Group autonomy enhancing treatment versus cognitive behavioral therapy for anxiety disorders: A cluster-randomized clinical trial

Background: Although cognitive behavioral therapy (CBT) is effective in the treatment of anxiety disorders, few evidence-based alternatives exist. Autonomy enhancing treatment (AET) aims to decrease the vulnerability for anxiety disorders by targeting underlying autonomy deficits and may therefore have similar effects on anxiety as CBT, but yield broader effects. Methods: A multicenter cluster-randomized clinical trial was conducted including 129 patients with DSM-5 anxiety disorders, on average 33.66 years of age (SD = 12.57), 91 (70.5%) female, and most (92.2%) born in the Netherlands. Participants were randomized over 15-week groupwise AET or groupwise CBT and completed questionnaires on anxiety, general psychopathology, depression, quality of life, autonomy-connectedness and self-esteem, pre-, mid-, and posttreatment, and after 3, 6, and 12 months (six measurements). Results: Contrary to the hypotheses, effects on the broader outcome measures did not differ between AET and CBT (d =.16 or smaller at post-test). Anxiety reduction was similar across conditions (d =.059 at post-test) and neither therapy was superior on long term. Conclusion: This was the first clinical randomized trial comparing AET to CBT. The added value of AET does not seem to lie in enhanced effectiveness on broader outcome measures or on long term compared to CBT. However, the study supports the effectiveness of AET and thereby contributes to extended treatment options for anxiety disorders

Meta‐analysis on the treatment of panic disorder with agoraphobia: Review and re‐examination

From three meta‐analyses on treatment outcome in panic disorder with agoraphobia, method, results and conclusions were reviewed. The meta‐analyses differed in methods used and conclusions derived. The conclusions conflicted on the relative efficacy of treatment with antidepressants, high‐potency benzodiazepines, psychological panic management, exposure in vivo and combination treatments. These conflicting findings can be caused by confounding variables, present in ‘between‐study’ comparisons. In ‘within‐study’ comparison, so‐called ‘same experiment studies’, these confounding variables are controlled for. Therefore, the literature was reviewed for same experiment studies. The differential efficacy of treatments compared within 25 identified same experiment studies was evaluated by calculating the effect size d between the treatments. Antidepressants and high‐potency benzodiazepines were equally effective. The comparison between these drugs and psychological panic management remained inconclusive. Exposure in vivo was superior to psychopharmacological and psychological panic management. The efficacy of exposure in vivo was not enlarged by the addition of psychological panic management. There was some evidence that the addition of psychopharmacological drugs to exposure in vivo enlarged the efficacy of the latter. This observation must be investigated more systematically

Evidence-based pharmacotherapy of panic disorder

Introduction Panic disorder is a common mental disorder that is associated with significant morbidity. Fortunately, effective treatments for panic disorder are available, and include both medication and cognitive–behavioral therapy (CBT). Ongoing research on the pharmacotherapy of panic disorder makes it timely to update an evidence-based approach to the pharmacotherapy of panic disorder (Bakker et al., 2005). Here we briefly emphasize the importance of adequate care before reviewing the available pharmacological evidence on treating panic disorder, focusing in particular on (1) the optimal first-line pharmacotherapy of panic disorder, (2) the optimal duration of maintenance therapy, and (3) the optimal approach to pharmacotherapy in the treatment-refractory patient. To reveal relevant research conducted since the publication of Bakker et al. (2005), a MEDLINE search (2003–2010) using the terms “panic’ and “treatment’ was undertaken. Importance of adequate care, Panic disorder is a common mental disorder, with a 12-month prevalence rate of 1.8% (Goodwin et al., 2005). Only a minority of those affected receive adequate care. The main reason is that not all patients seek help. It may take years before individuals with panic disorder seek help; only about one third of those affected seek help within the year of onset (Wang et al., 2005a). The gap between those affected and those seeking help for panic disorder is about 50% (Kohn et al., 2004; Wang et al., 2005b)

Relevance of assessment of cognitions during panic attacks in the treatment of panic disorder

Background: In this paper the effects of cognitive therapy on the belief in causal catastrophical misinterpretations (CCMs) of bodily sensations in panic disorder patients were studied. Methods: CCMs were formulated at the start of treatment and assessed at every treatment session for credibility during panic attacks and during that session. The relation between the belief in CCMs and other measures of panic was also studied. Sixty-six patients rated their belief in 1-3 CCMs during treatment with cognitive therapy. They also filled in questionnaires (ACQ and BSQ) at the start and end of treatment and kept a panic diary. Results: The belief in CCMs diminished significantly in the course of treatment. A significant correlation between panic frequency and belief in CCMs during panic attacks, but not during treatment sessions, was found. Relations between improvement in panic frequency, ACQ- and BSQ-scores on the one hand and belief in CCMs on the other, also revealed significant correlations with belief ratings during panic attacks only. Conclusions: Especially ratings of belief during panic attacks are important in assessing the outcome of cognitive therapy in panic disorder. This measure can be considered as a severity measure. Belief in CCMs during treatment sessions seems to have little clinical significance

Relieving the burden of family members of patients with obsessive-compulsive disorder

Objective: Obsessive-compulsive disorder (OCD) burdens family members. Certain responses of family members to OCD augment their burden, namely accommodation and antagonism. Family interventions are successful in reducing severity of OCD but surprisingly, the impact of family interventions on the burden of family members has received little attention. Method: 16 family members of patients with OCD were treated - together with the patient - with our brief CBT family intervention focusing on accommodation, antagonism and normalizing the family relationship. Family burden, accommodation and antagonism were measured before and after the family intervention with: Involvement Evaluation Questionnaire, Impact on Relatives Scale, EuroQol five dimensional questionnaire (EQ-5D), Family Accommodation Scale - Self Report and the Perceived Criticism Measure. Results: The burden of family members of patients with OCD was considerable and comparable to the burden of family members of patients with schizophrenia. Family burden was diminished after the brief dyadic family intervention and correlated to a decrease in accommodation. Conclusions: Our brief dyadic family intervention is promising in relieving the burden of family members of patients with OCD

Relieving the burden of family members of patients with obsessive-compulsive disorder

Objective: Obsessive-compulsive disorder (OCD) burdens family members. Certain responses of family members to OCD augment their burden, namely accommodation and antagonism. Family interventions are successful in reducing severity of OCD but surprisingly, the impact of family interventions on the burden of family members has received little attention. Method: 16 family members of patients with OCD were treated - together with the patient - with our brief CBT family intervention focusing on accommodation, antagonism and normalizing the family relationship. Family burden, accommodation and antagonism were measured before and after the family intervention with: Involvement Evaluation Questionnaire, Impact on Relatives Scale, EuroQol five dimensional questionnaire (EQ-5D), Family Accommodation Scale - Self Report and the Perceived Criticism Measure. Results: The burden of family members of patients with OCD was considerable and comparable to the burden of family members of patients with schizophrenia. Family burden was diminished after the brief dyadic family intervention and correlated to a decrease in accommodation. Conclusions: Our brief dyadic family intervention is promising in relieving the burden of family members of patients with OCD

Perceived upbringing and its relation to treatment outcome in agoraphobia

Agoraphobic patients tend to retrospectively report their parents as more rejecting and less warm than controls. Previous research indicates that such a negative rearing history may be associated with negative outcome in behavioural treatment. It has been suggested that the detrimental effect of an unfavourable parental rearing history on outcome of behaviour therapy is mediated by a negative view of the patients on behaviour therapists and their therapeutic style. To investigate these hypotheses, data of 76 patients were analysed who participated in a comparative outcome study of treatments for panic disorder with agoraphobia. The results using correlational analyses revealed neither an association between perceived parental rearing style and treatment outcome, nor between the patient's perception of the therapist and the outcome of treatment. Some significant, albeit small, associations were found between the way patients perceived their parental rearing style and their view towards the therapist. Perceived parental rejection and lack of parental favouring were slightly associated with a negative view of the therapist. The confidence in these findings is discussed with respect to the reliability and validity of the measurement instruments and with respect to the limitations of correlational analyses

The placebo response in social phobia

The placebo response forms a growing problem in randomized, placebo-controlled clinical trials in psychiatry. Research into the placebo response is on the increase, but remains very limited in relation to social phobia. Together with the dropout rate, the placebo effect is an important factor limiting the discriminative properties of any study. In this study, we reviewed 15 placebo-controlled studies in social phobia, focussing on patients and study characteristics. In social phobia, the placebo effect has turned out to be moderately large and has shown no increase over the past decade. Placebo response was highest in large, multicentred trials and was independent of study duration. No validation for a placebo run-in was found. Taking into account both response to placebo and active drug, as well as dropout rate, the most discriminative results are probably to be expected in a sample of patients who are moderately to severely impaired. More research in the field of the placebo response is needed

Prioritizing suicide prevention guideline recommendations in specialist mental healthcare: A Delphi study

Background: The Delphi technique is a proven and reliable method to create common definitions and to achieve convergence of opinion. This study aimed to prioritize suicide prevention guideline recommendations and to develop a set of quality indicators (QIs) for suicide prevention in specialist mental healthcare. Methods: This study selected 12 key recommendations from the guideline to modify them into QIs. After feedback from two face-to-face workgroup sessions, 11 recommendations were rephrased and selected to serve as QIs. Next, a Delphi study with the 11 QIs was performed to achieve convergence of opinion among a panel of 90 participants (23 suicide experts, 23 members of patients' advisory boards or experts with experiences in suicidal behavior and 44 mental healthcare professionals). The participants scored the 11 QIs on two selection criteria: relevance (it affects the number of suicides in the institution) and action orientation (institutions or professionals themselves can influence it) using a 5-point Likert scale. Also, data analysts working in mental healthcare institutions (MHIs) rated each QI on feasibility (is it feasible to monitor and extract from existing systems). Consensus was defined as 70% agreement with priority scores of four or five. Results: Out of the 11 recommendations, participants prioritized five recommendations as relevant and action-oriented in optimizing the quality of care for suicide prevention: 1) screening for suicidal thoughts and behavior, 2) safety plan, 3) early follow-up on discharge, 4) continuity of care and 5) involving family or significant others. Only one of the 11 recommendations early follow-up on discharge reached consensus on all three selection criteria (relevance, action orientation, and feasibility). Conclusions: The prioritization of relevant and action-oriented suicide prevention guideline recommendations is an important step towards the improvement of quality of care in specialist mental healthcare