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Cognitive-behaviour therapy (CBT) for panic disorder may consist of different combinations of several therapeutic components such as relaxation, breathing retraining, cognitive restructuring, interoceptive exposure and/or in vivo exposure. It is therefore important both theoretically and clinically to examine whether specific components of CBT or their combinations are superior to others in the treatment of panic disorder. Component network meta-analysis (NMA) is an extension of standard NMA that can be used to disentangle the treatment effects of different components included in composite interventions. We searched MEDLINE, EMBASE, PsycINFO and Cochrane Central, with supplementary searches of reference lists and clinical trial registries, for all randomized controlled trials comparing different CBT-based psychological therapies for panic disorder with each other or with control interventions. We applied component NMA to disentangle the treatment effects of different components included in these interventions. After reviewing 2526 references, we included 72 studies with 4064 participants. Interoceptive exposure and face-to-face setting were associated with better treatment efficacy and acceptability. Muscle relaxation and virtual-reality exposure were associated with significantly lower efficacy. Components such as breathing retraining and in vivo exposure appeared to improve treatment acceptability while having small effects on efficacy. The comparison of the most v. the least efficacious combination, both of which may be provided as ‘evidence-based CBT,’ yielded an odds ratio for the remission of 7.69 (95% credible interval: 1.75 to 33.33). Effective CBT packages for panic disorder would include face-to-face and interoceptive exposure components, while excluding muscle relaxation and virtual-reality exposure.
Contradictions and initial overestimates are not unusual among highly
cited studies. However, this issue has not been researched in
To assess how highly cited studies in psychiatry are replicated by
We selected highly cited studies claiming effective psychiatric
treatments in the years 2000 through 2002. For each of these studies we
searched for subsequent studies with a better-controlled design, or with
a similar design but a larger sample.
Among 83 articles recommending effective interventions, 40 had not been
subject to any attempt at replication, 16 were contradicted, 11 were
found to have substantially smaller effects and only 16 were replicated.
The standardised mean differences of the initial studies were
overestimated by 132%. Studies with a total sample size of 100 or more
tended to produce replicable results.
Caution is needed when a study with a small sample size reports a large