeadvantageous[25].
Tocomparetheresultsofclinicalresearchwiththestateoftreatmentinreality,twointerviewstudieswereconducted:first,amongPDA
patients,andsecond,amonghealthprofessionalstreatingthesepatients.Patientswereaskedwhichtherapeuticmodalitieshadbeen
appliedtothemandwhethertheyfeltthesetreatmentshadbeeneffective.Physicians,psychologistsandpsychotherapiststreatingpanic
patientsintheirdailypracticewereaskedabouttheirtreatmentpreferences.

Study1:PatientInterviews
Methods
OnehundredpatientswithcurrentorremittedDSMIIIRpanicdisorderandoragoraphobiawereaskedtoreportonanydrugand
psychologicaltreatmenttheyreceivedinthecourseoftheirillness.Ninetypatientswereformerorpresentclientsoftheanxietydisorders
unitoftheUniversityofGttingen,Germany.Thesepatientswerecontactedbymailoratavisitintheunit.Moreover,attemptsweremade
toconatactallPDApatientspresentlybeingtreatedintheurbaninpatientunitstreatinganxietypatients.Thus,10additionalpatientswho
werebeingtreatedinpsychiatricorpsychosomatichospitalsatpresentcouldbequestioned.Of207patientscontacted,24werenot
traceable.Eightythreegavetheirconsenttotheinterview.Patientswerequestionedbymeansofastructuredinterviewconcerningthe
pharmacologicalandpsychologicaltreatmentmodalitiestheyhadreceivedduringthecourseoftheillness.Selfapplicabletreatmentssuch
asautogenictrainingwerealsoevaluated.Singleacutetreatmentsofpanicattacks(e.g.emergencytreatmentswithbenzodiazepine
injections)werenotanalyzed.Onlytreatmentsthatwerewellrememberedbythepatientswereevaluated.Treatmentsthatweregiven
eitherinasubclinicaldoseornotlongenoughtobeeffectivewereincluded.Fortricyclicantidepressants(TCAs),selectiveserotonin
inhibitors(SSRIs),andmonoamineoxidaseinhibitors(MAOIs)onlytreatmentswithaminimumdurationoffourweekscontinuousintake
wereevaluated.Forbenzodiazepines,neurolepticsandherbalpreparations,aminimumintakedurationofoneweekwasrequired.Of241
drugtreatmentsreportedbythepatients,28werenotevaluablebecauseofthiscriterion.Forallpsychologicaltreatmentsaminimum
treatmentdurationof8weekswasnecessaryforinclusion.Forinpatienttreatmentinapsychologicaltreatmentunit,aminimumdurationof
4weekswasrequired.Fivepsychologicaltreatmentsoutof103hadtobeexcludedbecauseofinsufficientduration.
Patientswereaskedtoindicatetheirsatisfactionwithacertaintherapybyrespondingtothestatement,"thistherapyhasbeenveryhelpful
againstmyfear"ona5pointLikertscale(from0="nottrue"to4="true").Asthescalewasassumedtobeofordinalranklevel,the
centraltendency("mean")oftheseanswerswastakenasa"satisfactionindex".CentraltendencieswerecomparedwithMannWhitneysU
test.StatisticalanalysiswereperformedwiththeStatisticalAnalysisSystem(SAS6.08,SASInstitute,Heidelberg).
Finally,54patientswhohadreceivedbothdrugs(notincludingherbalpreparations)andpsychologicaltreatmentsinthecourseofthe
illnesshadtoindicatewhichkindoftreatmenthadhelpedmostinthecourseoftheillness.Onlyoneanswerwaspossibletothisquestion.

Results
FrequencyofApplicationofTreatments
Fourpercentofthepatientshadnotreceivedanytreatmentsbeforetheinterview.Eightyeightpercentofthepatientshadreceiveddrug
treatmentsinthecourseoftheiranxietydisorder.Alltogether213drugtreatmentswereevaluated.Alistofsubstancegroupsappliedon
thepatientsisshowninTable4.Benzodiazepineswerethemostfrequentlyuseddrugs,followedbytricyclicantidepressantsandherbal
preparations.Amongthebenzodiazepines,diazepam(21%)andlorazepam(13%)wereusedmostfrequently,amongtricyclic
antidepressantsdoxepine(18%)andimipramine(10%).Themostusedneurolepticdrugwasfluspirilene(18%).
ThepercentageofpatientswhoreceivedacertainpsychologicaltreatmentisgiveninTable5.Fiftyeightpercentofthepatientshad
receivedoneoftheindicatedpsychologicaltreatments.Alargenumberofpatients(28%)couldnotindicatethespecificationorschool"of
psychologicaltherapyappliedtothem.Noneofthesepatientsreportedtheapplicationofbehaviortechniqueslikeexposure.

Drugprescriptionbygeneralpractitionersandothernonpsychiatrists
Nonpsychiatrists(generalpractitioners,internistsandothers)showedadifferentprescriptionprofile,asreportedbythepatients.
Benzodiazepines,neuroleptics,andherbalpreparationsweremoreoftenprescribedbynonpsychiatristsascomparedtopsychiatrists,
whereaspsychiatriststendedtousemoretricyclicantidepressants(Table6).

Satisfactionwithtreatments
InFigure1thesatisfactionwiththedifferentdrugsappliedasratedbythepatientsisshown.Benzodiazepines,SSRIsandtricyclic
antidepressantswerethemostfavoredpsychopharmacologicaldrugs.TheSSRIswereonlyusedin7%sothattheresultsmaynotbe
representative.Neurolepticswerenotratedveryhighly,andherbalpreparationsandbetablockerswereassessedaspracticallyineffective.
InTable7thesignificantcomparisonsamongdrugtherapiesaregiven.
Amongpsychologicaltherapies,behaviortherapywaspreferred(Figure2).Satisfactionwiththismethodwassignificantlyhigherthanwith
psychodynamicallyorientedtherapy(p<0.005,U=171,Bonferronicorrection),"unknowntherapy"(p<0.005,U=141)andautogenic
training(p<0.0001,U=158).
StudyII:Interviewswithhealthprofessionals

Method
Inthissurvey,practicingphysicians,psychologistsandpsychotherapistswhotreatpanicdisorderpatientsinthetownofGttingen,
Germany,wereapproached:Generalpractitioners,internistsandothernonpsychiatricphysicians,psychiatrists/neurologists,psychologists
aswellaspsychotherapistswhoareneitherphysiciansnorpsychologists.Gttingen,atownwithapopulationof125.000,hasahigh
concentrationofphysicians,psychologistsandpsychotherapistsduetothepresenceofalargeuniversity.Allmajorpsychological
treatmentmodalities(likepsychoanalysis,clientcenteredpsychotherapyorcognitive/behaviortherapyareavailableandarebeingtaught
byuniversityinstructors.
TherespondentsweresentaquestionnairethatpresentedasymptomdescriptionofpanicdisorderandagoraphobiatakenfromtheDSM
IIIRandtheICD10.Itwasstatedthatthedescribeddisorderwascalledpanicdisorderwith/withoutagoraphobia"accordingtoDSMIII
R/ICD10.Respondentswereaskediftheyhadtreatedsuchpatientsintheiroffice.Onlyonerespondentansweredthathehadnever
treatedpanicpatientsandwasexcludedfromthestudy.Furthermore,therespondentswererequestedtospecifytheirqualificationand
durationoftheeducationinmedicine,psychology,psychiatry,orinpsychologicaltreatments.Theywereaskedtoindicatewhetherthey
acceptedthetermpanicdisorder"asadiagnosticentityandastotheirpreferredpharmacologicalorpsychologicaltherapy.

Results
Of104questionnaires,103wereevaluable.Of103respondents,78(76%)werephysicians,22(21%)psychologists,onepersonwasa
physicianandpsychologistatthesametime,and2wereneitherphysiciansnorpsychologistsbutpsychotherapistsrecognizedbythe
insurancecompanies.Amongthe78physicianswere38psychiatrists(specialistsortrainees).Fiftyfourpercentofthephysicianshada
specialeducationinpsychologicaltherapywhichallphysicianscanacquireinGermanywithoutnecessarilybeingapsychiatrist.On
averageallrespondentshadseen16.5PDApatientsinthepastyear(range10100SD=43,4).Psychiatristsnamedanaverageof17.9
(range5100SD28.1)panicpatientsperyear.Respondentsstatedanaverageof11.3yearsprofessionalexperience(range039SD=
8.4).
Mostphysiciansindicatedthattheypreferredtricyclicantidepressantsinpanicdisordertreatment(Table8).Secondinline,herbal
preparationsarebeingprescribed.Theprescribingpatternsofpsychiatristsandnonpsychiatricphysiciansdifferconsiderably:74%ofthe
psychiatristsusetricyclicantidepressants,whereasonly24%ofthenonpsychiatricphysicianspreferthesedrugs.Herbalpreparations
andhomoeopathicformulationsaremostpopularamongnonpsychiatricphysicians.Psychiatristsusemorebenzodiazepinesthanother
physicians.Selectiveserotoninreuptakeinhibitors,proposedby24%ofthepsychiatrists,areveryrarelyprescribedbynonpsychiatric
physicians(3%).Psychologistsarenotallowedtowriteprescriptions.
ThepreferenceofthepsychologicaltherapistsforthethreemajortherapyschoolsisshowninTable9(asmanypsychotherapistsare
educatedinmorethanonetreatmentmodalityandsometimesapplythesemethodssimultaneously,thepercentagesdonotaddupto
100).Psychologistsclearlyprefercognitive/behaviortherapyoverthetwoothertherapyschools(nodifferentiationwasmadebetween
cognitivetherapyandtraditionalbehaviortherapybecauseacomplexmixtureoftwoisusuallyusedinclinicalpractice).Amongphysicians,
psychoanalysiswasclearlypreferred.
Whenaskedastotheiropinionaboutefficacyproofs,43%oftheprofessionalswhousedpsychodynamictherapyasafirstlinetreatment
forpanicpatientswereconvincedthattheirpreferredmethodhadbeenproveneffectiveincontrolledstudies,whereas89%ofthe
behaviorallyorientedrespondentsthoughtthatcognitivebehaviortherapyhasbeenshowntobeeffectiveinsuchstudies.

Acceptanceoftheterm"PanicDisorder"
Ofallrespondents,41(40%)statedthattheywouldnotagreeinusingthetermpanicdisorder"forthedescribedsyndrome(41%ofthe
psychiatrists,23%ofthepsychologists).Therejectionofthetermpanicdisorder"wasparticularlyhigh(73%)in22respondentswith

psychoanalytictraining,comparedto17%ofthe22respondentswithbehaviorallyorientedtraining.
Discussion
Thetreatmentofpatientswithpanicdisorderandagoraphobia(PDA)couldfurtherbeimprovediftheresultsofclinicalstudieswereput
intopractice.Thiswasshowninasurveyamong100patientswithPDAand103healthprofessionalstreatingPDApatients.Differences
betweenthetwosurveyscanbeexplainedbythefactthatthepatientshadtoreportretrospectivelyabouttheirtreatments,whereasthe
healthprofessionalshadtoreportaboutthestateoftheirknowledgetodate.Bothresultsmightbebiased:thepatientsanswersbythe
possibilitythattheydidnotremembertheappliedtreatmentsverywell,andthehealthprofessionalsanswersbythefactthattheyhadthe
chancetoinformthemselvesintheliteraturebeforefillingoutthequestionnaire.Nevertheless,bothsurveyswereconsistentinshowing
thattreatmentmodalitiesforwhichefficacyproofsexistwereunderutilized.Ontheotherhand,treatmentmodalitiesthathaveneverbeen
investigatedinPDApatientsarebeingwidelyapplied.Forexample,nonpsychiatristsproposedherbalandhomoeopathicpreparationsas
afirstlinetreatmentforpanicdisorder.Alowincidenceofadverseeventsisoftenofferedasanargumentfortheuseofthese
preparations.However,thechoiceofdrugtreatmentshouldnotbeguidedbysideeffects,butprimarilybyefficacy.Ifaprescriberputshis
hopeonlyintheplaceboeffect,aneffectivealternativetreatmentmightbewithheldfromthepatient.
InGermanyitiscommontotreatanxietydisorderswithneuroleptics,butproofofefficacyproofsislackingforpanicdisorderpatients.A
consensusconferenceoftheNationalInstituteofMentalHealthdidnotrecommendneurolepticsforpanicdisorder.Nevertheless,onethird
ofthepatientsreportedhavingbeentreatedwithneurolepticsevenonethirdofthepsychiatristsindicatedthattheyuseneurolepticsfor
treatmentofpanicdisorder.
Thoughnoconvincingefficacyproofsexistforbetablockers,theywerenamedby26%ofthepsychiatristsasapossibletreatmentoption.
Ontheotherhand,only6%ofthepatientsindicatedthattheyhadbeentreatedwithbetablockers.
Selectiveserotoninreuptakeinhibitorswereunderrepresentedinbothsurveys.ThepossiblereasonmaybethatSSRIsarerelativelynew
onthemarket.Tricyclicantidepressantswhichareproposedasfirstlinetreatmentintheliteraturehavenotevenbeentriedinhalfofthe
patients.Onlyonequarterofnonpsychiatrists,butthreequartersofthepsychiatristsreportedprescribingthesedrugs.
Halfofthepatients(48%)reportedthattheyhadreceivedbenzodiazepinetreatment.Twiceasmanypsychiatrists(45%)asnon
psychiatrists(22%)reportedprescribingthesedrugs.However,accordingtothestatementsofthepatients,theyhadreceivedevenmore
benzodiazepineprescriptionsfromnonpsychiatrists.Inothercountriesbenzodiazepinesaremorefrequentlyprescribedtopanicpatients,
ascomparablestudiesintheUnitedStates[8]andinCanada[24]haveshown.
Lookingatproposedpsychologicaltherapies,underutilizationofeffectivemethodsisevenmorestriking.Manypatientswereinstructedto
treattheirdisorderwithautogenictraining,thoughnoproofofefficacyisavailableforthistreatmentmodality.Onethirdofthepatients
indicatedtheyhadbeentreatedwithdepthpsychologyorpsychoanalytictherapy.Asstatedabove,thedatabaseforthistreatmentmethod
ispoorinspiteofitswidespreaduse.
Asubstantialnumberofpatientscouldnotindicatethepsychologicaltherapyschoolappliedtothem.Inthesecasespatientswereaskedif
specifictechniqueslikeexposuretofearfulsituationshadbeenperformedduringsessions.Inallcases,patientsdeniedtheuseofsuch
techniquessoitcanbeexcludedthatthesepatientshadbeentreatedwithbehaviortherapy.
InvestigationsintheUSAandCanadaalsoshowedalackofconcordancebetweenresultsofclinicalstudiesandthecurrentstateof
treatment[582324].InGermanyonereasonfortheuncriticaluseofineffectivetreatmentmodalitiesmaybeinsufficientknowledge,the
otheronemaybethatthenewclassificationofanxietydisordersbyDSMIIIorICD10doesnotfindunequivocalacceptance:40%ofthe
healthprofessionalsindicatedthattheywouldnotacceptthetermpanicdisorder"forthedescribedsymptompattern.Acceptanceofthe
modernDSM/ICDclassificationoftheanxietydisordersbyhealthcareprofessionalstreatingthesepatientscouldhelptoimprovethe
acceptanceofresearchresults.
Theresultsofthisretrospectiveinvestigationshouldbeinterpretedwithcautionbecauseanumberoffactorscouldnotbecontrolledinthe
study:properrecollectionofappliedtherapiesbythepatients,adequatedurationanddoseofthedrugs,complianceofdrugintake,
availabilityofpsychologicaltreatments,adequatedurationofpsychologicaltreatments,classificationleveloftherapists,assessment
problemsarisingfromcombinationtreatmentsandmanyotherfactors.Mostoftheinterviewedpatientswereclientsofour
psychopharmacologicalandbehaviorallyorientedanxietydisordersunit.Thismighthaveledtoadistortionofthepicture.Resultsmight
havebeendifferentiftheinterviewshadmostlybeenconductedinaninstitutionapplyingonlypsychologicaltherapy.However,a
comparableinvestigationwasconductedinamainlybehavioraltreatmentinstitutionandshowedalmostthesameresults[24].Moreover,
thestatementsofpatientsconcerningtheefficacyoftreatmentsrevealedthatpatientsappreciatedpreciselythosetreatmentmethodsthat
havebeenshowntobeeffectiveincontrolledstudies.
Anotherreasonwhytheresultsshouldbeinterpretedwithcautionisthefactthatpatientsdonothavethesamepossibilitytojudgethe

risk/benefitratioofcertaintreatmentsashealthprofessionalsdo.Resultsmayhavebeenbiasedinfavoroftreatmentsshowingimmediate
success,suchasbenzodiazepinetreatment,ascomparedtotreatmentswithdelayedefficacy,likepsychologicaltherapies.Longterm
effectssuchaspossibleaddictiontobenzodiazepinesmaynothavebeentakenintoconsideration.
Muchefforthasbeenputintocontrolledstudiesontheefficacyofpanictreatments.Forthebenefitofthepatientsconcerned,theresultsof
theseinvestigationsshouldbeacceptedbyprofessionalstreatingpanicdisorderpatientsinordertoimprovetheoutcomeoftreatment.

Drug

Positive
studies

Alprazolam

Imipramine

Fluvoxamine

Clomipramine

Paroxetine

Adinazolam,clonazepam,lorazepam,diazepam,
sertraline
Amitriptyline,brofaromine,carbamazepine,
citalopram,desipramine,etizolam,inositol,
lofepramine,phenelzine,valproicacid,
zimelidine
Propranolol

Bupropion,clonidine,ibuprofen,
maprotiline,ritanserine,trazodone,verapamil
Buspirone

Negative
studies*

15

15

Table1.Overviewoftheefficacyofdrugsinpanicdisorderandagoraphobia(doubleblindstudies)moreeffectivethanplacebo
oraseffectiveasreferencedrug*notmoreeffectivethanplaceboorlesseffectivethanreferencedrug

Psychologicaltreatment
Cognitivetherapy

Exposuretherapy

Systematicdesensitization

Positivestudies

Negativestudies*

Table2.Efficacyofpsychologicaltreatmentsinpanicdisorderandagoraphobiamoreeffectivethancontrolcondition*no
moreeffectivethancontrolcondition

Drugs
Tricyclicantidepressants(e.g.imipramine,clomipramine)

Serotoninreuptakeinhibitors(e.g.fluvoxamine,citalopram,paroxetine)

Benzodiazepines(e.g.alprazolam)

IrreversibleMAOinhibitors(e.g.phenelzine)
Psychologicaltherapies
Cognitivetherapy

Exposuretherapy(foragoraphobicpatients)

Table3.Overview:treatmentmodalitiesforPDAthathavebeenshowntobeeffectiveincontrolledtrials

Drugs
Benzodiazepines

Tricyclicantidepressants

Herbalpreparations

Neuroleptics

Serotoninreuptakeinhibitors

Betablockers

Tetracyclicantidepressants

IrreversibleMAOinhibitors

Percent
48%

42%

32%

29%

7%

6%

3%

2%

Table4.PercentageofPDApatientswhoreceiveddrugsinthecourseoftheirillness(n=100)

Psychologicaltreatment

Percent

Autogenictraining

43%

Psychodynamictherapy

33%

Unknown

28%

Cognitive/behaviortherapy

20%

Biofeedback

6%

Progressiverelaxation

6%

Hypnosis

4%

Table5.Psychologicaltherapies:frequencyofapplicationinpercent

Benzodiazepines

Tricyclic
antidepressants
Neuroleptics

Herbal
preparations
Total

n
Psychiatrists Non
no
unknown
prescriptions
psychiatrists prescription
77

40.2%

57.1%

2.6%

51

64.7%

31.4%

3.9%

30

33.3%

63.3%

3.3%

37

10.8%

54.9%

35.1%

0.0%

195

40.0%

50.7%

6.7%

2.6%

Table6.Prescriptionofdrugsbypsychiatristsandnonpsychiatrists(generalpractitioners,internists,andothers)

SSRI TCA Neuroleptics

Benzodiazepines

N.S.

N.S. P<0.001(U=167)

SSRI

Tricyclic
antidepressants

Neuroleptics

N.S.

Herbalpreparations
P<0.0001(U=214)

N.S.

P<0.005(U=35)

P<0.005(U=381)

P<0.0001(U=248)

N.S.

Table7.Significanceofcomparisonsbetweendifferentmedications(MannWhitneysUtestBonferronicorrection)

All
physicians
(n=79)

Non
psychiatric
physicians

Psychiatrists
(n=38)

(n=41)
Tricyclicantidepressants

Herbalpreparations

Benzodiazepines

Neuroleptics

Betablockers

Homoeopathicformulations

Serotoninreuptakeinhibitors

Irreversiblemonoamineoxidase
inhibitors
Others

48%

24%

74%

40%

46%

29%

33%

22%

45%

24%

20%

29%

20%

15%

26%

18%

32%

3%

13%

3%

24%

8%

0%

16%

1%

3%

3%

Table8.Percentageofdifferentgroupsofphysicianswhoproposedifferentdruggroups(morethanonechoicepossible)

Psychological
therapy

All
psychological
therapists

All
physicians

Psychiatrists Psychologists
(n=33)

(n=22)

(n=49)

(n=68)
Psychoanalysis

44%

57%

51%

9%

Clientcentered
therapy(Rogerian)

28%

35%

33%

9%

Cognitive/behavior
therapy

28%

4%

6%

64%

Table9.Respondentspracticingpsychologicaltherapies:treatmentmodalityproposedinthefirstline

Figure1.Meansatisfactionwithdrugtherapy,indicatedona5pointscale(from0=notatallhelpfulto4=veryhelpful)

Figure2.Meansatisfactionwithpsychologicaltherapies,indicatedona5pointscale(from0=notatallhelpfulto4=very
helpful)

References
BallengerJC,BurrowsGD,DuPontRL,Jr.,etal.(1988)Alprazolaminpanicdisorderandagoraphobia:resultsfromamulticentertrial.I.
Efficacyinshorttermtreatment.ArchGenPsychiatry,45,41322.
BandelowB,SievertK,RthemeyerM,HajakG,BroocksA,RtherE(1995)PanikstrungundAgoraphobie:Waswirkt?FortschrNeurol
Psychiat,63,451464.

BarlowD(1994)Effectivenessofbehaviortreatmentforpanicdisorderwithandwithoutagoraphobia.In:WolfeB,MaserJ,eds.Treatment
ofpanicdisorder.Aconsensusdevelopmentconference.AmericanPsychiatricPress,Washington,DC,pp.10520(
BlackDW,WesnerR,BowersW,GabelJ(1993)Acomparisonoffluvoxamine,cognitivetherapy,andplacebointhetreatmentofpanic
disorder.ArchGenPsychiatry,50,4450.
BreierA,CharneyDS,HeningerGR(1986)Agoraphobiawithpanicattacks.Development,diagnosticstability,andcourseofillness.Arch
GenPsychiatry,43,102936.
ClarkDM(1994)Cognitivetherapyforpanicdisorder.In:WolfeB,MaserJ,eds.Treatmentofpanicdisorder.Aconsensusdevelopment
conference.AmericanPsychiatricPress,Washington,DC,pp.75969(
CNCPS(1992)Crossnationalcollaborativepanicstudy.Drugtreatmentofpanicdisorder.Comparativeefficacyofalprazolam,imipramine,
andplacebo.BrJPsychiat,160,191202.
GoismanRM,WarshawMG,PetersonLG,etal.(1994)Panic,agoraphobia,andpanicdisorderwithagoraphobia.Datafroma
multicenteranxietydisordersstudy.JNervMentDis,182,729.
HatchJP,SaitoI(1990)Growthanddevelopmentofbiofeedback:abibliographicupdate.BiofeedbackandSelfregulation,15,3746.
HoffartA,MartinsenEW(1990)Exposurebasedintegratedvs.purepsychodynamictreatmentofagoraphobicinpatients.Psychotherapy,
27,210218.
JacobsonE(1938)Progressiverelaxation.UniversityPress,Chicago.
JohnstonD,TroyerI,WhitsettS(1988)Clomipraminetreatmentofagoraphobicwomen.Aneightweekcontrolledtrial.ArchGenPsychiat,
45,45359.
MarksI(1987)Fears,phobiasandrituals.OxfordUniversityPress,Oxford.
MarksI,GrayS,CohenD,etal.(1983)Imipramineandbrieftherapistaidedexposureinagoraphobicshavingselfexposurehomework.
ArchGenPsychiat,40,15362.
MarksIM,SwinsonRP,BasogluM,etal.(1993)Alprazolamandexposurealoneandcombinedinpanicdisorderwithagoraphobia.A
controlledstudyinLondonandToronto[seecomments].BrJPsychiatry,162,77687.
MunjackDJ,CrockerB,CabeD,etal.(1989)Alprazolam,propranolol,andplacebointhetreatmentofpanicdisorderandagoraphobia
withpanicattacks.JClinPsychopharmacol,9,227.
NIH(1991)NationalInstitutesofHealthConsensusDevelopmentConferenceStatement:TreatmentofPanicDisorderSeptember2527.
126.
NoyesR,Jr.,AndersonDJ,ClancyJ,etal.(1984)Diazepamandpropranololinpanicdisorderandagoraphobia.ArchGenPsychiatry,41,
28792.
OehrbergS,ChristiansenPE,BehnkeK,etal.(1995)Paroxetineinthetreatmentofpanicdisorder.Arandomised,doubleblind,placebo
controlledstudy.BrJPsychiatry,167,3749.
RogersC(1951)Clientcenteredpsychotherapy.HoughtonMifflin,Boston.
SchultzHJ(1987)DasAutogeneTraining.(18ed.)Thieme,Stuttgart.
SheehanDV,BallengerJ,JacobsenG(1980)Treatmentofendogenousanxietywithphobic,hysterical,andhypochondriacalsymptoms.
ArchGenPsychiatry,37,519.
SwinsonRP,CoxBJ,WoszczynaCB(1992)Useofmedicalservicesandtreatmentforpanicdisorderwithagoraphobiaandforsocial
phobia.CanMedAssocJ,147,87883.
TaylorCB,KingR,MargrafJ,etal.(1989)Useofmedicationandinvivoexposureinvolunteersforpanicdisorderresearch.AmJ
Psychiatry,146,14236.
TelchM,AgrasW,TaylorC,RothW,GallenC(1985)Combinedpharmacologicalandbehavioraltreatmentforagoraphobia.BehavRes
Ther,23,32535.

WolpeJ(1958)Psychotherapybyreciprocalinhibition.StanfordUniversityPress,Stanford.
Thisversionis1.2published:28/03/99
Alternativelyyoucancopythepageaddressfromyourbrowser'saddressbarandpasteitinbelowhere.
Submit

Printthispage
AllpagescopyrightPrioryLodgeEducationLtd19942015