Current Medical Diagnosis & Treatment in Psychiatry

THE MEASUREMENT OF THERAPIES

Current Concepts in AnxietyAug 01, 06

A stimulating therapeutic development is the complex study of panic disorder by the team of Barlow, Gorman, Shear and Woods (2000) comparing cognitive-behavioral treatment versus imipramine and their combination with placebo in panic disorder.

This is, by far, the best controlled study in this area, although, unfortunately, the sample was limited to panic patients with minimal or no agoraphobia, who have the best prognosis in any case.

Using a Clinical Global Improvement Scale, cognitive-behavioral therapy did as well as imipramine, but within these responders imipramine was superior, with regard to degree of symptomatic remission. It follows that if response had been defined by a cutting level on this symptom scale, there would have been more responders on imipramine.

This difficulty in estimating meaningful clinical therapeutic response was paralleled by the other first-rate placebo-controlled comparison of cognitive behavioral group therapy versus phenelzine for social phobia, co-sponsored by R.G. Heimberg and M.R. Liebowitz (1998). Here too a Clinical Global Improvement Scale indicated equivalent effectiveness for pharmacotherapy and psychotherapy but on analysis of symptomatic scales specifically relevant to social phobia, the superiority of phenelzine became plain.

Another example of difficulty in clinically meaningful description of therapeutic response was pointed out by Rappaport et al. (2000). This study had shown sertraline to be superior to placebo in the treatment of panic disorder. Nevertheless many patients on placebo had done well with regard to symptomatic ratings. However, the authors then looked, within the responders, at a patient self-rating of Quality of Life Enjoyment and Satisfaction. They found that despite equivalent initial demographic and clinical characteristics, sertraline responders were substantially superior to placebo responders on the total Quality of Life score. Such a self-rating is clearly a step in the right direction. Objective life functioning measures would be desirable.

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