Abstract
Cognitive-behaviour therapy (CBT) for panic disorder may consist of different combinations of several therapeutic components such as relaxation, breathing retraining, cognitive restructuring, interoceptive exposure and/or in vivo exposure. It is therefore important both theoretically and clinically to examine whether specific components of CBT or their combinations are superior to others in the treatment of panic disorder. Component network meta-analysis (NMA) is an extension of standard NMA that can be used to disentangle the treatment effects of different components included in composite interventions. We searched MEDLINE, EMBASE, PsycINFO and Cochrane Central, with supplementary searches of reference lists and clinical trial registries, for all randomized controlled trials comparing different CBT-based psychological therapies for panic disorder with each other or with control interventions. We applied component NMA to disentangle the treatment effects of different components included in these interventions. After reviewing 2526 references, we included 72 studies with 4064 participants. Interoceptive exposure and face-to-face setting were associated with better treatment efficacy and acceptability. Muscle relaxation and virtual-reality exposure were associated with significantly lower efficacy. Components such as breathing retraining and in vivo exposure appeared to improve treatment acceptability while having small effects on efficacy. The comparison of the most v. the least efficacious combination, both of which may be provided as 'evidence-based CBT,' yielded an odds ratio for the remission of 7.69 (95% credible interval: 1.75 to 33.33). Effective CBT packages for panic disorder would include face-to-face and interoceptive exposure components, while excluding muscle relaxation and virtual-reality exposure.
Highlights
Panic disorder is an anxiety disorder characterized by the recurrence of unexpected panic attacks, in which an intense fear accompanied by a series of bodily and/or cognitive symptoms develops abruptly, without an apparent external cause (American Psychiatric Association, 2013)
In clinical practice and in the research literature, we find therapies which correspond to the general definition of cognitive-behaviour psychotherapy (CBT), but which consist of different sets of therapeutic components
Apart from third wave components, which were administered only in two studies, all other components were well represented in the network
Summary
Panic disorder is an anxiety disorder characterized by the recurrence of unexpected panic attacks, in which an intense fear accompanied by a series of bodily and/or cognitive symptoms develops abruptly, without an apparent external cause (American Psychiatric Association, 2013). Panic disorder is common in the general population, with a life-time prevalence of 3.7% without agoraphobia and 1.1% with agoraphobia (Kessler et al 2006). Guidelines recommend the use of cognitive-behaviour psychotherapy (CBT) (American Psychiatric Association, 1998; Royal Australian & New Zealand College of Psychiatrists, 2003; NICE, 2011; Katzman et al 2014). In line with these recommendations, a recent Cochrane review and network meta-analysis (Pompoli et al 2016) found CBT to be the most efficacious treatment among other competing psychological therapies
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