Combined psychotherapy plus antidepressants for panic disorder with or without agoraphobia

 

Abstract

Background

Panic disorder can be treated with pharmacotherapy, psychotherapy or in combination, but the relative merits of combined therapy have not been well established.

Objectives

To review evidence concerning short- and long-term advantages and disadvantages of combined psychotherapy plus antidepressant treatment for panic disorder with or without agoraphobia, in comparison with either therapy alone.

Search methods

The Cochrane Collaboration Depression, Anxiety and Neurosis Controlled Trials Registers (CCDANCTR-Studies and CCDANCTR-References) were searched on 11/10/2005, together with a complementary search of the Cochrane Central Register of Controlled Trials and MEDLINE, using the keywords antidepressant and panic. A reference search, SciSearch and personal contact with experts were carried out.

Selection criteria

Two independent review authors identified randomised controlled trials comparing the combined therapy against either of the monotherapies among adult patients with panic disorder with or without agoraphobia.

Data collection and analysis

Two independent review authors extracted data using predefined data formats, including study quality indicators. The primary outcome was relative risk (RR) of "response" i.e. substantial overall improvement from baseline as defined by the original investigators. Secondary outcomes included standardised weighted mean differences in global severity, panic attack frequency, phobic avoidance, general anxiety, depression and social functioning and relative risks of overall dropouts and dropouts due to side effects.

Main results

We identified 23 randomised comparisons (representing 21 trials, 1709 patients), 21 of which involved behaviour or cognitive-behaviour therapies. In the acute phase treatment, the combined therapy was superior to antidepressant pharmacotherapy (RR 1.24, 95% confidence interval (CI) 1.02 to 1.52) or psychotherapy (RR 1.17, 95% CI 1.05 to 1.31). The combined therapy produced more dropouts due to side effects than psychotherapy (number needed to harm (NNH) around 26). After the acute phase treatment, as long as the drug was continued, the superiority of the combination over either monotherapy appeared to persist. After termination of the acute phase and continuation treatment, the combined therapy was more effective than pharmacotherapy alone (RR 1.61, 95% CI 1.23 to 2.11) and was as effective as psychotherapy (RR 0.96, 95% CI 0.79 to 1.16).

Authors' conclusions

Either combined therapy or psychotherapy alone may be chosen as first line treatment for panic disorder with or without agoraphobia, depending on patient preference.

 

Plain language summary

Psychotherapy combined with antidepressants for panic disorder

Psychotherapy plus antidepressant treatment were compared with each of the two individual treatments alone for panic disorder. At the end of the acute phase treatment, the combined therapy was superior to psychotherapy or antidepressant treatment alone. After termination of active treatment, the combined therapy was superior to antidepressants alone and was as effective as psychotherapy alone. Either combined therapy or psychotherapy alone may be chosen as first line treatment for panic disorder with or without agoraphobia, depending on patient preference.

 

摘要

背景

針對伴隨或未伴隨懼曠症之恐慌性疾患合併心理治療及抗憂鬱劑治療

恐慌症可以使用藥物治療、心理治療或合併一起治療，但合併兩者治療的相對優點並未被證實。

目標

回顧有關恐慌性疾患(伴隨或未伴隨懼曠症)，合併心理治療及抗憂鬱劑治療與單獨治療間的短期及長期優缺點的證據。

搜尋策略

2005年11月10號搜尋Cochrane Collaboration Depression, Anxiety and Neurosis Controlled Trials Registers (CCDANCTRStudies and CCDANCTRReferences)，而且加上搜尋Cochrane Central Register of Controlled Trials及Medline，使用antidepressant及panic為關鍵字。相關文獻搜尋，SciSearch及專家諮詢都有。

選擇標準

兩位獨立的文獻回顧作者找出針對伴隨或未伴隨懼曠症之恐慌性成人疾患，比較合併治療相對於單獨個別治療的隨機對照試驗。

資料收集與分析

兩位獨立回顧作者數據格式使用之前預定的擷取數據，包括研究品質指標。主要的結果指標為「反應」的相對風險，即由原作者所定義的治病前受試者的臨床特徵的整體改善。次要的預後指標包括整體的嚴重度、恐慌發作的頻率、畏避程度、整體焦慮、憂鬱和社會功能的標準化加權均值差異以及全部退出試驗和因為副作用而退出試驗比率的相對風險。

主要結論

我們我們找到了23個隨機比較(共計21個試驗，1709位病人)，其中21個隨機比較包含有行為治療或認知行為治療。在急性期的治療，合併治療優於抗鬱劑藥物治療(RR 1.24, 95% confidence interval (CI) 1.02 to 1.52)或心理治療(RR 1.17, 95% CI 1.05 to 1.31)。合併治療比單用心理治療容易因副作用而退出試驗(害一需治數，NNH約為26)。在急性期治療過後，只要藥物仍在繼續治療，合併治療優於單獨治療仍持續。在急性期以及持續治療期過後，合併治療優於單獨的藥物治療(RR 1.61, 95% CI 1.23 to 2.11)，同時與心理治療一樣有效(RR 0.96, 95% CI 0.79 to 1.16)。

作者結論

在治療伴隨或未伴隨懼曠症之恐慌性疾患上，可以依患者喜好來選擇合併心理治療及藥物治療或單獨心理治療做為第一線的治療。

翻譯人

本摘要由彰化基督教醫院許文郁翻譯。

此翻譯計畫由臺灣國家衛生研究院(National Health Research Institutes, Taiwan)統籌。

總結

心理治療合併抗鬱劑治療和個別單一治療在恐慌疾患的比較。針對恐慌性疾患來比較心理治療合併抗鬱劑治療和個別單一治療的效果。在急性期治療的最後，合併治療優於單獨抗鬱劑藥物治療或單獨心理治療，在積極治療結束後，合併治療優於藥物治療，但和單獨心理治療一樣有效。所以在治療伴隨或未伴隨懼曠症之恐慌性疾患上，可以依患者喜好來選擇合併心理治療及藥物治療或單獨心理治療做為第一線的治療。