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Optimizing Effective Treatments for Anxiety Disorders

Both medications and psychological treatments have been shown to be effective for treating anxiety disorders, but optimum treatment approaches for the various patient subtypes have not been determined. These two studies provide helpful, complementary information about the treatment of patients with panic disorder and agoraphobia.

The first study randomized 80 patients with panic disorder and agoraphobia to receive low (0.5 mg/kg), medium (1.5 mg/kg), or high (3.0 mg/kg) doses of imipramine or placebo daily for eight weeks. Patients who received the medium and high doses were significantly more improved than those in the placebo or low-dose groups. However, there were no significant differences between the medium-and high-dose groups, or between the low dose and placebo groups. The dropout rate due to side effects increased with dosage; 6%, 15%, and 36%, respectively, in the three imipramine groups. For patients with panic disorder, improvement tapered off at a drug plasma level of 140 ng/ml, while agoraphobics actually worsened at levels higher than 140 ng/ml. This suggests different mechanisms of drug action for these two disorders.

The second study randomized 96 patients with panic disorder and agoraphobia to one of four treatments: fluvoxamine (up to 150 mg/day) or placebo for 12 weeks, with in vivo exposure (patients are gradually exposed to the situations they fear) starting at week seven; psychological panic management (hyperventilation provocation and respiratory training) for 12 weekly sessions, with in vivo exposure starting at week seven; and in vivo exposure alone. Long-term benzodiazepine users continued with steady doses and their compliance was checked frequently.

While all four treatments resulted in a significant decrease in agoraphobic avoidance, patients treated with a combination of fluvoxamine and in vivo exposure reported a two-fold decrease in agoraphobic avoidance when compared with the other groups. However, the low pretest panic rate made it difficult to assess specific effects of these treatments on panic attacks.

Comment: Together, these two studies suggest that medications and psychological treatments have different effects on anxiety disorder subtypes. Therefore, clinicians should pay attention to individual responses to different medications, doses, blood levels, and side-effects, as well as psychological treatment packages. It seems reasonable to fine-tune combination therapy according to individual symptom profiles and initial treatment responses. Moderate doses of antidepressants combined with in vivo exposure programs may be prudent starting strategies.

— J Yager

Published in Journal Watch Psychiatry July 1, 1995

Citation(s):

Mavissakalian MR; Perel JM. Imipramine treatment of panic disorder with agoraphobia: dose ranging and plasma level-response relationships. Am J Psychiatry 1995 May 152 673-682.

• Medline abstract (Free)

de Beurs E et al. Treatment of panic disorder with agoraphobia: comparison of fluvoxamine, placebo, and psychological panic management combined with exposure and of exposure in vivo alone. Am J Psychiatry 1995 May 152 683-691.

• Medline abstract (Free)