Quetiapine extended-release augmentation has not been found to be beneficial , in comparison to placebo , in non-responders to previously recommended pharmacotherapy .
In non-responders to cognitive behavioral therapy ( CBT ) , switching to paroxetine/citalopram has been found to be more effective than continuing CBT .
Acceptance and commitment therapy ( ACT ) has shown some improvement in patients ’ resistance to previous psychological/pharmacological interventions compared with a waiting-list condition .
Prolonged pharmacotherapy may produce significant improvement in patients with unsatisfactory response to short-term pharmacotherapy  , while switching to pharmacotherapy may help non-responders to CBT .
Purpose of Review Purpose of Review Management of treatment-resistant ( TR ) panic disorder ( PD ) is an unresolved issue .
In this paper , we provide a brief summary of previous findings , an up date d ( 2015–2017 ) systematic review of pharmacological/non-pharmacological studies , and our personal perspective on this topic .
Treating Treatment-Resistant Patients with Panic Disorder and Agoraphobia Using Psychotherapy: A Randomized Controlled Switching Trial
Background : Nonresponsiveness to therapy is generally acknowledged , but only a few studies have tested switching to psychotherapy . This study is one of the first to examine the malleability of treatment-resistant patients using acceptance and commitment therapy ( ACT ) .  Methods : This was a r and omized controlled trial that included 43 patients diagnosed with primary panic disorder and /or agoraphobia ( PD/A ) with prior unsuccessful state-of-the-art treatment ( mean number of previous sessions = 42.2 ) . Patients were treated with an ACT manual administered by novice therapists and followed up for 6 months . They were r and omized to immediate treatment ( n = 33 ) or a 4-week waiting list ( n = 10 ) with delayed treatment ( n = 8) . Treatment consisted of eight sessions , implemented twice weekly over 4 weeks . Primary outcomes were measured with the Panic and Agoraphobia Scale ( PAS ) , the Clinical Global Impression ( CGI ) , and the Mobility Inventory ( MI ) . Results : At post-treatment , patients who received ACT reported significantly more improvements on the PAS and CGI ( d = 0.72 and 0.89 , respectively ) than those who were on the waiting list , while improvement on the MI ( d = 0.50 ) was nearly significant . Secondary outcomes were consistent with ACT theory . Follow-up assessment s indicated a stable and continued improvement after treatment . The dropout rate was low ( 9 % ) . Conclusions : Despite a clinical ly challenging sample and brief treatment administered by novice therapists , patients who received ACT reported significantly greater changes in functioning and symptomatology than those on the waiting list , with medium-to-large effect sizes that were maintained for at least 6 months . These proof-of-principle data suggest that ACT is a viable treatment option for treatment-resistant PD/A patients . Further work on switching to psychotherapy for nonresponders is clearly needed
Quetiapine extended-release augmentation has not been found to be beneficial , in comparison to placebo , in non-responders to previously recommended pharmacotherapy .
In non-responders to cognitive behavioral therapy ( CBT ) , switching to paroxetine/citalopram has been found to be more effective than continuing CBT .
Acceptance and commitment therapy ( ACT ) has shown some improvement in patients ’ resistance to previous psychological/pharmacological interventions compared with a waiting-list condition .
Prolonged pharmacotherapy may produce significant improvement in patients with unsatisfactory response to short-term pharmacotherapy  , while switching to pharmacotherapy may help non-responders to CBT .
Purpose of Review Purpose of Review Management of treatment-resistant ( TR ) panic disorder ( PD ) is an unresolved issue .
In this paper , we provide a brief summary of previous findings , an up date d ( 2015–2017 ) systematic review of pharmacological/non-pharmacological studies , and our personal perspective on this topic .