گسترش محدوده کتاب درمانی برای اختلال پانیک: کارآزمایی تصادفی خودیاری بدون حمایت اما با یک ضرب الاجل روشن

Cognitive behavioral bibliotherapy for panic disorder has been found to be less effective without therapist support. In this study, participants were randomized to either unassisted bibliotherapy (n = 20) with a scheduled follow-up telephone interview or to a waiting list control group (n = 19). Following a structured psychiatric interview, participants in the treatment group were sent a self-help book consisting of 10 chapters based on cognitive behavioral strategies for the treatment of panic disorder. No therapist contact of any kind was provided during the treatment phase, which lasted for 10 weeks. Results showed that the treatment group had, in comparison to the control group, improved on all outcome measures at posttreatment and at 3-month follow-up. The tentative conclusion drawn from these results is that pure bibliotherapy with a clear deadline can be effective for people suffering from panic disorder with or without agoraphobia.

Self-help treatment has developed over the years and is considered a complement or alternative to traditional therapy when such is not available due to geographical distances or a shortage of trained CBT therapists (Newman, Erickson, Preworski, & Dzus, 2003). Self-help treatments may also be more cost-effective than traditional therapies and therefore increase the accessibility and affordability of evidence-based psychological treatments (Cuijpers and Schuurmans, 2007 and den Boer et al., 2004). Self-help treatments can take various forms with varying levels of therapist contact (Carlbring & Andersson, 2006). The therapist contact, if there is any, is usually administered via telephone or, more recently, via e-mail. Common forms of self-help include books (bibliotherapy), audiotapes, computer-assisted programs, Internet, videotapes, or some combination (Hirai and Clum, 2006 and Marks et al., 2007). A meta-analytic study of self-help interventions for anxiety problems found treatment effects for self-help interventions in the moderate range, with an average controlled between-group effect size of d = 0.56 at posttreatment and d = 0.53 at follow-up for panic disorder ( Hirai & Clum, 2006). When compared to therapist-directed interventions for panic, self-help interventions demonstrated comparable efficacy. In this meta-analysis, separate effects of guided versus unguided self-help for panic disorder were not presented, but the overall findings across anxiety disorders did not suggest that guided self-help was superior, with average between-group effect sizes of d = 0.57 for unguided self-help and d = 0.68 for therapist-guided self-help. Bibliotherapy refers to the use of written instructional materials, often in the form of a self-help book or manual, to guide the patient through the course of treatment (Taylor, 2000). Justified criticism against bibliotherapy is that it may not be sufficient for individuals with severe panic disorder or with comorbid psychopathology and that it is unsuitable for individuals with limited reading skills (Taylor, 2000). Less obvious is the potential lack of motivation to follow a self-directed program, as it probably relates to amount of support and the quality of the program. As bibliotherapy per definition is structured and manualized, there are also fewer possibilities to handle issues unrelated to the treatment (e.g., sudden loss of employment), which are more readily managed in face-to-face therapy. Adherence and the risk of dropout is another issue, and for this reason, researchers have encouraged proper tests of self-help materials and examination of the role of therapist input (Rosen, 1987 and Rosen, 1993). Previous studies have clearly indicated that bibliotherapy for panic disorder can be an effective treatment when it is delivered with minimal therapist contact (Gould and Clum, 1995, Gould et al., 1993, Hecker et al., 1996, Hecker et al., 2004 and Lidren et al., 1994). In a review of published self-help books on panic disorder, Carlbring, Westling, and Andersson (2000) found moderate to large between-group effect sizes (d = 0.5-1.5), although all books they reviewed had not been evaluated in research. There are also more recent studies on Internet-delivered bibliotherapy with minor therapy assistance via e-mail, showing promising outcomes (e.g., Carlbring et al., 2001, Carlbring et al., 2005, Carlbring et al., 2006, Klein et al., 2006 and Richards et al., 2003). However, not all people have access to the Internet, and there are, to our knowledge, no studies indicating that Internet-delivered bibliotherapy should be preferred over traditional bibliotherapy. One crucial question is, Does bibliotherapy for panic disorder require therapist contact, and if so, how much (Palmqvist, Carlbring, & Andersson, 2007)? This question was addressed in a study by Febbraro, Clum, Roodman, and Wright (1999), who compared bibliotherapy alone (n = 17), bibliotherapy plus monitoring (n = 15), monitoring alone (n = 13), and wait-list control (n = 18) conditions. Monitoring consisted of self-observation and rating of panic symptoms. In this study, there was no contact with the researchers at pretreatment assessment as participants assessed themselves. It was not necessary for participants to meet criteria for panic disorder to be included in the study. All participants had approximately 1 hour of telephone or in-person contact during the posttreatment assessment, when a clinical interview was conducted. There were no significant differences between the groups at posttreatment, but some within-group effects. Febbraro et al. questioned the efficacy of bibliotherapy and self-monitoring interventions when practiced without contact with a clinician who conducts the assessments and monitors treatment compliance. In a later study, Febbraro (2005) contrasted three conditions: bibliotherapy alone (n = 9), bibliotherapy plus phone contact (n = 9), and phone contact alone (n = 12). In this trial, dropout rate from inclusion to completion was substantial, with 18 of 48 not completing the trial. In terms of clinically significant change, there were large differences between the three groups on a measure of full panic attacks (55.6%, 100%, and 33.3% for the three conditions, respectively). Overall, the study showed superior outcome for telephone-guided bibliotherapy when compared with unguided self-help and phone contact alone. A similar conclusion was reached in another study in which standard therapist contact (n = 37) was compared with minimal contact treatment (n = 32) and pure bibliotherapy (n = 35) ( Powers, Sharp, Swanson, & Simpson, 2000). These researchers found a much better outcome for the standard therapist contact group and the group with minimal therapist contact. For example, using a criterion of clinically significant change on the Hamilton Anxiety Scale, 83.3% improved in the standard therapist contact group, 67.7% in the minimal contact treatment group, but only 34.5% in the pure bibliotherapy group. In sum, there is evidence to suggest that using bibliotherapy as a self-help treatment can be as effective as face-to-face individual therapy for panic disorder, but only if therapist support is provided. However, studies may differ in the amount of therapist contact during (a) the assessment phase, (b) the self-help phase, and (c) the follow-up phase. The purpose of the present study was to investigate the effect of bibliotherapy for panic disorder in the absence of therapist contact during Phase 2. In other words, participants were screened and diagnosed (Phase 1), completed the self-help treatment without any assistance (Phase 2), but were given a clear early deadline when a follow-up interview was to be conducted (Phase 3). Although previous studies (e.g., Febbraro et al., 1999 and Febbraro, 2005) have included a deadline for the follow-up assessment, it has been presented late in the treatment process (e.g., 2 weeks after the completion of the treatment or close to the end), and not as an early deadline which more likely influences the uptake of the treatment. Although previous literature has found larger dropout rates when no support is given during the self-help phase, we hypothesized, based on our previous experiences with studies of Internet self-help (Andersson et al., 2008), that there would be few dropouts. We suspected that the treatment could prove effective compared to a waiting list control condition at posttreatment even if no support was provided during the treatment phase. In effect, we believed that the contact during the assessment phase and the prospect of being assessed again at a specific scheduled time (e.g., a deadline), in conjunction with the suffering of persons who experience panic attacks, would be enough to motivate the participant to complete the self-help treatment. Moreover, we included a 3-month follow-up to investigate if possible gains would be maintained.