Robert A. Gould

A meta-analysis of treatment outcome for panic disorder

We compared the effectiveness of pharmacological, cognitive-behavioral, and combined pharmacological and cognitive-behavioral treatments in a meta-analysis of 43 controlled studies that included 76 treatment interventions. Cognitive-behavioral treatments yielded the highest mean effect sizes (ES = 0.68) relative to pharmacological (ES = 0.47) and combination treatments (ES = 0.56). In addition, the proportion of subjects who dropped out of cognitive-behavioral treatments was 5.6% relative to 19.8% in pharmacological treatments and 22.0% in combined treatments. Among cognitive-behavioral treatments, those studies that combined cognitive restructuring with interoceptive exposure yielded the strongest effect sizes (ES = 0.88). With regard to pharmacological treatments, there was no significant difference between antidepressants (ES = 0.55) and benzodiazepines (ES = 0.40). Long-term outcome analyses suggested that cognitive-behavioral interventions were the most successful at maintaining treatment gains. Cost analyses indicated that the lowest cost interventions were imipramine treatment and group cognitive-behavioral therapy. In general, cognitive-behavioral treatments yielded the largest effects sizes and the smallest attrition rates relative to pharmacotherapy and combined treatments, and are cost-effective.

Cognitive therapy for psychosis in schizophrenia: an effect size analysis

We conducted a meta-analysis using all available controlled treatment outcome studies of cognitive therapy (CT) for psychotic symptoms in schizophrenia. Effect sizes were calculated for seven studies involving 340 subjects. The mean effect size for reduction of psychotic symptoms was 0.65. The findings suggest that cognitive therapy is an effective treatment for patients with schizophrenia who have persistent psychotic symptoms. Follow-up analyses in four studies indicated that patients receiving CT continued to make gains over time (ES=0.93). Further research is needed to determine the replicability of standardized cognitive interventions, to evaluate the clinical significance of cognitive therapy for schizophrenia, and to determine which patients are most likely to benefit from this intervention.

Cognitive behavioral and pharmacological treatment of generalized anxiety disorder: A preliminary meta-analysis

This study provides a meta-analytic review of controlled trials examining cognitive behavior therapy (CBT) and pharmacotherapy for generalized anxiety disorder (GAD). Thirty-five studies, published or presented between 1974 and January 1996, were identified, and provided 61 separate treatment interventions. Both modalities of treatment offered clear efficacy to patients, and the overall effect size (ES) for CBT (ES = .70) was not statistically different from pharmacotherapy (ES = 0.60) for measures of anxiety severity. CBT was associated with significantly greater effects on depression severity, and was associated with clear maintenance of treatment gains, whereas the long-term efficacy of pharmacologic treatment was attenuated following medication discontinuation. Data concerning the efficacy of specific cognitive behavioral and pharmacologic interventions are provided, as are analyses of the influence of methodological factors (e.g., gender distribution, length of treatment) on the efficacy of treatments.

A comparison of the efficacy of clonazepam and cognitive-behavioral group therapy for the treatment of social phobia

There is a growing body of evidence that social phobia may be treated effectively by either pharmacologic or cognitive-behavioral interventions. but few studies have examined the relative benefits of these treatments. In this study, we examined the relative efficacy of pharmacotherapy with clonazepam and cognitive-behavioral group therapy (CBGT) for treating social phobia. In addition, we examined potential predictors of differential treatment response. Outpatients meeting Diagnostic and Statistical Manual of Mental Disorders (3rd ed., revised) criteria for social phobia were randomly assigned to treatment. Clinician-rated and patient-rated symptom severity was examined at baseline and after 4, 8, and 12 weeks of treatment. All clinician-rated assessments were completed by individuals blind to treatment condition. Patients in both conditions improved significantly, and differences between treatment conditions were absent, except for greater improvement on clonazepam on several measures at the 12-week assessment. Symptom severity was negatively associated with treatment success for both methods of treatment, and additional predictors-sex, comorbidity with other anxiety or mood disorders, fear of anxiety symptoms, and dysfunctional attitudes-failed to predict treatment outcome above and beyond severity measures. In summary, we found that patients randomized to clinical care with clonazepam or CBGT were equally likely to respond to acute treatment, and pretreatment measures of symptom severity provided no guidance for the selection of one treatment over another.

Bulimia nervosa: A meta-analysis of psychosocial and pharmacological treatments*

Nine double-blind, placebo-controlled medication trials (870 subjects) and 26 randomized psychosocial studies (460 subjects) were included in a meta-analysis of bulimia nervosa (BN). Four treatment outcomes were analyzed: binge and purge frequency, depression (self-reported and interviewer-rated), and self-reported eating attitudes. When compared to medication, cognitive behavioral therapy (CBT) studies produced significantly larger-weighted effect sizes for all treatment outcomes. These quantitative results correspond to qualitative reviews and suggest that CBT is the treatment of choice for BN.

Self-help plus minimal therapist contact in the treatment of panic disorder: A replication and extension

A self-help (SH) treatment for panic disorder was compared to a wait-list (WL) control. The SH treatment consisted of reading the book Coping With Panic, watching a 15-minute videotape providing information regarding panic attacks and instruction in diaphragmatic breathing, and being provided with a relaxation tape that taught progressive muscle relaxation. Evidence strongly supported the effectiveness of SH relative to WL both at posttreatment and at 2-month follow-up. The results provide support for the possible treatment of panic disorder with SH methods.

Prevalence and correlates of anger attacks: A two site study

Although anger attacks have been described in depressed outpatients, they have not been well studied in other disorders. In Study 1, we examined the prevalence of anger attacks in 50 outpatients with panic disorder. In Study 2, we replicated the initial findings at an independent site and examined the specificity of anger attacks by comparing their occurrence in patients with panic disorder, patients with other non-panic anxiety disorders and patients with a depressive disorder. At both sites, we also explored the relationship between anger attacks and demographic and clinical characteristics, such as gender, presence and severity of depression, and social anxiety measures. In both sites, the prevalence of anger attacks in patients with panic disorder was approximately one-third. However, anger attacks were not unique to panic disorder, with similar rates emerging for patients with other anxiety disorders. Furthermore, patients with depressive diagnoses had twice the prevalence of anger attacks than did anxiety patients. At both sites, those with anger attacks were significantly more depressed and were likely to have either current or past history of major depression. Anger attacks were not associated with social anxiety measures, but were related to cluster B, cluster C and self-defeating personality disorder traits. Our findings support the notion that anger attacks are best conceptualized as an associated feature of depression.

The effectiveness of cognitive-behavior therapy for panic disorder without concurrent medication treatment: a reply to Power and Sharp.

In a recent letter to the editor, Power and Sharp (1995) questioned the efficacy of cognitive-behavior therapy (CBT) for panic disorder based on the inclusion, in some studies, of patients using concurrent psychotropic medication. It should be noted that patients who were using concurrent medication still met the criteria for severity for entry into the study. Nonetheless, Power and Sharp (1995) questioned whether CBT is ’as effective when used in the absence of concurrent psychotropic medication as is claimed on the basis of these predominantly flawed studies’. This letter provides an empirical response to this issue. The basis for our response is a recently published metaanalysis of the panic disorder treatment literature (Gould, Otto and Pollack, 1995). In this meta-analysis, we examined the

The pharmacotherapy of social phobia.

Social phobia has been recognized as a discrete diagnostic condition only relatively recently. Epidemiological studies have shown that social phobia is associated with significant impairment and an increasing body of evidence has now indicated that pharmacological treatment is effective. Placebo-controlled studies have demonstrated the efficacy of the monoamine oxidase inhibitor phenelzine. A reversible inhibitor of monoamine oxidase A, moclobemide, is better tolerated and safer than the irreversible monoamine oxidase inhibitors and placebo-controlled studies have also demonstrated efficacy for this compound; moreover, positive results from a small study of brofaromine also support the efficacy of this class of compounds. It has been reported that a high-potency benzodiazepine, clonazepam, is effective but there is little placebo-controlled evidence to support the use of other benzodiazepines. Selective serotonin reuptake inhibitors are also being tested in social phobia with encouraging results. More studies are now needed on the long-term treatment of social phobia.