Simultaneous major depression and panic disorder: treatment with electroconvulsive therapy.

BACKGROUND: Major depression and panic disorder commonly occur together. Patients with simultaneous depression and panic disorder may have a higher lifetime rate of suicide attempts and an overall worse prognosis than patients with either depression or panic disorder alone. In addition, preliminary work suggests that some of these patients may not respond satisfactorily to antidepressants. In this report, we describe the clinical courses of eight consecutive patients with simultaneous major depression and panic disorder who were referred for ECT at our institution. METHOD: Eight consecutive patients who met DSM-III-R criteria for simultaneous major depression and panic disorder received ECT. All eight patients were evaluated by a structured clinical interview and the patients' major depression and panic disorder were evaluated with a 7-point Clinical Global Impressions severity rating scale. RESULTS: Before ECT was begun, each subject's panic disorder and depression were rated as at least markedly ill. After receiving ECT, all eight showed improvement in their depression. In addition, none of the eight patients reported having a panic attack from the time of their fourth ECT treatment until discharge. CONCLUSION: In this report, eight consecutive patients with simultaneous major depression and panic disorder improved with ECT. Further work is required which examines the potential utility of ECT in treating these patients.     

Electroconvulsive therapy for comorbid major depressive disorder and posttraumatic stress disorder

OBJECTIVE: Posttraumatic stress disorder (PTSD) and major depressive disorder frequently co-occur. Electroconvulsive therapy (ECT) is the most effective treatment for refractory major depressive disorder. We examined the effect of ECT in patients with co-occurring major depression and PTSD. METHOD: Using a retrospective chart review, we examined the outcome of the cases of 26 patients with major depression and co-occurring PTSD who received a course of ECT. The patients received either suprathreshold right unilateral, bilateral, or a combination of both. Using paired t test analysis, we compared the pretreatment and the posttreatment symptoms using the Montgomery-Asberg Depression Rating Scale and the PTSD Checklist. RESULTS: The patients receiving ECT had a significant reduction in the symptoms of major depression and some amelioration in PTSD symptoms. CONCLUSIONS: Electroconvulsive therapy may be an effective treatment for patients with refractory depression and co-occurring PTSD.     

A cognitive therapy conceptualization of panic disorder exacerbated by interferon treatment

This case conference presents a patient with von Willebrand disease, receiving year-long interferon treatment for hepatitis C. She was referred to C-L Psychiatry following a severe exacerbation of panic disorder. Our guest interviewer is Dr. Craig White, a Scottish cognitive therapist. The subsequent discussion outlines the treatment challenges of panic disorder that occurs when a patient is receiving interferon. A literature review evaluates psychological effects of interferon and biological mechanisms by which interferon may exacerbate anxiety and depression. A cognitive therapy conceptualization of interferon-induced exacerbation of panic disorder is proposed.     

Electroconvulsive therapy in a physically restrained man with comorbid major depression, severe agoraphobia with panic disorder, and histrionic personality disorder

A 36-year-old man with comorbid panic disorder with agoraphobia, major depression, and histrionic personality disorder since age 21 was resistant to combined drug and psychotherapy treatment. His conditions had progressively worsened with time, causing him to withdraw socially and to simultaneously require continuous physical restraint, which further worsened his functioning. He spent almost 3 consecutive years in restraint, until he consented to receive bilateral ECT treatment. He improved after 13 sessions in all areas (social and role functioning, and panic, depressive, and histrionic symptoms) and is well 3 months later with a lithium-atypical antipsychotic combination.     

Is electroconvulsive therapy effective for the depressed patient with comorbid borderline personality disorder?

Among the more common current indications for electroconvulsive therapy (ECT) is treatment-resistant depression. Treatment resistance is correlated with a number of factors, including the presence of comorbid personality disorders, such as borderline personality disorder (BPD). A detailed review of the literature was undertaken and very few reports or studies have dealt specifically with ECT in borderline patients. Thirteen original reports on ECT outcome in personality disordered patients were identified. Depressed patients with a personality disorder, particularly BPD, may have a poorer outcome on some measures. However, the available data suggests that depression in these patients can be effectively treated with ECT. The depressed, borderline patient appears to have two distinct disorders, one which is responsive to ECT and the other which is not. Unfortunately, the literature is limited by lack of rigorous randomized treatment studies, lack of long-term follow-up, and other methodological weaknesses. Clinical guidelines are suggested.     

Cognitive therapy of panic disorder. A nonpharmacological alternative

A naturalistic study with no predetermined duration of treatment was undertaken in order to examine the effectiveness of cognitive therapy in the treatment of panic disorder. Seventeen patients diagnosed as having panic disorder according to the Structured Clinical Interview for DSM-III Personality Disorders received a mean of 18 individual cognitive therapy sessions. Patients with personality disorder or depression required a longer duration of treatment to become symptom-free. As measured by a self-report weekly panic log, the mean number of panic attacks was reduced significantly to zero at the end of treatment. There was a concomitant reduction in self-report measures of depression and anxiety. Further, there was a significant reduction on a measure of cognitive dysfunction during panic attacks. Treatment results were maintained at 12-month follow-up.     

Panic disorder. Spectrum of severity and somatization

One hundred++ ninety-five primary care patients were screened for panic disorder utilizing the National Institute of Mental Health Diagnostic Interview Schedule (DIS) as well as four additional questions that screened for core autonomic symptoms of panic disorder. A spectrum of severity of panic disorder was found. A subgroup of patients, labeled in the study as having simple panic, was found to have anxiety attacks associated with four or more autonomic symptoms, but they did not meet DSM-III recurrence criteria (three anxiety attacks within a 3-week period). Compared to primary care patients without panic attacks, patients with both simple panic and panic disorder exhibited multiple phobias, avoidance behavior, a high lifetime risk of major depression, and elevated scores on self-rating scales of anxiety and depression. The four autonomic screening questions that the authors added to the DIS interview increased the sensitivity of the DIS in identifying patients with panic disorder. Patients with panic disorder who selectively focus on their frightening autonomic symptoms may not be identified by screen questions that only focus on the cognitive awareness of anxiety.     

Respiratory variability in panic disorder.

Disordered breathing may play an important role in the pathophysiology of panic disorder. Several studies have now indicated that panic disorder patients have greater respiratory variability than normal controls. In this study, we examine baseline respiratory measures in four diagnostic groups to determine whether greater respiratory variability is specific to panic disorder and whether effective anti-panic treatment alters respiratory variability. Patients with panic disorder, major depression, or premenstrual dysphoric disorder, and normal control subjects underwent two respiratory exposures (5% and 7% CO(2) inhalation), while in a canopy system. Panic disorder patients returned after 12 weeks of either anti-panic medication or cognitive behavioral therapy, and were retested. Normal control subjects were also retested after a period of 12 weeks. Panic disorder patients had significantly greater respiratory variability at baseline than normal control subjects and patients with major depression. The premenstrual dysphoric patients also had greater variability than the normal control group. Panic disorder patients who panicked to 7% CO(2) inhalation had significantly greater baseline variability than panic disorder patients who did not panic. Anti-panic treatment did not significantly alter baseline respiratory variability. Our data suggest that increased respiratory variability may be an important trait feature for some panic disorder patients and may make them more vulnerable to CO(2)-induced panic.     

Specificity of panic response to CO(2) inhalation in panic disorder: a comparison with major depression and premenstrual dysphoric disorder

OBJECTIVE: The behavioral response to CO(2) inhalation has been used to differentiate panic disorder patients from normal subjects and other clinical populations. This study extended examination of the diagnostic specificity of CO(2)-induced anxiety by testing panic disorder patients and clinical populations with reported low and high sensitivity to CO(2) inhalation (patients with major depression and patients with premenstrual dysphoric disorder, respectively). METHOD: The behavioral responses to inhalation of 5% and 7% CO(2), administered by means of a respiratory canopy, were studied in 50 patients with panic disorder, 21 with major depression, and 10 with premenstrual dysphoric disorder and in 34 normal comparison subjects. Occurrence of panic attacks was judged with DSM-IV criteria by a blind rater. Subjects were rated on three behavioral scales at baseline and after each CO(2) inhalation. RESULTS: Panic disorder patients had a higher rate of CO(2)-induced panic attacks than depressed patients and normal subjects, whose panic rates were not distinguishable. The panic rate for patients with premenstrual dysphoric disorder was similar to that for panic disorder patients and higher than that for normal subjects. Subjects with CO(2)-induced panic attacks had similarly high ratings on the behavioral scales, regardless of diagnosis, including the small number of panicking normal subjects. Seven percent CO(2) was a more robust panicogen than 5%, and response to 7% CO(2 )better distinguished panic disorder patients from normal subjects than response to 5% CO(2). CONCLUSIONS: Patients with panic disorder and patients with premenstrual dysphoric disorder are highly susceptible to CO(2)-induced panic attacks, and depressed patients appear to be insensitive to CO(2) inhalation. The symptoms of CO(2)-induced panic attacks have a similar intensity regardless of the subject's diagnosis.     

The treatment of psychotic major depressive disorder with drugs and electroconvulsive therapy.

A retrospective chart review of 54 patients demonstrating depression with psychotic symptoms was accomplished with the use of Research Diagnostic Criteria (RDC) for diagnosis of psychotic major affective disorder. Patients received adequate trials of either tricyclic antidepressants alone, antipsychotics, the two in combination, or electroconvulsive therapy (ECT). Antidepressants alone were found to be ineffective or only partially effective in treating psychotic depression unless somatic or depressive declusions were the only psychotic symptoms. Antipsychotics alone were usually effective in providing at least a partial response, particularly with psychotic symptoms. Excellent responses of the depressive and psychotic elements were provided with ECT, ECT with antipsychotic medication, and the combination of antidepressant and antipsychotic medications. These latter treatments may be the most appropriate for depression with psychotic features.     

Electroconvulsive therapy: an effective therapy of medication-resistant bipolar disorder

OBJECTIVES: We report our experience with a medication-refractory patient with bipolar I disorder, who remained clinically stable under continuation electroconvulsive therapy (C-ECT). We found ECT to be effective in providing functionality for a patient when various medications had failed. METHODS AND RESULTS: A 53-year-old woman with a 31-year history of recurrent manic and depressive episodes poorly responsive to medications warranted an ECT trial. Remission was achieved after 12 treatments and C-ECT at weekly intervals was used as maintenance therapy. C-ECT was continued for 37 months and 85 treatments, and discontinued when anesthetic difficulties precluded further treatment. Three months after the last ECT, she was readmitted in a severe manic relapse. Restarting ECT caused rapid remission. There are no signs of cognitive deterioration during C-ECT. CONCLUSION: Long-term C-ECT is an effective and safe prophylactic treatment in individual treatment-resistant patients with bipolar disorder.     

Predicting efficacy of electroconvulsive therapy in major depressive disorder

The aim of this study was to investigate methods for predicting the efficacy of electroconvulsive therapy (ECT) in patients with major depressive disorder. Subjects comprised 24 inpatients with major depressive disorder diagnosed according to DSM-IV criteria who were resistant to antidepressant therapy or who, due to adverse reactions, could not undergo pharmacotherapy at adequate doses for sufficient durations. ECT was generally performed 12 times using a sinusoidal-wave device. Efficacy of ECT was evaluated using the 17-item Hamilton Rating Scale for Depression (HRSD). Multiple regression analysis was performed, using the final rate of improvement with ECT as the dependent variable, and improvement rate at completion of three ECT sessions and adequacy of pharmacotherapy before ECT as independent variables. Significant positive correlations were seen between final improvement rate with ECT and improvement rate at completion of three ECT sessions (partial correlation coefficient, 0.50, P<0.02), and significant negative correlations were seen between final improvement rate and adequacy of pharmacotherapy before ECT (partial correlation coefficient, -0.51, P<0.02). No significant differences were identified between responders and non-responders with respect to age, sex, duration of index episode, number of previous depressive episodes, whether depression was melancholia-type, whether depression was accompanied by psychotic features, total HRSD score immediately before ECT, and HRSD retardation or agitation scores. These results suggest that history of pharmacotherapy prior to ECT and improvement rate at completion of three ECT sessions may offer predictors for the final rate of improvement with ECT.     

Patterns of psychopathology and dysfunction in high-risk children of parents with panic disorder and major depression

OBJECTIVE: The purpose of the study was to evaluate 1) whether an underlying familial predisposition is shared by all anxiety disorders or whether specific risks are associated with specific disorders, and 2) whether panic disorder and major depression have a familial link. METHOD: The study compared four groups of children: 1) offspring of parents with panic disorder and comorbid major depression (N=179), 2) offspring of parents with panic disorder without comorbid major depression (N=29), 3) offspring of parents with major depression without comorbid panic disorder (N=59), and 4) offspring of parents with neither panic disorder nor major depression (N=113). RESULTS: Parental panic disorder, regardless of comorbidity with major depression, was associated with an increased risk for panic disorder and agoraphobia in offspring. Parental major depression, regardless of comorbidity with panic disorder, was associated with increased risks for social phobia, major depression, disruptive behavior disorders, and poorer social functioning in offspring. Both parental panic disorder and parental major depression, individually or comorbidly, were associated with increased risk for separation anxiety disorder and multiple (two or more) anxiety disorders in offspring. CONCLUSIONS: These findings confirm and extend previous results documenting significant associations between the presence of panic disorder and major depression in parents and patterns of psychopathology and dysfunction in their offspring.     

Comorbidity of ictal fear and panic disorder

Purpose. We sought to determine the prevalence of psychiatric conditions, particularly panic disorder, in epilepsy patients with ictal fear.Methods. A consecutive series of 12 patients with ictal fear underwent psychiatric evaluation, via either formal consultation with a psychiatrist or standardized interview using the Mini International Neuropsychiatric Interview; the latter was addended to create an instrument specifically for use in epilepsy patients (MINI-Epi).Results. Four of the twelve patients (33%) with ictal fear had a comorbid diagnosis of panic disorder. One of these developed panic attacks only after epilepsy surgery, and another worsened after surgery, while in the other two panic attacks were not related to any surgical procedure. Two patients had other anxiety disorders. Eight patients (67%) had current or past depression; this did not appear to be related to the presence of panic disorder.Conclusion. A specific comorbidity exists between focal epilepsy with ictal fear and panic disorder. Involvement of the amygdala in both temporal lobe epilepsy and panic disorder may underlie this. The predisposition to panic disorder in these patients may be exacerbated by anterior temporal lobectomy.     

Relationship between panic disorder and agoraphobia. A family study

A family study of patients with agoraphobia (n = 40), panic disorder (n = 40), and nonanxious controls (n = 20) showed that the morbidity risk for panic disorder was increased among the relatives of agoraphobics (8.3%) and the relatives of patients with panic disorder (17.3%). The morbidity risk for agoraphobia was also increased among the relatives of agoraphobics (11.6%) but not the relatives of panic disorder patients (1.9%). Male relatives of agoraphobics were shown to be at higher risk for alcohol disorders (30.8%). No greater risk for primary affective disorders was found among the relatives of agoraphobic or panic disorder patients or among the relatives of probands with secondary depression compared with relatives of probands without secondary depression. Probands and relatives with agoraphobia reported an earlier onset of illness, more persistent and disabling symptoms, more frequent complications, and a less favorable outcome than probands and relatives with panic disorder. The findings suggest that agoraphobia is a more severe variant of panic disorder. They also lend support to the separation between anxiety disorders and affective disorders.     

Clinical differentiation between major depression only, major depression with panic disorder and panic disorder only. Childhood, personality and personality disorder

A consecutive sample of 298 nonpsychotic psychiatric outpatients was classified according to DSM-III and divided into 4 diagnostic groups: pure major depression, mixed major depression/panic disorder, pure panic disorder and a remaining group of other disorders. The patients' report of childhood relationship to parents and siblings, family atmosphere, their own personality characteristics as children and precipitating events were compared in the various groups. In addition, differences in personality and frequencies of personality disorders were investigated by means of various instruments. Our results show that the type of relationship to parents in childhood differed in the various groups. The mother seems to be the most crucial person for the development of depression, the father for the development of panic disorder. Patients with major depression are more obsessive and patients with panic disorder more infantile and avoidant with less control of their personality. Finally, patients with mixed conditions are more in accordance with the DSM-III anxious personality disorder cluster.     

Seasonal panic disorder: a possible variant of seasonal affective disorder.

The present communication concerns a 30 year-old female patient with panic disorder in whom panic attacks appeared to be seasonally-related. Characteristically, attacks were more frequent and severe during the months of October to May with spontaneous remissions during the months of June to September. Since 70% of patients with seasonal affective disorder (SAD), a variant of affective illness characterized by recurrent winter depressions with remissions in summer, suffer from anxiety disorders, we propose that seasonal panic disorder may be a variant of SAD. Since SAD is associated with phase delay of circadian rhythms, some forms of panic disorder may be related to phase instability of circadian rhythms. Moreover, since administration of artificial bright light therapy is currently the most effective treatment for SAD, it is suggested that patients with panic disorder should be questioned as to whether their symptoms are seasonally related. If a positive association is established, these patients should be offered treatment with light therapy prior to or coincident with the institution of pharmacotherapy.     

Major depression and agoraphobia in patients with angiographically normal coronary arteries and panic disorder

Patients with panic disorder and/or agoraphobia appearing in psychiatric settings report rates for lifetime major depression between 24% and 91%. Between 40% and 90% of patients with panic disorder in psychiatric populations report concomitant agoraphobia. A recent study of panic disorder subjects appearing in an outpatient cardiology clinic confirmed the strong link between panic and depression but found only a weak association between panic disorder and agoraphobia. In order to test the reliability of these outpatient cardiology findings, the authors studied major depression and agoraphobia in patients with angiographically normal coronary arteries and panic disorder. Twelve of the 32 (37.5%) panic disorder subjects reported a lifetime history of major depression (nine current, three past only). Only two of the 32 (six percent) reported any phobic avoidance. This study confirms the previous findings which suggest that major depression is common in cardiology populations with panic disorder and that phobic avoidance is uncommon in this group.     

Moderating effects of major depression on patterns of comorbidity in patients with panic disorder

Given the high rate of co-occurring major depression in patients with panic disorder, it is unclear whether patterns of comorbidity in individuals with panic disorder reported in the literature are associated with panic disorder or with the presence of major depression. Subjects were 231 adult subjects with panic disorder and major depression (n=102), panic disorder without comorbid major depression (n=29), major depression without comorbid panic disorder (n=39), and neither panic disorder nor major depression (n=61). Subjects were comprehensively assessed with structured diagnostic interviews that examined psychopathology across the life cycle. Panic disorder, independently of comorbidity with major depression, was significantly associated with comorbid separation anxiety disorder, simple phobia, obsessive-compulsive disorder, generalized anxiety disorder, and agoraphobia. Major depression, independently of comorbidity with panic disorder, was significantly associated with comorbidity with psychoactive substance use disorders and childhood disruptive behavior disorders. Overanxious disorder was associated with both panic disorder and major depression. Major depression has important moderating effects on patterns of comorbidity of panic disorder in referred adults.     

High cholesterol levels in patients with panic disorder.

OBJECTIVE: This study was undertaken to help clarify whether the higher cholesterol levels found in patients with panic disorder are a complication of panic disorder only or are associated with any psychiatric disorder. METHOD: The subjects of the study were 30 patients with panic disorder and 30 patients with major depression, diagnosed according to the Structured Interview for DSM-III-R, and 30 normal control subjects. The three groups were matched for sex and age, and none of the subjects had alcohol/drug abuse, abnormal ECGs, or unstable medical conditions. Blood samples were drawn at random times, and serum cholesterol levels were determined. RESULTS: The patients with panic disorder had significantly higher serum cholesterol levels than did the patients with major depression and the normal control subjects. Among the patients with major depression, histories (current or past) of anxiety disorders were associated with significant elevation of serum cholesterol levels. The presence of stable medical conditions was not associated with higher cholesterol levels in any of the three groups of subjects. CONCLUSIONS: Higher cholesterol levels were particularly associated with panic disorder in comparison with major depression. Higher levels of cholesterol in panic disorder are hypothesized to be a result of increased noradrenergic activity, which may be the underlying biological/neurochemical mechanism for symptoms of panic disorder, including anticipatory anxiety.