Treating Treatment-Resistant Patients with Panic Disorder and Agoraphobia Using Psychotherapy: A Randomized Controlled Switching Trial

Abstract

Background: Nonresponsiveness to therapy is generally acknowledged, but only a few studies have tested switching to psychotherapy. This study is one of the first to examine the malleability of treatment-resistant patients using acceptance and commitment therapy (ACT). Methods: This was a randomized controlled trial that included 43 patients diagnosed with primary panic disorder and/or agoraphobia (PD/A) with prior unsuccessful state-of-the-art treatment (mean number of previous sessions = 42.2). Patients were treated with an ACT manual administered by novice therapists and followed up for 6 months. They were randomized to immediate treatment (n = 33) or a 4-week waiting list (n = 10) with delayed treatment (n = 8). Treatment consisted of eight sessions, implemented twice weekly over 4 weeks. Primary outcomes were measured with the Panic and Agoraphobia Scale (PAS), the Clinical Global Impression (CGI), and the Mobility Inventory (MI). Results: At post-treatment, patients who received ACT reported significantly more improvements on the PAS and CGI (d = 0.72 and 0.89, respectively) than those who were on the waiting list, while improvement on the MI (d = 0.50) was nearly significant. Secondary outcomes were consistent with ACT theory. Follow-up assessments indicated a stable and continued improvement after treatment. The dropout rate was low (9%). Conclusions: Despite a clinically challenging sample and brief treatment administered by novice therapists, patients who received ACT reported significantly greater changes in functioning and symptomatology than those on the waiting list, with medium-to-large effect sizes that were maintained for at least 6 months. These proof-of-principle data suggest that ACT is a viable treatment option for treatment-resistant PD/A patients. Further work on switching to psychotherapy for nonresponders is clearly needed.

Methodological Recommendations for Trials of Psychological Interventions

“…The Sequential Multiple Assignment Randomized Trial (SMART) involves multiple intervention stages; each stage corresponds to one of the critical decisions and the participant is randomly reassigned to one of the intervention options [46]. Examples are adaptive interventions that followed nonresponse to initial treatment (whether pharmacotherapy or psychotherapy or both) in mood [47][48][49] and anxiety disorders [50][51][52]. The conceptual assumption is that after testing a standard treatment in a group of patients we are left with a fairly homogeneous group characterized by resistance.…”

Aligning the many definitions of treatment resistance in anxiety disorders: A systematic review

“…Included studies were published between 1986 and 2018. They consisted of eight narrative reviews (Bakker, Van Balkom, & Stein, ; Bandelow et al, ; Bystritsky, ; Chen & Tsai, ; Holt & Lydiard, ; Lorenz, Jackson, & Saitz, ; Pollack, ; Starcevic, ), five systematic reviews (Barton et al, ; Cosci & Fava, ; Ipser et al, ; Patterson & Van Ameringen, ; Samuel, Zimovetz, Gabriel, & Beard, ), of which three also performed meta‐analyses (Barton et al, ; Ipser et al, ; Patterson & Van Ameringen, ), seven treatment guidelines/algorithms (Bandelow, ; Bandelow, Zohar, Hollander, Kasper, & Moller, ; National Institute for Health & Clinical Excellence, ; Stein et al, ; Stein et al, ; Stein, ; Stein, ), three book chapters (Baldwin, Polkinghorn, Lerer, & Stahl, ; Deligiannidis & Rothschild, ; Van Ameringen, Mancini, Patterson, & Stein, ), 21 open‐label trials (Gabriel & Violato, ; Gabriel, ; George et al, ; Glue et al, , ; Heldt et al, ; Heldt et al, ; Hoge et al, ; Hollifield, Thompson, Ruiz, & Uhlenhuth, ; Katzman et al, ; Kinrys, Vasconcelos E Sa, & Nery, ; Menza, Dobkin, & Marin, ; Ociskova, Prasko, Latalova, Kamaradova, & Grambal, ; Pallanti & Quercioli, ; Pollack, Otto, Kaspi, Hammerness, & Rosenbaum, ; Simon et al, ; Snyderman et al, ; Solbakken & Abbass, , ; Worthington III, Kinrys, Wygant, & Pollack, ; Yoshinaga et al, ), eight RCTs (Brawman‐Mintzer, Knapp, & Nietert, ; Castle, Gray, Neehoff, & Glue, ; Gloster et al, ; Hirschmann et al, ; Lohoff et al, ; Pollack et al, ; Rickels et al, ; Simon et al, ), ...…”

Psychotherapy and Mental Health as a Psychological Science Discipline

“…Furthermore, the development of empirically grounded strategies for switching between and within pharmacological and psychotherapeutic treatments in case of non-or insufficient response is an important challenge for the future (e.g. [Gloster et al, 2015]). …”