The generalizability of cognitive behavior therapy for panic disorder.

The current study examined the generalizability of manual-driven cognitivebehavior therapy (CBT) for panic disorder to a clinical setting representing an ethnically diverse population. This treatment had previously been shown to be effective in a controlled clinical trial at a research clinic (Barlow, Craske, Cerny, & Klosko, 1989). In the present study, 30 patients with panic disorder received 12 sessions of CBT. Patients were evaluated at pre- and posttreatment with measures assessing the full spectrum of symptoms associated with panic disorder (panic attacks, agoraphobia, generalized anxiety, depression). Following treatment, there were significant and clinically meaningful reductions on all measures. In order to determine how well the efficacy of CBT generalizes to nonresearch clinical settings and to ethnically diverse urban populations, data in the present study were compared to those collected by Barlow and associates (1989). Patients in our clinical setting showed higher pretreatment levels of symptomatology than patients in Barlow and colleagues' (1989)research setting, but similar posttreatment symptom levels and response rates. Thus, this study provides evidence for the generalizability of CBT from clinical research centers to clinically representative settings. The efficacy of cognitive behavioral treatment (CBT) for panic disorder (PD, with and without agoraphobia) has been well established in controlled research trials at clinical research centers (cf. Barlow, 1994; Chambless & Gillis, 1994; Clark, 1994). Efficacy data from studies conducted at clinical research centers involved in the development of this treatment approach have been quite impressive, reporting panic-free rates of 85% to 94% (Barlow, Craske, Cerny, & Klosko, 1989; Beck, Sokol, Clark, Berchick, & Wright, 1992; Clark et al., 1994) with concomitant reductions in general anxiety, agoraphobia, and depression. For the most part, the CBT protocols employed in these studies were similar, and included a combination of the following treatment components: psychoeducation about the nature of panic and anxiety; cognitive restructuring to challenge inaccurate predictions and catastrophic interpretations of anxiety symptoms; breathing retraining and/or relaxation exercises to decrease somatic arousal; exposure to feared somatic sensations and situations to reduce phobic avoidance. The demonstration of treatment efficacy in controlled research environments is only the first step in treatment research (Agras & Berkowitz, 1980). Once a positive therapeutic effect has been conclusively demonstrated, generalizability becomes of paramount importance. The National Institute of Mental Health (National Institute of Mental Health, 1991) has recently stimulated Clinical Services Research, which specifically examines the efficacy of empirically supported treatments in nonresearch settings where most patients are usually treated. With regard to CBT for PD, it seems fair to conclude that CBT is an effective treatment for PD in clinical research settings. But data are not available on the efficacy of CBT for PD when delivered in nonresearch clinical settings to a diverse group of patients (this is not unique to CBT, and applies to other empirically supported treatments as well, e.g., pharmacological approaches). Without data, one must be cautious in generalizing the results from research settings to typical clinical settings because there are several factors which might reduce the efficacy of this treatment. First of all, demonstration studies usually use a highly selected patient sample with narrow inclusion and exclusion criteria. Research samples may not be representative of the full range of patients with PD (National Institute of Mental Health, 1991). For example, although most studies evaluating CBT for PD do not report the racial composition of their sample, one may assume that this is because there was little variation, and thus, patients from these research centers may not represent the ethnic diversity found in urban clinical settings. …