DEPRESSION AND ANXIETY 26:251–258 (2009) Research Article EFFECT OF MEDICATION AND PSYCHOTHERAPY ON HEART RATE VARIABILITY IN PANIC DISORDER Amir Garakani, M.D., 1Ã Jose M. Martinez, M.A., 1 Cindy J. Aaronson, M.S.W. Ph.D., 1 Andrei Voustianiouk, Ph.D., 2 Horacio Kaufmann, M.D., 2 and Jack M. Gorman, M.D. 3 Background: Panic disorder (PD) patients have been shown to have reduced heart rate variability (HRV). Low HRV has been associated with elevated risk for cardiovascular disease. Our aim was to investigate the effects of treatment on heart rate (HR) in patients with PD through a hyperventilation challenge. Methods: We studied 54 participants, 43 with Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) PD and 11 controls. Subjects lay supine with their heads in a plastic canopy chamber, resting for 15 min and then breathing at a rate of 30 breaths per minute for 10 min. HRV was sampled for spectral analysis. Clinical and behavioral measures of anxiety were assessed. Treatment was chosen by patients: either 12 weeks of CBT alone or CBT with sertraline. Results: All patients showed significant decrease on clinical measures from baseline and 31 were treatment responders, 8 dropped out of the study before completion of the 12-week treatment phase and 4 were deemed nonresponders after 12 weeks of treatment. Although both treatments led to significant clinical improvement, only CBT alone demonstrated a significant reduction in HR and increase in HRV. Conclusions: Our study replicated the finding that increased HR and decreased HRV occur in PD patients. Given the evidence of cardiac risk related to HRV, CBTappears to have additional benefits beyond symptom reduction. The mechanisms of this difference between CBT and sertraline are unclear and require further study. Depression and Anxiety 26:251–258, 2009. r 2008Wiley-Liss, Inc. Key words: anxiety; cognitive behavioral therapy; SSRI; cardiac; life stress; breathing INTRODUCTION Panic disorder (PD), with a lifetime prevalence of 4.7%, continues to remain a significant health pro- blem. [1] Expert guidelines call for the use of either selective serotonin reuptake inhibitors (SSRIs) or cognitive behavioral therapy (CBT), as both have been reported to be effective in the treatment of PD. [2] A large-scale study found that combination treatment of CBT plus medication was as effective when compared to medication or CBT alone after acute treatment. [3] It has been reported, however, that only 11% of patients with PD receive an SSRI, [4] and not many more receive some form of CBT. [5] Published online 6 October 2008 in Wiley InterScience (www. interscience.wiley.com). DOI 10.1002/da.20533 Received for publication 23 May 2008; Revised 14 August 2008; Accepted 19 August 2008 Contract grant sponsor: NIMH; Contract grant number: RO1 071827-01A2; Contract grant sponsor: Mount Sinai School of Medicine, General Clinical Research Center; Contract grant number: MO1-RR-00071 Ã Correspondence to: Amir Garakani, M.D., Department of Psychiatry, Mount Sinai Hospital, One Gustave L. Levy Place, Box 1230, New York, NY 10029.. E-mail: amir.garakani@mssm.edu 1 Department of Psychiatry, Mount Sinai School of Medicine, New York, New York 2 Department of Neurology, New York University School of Medicine, New York, New York 3 Comprehensive NeuroScience, Inc., White Plains, New York r r 2008 Wiley-Liss, Inc.