Title: Cognitive therapy for the treatment of panic disorder in adolescents: a feasibility study
Funder: Department of Health and Social Care

Abstract: Background to the research Panic disorder affects one in fifty adolescents and is a disabling condition, associated with adverse long-term outcomes. Despite this, adolescents with panic disorder have typically been excluded from treatment trials of children and young people with anxiety disorders, and there is limited current guidance for NHS Child and Adolescent Mental Health Services (CAMHS) as to how adolescents with panic disorder should be treated. Clark's Cognitive Therapy (CT) has been shown to be highly effective for adults with panic disorder, even in a brief format with self-study modules. To date there has been no adaptation of this treatment for adolescents with panic disorder, despite the psychological processes targeted in CT for adults being evident in adolescents. It is possible that recovery rates for adolescents could be substantially improved and treatment considerably shortened by using this alternative treatment approach, adapted for use with adolescents. Aims of the work The proposed fellowship will provide the groundwork for a future definitive trial to investigate the clinical and cost-effectiveness of CT for panic disorder in adolescents compared to standard care (generic CBT for anxiety disorders; the C.A.T. Project) in CAMHS. The main research question to be addressed is whether CT can be adapted in a way that takes account of the specific needs of adolescents and is acceptable to adolescents and their carers. Plan of investigation The plan of investigation is first, to adapt and manualise Clark's brief CT for panic disorder for use with adolescents, taking into account developmental considerations and feedback from adolescents and their carers. Second, a programme will be developed to train CAMHS clinicians to deliver the adapted treatment and competency will be assessed. Finally, a feasibility trial will be conducted to evaluate the treatment delivered by CAMHS clinicians in two local NHS Trusts, compared to standard care (the C.A.T. Project) to determine any potential negative impacts of the treatments and trial procedures, the acceptability of the treatments and trial procedures, recruitment rates, treatment completion rates, retention to research assessments and to establish the extent to which CT is adhered to by practitioners, is credible and is distinct from standard care, and to identify appropriate clinical and economic outcome measures on the basis of exploratory analyses, PPI feedback and qualitative interviews with participants. Potential benefits to patients and the NHS In adults, panic disorder has have been shown to be one of the most expensive common mental health disorders, with patients having high levels of service utilisation, typically presenting regularly in primary care and A&E departments as a result of intense somatic symptoms, as well as mental health services. It is likely that this is also the case for adolescents. The peak period of onset for panic disorder is mid to late adolescence and an onset in adolescence is associated with greater severity and an increased likelihood of recurrence after periods of recovery than an onset in adulthood. This highlights the need for effective and accessible treatment for adolescents with panic disorder to prevent a negative trajectory in adulthood. Beyond this, there are wider social and economic costs to panic disorder, such as difficulties attending school regularly, which is likely to lead to poorer life course outcomes. Both the NHS and broader society will benefit from the provision of a cost-effective treatment that stands to improve long-term life course outcomes for adolescents with panic disorder and reduce the associated economic burden of the condition on society.

Lay abstract: Aims of the research The proposed fellowship will adapt a highly effective psychological therapy for panic disorder in adults (Cognitive Therapy') so that it is suitable and acceptable for adolescents and can be delivered in NHS Child and Adolescent Mental Health Services (CAMHS). A feasibility trial will be conducted to establish how many adolescents would need to take part in a trial and what outcomes are relevant and appropriate for a full trial. Background to the research Around one in fifty adolescents meet or have previously met diagnostic criteria for panic disorder. People who have panic disorder experience repeated, unexpected panic attacks. Panic attacks involve an abrupt onset of intense fear or discomfort that reaches a peak within minutes and includes symptoms such as increased heart rate, sweating and shaking. For many people panic disorder begins in adolescence and this early onset may be associated with more severe symptoms and a worse outcome than when it begins in adulthood. Panic disorder is a disabling condition, typically accompanied by difficulties academically, such as attending school or lessons, or with peers, friends and family. It typically does not go away without treatment, has a lasting, negative impact on normal adolescent development and, unsurprisingly, is associated with high rates of depression, substance abuse and suicidal behaviour. These factors highlight the need for effective and accessible treatment for adolescents with panic disorder. Clark's Cognitive Therapy (CT) is a talking therapy for adults with panic disorder which produces excellent outcomes. The treatment is not currently being used with adolescents. Instead, in CAMHS young people with panic disorder usually receive a type of Cognitive Behaviour Therapy (CBT) that was developed for all anxiety problems. Most treatment trials of CBT for anxiety disorders in young people exclude young people with panic disorder and, where they are included, there is some preliminary evidence that they are likely to drop out of treatment. There is good reason to think that CT based on the Clark's model might be suitable for young people, as well as adults. As such CT that specifically targets adolescent panic disorder may have great promise for use in NHS CAMHS. Design and methods used The study will involve adapting CT for panic disorder for adolescents, training CAMHS clinicians to deliver it and assessing their competency, and examining the feasibility of a trial to compare CT to standard care (generic CBT for anxiety disorders; the C.A.T. Project). It will explore what adolescents and their carers think of CT, how many young people would need to take part in a full trial and what outcomes should be assessed. Patient and public involvement The study will involve working with adolescents and their carers to develop materials, make sure that CT and the trial processes are acceptable, and identify what outcomes are important to them. It will also work with young people and their carers to ensure that the study findings are communicated to patients and the public in a meaningful way. Dissemination The results of the feasibility study will be shared with professionals, adolescents and their carers through journals, talks at conferences, newsletters, and online information.

Research activity codes: 6.6 PSYCHOLOGICAL AND BEHAVIOURAL
Health categories: MENTAL HEALTH