Evaluation for Panic disorder treatments
Panic disorder as one of the most prevalent and severe anxiety disorders has been well studied in the past century (Barlow et al. 1997). According to Hood and Antony (2015)( as cited in DSM-5, American Psychiatric Association, 2013), Panic disorder is associated with recurrent and unexpected panic attack, featured in sudden surges of physical arousal and fear. Due to panic disorder's peculiarities, which include being afraid of the specific environment or consistently worrying about having a panic attack. Agoraphobia, "a fear of situations in which escape might be difficult or embarrassing, or in which help might be unavailable in the event of a panic attack" (Hood & Antony, 2015. Para 2), often is viewed as a complication of panic disorder. Despite the fact that agoraphobia is no longer associated with panic disorder in the DSM-5 because it can be diagnosed without panic attacks.
Although panic disorder is not life threating disease, it could bring severe outcomes to life. "The illness is associated with significant impairments in life quality and psychosocial functioning (as cited in Mendlowicz & Stein, 2000; Pollack & Marzo, 2000), but it also poses an enormous economic burden (as cited in Otto, Pollack, & Maki, 2000)." (Reinecke, Thilo, Filippini, et al. 2014 para 1).
Fortunately, panic disorder is entirely curable with appropriate treatments. The recently updated American Psychiatric Association (2009) discussed there are two treatments, medications treatment and cognitive behaviour therapy (CBT). More specifically, the medication treatment includes using antidepressants: selective serotonin reuptake inhibitor (SSRIs) and SNRIs medication. For instance, fluoxetine, fluvoxamine, sertraline, paroxetine, citalopram and venlafaxine. Benzodiazepine anxiolytics have positive effects using medication for panic disorder treatment as well (Moylan et al., 2011; Hood & Antony, 2015).
CBT for panic disorder includes four types of strategies: education about the nature of anxiety and panic; exposure treatment (i.e., in vivo exposure and overbreathing, etc.); cognitive restructuring; and relaxation strategies. Usually, therapists will conduct all strategies to achieve the maximum result. (Hood & Antony, 2015) Several randomized controlled trials have demonstrated that the combination of medication and CBT is effective for panic disorder treatment as well. (Furukawa et al., 2006; Mitte 2005)
In order to evaluate the panic disorder treatments' efficiency, this paper divides into four aspects to assess panic disorder treatments: medication treatment, CBT and combination treatment. These four aspects are the final result; cost-efficiency; treatment time consume and possibility of relapsing after the procedure.
Evaluation for final result
Cognitive-behavioral therapy is one of the most substantial forms of psychotherapy. Within eight years (1986-1993), there are over 120 controlled clinical trials had been adding to the literature (Hollon & Beck, 1994). Nowadays, regarding cognitive behavioural intervention, there are over 325 published outcome studies (Butler et al., 2005). Gould et al. (1995) conducted a meta-analysis comparing the effectiveness of different interventions. The result illustrated that "CBT in general had the highest effect size (ES=0.68) compared to pharmacological treatments (ES=0.47) or combination treatments (ES=0.56)" (Butler et al., 2005 P.9), which indicates that CBT is more effective than combination treatment and medication treatment.
Kolar et al., (2011) illustrated that "patients with panic attacks in which case a short-term pharmacotherapy with high-potency benzodiazepines may be very useful." (Para. 1) Comparing with pharmacotherapy, CBT works the best for treating agoraphobic avoidance and anticipatory anxiety. Due to the different outcomes, (Kolar, Starcevic & Marinkovic-Eric 2011) researched if the combination treatment is more effective in treating the panic disorder with agoraphobia than CBT alone. The research result showed the combination treatment is more effective than CBT alone in the short-term treatment for panic disorder with agoraphobia.
Within the Craske et al., (2005) research, results showed after receiving CBT, there are statistically and clinically significant improvements in symptoms at the third month. Comparing with pharmacotherapy treatment alone, the result in 12 months is less improved than the first three months CBT's. Amount a large number of panic disorder treatment literature, the results show that both CBT and pharmacotherapy (medication treatment) are efficient in the short term. Nevertheless, evidence indicates that CBT is more efficient for ensuring the treatment gains are maintained over a long time(Hood & Antony, 2015). However, regarding the importance of primary care, physicians encourage their panic disorder patients to receive CBT as well as medication.
Generally speaking, depending on the needs for the length of outcomes, different types of treatment is variable. Seeking the maximum result in short-term, combination treatment has a better performance than pharmacotherapy and CBT alone. In contrast, CBT in treating the panic disorder shows a more efficient outcome comparing with medication treatment and combination treatment.
Evaluation for Cost-effectiveness
Numerous studies have demonstrated that both CBT and pharmacotherapy treatment along with the combination treatment showed competent effective in treating panic disorder. However, the cost of the procedure needs to be considered in evaluation. In this rigorous research Apeldoorn et al., (2013) researchers pointed out that costs associated with Panic disorder contain not only medical costs but also indirect costs (e.g. from reduced productivity). Therefore, ascertaining out the cost-effectiveness of three treatments of panic disorder: cognitive behavioural therapy (CBT), pharmacotherapy using SSRI, and the combination of both (CBT+SSRI) can be very valuable.
In the research, 150 participants were randomly drawn from the population where patients with panic disorder diagnosis with or without agoraphobia and fall into age from 18 to 65 excluding pregnant, lactating, suicidal, psychotic and severely depressed patients. The whole experiment last 24 months, contains 21 treatment sessions where 19 treatment sessions were held in the first 12 months, and two follow up sessions in the following 12 months. Patients' anxiety level and costs from a societal perspective were examed during the experiment.
The result describes the average societal costs in CBT is lower comparing with SSRI and combination treatment. In addition, the costs of medication use were substantial among the treatments. Consider of health outcomes; the results showed both CBT and combination treatment is more efficacious than SSRI. Although CBT and combination treatment are more cost-effective than SSRI for panic disorder with or without agoraphobia, there still are differences to be detected between CBT and combination treatment, in which the cost differences are €2224 and €3590 in 24 months contrasting the improvement means are 14.5 (CBT) and 16.2 (CBT+SSRI).
In conclusion, CBT associated with the lowest societal costs whereas pharmacotherapy associated with the much more expensive societal costs but least effectiveness. Combination treatment shows a slightly higher score in effectiveness while costs substantial amount than CBT.
Evaluation for Time
Apart from the cost, the treatment is significantly time-consuming for the patients with panic disorder not only mentally but also physically. The sooner patients get treated, the faster they can devote to a career or daily life. Therefore, the onset time is an essential criterion for treatment evaluation.
Typically, the CBT for panic disorder consists of 10-15 weekly sessions. However, several of recent studies propose that outcome can be gained relatively promptly, with a minimal investment of therapist time (Hood & Antony, 2015). CBT via telephone and video-conferencing showed favourable rate for treating patients who do not have access to therapists (Swinson et al., 1995 & Bouchard et al., 2004). In addition, Internet-based (Carlbring et al., 2005) and bibliotherapy (Febbraro, 2005) self-help indicate ascending success rate for CBT. Ultimately, studies proved that brief CBT (five sessions) could show significant improvements in panic disorder. Optimistically, one single session of CBT has shown the prevention to onsets of panic disorder (Swinson et al., 1992).
Medication can further control the onset of the panic disorder. However, the medication itself can only suppress or reduce some of the panic disorder symptoms. The medications for panic attacks and panic disorder include antidepressants, known as SSRI and benzodiazepines. For antidepressants using, usually taking several weeks before it actives; taking regularly and continuously for the pesticide effect. Whereas benzodiazepines act very quickly (regularly within 30 minutes to an hour) and it only needs to be taken during the panic attacks. (Smith & Segal, 2017)
Theoretically, because the medication cannot cure the panic disorder, it is often paired with CBT as combination treatments for a more comprehensive result. Although some studies determined combined treatment has a slight advantage for treatment, it should be paid attention that most of the studies have focused on the short-term (2-3months) treatment outcome. Combination treatment shows no advantage than CBT at long-term follow-up (Furukawa et al., 2006).
Conclusively, CBT has a short onset time which five sessions while the medications take action from 30 minutes up to several weeks depending on the different type of drugs. Dismissing the side effect of medications, the benzodiazepines onset time provides combination treatment with a possibility works faster than CBT that often last 50 minutes per session.
Evaluation for Possibility of relapsing
In the matter of psychological treatment, less possibility of relapsing after procedures is crucial. As a result of CBT's pervasiveness in the psychotherapy, along with its development, the treatment results presented impressively. The treatment outcomes showed no decline by one-year follow-up compared to sizable slippage for pharmacological treatment. Regarding attrition, CBT shows significant lower rate than pharmacological treatment (Gould et al., 1995 & Butler et al., 2006).
Benzodiazepines have 15 years of history of being used as a panic disorder treatment due to its rapid onset of action contrasting to the slow onset of antidepressants. However, the long-term of benzodiazepines use might lead to dependency and cause harmful side effects (Bruce, Vasile, & Goisman, et al., 2003). Keshen, Balonet, & Kline. (2004) argued that despite the advantages of using benzodiazepines, lower cost and less frequent side effects comparing to use SSRI regularly, long-term benzodiazepines used "patients commonly leads to dose escalation or recreational abuse" (American Psychiatric Association, 1990). Even benzodiazepine treatment has demonstrated efficacy in panic disorder treatments, the abrupt withdrawal of benzodiazepine may trigger severe symptoms of anxiety(Fontaine, Chouinard, & Annable, 1984 & Otto et al., 2010). "Even with careful, gradual tapering, a significant proportion of patients experience symptoms of BZ withdrawal, rebound anxiety and relapse of the disorder." (Otto et al., 2010)( as cited in Mellman & Uhde, 1986; Pecknold, Swinson, Kuck, & Lewis, 1988; Schweizer, Rickels, Case, & Greenblatt, 1991)
In fact, studies showed that medication treatment with CBT has a more consistently maintained outcome over the long-term over the medication treatment itself (Barlow et al., 2000 & Marks et al., 1993 & Sharp et al., 1996). Also, Hood & Antony (2015) indicated "CBT has been used successfully to prevent replace and facilitate discontinuation of benzodiazepines among individuals with PD" (p.4) (as cited in Otto et al., 2010).
As such, due to CBT's stabilities, working with medication as the combined treatment can result in the maximum outcome, which is introduced CBT during discontinuation of pharmacological treatment for relapse prevention purpose. Oppositely, the pharmacotherapy shows the highest risk for relapsing after producers.
Conclusion
In general, based on four perspectives of evaluation, as for final results in long-term treatment, CBT performs as well as combined treatment in a better quality than pharmacotherapy. Oppositely, in short-term treatment, combined treatment shows better performance than CBT and pharmacotherapy. Regarding treatment onset time, medications act distinctively. Antidepressants take several weeks whereas benzodiazepines begin actively within 30 minutes to an hour. Additionally, CBT demonstrates improvement after one session that lasts 50 minutes and takes five to fifteen weeks to achieve ideal outcomes. According to Apeldoorn et al.,(2013) combined treatment cost more than pharmacotherapy and CBT while it shows slightly higher performance than CBT in short-term treatment. Most importantly, medications lead to the highest risk for relapsing after procedures. Because of CBT's stability, it usually pairs with combined treatment for preventing and reducing discontinuous hazards.
In summary, pharmacotherapy is the least recommend treatment for panic disorder because of its high risks. For patients who need long-term treatment, CBT and combination performance almost equally in results, while combined treatment has a significantly higher cost. Logically, CBT is more substantial for long-term panic disorder treatment. Contrarily, combined treatments show better outcomes in short-term than CBT. However, because of the expense differences, substantiality is viewed individually.
 
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