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Objective: Concurrent use of benzodiazepines and psychotherapy for panic disorder is a prevalent but highly controversial practice. Although there are many rationales for that approach, critics contend that benzodiazepines foster drug abuse and dependence and undermine psychosocial treatments in various ways. The authors examine that controversy in the light of recent empirical findings and offer some tentative conclusions and recommendations., Method: Data from studies combining benzodiazepines and the leading psychosocial treatment for panic disorder, exposure-based cognitive behavior therapy, are reviewed, and their application to clinical practice is discussed., Results: The strongest support for combined treatment is for the addition of cognitive behavior therapy to pharmacotherapy for patients with agoraphobia and for those whose benzodiazepine treatment is being discontinued. The greatest problem with combined treatment is relapse after drug discontinuance., Conclusions: Combined treatment may be advantageous for some patients, but it must be carefully designed to avoid potential problems. Suggestions for that are given.

Objective: In a previous paper the authors reported survival data for 20 panic disorder patients whose therapeutic doses of alprazolam were tapered by one of two methods: slow, flexible drug taper with supportive medical management or the same taper procedure carried out concurrently with cognitive behavior therapy. This report is an analysis of predictors of drug discontinuation success in that study. In addition, between-group comparisons of clinical measures at follow-up are presented., Method: The subjects in the previous study (10 in each group) were assessed blindly at baseline, 2 weeks after completion of drug taper, and at 3- and 6-month follow-up. Potential predictors of drug discontinuation success were tested by using logistic regression. Between-group differences in symptom severity at 3-month follow-up were examined by using analyses of covariance., Results: Thirteen subjects (nine receiving alprazolam plus cognitive behavior therapy and four receiving alprazolam only) completed the drug taper on schedule and were still medication free at follow-up. A single variable--baseline-to-posttaper change in anxiety sensitivity--predicted drug status at follow-up in 85% of the cases. At follow-up, subjects in the combined-treatment group were significantly more improved on measures of anxiety, depression, catastrophic thinking related to anxiety, perception of emotional control, and disability than subjects in the drug-only group., Conclusions: Across groups, reduction in the fear of anxiety symptoms was the best predictor of patients' ability to achieve and maintain drug abstinence. Some implications of that finding for the pharmacotherapy of panic disorder are discussed.

Objective: The authors investigated whether cognitive behavioral treatment could facilitate discontinuation of alprazolam therapy and maintenance of drug abstinence among panic disorder patients treated with alprazolam doses sufficient to suppress spontaneous panic attacks., Method: Twenty-one outpatients who met DSM-III-R criteria for panic disorder with mild to severe agoraphobia were made panic-free with alprazolam (mean dose = 2.2 mg/day) and were then randomly assigned to receive either supportive drug maintenance and slow, flexible drug taper or an identical medication treatment plus 12 weeks of concurrent, individual cognitive behavioral treatment. Taper in the combined treatment group was sequenced to conclude before cognitive behavioral treatment ended., Results: Twenty subjects completed the study. There was no significant difference between groups in the rate of alprazolam discontinuation (80% and 90%, respectively, in the alprazolam-only group and the combined treatment group). However, during the 6-month follow-up period, half of the subjects who discontinued alprazolam without cognitive behavior therapy, but none of those who were given cognitive behavior therapy, relapsed and resumed alprazolam treatment., Conclusions: Cognitive behavioral treatment administered in parallel with alprazolam maintenance and taper was effective in preventing relapse after drug discontinuation. The results warrant further research on the thoughtful integration of these two therapeutic modalities.