|A review of self-management interventions for panic disorders, phobias and obsessive-compulsive disorders
|Barlow J H, Ellard D R, Hainsworth J M, Jones F R, Fisher A
This review examined current evidence for the effectiveness of self-management interventions for panic disorder, phobias and obsessive-compulsive disorder. The authors concluded that there is sufficient evidence to warrant greater exploration of self-management for these conditions. Given the limitations in the current evidence, further research as indicated by the authors would help clarify the effectiveness of these interventions.
To review current evidence for the clinical and cost-effectiveness of self-management interventions for panic disorder, phobias and obsessive-compulsive disorder.
The Cochrane Library, the National Research Register, PsycINFO, PubMed, CINAHL, Index to Theses, Index to Scientific and Technical Proceedings, the Science Citation Index and EconLit were searched from 1995 to 2003. In addition, the identified papers were checked for relevant studies, and key experts, authors and voluntary organisations were contacted. Only articles available in English were included.
Study designs of evaluations included in the review
Randomised controlled trials (RCTs) were included in the review.
Specific interventions included in the review
Studies that evaluated a self-management approach were eligible for inclusion. Studies of bibliotherapy with no professional or paraprofessional input were excluded. The interventions actually included in the review were full cognitive therapy, brief cognitive therapy, self-exposure, internet-delivered self-help, internet-delivered cognitive-behaviour therapy (CBT), graded exposure, relaxation, breathing techniques, computer-aided exposure, exposure with feedback, behaviour therapy and computer-guided self-help, behaviour therapy system (BT STEPS). The authors stated that none of the included studies could be considered 'pure' self-management interventions, but all did include an element of self-management.
Participants included in the review
Studies of individuals with panic disorder, phobias or obsessive- compulsive disorder were included in the review. The mean age of the participants ranged from 31 to 39 years.
Outcomes assessed in the review
No inclusion criteria for the outcomes were stated. A wide range of outcome measures were used in the included studies; these focused primarily on the reduction of symptoms.
How were decisions on the relevance of primary studies made?
The research team selected papers, resolving any discrepancies through consensus.
Assessment of study quality
The authors did not state that they assessed validity.
The research team read and summarised the papers using a predefined record sheet. Any discrepancies were resolved by consensus. Effect sizes were calculated for each study using the reported mean scores at follow-up and standard deviations.
Methods of synthesis
How were the studies combined?
The studies were grouped according to disorder and combined in a narrative.
How were differences between studies investigated?
Differences between the studies in terms of the participants and interventions were discussed in the text and displayed in a table.
Results of the review
Ten RCTs with a total of 722 participants were included in the review. One was on obsessive-compulsive disorder, five were on panic disorder and four were on phobias.
CBT and self-exposure were effective, with improvements in panic frequency, panic-related cognitions, agoraphobic avoidance, anxiety and depression being maintained at follow-up (2 studies). Both internet-delivered CBT and applied relaxation produced improvements in terms of psychological well-being and a reduction in symptoms (1 study). An internet-based self-help programme was effective in reducing panic cognitions and improving psychological well-being (1 study). Self-directed exposure combined with cognitive therapy, relaxation training or therapist-assisted exposure were equally effective for people with panic disorder and agoraphobia (one study).
The addition of CBT and the provision of a self-help manual to self-exposure therapy for people with social phobia did not improve benefits. There were no differences in outcomes between professionally-led exposure and either self-exposure or computer-aided exposure. Exposure was more effective than relaxation.
BT STEPS and clinician-led behaviour therapy were significantly more effective than relaxation and had greater patient satisfaction ratings. Clinician-led behaviour therapy was more effective than BT STEPS.
Effect sizes for the treatment groups in each individual study were tabulated.
One study estimated the cost of developing the internet-delivered self-help programme for individuals with panic disorder to be 1,000 dollars, with an additional investment in time of 10 working days.
There is evidence to support the use of self-management in panic disorder, phobias and obsessive-compulsive disorder. Despite some limitations of the reviewed studies, further developments of interventions in this field should be explored.
The authors set out a clear objective at the beginning of the review, and inclusion criteria were defined in terms of the intervention, participants and study design. A thorough search of several databases was carried out. However, the search was restricted to studies published in English, which might have introduced language bias, and relevant studies might have been missed. Although not explicitly stated, the authors appear to have carried out the study selection and data extraction processes in duplicate, which helps reduce the risk of bias. Whilst the authors commented on the adequacy of sample size and use of intention-to-treat analysis, they did not formally assess the quality of the included studies. Details of the individual studies were tabulated clearly. In light of the differences between the studies in terms of the intervention and participants, the narrative synthesis was appropriate. Given the limitations in the current evidence, further research as indicated by the authors would help clarify the effectiveness of these interventions.
Implications of the review for practice and research
Practice: The authors did not state any implications for practice.
Research: The authors stated that studies with longer follow-up, based on larger, more heterogeneous samples, and cost-effectiveness analyses of clinically effective interventions are needed. In addition, they stated that there is a need to determine both the optimum length of intervention for each condition, and how much professional involvement is required to produce a positive change. Furthermore, the authors stated that there is a gap in the research relating to interventions for younger people and increasing the use of peer-led interventions.
Barlow J H, Ellard D R, Hainsworth J M, Jones F R, Fisher A. A review of self-management interventions for panic disorders, phobias and obsessive-compulsive disorders. Acta Psychiatrica Scandinavica 2005; 111(4): 272-285
Subject indexing assigned by NLM
Cognitive Therapy /economics; Cost-Benefit Analysis /economics; Desensitization, Psychologic /economics; Follow-Up Studies; Humans; Panic Disorder /economics /psychology /therapy; Phobic Disorders /economics /psychology /therapy; Randomized Controlled Trials as Topic; Self Care /economics /methods /psychology; Treatment Outcome
Database entry date
This is a critical abstract of a systematic review that meets the criteria for inclusion on DARE. Each critical abstract contains a brief summary of the review methods, results and conclusions followed by a detailed critical assessment on the reliability of the review and the conclusions drawn.