Special Articles
JHofmann
Anxiety
Psychother
and
SG,Panic;
Pract
Spiegel
Res
Agoraphobia;
DA:
1999;
Panic
8(1):3–11
control
Cognitive-Behavioral
treatment and its Therapy
applications.
Panic Control Treatment and
Its Applications
Stefan G. Hofmann, Ph.D.
David A. Spiegel, M.D.
Panic Control Treatment (PCT) is a widely used,
empirically validated cognitive-behavioral treatment for
panic disorder. Initially developed for the treatment of
panic disorder with limited agoraphobic avoidance,
PCT more recently has been finding broader
applications. It has been used as an aid to
pharmacotherapy discontinuation in panic disorder; in
the treatment of panic attacks associated with other
disorders such as schizophrenia; and, in combination
with a situational exposure component, in the
treatment of patients with moderate to severe
agoraphobia. The authors critically review the evidence
for the clinical efficacy of PCT and recent work directed
at further enhancing the long-term efficacy and
cost-effectiveness of treatment.
(The Journal of Psychotherapy Practice and
Research 1999; 8:3–11)
S
ince panic disorder was formally recognized as a discrete entity in DSM-III, it has become one of the
most intensively studied anxiety disorders. By definition,
panic disorder causes significant distress or interference
with the individual’s life, exacting substantial personal
costs. In addition, the disorder imposes high direct and
indirect costs on the nation in medical resources used for
care, treatment, and rehabilitation and in reduced or lost
productivity.1
A growing body of evidence supports both the efficacy and effectiveness (clinical utility) of psychosocial
interventions for panic disorder. For example, a recent
meta-analysis of 43 controlled studies found that cognitive and cognitive-behavioral treatments, collectively,
had a higher mean treatment effect size and a lower attrition rate than pharmacological treatments.2 In addition, evidence is beginning to appear from naturalistic
studies that cognitive-behavioral therapy for panic disorder may be more cost-effective than pharmacotherapy,
even within the first treatment year.3
Yet despite the demonstrated efficacy and favorable
cost profile of cognitive-behavioral therapy for panic
disorder,4 most patients treated in clinical practice settings do not receive it.5–7 That situation is due in large
part to two problems: limited knowledge by physicians
and the general public about the nature and benefits of
Received June 22, 1998; revised August 27, 1998; accepted September
1, 1998. From the Department of Psychology, Boston University, and
the Center for Anxiety and Related Disorders at Boston University.
Address correspondence to Dr. Hofmann, Center for Anxiety and
Related Disorders at Boston University, 648 Beacon Street, 6th Floor,
Boston, MA 02215.
Copyright © 1999 American Psychiatric Press, Inc.
J Psychother Pract Res, 8:1, Winter 1999
3
Panic Control Treatment and Its Applications
cognitive-behavioral therapies, and the lack of an effective means for disseminating new treatments, resulting
in reduced treatment availability.8 The present article
provides an overview of one of the most well-studied
forms of cognitive-behavioral therapy for panic disorder,
Panic Control Treatment (PCT),9,10 and reviews the evidence for its efficacy. Also reviewed is some recent work
directed at extending the application of PCT to new
populations and enhancing its long-term efficacy and
cost-effectiveness.
DESCRIPTION OF TREATMENT
The general goal of PCT is to foster within patients the
ability to identify and correct maladaptive thoughts and
behaviors that initiate, sustain, or exacerbate anxiety and
panic attacks. In service of that goal, the treatment combines education, cognitive interventions, relaxation and
controlled breathing procedures, and exposure techniques. It is usually delivered in 11 or 12 weekly sessions,
either individually to patients or in a small group format.
The PCT protocol includes a variety of information
and skill-building components.10 In early sessions, patients are taught about the nature and function of fear
and its nervous system substrates. The fear response is
presented as a normal and generally protective state that
enhances our ability to survive and compete in life. Panic
attacks are conceptualized as inappropriate fear reactions
arising from spurious but otherwise normal activation of
the body’s fight-or-flight nervous system. Like other fear
reactions, they are portrayed as alarms that stimulate us
to take immediate defensive action. Because we normally
associate fight-or-flight responses with the presence of
danger, panic attacks typically motivate a frantic search
for the source of threat. When none is found, affected
individuals may look inward and interpret the symptoms
as signs that something is seriously wrong with them (e.g.,
“I’m dying of a heart attack,” “I’m losing my mind”).
In addition to normalizing and demystifying panic
attacks, the educational component of PCT provides patients with a model of anxiety that emphasizes the interaction between the mind and body and provides a rationale and framework for the skills to be taught during
treatment. A three-component model is used, in which
the dimensions of anxiety are grouped into physical, cognitive, and behavioral categories. The physical component includes bodily changes (e.g., neurological, hormonal, cardiovascular) and their associated somatic
sensations (e.g., shortness of breath, palpitations, light4
headedness). The cognitive component consists of the
rational and irrational thoughts, images, and impulses
that accompany anxiety or fear (e.g., thoughts of dying,
images of losing control, impulses to run). The behavioral
component contains the things people do when they are
anxious or afraid (e.g., pacing, leaving or avoiding a situation, carrying a safety object). Most important, these
three components are described as interacting with each
other, often with the result that anxiety is heightened.
Having laid this foundation, PCT then teaches patients skills for controlling each of the three components
of anxiety. To manage some of the physical aspects of
anxiety, such as sensations due to hyperventilation (e.g.,
lightheadedness and tingling sensations) or muscle tension (e.g., trembling and dyspnea), patients are taught
slow, diaphragmatic breathing or progressive muscle relaxation. To reduce anxiety-exacerbating thoughts and
images, patients are taught to critically examine, on the
basis of past experience and logical reasoning, their estimations of the likelihood that a feared event will occur,
the probable consequences if it should occur, and their
ability to cope with it. In addition, they are helped to
design and conduct behavioral experiments to test their
predictions.
To change maladaptive anxiety and fear behaviors,
patients are taught to engage in graded therapeutic exposure to cues they associate with panic attacks. The exposure component of standard PCT (called interoceptive
exposure) focuses primarily on internal cuesspecifically, frightening bodily sensations. During exposure, patients deliberately provoke physical sensations like
smothering, dizziness, or tachycardia by means of exercises such as breathing through a straw, spinning, or vigorous exercise. These exercises are done initially during
treatment sessions, with therapist modeling, and subsequently by patients at home. As patients become less
afraid of the sensations, more naturalistic activities are
assigned, such as drinking caffeinated beverages, having
sexual intercourse, or watching scary movies.
Exposure to external cues (traditional situational exposure) is not systematically addressed in standard PCT,
although as patients begin to apply the techniques they
have learned, they are encouraged to gradually reenter
situations they have been avoiding. The developers did
not include a more systematic situational exposure component in PCT because they wanted to focus initially on
the experience of panic attacks, rather than on avoidance
behavior, since this had not been done previously. An
optional agoraphobia supplement was developed later,
J Psychother Pract Res, 8:1, Winter 1999
Hofmann and Spiegel
for use with patients who have significant situational
avoidance.11
EFFICACY OF PCT
The practice guidelines published by the American Psychiatric Association concluded that pharmacotherapy
and cognitive-behavioral therapy are the first-line treatments for panic disorder.4 Moreover, PCT is classified
as a “well-established” intervention for panic disorder by
the Task Force on Promotion and Dissemination of Psychological Procedures of the American Psychological Association, Division of Clinical Psychology.12 For a treatment to be classified as “well-established,” the following
criteria had to be met: first, the efficacy of the intervention had to be demonstrated in at least two clinical trials
conducted by different investigators or in a large series
of well-designed single case studies; second, treatment
had to be delivered in accordance with a manual; third,
the characteristics of the subject sample had to be clearly
delineated; and fourth, the treatment had to be either as
efficacious as an already established treatment or superior to a placebo or other treatment.
The efficacy of PCT for the treatment of panic disorder with limited agoraphobia has been demonstrated
in numerous clinical trials. In an early study, PCT was
found to be superior to a waitlist condition and a relaxation condition.9 In an intent-to-treat analysis, approximately 80% of patients assigned to PCT were panic free
at posttreatment, compared with 40% of patients assigned to applied relaxation and 30% of waitlist patients.
Similar results were reported by Klosko and colleagues,13,14 who demonstrated that PCT was superior to
either the waitlist or drug placebo as well as alprazolam
in the treatment for panic disorder. The authors found
that 87% of patients in the PCT group were panic free
by the end of treatment, compared with 50% in the alprazolam condition, 36% in the placebo group, and 33%
in the waitlist group. A 2-year follow-up of PCT completers found that gains were maintained.15,16 Subsequently, Telch et al.17 found that a treatment similar to
PCT was effective when administered in an 8-week
group therapy format. At posttreatment, 85% of PCTtreated patients were panic free, versus 30% in a waitlist
condition. When a more stringent outcome criterion was
used, including measures of panic frequency, general
anxiety, and agoraphobic avoidance, 63% of PCTtreated patients and only 9% of waitlist subjects were
classified as improved.
J Psychother Pract Res, 8:1, Winter 1999
Most recently, M. Katherine Shear at the University
of Pittsburgh, Jack M. Gorman at Columbia University,
Scott Woods at Yale University, and David H. Barlow at
our center at Boston University compared PCT to imipramine, a pill placebo, and combinations of PCT with
imipramine or a pill placebo. The results from that study
suggest that PCT was comparable to imipramine on
nearly all measures during treatment, with better maintenance of gains after treatment discontinuation.18 Furthermore, the results showed that more than one-third
of all eligible patients refused participation in the study
because they were unwilling to take imipramine.19 In
contrast, only 1 out of 308 potential participants refused
the study because of the possibility of receiving psychotherapy.19
ACTIVE INGREDIENTS OF PCT
PCT consists of a combination of cognitive and behavioral treatment components, including education, cognitive restructuring, breathing retraining or relaxation, and
interoceptive exposure. It is not known at present
whether all of those components contribute uniquely to
the efficacy of the treatment. Good outcomes have been
reported for related treatments that differ in their emphasis on the components of PCT.20–22
Direct comparisons of the various components of
PCT are lacking, but some case studies23 and the aforementioned meta-analysis of panic disorder treatment
studies2 provide some indirect data relating to active ingredients. Among the psychosocial treatments studied,
therapies incorporating both cognitive restructuring and
interoceptive exposure had the highest overall mean effect size (ES = 0.88, 7 studies). Only three studies evaluated cognitive interventions alone as treatment, and the
results were varied, with effect sizes ranging from –0.95
to 1.10 (mean ES = 0.18). However, other studies suggest
that a combination of interoceptive exposure and cognitive restructuring is not significantly more effective than
either treatment alone.21,24 Until further information is
available, the relative importance of the elements of PCT
remains unclear.
LIMITATIONS OF
EXISTING TREATMENT STUDIES
Although no other type of psychosocial intervention has
been shown to be more effective for panic disorder than
PCT, several limitations of existing studies necessitate
5
Panic Control Treatment and Its Applications
care in interpreting published efficacy data.
First, as noted earlier, most studies of PCT have enrolled panic disorder patients with little or no agoraphobia. The efficacy of PCT for patients with greater degrees
of agoraphobia is largely unknown, but it is probably
lower than for less avoidant patients.
Second, even in samples with little or no agoraphobia, panic-free rates generally are higher than response
rates based on more global measures of improvement.
For example, in the Telch et al. study,17 although 85% of
patients were panic free at posttreatment, only 63% met
a more stringent response criterion including measures
of general anxiety and agoraphobic avoidance. Similarly, a study of subjects treated with variations of PCT
at our center found that 68% were panic free 3 months
posttreatment, but only 40% met broader criteria for high
endstate functioning.25
Third, the efficacy data from nearly all treatment
studies to date have been based on cross-sectional assessments. Although such assessments show good maintenance of gains on average following cognitive-behavioral
therapy, longitudinal data reveal that many patients have
a fluctuating posttreatment course, with periods of symptom recrudescence. For example, in the Brown and Barlow study,25 40% of subjects met criteria for high endstate
functioning at 3 months posttreatment and 57% at 24
months posttreatment, but only 27% met the criteria at
both 3 and 24 months. These findings indicate that there
still is room for improvement in PCT and similar cognitive-behavioral interventions for panic disorder.
Fourth, it is uncertain how PCT compares with some
of the more recently investigated pharmacotherapies,
such as selective serotonin reuptake inhibitors. Most of
the comparative treatment outcome studies have used
“older” medications, such as imipramine, thus limiting
the generalizability of the results.
MODIFICATIONS TO PCT
In recent years, clinicians and researchers have begun to
experiment with variations of PCT. Some modifications,
such as combining PCT with situational exposure, including significant others in treatment, or adding a relapse prevention component, are intended to extend the
applicability of the treatment or improve its long-term
outcome. Others, such as administering PCT in abbreviated or self-help formats, are intended to improve the
cost-effectiveness of treatment or make it more accessible
to patients.
6
Combining PCT With
Situational Exposure
When PCT initially was developed, the necessary
and sufficient criterion for the diagnosis of panic disorder
was the presence of a minimum number of panic attacks
within a specified period of time. Psychosocial treatments
at the time (e.g., relaxation therapies and situational exposure) tended to focus on general arousal and tension
or situational avoidance. PCT differed in that it specifically targeted patients’ experiences of panic attacks and
anticipatory anxiety. Consistent with that focus, trials of
PCT were conducted among patients for whom panic
attacks were the principal problemthat is, patients having limited agoraphobic avoidance. As discussed earlier,
the treatment was very effective in eliminating attacks in
that group. However, other measures indicated that despite being panic free, some patients continued to evidence functional impairment, largely owing to residual
agoraphobic avoidance. Presumably that would have
been even more the case if patients having more marked
agoraphobia were included.
To address that problem, clinicians often combine
PCT with in vivo situational exposure assignments,11
which require patients to systematically enter anxietyprovoking situations and stay there until their anxiety
subsides. Although such combinations have not been
well studied, clinical experience and what empirical evidence there is suggest that this approach is effective. For
example, several investigators have reported good results with combinations of exposure therapy and cognitive interventions like those used in PCT.26–32 Recently,
we have been experimenting with the combination of
PCT and brief (2 or 3 days) massed exposure for treating
panic disorder patients with moderate to severe agoraphobia. Preliminary results are encouraging.33
Including Significant Others
in Treatment
As a result of early clinical observations that the
interpersonal systems of individuals with panic disorder
and agoraphobia may be disrupted by treatment interventions,34 some researchers have tried including significant others in treatment. Although the original observations have not been supported consistently,35 data do
suggest that inclusion of family members in treatment
may enhance the efficacy of PCT and related psychosocial treatments, particularly exposure therapy. For
J Psychother Pract Res, 8:1, Winter 1999
Hofmann and Spiegel
example, Barlow and colleagues36,37 found that including
significant others in exposure therapy significantly improved the outcome at posttreatment and at both 12- and
24-month follow-ups. Additionally, the inclusion of
spouses in treatment for panic disorder and agoraphobia
(including PCT) has been associated with improvement
in marital satisfaction.37–40 Advantages also have been
found for the involvement of mothers in the treatment
of adolescents with agoraphobia. 41
Adding Relapse Prevention Strategies
To further improve the long-term outcome of PCT,
we currently are experimenting with the inclusion of a
relapse prevention component, the goal of which is to
teach patients to anticipate and respond constructively
to setbacks that might occur after treatment has ended.
Interventions like these have been shown to be helpful
in various psychiatric disorders.42–44 Other strategies also
may be useful. For example, in a recent case at our center,
the use of psychophysiological recording was helpful in
treating relapse after PCT.45
Abbreviated and Self-Help Formats
A burgeoning area of interest has been the use of
abbreviated or self-help treatments for anxiety disorders,
and evidence is accumulating that such approaches are
viable for panic disorder. For example, Craske et al.46
found a 4-session PCT protocol more effective than an
equivalent amount of nondirective supportive therapy.
Furthermore, Côté et al. found that 10 hours of in-person
and telephone therapy was as effective as 20 hours of
standard face-to-face cognitive-behavioral therapy administered over the same time period.47 The two groups
combined (total N = 21) had a 90% panic-free rate at
follow-up. However, the study is limited by the small
number of subjects, which might have contributed to the
lack of significant findings.
Promising results also have been reported with selfhelp treatments involving minimal therapist contact (e.g.,
3 hours).48–50 Hecker et al.,49 for example, found that
self-directed PCT was not significantly different from
therapist-directed PCT. The authors provided panic disorder patients (N = 16) with the first edition of the PCT
workbook Mastery of Your Anxiety and Panic51 and randomly assigned participants to either a self-directed
group or a therapist-directed group. Individuals in the
therapist-directed group met with the therapist weekly
J Psychother Pract Res, 8:1, Winter 1999
for 12 weeks to work through the materials. Participants
in the self-directed group met with the therapist only
three times over 12 weeks to assign readings and answer
questions. Statistical tests revealed no difference between
the two groups. Participants in both groups improved
with treatment and maintained their gains at 6-month
follow-up. However, the lack of significant findings might
have been a result of the weak statistical power due to
the small number of subjects. Unfortunately, the authors
did not report the necessary information to calculate effect sizes.
On the other hand, there is also some evidence to
suggest that individuals having severe levels of interference and symptomatology may require more therapist
involvement. For example, in a study of panic disorder
patients with severe agoraphobia, therapist-administered
treatment was substantially more effective than a selfhelp manual.52
Further enhancement of the cost-effectiveness and
dissemination of PCT may be possible through the incorporation of new technologies into treatment. As early
as 1987, Ghosh and Marks53 demonstrated that exposure
therapy administered by means of a computer program
was as effective as therapist-administered exposure for
the treatment of agoraphobia. Recently, Newman et al.54
used a palmtop computer to administer a portion of the
PCT. Preliminary data suggest that this method can lead
to a significant reduction in the need for therapist contact.
For a review of the current status of computer-aided treatments for mental health problems, see Marks et al.55
Overall, then, in cases that do not involve severe
disability, there are effective alternatives to standard outpatient treatment by a therapist. Moreover, many empirically validated treatments have been published in
manualized form, so that individuals can follow them
either on their own or in conjunction with a therapist.10
Increased focus on services research will allow practitioners to determine the efficacy of this treatment format.
USE OF PCT IN SPECIAL POPULATIONS
Most studies of PCT have involved patients with a principal diagnosis of panic disorder (with limited agoraphobia) who were either unmedicated or on a stable dose of
medication. However, researchers have begun to investigate its efficacy in other populations. Two examples are
panic disorder patients being discontinued from benzodiazepine therapy and patients with schizophrenia and
panic attacks.
7
Panic Control Treatment and Its Applications
Patients Being Discontinued From
Benzodiazepine Therapy
The efficacy of benzodiazepine medications in the
treatment of panic disorder has been well established,56,57 and two of these medicationsalprazolam
and clonazepamare approved by the Food and Drug
Administration for the treatment of panic disorder. Unfortunately, a drawback of these treatments is that a substantial proportion of patients relapse when drug discontinuation is attempted.58,59 Recently, several small
studies have found that the administration of PCT concurrently with drug taper and discontinuation markedly
improved the ability of panic disorder patients to stop
and remain abstinent from benzodiazepine use.
For example, Spiegel et al.60 assigned patients
treated with alprazolam to either supportive medical
management (SMM) with slow, flexible drug taper or
the same taper procedure done concurrently with PCT.
The taper procedure was highly effective in that 80% of
subjects in the SMM group and 90% in the PCT group
were able to stop alprazolam use for at least 2 weeks.
However, by 6-month follow-up, half of the patients in
the SMM group had relapsed, versus none in the PCT
group. In a similar study, Otto et al.61 discontinued panic
disorder patients from alprazolam or clonazepam either
with or without concurrent PCT, using a somewhat
faster, fixed taper procedure. Seventy-six percent of the
patients who received PCT, versus 25% of those who did
not, were able to discontinue drug use, and at 3-month
follow-up, 77% of those in the PCT group who had discontinued the drug were still benzodiazepine free. We
currently are participating in a larger, two-site study to
confirm and extend those findings.
PCT as a Treatment for Panic Attacks in
Patients With Schizophrenia
Patients with schizophrenia often report recurrent
episodes of panic attacks.62,63 Most treatment studies of
panic disorder and panic attacks in patients with schizophrenia have used benzodiazepines64 or imipramine65
as an adjunct to antipsychotic medication. In addition to
the usual side effect and risk profile of benzodiazepines
(sedation, cognitive impairment, and abuse potential),
there is also some evidence of increased risk of behavioral and social disinhibition in schizophrenic patients
taking some anti-anxiety medications.
For panic attacks associated with schizophrenia, a
8
recent preliminary study suggests that PCT may be an
effective alternative to pharmacotherapy.66 In that study,
11 consecutively admitted patients who met DSM-III-R
criteria for schizophrenia and panic disorder participated
in a 16-week open trial of group cognitive-behavioral
therapy for panic disorder. Eight patients completed the
treatment, with the majority of those showing significant
reductions in both the frequency of panic attacks and
functional interference due to panic attacks. Encouraged
by those results, our group is currently conducting a controlled trial that is funded by the National Alliance for
Research on Schizophrenia and Depression to evaluate
the efficacy of PCT as a treatment to reduce panic attacks
in patients with schizophrenia.
Combination of PCT With
Pharmacotherapy
In their introduction to the report of the 1992 Consensus Development Conference on the Treatment of
Panic Disorder, Wolfe and Maser67 noted that the modal
clinical treatment for panic disorder at that time was a
combination of medication and psychosocial therapy.
More recently, Uhlenhuth68 reported that the consensus
among world experts on pharmacotherapy for panic disorder still highly favors a combined treatment approach.
These findings reflect the widely held belief that combined treatment regimens are superior to treatments administered alone, but there is very little empirical evidence
to support that impression.69 Considering the added cost
of combined therapy, it would seem important to demonstrate a sufficient benefit to warrant the expense.
A recent review of published studies combining benzodiazepines and cognitive-behavioral therapy for panic
disorder found little evidence that the combination was
superior to cognitive-behavioral therapy alone for most
patients.64 In fact, some studies have found poorer longterm outcomes for PCT when it has been administered
in combination with benzodiazepines.25,60 Those findings are consistent with results from animal laboratories
indicating that benzodiazepines may interfere with the
types of learning that are most important for psychosocial
treatment interventions.35,70 This potentially detrimental
effect of benzodiazepines on the outcome of PCT appears to be minimized if the drugs are discontinued prior
to the conclusion of PCT. Therefore, if benzodiazepines
are to be prescribed in conjunction with PCT (e.g., when
urgent relief of impairment due to panic symptoms is
needed), it should be done as a temporary measure with
J Psychother Pract Res, 8:1, Winter 1999
Hofmann and Spiegel
the understanding that the medication will be tapered
during the psychosocial treatment.
The situation is less clear with regard to the combination of antidepressant medications and cognitive-behavioral therapy. Studies have fairly consistently found
a benefit to combining an antidepressant with in vivo situational exposure therapy for patients with panic disorder and agoraphobia.26,71–73 However, there is little information regarding the combination of antidepressants
with more cognitively focused therapies for patients with
little or no agoraphobia. In the multicenter comparative
treatment study of panic disorder referred to earlier,18
the combination of PCT plus imipramine was compared
to PCT, imipramine, and a pill placebo, each administered alone, and to the combination of PCT and a pill
placebo. Preliminary reports indicate that the combined
treatment may be modestly better than either PCT or
imipramine alone on some measures (although not overall response) during both acute and maintenance treatment but loses its advantage over PCT when the medication is discontinued.18 It would appear, on the basis of
these data, that the routine administration of an antidepressant with PCT is not warranted; however, whether
there are some patients for whom such an approach
would be indicated is presently unknown.
SUMMARY AND CONCLUSION
Panic Control Treatment is a brief, structured, cognitivebehavioral therapy developed initially for the treatment
of panic disorder with limited agoraphobia. The efficacy
of PCT in its intended population has been well established, and when PCT is combined with a situational
exposure module, its applicability may be extended to
more agoraphobic patients. Follow-up assessments out
to at least 2 years posttreatment show that patients as a
group maintain their improvement, although individuals
may experience some symptom fluctuation. The inclusion of a relapse prevention component may be helpful
for those cases. In addition, there is some evidence that
including a significant other in treatment may improve
compliance with homework assignments and reduce interpersonal conflict associated with panic disorder.
Among its more novel applications, PCT has shown
promise in helping panic disorder patients to discontinue
high-potency benzodiazepines and as an alternative to
pharmacotherapy for treating panic attacks in patients
with schizophrenia.
Given the cost-effectiveness and clinical value of
PCT and related therapies for panic disorder, it is imperative that efforts be made to make these treatments
more widely accessible to patients. National probability
samples indicate that only three out of four individuals
with panic disorder seek treatment for their condition.74
Worse still, surveys consistently have shown that only a
small number of those who do seek care receive empirically supported psychosocial treatments.5–7 As Barlow
and Hofmann8 have noted, this latter situation is due at
least in part to a lack of availability, especially in primary
care settings, of therapists who have been trained in these
interventions. A misguided belief that pharmacotherapy
is less expensive than PCT may also be a factor.
To facilitate its dissemination, PCT has been published in manual and workbook formats.10,11,75 In addition, there have been encouraging trials of self-help and
computer-assisted versions, which may be useful when
trained therapists are not available or to reduce the
amount of therapist time required for treatment.46 Further efforts in this direction are needed and currently are
under way.
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