Skip to main content Accessibility help

A randomized trial of sertraline, self-administered cognitive behavior therapy, and their combination for panic disorder

  • D. Koszycki (a1) (a2), M. Taljaard (a3) (a4), Z. Segal (a5) and J. Bradwejn (a2)



Self-administered cognitive behavior therapy (SCBT) has been shown to be an effective alternative to therapist-delivered treatment for panic disorder (PD). However, it is unknown whether combining SCBT and antidepressants can improve treatment. This trial evaluated the efficacy of SCBT and sertraline, alone or in combination, in PD.


Patients (n=251) were randomized to 12 weeks of either placebo drug, placebo drug plus SCBT, sertraline, or sertraline plus SCBT. Those who improved after 12 weeks of acute treatment received treatment for an additional 12 weeks. Outcome measures included core PD symptoms (panic attacks, anticipatory anxiety, agoraphobic avoidance), dysfunctional cognitions (fear of bodily sensations, agoraphobic cognitions), disability, and clinical global impression of severity and improvement. Efficacy data were analyzed using general and generalized linear mixed models.


Primary analyses of trends over time revealed that sertraline/SCBT produced a significantly greater rate of decline in fear of bodily sensations compared to sertraline, placebo/SCBT and placebo. Trends in other outcomes were not significantly different over time. Secondary analyses of mean scores at week 12 revealed that sertraline/SCBT fared better on several outcomes than placebo, with improvement being maintained at the end of continuation treatment. Outcome did not differ between placebo and either sertraline monotherapy or placebo/SCBT. Moreover, few differences emerged between the active interventions.


This trial suggests that sertraline combined with SCBT may be an effective treatment for PD. The study could not confirm the efficacy of sertraline monotherapy or SCBT without concomitant medication or therapist assistance in the treatment of PD.


Corresponding author

*Address for correspondence: D. Koszycki. Ph.D., C.Psych., Faculty of Education, University of Ottawa, 145 Jean-Jacques Lussier, Ottawa, Ontario, K1N 6N5, Canada. (Email:


Hide All
Bakker, A, van Balkom, AJ, Stein, DJ (2005). Evidence-based pharmacotherapy of panic disorder. International Journal of Neuropsychopharmacology 8, 473482.
Carlbring, P, Ekselius, L, Andersson, G (2003). Treatment of panic disorder via the Internet: a randomized trail of CBT vs applied relaxation. Journal of Behavior Therapy and Experimental Research 34, 129140.
Carlbring, P, Nillsson-Ihrfelt, E, Waara, J, Kollenstam, C, Burman, M, Kaldo, V, Soderberg, M, Ekselius, L, Anderson, G (2005). Treatment of panic disorder: live therapy vs. self-help via internet. Behaviour Research and Therapy 43, 13211333.
Carlbring, P, Westling, BE, Ljungstrad, P, Ekselius, L, Andersson, G (2001). Treatment of panic disorder via the Internet: A randomized trial of a self-help intervention. Behaviour Therapy 32, 751764.
Chambless, DL, Caputo, GC, Bright, P, Gallagher, R (1984). Assessment of fear in agoraphobics: The Body Sensations Questionnaire and the Agoraphobic Cognitions Questionnaire. Journal of Consulting and Clinical Psychology 52, 10901097.
Chambless, DL, Caputo, GC, Jasin, SE, Gracely, EJ, Williams, C (1985). The Mobility Inventory for Agoraphobia. Behaviour Research and Therapy 23, 3544.
Craske, MG, Zucker, BG (2001). Consideration of the APA practice guideline for the treatment of patients with panic disorders: strengths and limitations of behavior therapy. Behavior Therapy 32, 259281.
Fawcett, J, Epstein, P, Fiester, SJ, Elkin, I, Autry, JH (1987). Clinical management – imipramine/placebo administration manual. NIMH Treatment of Depression Collaborative Research Program. Psychopharmacology Bulletin 23, 309324.
Febbraro, GA (2005). An investigation into the effectiveness of bibliotherapy and minimal contact interventions in the treatment of panic attacks. Journal of Clinical Psychology 61, 763779.
Febbraro, GA, Clum, GA, Roodman, AA, Wright, JH (1999). The limits of bibliotherapy: a study of the differential effectiveness of self-administered interventions in individuals with panic attacks. Behavior Therapy 30, 209222.
First, MB, Spitzer, RL, Gibbon, M, Williams, JBW (1997). Structured Clinical Interview for DSM-IV Axis I Disorders (SCID-I), Clinician Version. American Psychiatric Publishing, Inc: Washington, DC.
Furukawa, TA, Watanabe, N, Churchill, R (2006). Psychotherapy plus antidepressants for panic disorder with or without agoraphobia. British Journal of Psychiatry 188, 305312.
Furukawa, TA, Watanabe, N, Omori, IM, Churchill, R (2007). Can pill placebo augment cognitive-behavior therapy for panic disorder? BMC Psychiatry 7, 73.
Gould, RA, Clum, GA (1995). Self-help plus minimal therapist contact in the treatment of panic disorder: a replication and extension. Behavior Therapy 26, 533546.
Gould, RA, Clum, GA, Shapiro, D (1993). The use of bibliotherapy in the treatment of panic: a preliminary investigation. Behavior Therapy 24, 241252.
Guy, W (1976). ECDEU Assessment Manual for Psychopharmacology – Revised, pp. 218222. Publication ADM 76-338. National Institute of Mental Health: Rockville, MD.
Hamilton, M (1960). A rating scale for depression. Journal of Neurology, Neurosurgery and Psychiatry 23, 5662.
Hecker, JE, Losee, MC, Fritzler, BK, Fink, CM (1996). Self-directed versus therapist-directed cognitive behavioral treatment for panic disorder. Journal of Anxiety Disorders 10, 253265.
Holden, AE, O'Brien, GT, Barlow, DH, Stetson, D, Infantino, A (1983). Self-help manual for agoraphobia: a preliminary report of effectiveness. Behavior Therapy 15, 545556.
Kiropoulos, LA, Klein, B, Austin, DW, Gilson, K, Pier, C, Mitchell, J, Ciechomski, L (2008). Is internet-based CBT for panic disorder and agoraphobia as effective as fact-to-fact CBT? Journal of Anxiety Disorder 22, 12731284.
Lidren, DM, Watkins, PL, Gould, RA, Clum, GA, Asterino, M, Tulloch, HL (1994). A comparison of bibliotherapy and group therapy in the treatment of panic disorder. Journal of Consulting and Clinical Psychology 62, 865869.
Littell, RC, Milliken, GA, Stroup, WW, Wolfinger, RD, Schabenberber, O (2006). SAS for Mixed Models, 2nd edn, p. 814. SAS Institute Inc.: Cary, NC.
Londborg, PD, Wolkow, R, Smith, WT, DuBoff, E, England, D, Ferguson, J, Rosenthal, M, Weise, C (1998). Sertraline in the treatment of panic disorder: a multi-site, double-blind, placebo-controlled, fixed-dose investigation. British Journal of Psychiatry 173, 5460.
Marks, IM, Kenwright, M, McDonough, M, Whittaker, M, Mataix-Cols, D (2004). Saving clinicians' time by delegating routine aspects of therapy to a computer: a randomized controlled trial in phobia/panic disorder. Psychological Medicine 34, 9–17.
McAlister, FA, Straus, SD, Sackett, DL, Altman, DG (2003). Analysis and reporting of factorial trials: a systematic review. Journal of the American Medical Association 289, 25452575.
National Institutes of Health (1991). Treatment of Panic Disorder. National Institutes of Health Consensus Development Conference Statement September 25–27, 9, 124.
Ott, MB, Yingling, GL (2006). Guide to Good Clinical Practice. Thompson Publishing Group Inc.: Washington, DC.
Park, JM, Mataix-Cols, D, Marks, IM, Ngamthipwatthana, T, Marks, M, Araya, R, Al Kubaisy, T (2001). Two-year follow-up after a randomised controlled trial of self- and clinician-accompanied exposure for phobia/panic disorders. British Journal of Psychiatry 178, 543548.
Pohl, RB, Wolkow, RM, Clary, CM (1998). Sertraline in the treatment of panic disorder: a double-blind multicenter trial. American Journal of Psychiatry 155, 11891195.
Pollack, MH, Otto, MW, Worthington, JJ, Manfro, GG, Wolkow, R (1998). Sertraline in the treatment of panic disorder: a flexible-dose multicenter trial. Archives of General Psychiatry 55, 10101016.
Pollack, MM, Rappaport, MH, Clary, CM, Mardelian, J, Wolkow, R (2000). Sertraline treatment and panic disorder: response in patients at risk for poor outcome. Journal of Clinical Psychiatry 61, 922927.
Proschan, MA, Waclawiw, MA (2000). Practical guidelines for multiplicity adjustment in clinical trials. Controlled Clinical Trials 21, 527539.
Shear, K, Maser, JD (1994). Standardized assessment for panic disorder research. A conference report. Archives of General Psychiatry 51, 346354.
Sheehan, DV, Harnett-Sheehan, K, Raj, BA (1996). The measurement of disability. International Clinical Psychopharmacology 57 (Suppl. 10), 8995.


Related content

Powered by UNSILO

A randomized trial of sertraline, self-administered cognitive behavior therapy, and their combination for panic disorder

  • D. Koszycki (a1) (a2), M. Taljaard (a3) (a4), Z. Segal (a5) and J. Bradwejn (a2)


Altmetric attention score

Full text views

Total number of HTML views: 0
Total number of PDF views: 0 *
Loading metrics...

Abstract views

Total abstract views: 0 *
Loading metrics...

* Views captured on Cambridge Core between <date>. This data will be updated every 24 hours.

Usage data cannot currently be displayed.