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Combined therapy vs. CBT or SSRIs alone in patients with panic disorder

Both cognitive behaviour therapy (CBT) and selective serotonin reuptake inhibitors (SSRIs) have proven efficacy in the treatment of panic disorder. Due to their radically different mechanisms of action, the notion that a combination of both treatments will be superior to either alone has significant face validity. To date, this is not supported by robust evidence (1, 2). In public health settings, the lack of availability of CBT often necessitates treatment with an SSRI in the first instance, with CBT a second line intervention. This clinical practice is supported by the paper, SSRIs alone will perform as well as SSRIs + CBT and may perform better than CBT alone (3). Thus, stepwise treatment algorithms such as those advocated by the British National Institute of Clinical Excellence (NICE) (4) are both pragmatic and supported by the evidence. However, there are a few methodological concerns that remain unaddressed by this paper. First, the authors found no difference between efficacy of CBT provided by the different centres (academic specialist vs. standard mental health) and cite this as evidence that CBT can effectively be reproduced outside of expert centres (3) (a criticism oft levelled at the evidence base of CBT is that it is delivered in expert settings that may not be reproducible in routine mental health services). Moreover, there was a difference in expertise between the treatment centres; the expert centres used trainees with close supervision, whereas the standard teams used experienced therapists. Neither of these may give the same efficacy as is seen in other trials where experienced therapists in expert centres provide the CBT. This problem is compounded by the second methodological issue, viz. the lack of any placebo controls. The authors cite the good evidence for both SSRIs and CBT in panic disorder as a reason not to have any placebo controls in this study. However, this then distorts any comparison with the existing evidence base (5). A parsimonious alternative explanation for the results here is that results overall were inflated by a large placebo response (explaining the better than expected effect sizes of SSRI and SSRI + CBT groups), but that the CBT provided in the study was no better than placebo. Therefore, this paper does not inform us whether CBT is equally efficacious when provided in naturalistic settings compared with expert ones. This study also brings back into focus another issue: the need to determine which patients will respond best to CBT. With blunderbuss augmentation of SSRI treatment performing no better than SSRI treatment alone, this is especially important for public health services with scarce resources. The targeting ofCBT to thosewithmost to benefit from itmay well provide not only a more cost-effective solution, but also provide further insights into the heterogeneity of panic disorder.