Antidepressants and behavior therapy in agoraphobia and obsessive-compulsive disorders: a commentary.

Happily, it is no longer necessary to state that pharmacotherapy and behavior therapy are compatible. Unfortunately, however, it remains true that most therapists experienced in one are inexperienced in the other. It is for this reason that the editors have invited papers by two of the leading investigators of this interface. Dr. Zitrin reviews the evidence for the differential effects of antidepressants and behavior therapy in the treatment of panic attacks and Dr. Stern does the same for obsessive-complusive disorders. On the basis of her review, Dr. Zitrin concludes that antidepressants effectively suppress panic and that the combination of antidepressants and behavior therapy are superior to behavior therapy alone in those patients (with “spontaneous” panic attacks) completing treatment. This conclusion notwithstanding, she recommends behavior therapy alone as the treatment of choice, to be supplemented by imipramine in intractable cases. Although not the position of Dr. Zitrin, some proponents of the psychopharmacological approach to panic suppression equate “spontaneous” with endogenous, biological and unlearned (Sheehan, Ballenger and Jacobson, 1980). According to this view “spontaneous” panics are primary phenomena which may lead to learned anticipatory anxiety and avoidance behavior in psychologically susceptible individuals; they occur in much the same way as a depressive or manic episode of a major affective disorder and likewise respond to biologically based treatments such as antidepressants. Dr. Zitrin refers to the “spontaneous” panic attack as “the core disorder in agoraphobia”. Although it is clearly a very common and conspicuous clinical feature, Dr. Zitrin acknowledges that the panic attack is not an invariable accompaniment of agoraphobia. It appears, therefore, that panic attacks are neither necessary nor sufficient to account for the development of agoraphobia. Whatever their role in agoraphobia, it is of greater relevance to this paper to focus on the evidence presented to support the conclusion that antidepressants (tricyclics and MAO inhibitors) actually suppress the panic attacks. In this regard, several points warrant emphasis. First, as Dr. Zitrin notes, there are no published controlled studies showing the effects of imipramine alone on panic attacks. Conclusions must therefore be confined to the suppressing effects of imipramine plus psychotherapy/behavior therapy. Second, none of the studies cited actually report frequency and intensity of panic attacks, even though these would be the most direct measures of panic suppression effects. The outcome measures used in the Zitrin, Klein and Woerner (1978) study, for example, are global clinical judgements subsuming phobic avoidance, anticipatory anxiety, panic attacks, functioning, mood, self-esteem and interpersonal relationships. Needless to say, such a global measure does not directly test the hypothesis that imipramine suppresses panic attacks. In a subsequent report (Zitrin et al., 1981) data are reported on the results of an Acute Panic Inventory which was completed by patients and which included rating scales for frequency of panic attacks in the past month (1 = several times; 7 = no anxiety), frequency