Poverty and response to treatment among panic disorder patients in primary care

OBJECTIVE: Despite well-established links between poverty and poor mental illness outcome as well as recent reports exploring racial and ethnic health disparities, little is known about the outcomes of evidence-based psychiatric treatment for poor individuals. METHOD: Primary care patients with panic disorder (N=232) who were participating in a randomized controlled trial comparing a cognitive behavior therapy (CBT) and pharmacotherapy intervention to usual care were divided into those patients above (N=152) and below (N=80) the poverty line. Telephone assessments at 3, 6, 9, and 12 months were used to compare the amount of evidence-based care received as well as clinical and functional outcomes. RESULTS: Poor subjects were more severely ill at baseline, with more medical and psychiatric comorbidity. The increases in the amount of evidence-based care and reductions in clinical symptoms and disability were comparable in the two groups such that poorer individuals, although responding equivalently, continued to be more ill and disabled at 12 months. CONCLUSIONS: The comparable response of poor individuals in this study suggests that standard CBT and pharmacotherapy treatments for panic disorder do not need to be "tailored" to be effective in poor populations. However, the more severe illness both at baseline and follow-up in these poor individuals suggests that treatment programs may need to be extended in order to treat residual symptoms and disability in these patients so that they might achieve comparable levels of remission.     

Panic disorder in public sector primary care: clinical characteristics and illness severity compared with "mainstream" primary care panic disorder

The prevalence of anxiety disorders is increased among low-income individuals, who are more likely to seek mental health care in medical as opposed to specialty settings because of limited insurance access and restricted availability of public sector mental health resources. However, little is known about the clinical characteristics and illness severity of anxiety disorders in this setting. We studied the clinical characteristics of low-income compared with middle-income primary care panic patients. Clinical, functional, and service use measures obtained at baseline interview in 39 panic disorder patients seen in one public sector medical clinic were compared with 76 patients seen in two middle-income clinics. All patients were participants in a randomized effectiveness pharmacotherapy trial [Roy Byrne et al., Arch Gen Psychiatry 2001;58:869-876]. Public sector patients were more often older, male, single, unemployed, of lower income, and non-Caucasian ethnicity. They had more severe clinical symptoms, more medical comorbidity, worse physical and role health status, and more emergency room visits. Low income and unemployment accounted for most of the differences in non-anxiety-related measures. However, type of clinic still contributed independently to the greater severity of specific measures of panic/anxiety (Panic Disorder Severity Scale and Marks Fear Scale scores), suggesting that the increased stress and limited social resources associated with low-income and disadvantaged status may have more specific effects on anxiety than other aspects of psychopathology.     

Characteristics and course of panic disorder and panic disorder with agoraphobia in primary care patients

Objective: To examine the course of panic disorder (PD) and panic disorder with agoraphobia (PDA) in 235 primary care patients during a 3-year period.Method: Patients were recruited from primary care waiting rooms and diagnosed using the Structured Clinical Interview for DSM-IV. They were reassessed at 6 months, 1 year, and annually thereafter for diagnosis, treatment, and other clinical and demographic variables. Recruitment occurred between July 1997 and May 2001.Results: At intake, 85 patients were diagnosed with PD and 150 were diagnosed with PDA. Patients with PD were significantly more likely to achieve recovery (probability estimate, 0.75) from their disorder than patients with PDA (0.22) at the end of 3-year follow-up (p < .0001). There was no difference in recurrence rates between the 2 disorders. Women were more likely to recover from PD (p = .001). At intake, comorbid generalized anxiety disorder (p = .004), higher Global Assessment of Functioning score (p = .0003), and older age at panic onset (p = .05) were related to recovery from PDA, and comorbid major depressive disorder (p = .05) and psychosocial treatment (p = .002) predicted remaining in an episode of PDA. The relationship between psychosocial treatment and poor recovery must be interpreted with caution and is most likely due to the treatment bias effect.Conclusion: Primary care patients with PDA have a chronic course of illness, whereas those with PD have a more relapsing course. Given the significant burden of PD and PDA in primary care, attention to factors relevant to the course of these disorders is important for recognition and for continued improvement of treatment interventions in this setting.     

Predictors of willingness to consider medication and psychosocial treatment for panic disorder in primary care patients

The purpose of this investigation was to identify demographic and clinical patient characteristics related to willingness to consider panic disorder treatments in the primary care setting. Given the prevalence of anxiety disorders and the increased provision of mental health treatments in general medical settings, patients were selected from primary care settings. An unselected sample of 4,198 patients completed a brief questionnaire containing questions about demographic characteristics, physical health status, and symptoms of panic disorder, social phobia and PTSD. The 1,043 patients indicating a recent panic attack episode answered additional questions about their willingness to consider both medication and psychosocial forms of intervention for panic. Of these panic patients, 64% reported willingness to consider medication and 67% reported willingness to consider a psychosocial intervention for their panic. Logistic regression analyses for these panic patients revealed that willingness to consider medication treatment for panic was associated with older age, lower education, poorer health status and the presence of social phobia and/or PTSD symptoms. In addition, Asian and African American patients were less likely than Caucasian patients to indicate willingness to consider medication treatment for their panic. However, only the presence of comorbid social phobia and PTSD symptoms predicted willingness to consider a psychosocial intervention. Results suggest that acceptability of psychosocial treatment is unrelated to demographic and physical health factors, while primary care patients with certain demographic characteristics, good physical health, or who suffer from fewer comorbid mental health conditions may need additional encouragement to begin medication treatment for panic.     

Understanding and treating panic disorder in the primary care setting

According to studies, the median prevalence of panic disorder in the primary care setting is 4%. Rates are higher among certain patient populations, such as those with cardiac (20% to 50%) or gastrointestinal presentations (28% to 40%). Consequently, patients with panic disorder are high utilizers of medical services and are heavily represented among patients classified as high health care utilizers, compared with other psychiatric or non-psychiatric groups. Despite its frequency in the primary care setting, panic disorder is significantly under-recognized by medical providers. Corresponding with inadequate recognition is the substantial proportion of these patients who fail to receive appropriate treatment (pharmacotherapy and psychotherapy). Most experts have concluded that panic disorder is poorly managed in the primary care setting because of the process of care and patient engagement. In terms of process of care, primary care practice still operates on an acute disease model (leaving no time for initial patient education or follow-up), which is a poor fit for the management of chronic diseases. Insufficient patient engagement in treatment (i.e., being involved in the treatment process, "buying into" rationale for treatment, and being willing to collaborate with clinician and adhere to recommendations) is the second important contributor to inadequate treatment. Use of a chronic disease self-management approach would enhance treatment of panic disorder. This model requires that patients, in collaboration with the health care provider/system, take day-to-day responsibility for managing their illness by doing 3 things: adhering to recommended medical management, adopting improved health habits/coping skills, and assisting in ongoing monitoring of illness status/change. Future approaches to treating panic disorder in primary care would be enhanced by including assessments of patient beliefs and preferences, spending more time in preparing the patient for treatment, utilizing a simple pharmacotherapy algorithm, utilizing simple rating scales to monitor outcomes, and training providers in brief CBT interventions.     

Unemployment and emergency room visits predict poor treatment outcome in primary care panic disorder

BACKGROUND: To complement existing data on predictors of treatment response in groups of "pure" panic disorder patients studied in clinical trials or in poorly controlled naturalistic follow-up, we sought to elucidate predictors of treatment response over 1 year in a diagnostically heterogeneous and comorbidly ill group of primary care patients with panic disorder participating in a randomized effectiveness study. METHOD: Patients with DSM-IV panic disorder (N = 115), mostly without agoraphobia, were recruited from 3 primary care clinics in Seattle, Wash., and randomly assigned to an on-site collaborative care intervention (N = 57), in which psychiatrists provided education, 2 visits, follow-up phone calls, and paroxetine, or to usual care by their primary care physician (N = 58). Predictors of response at 3-month intervals over 1 year were determined using logistic regression analysis. RESULTS: Patients with consistent response over the year (response at the majority of available timepoints) were significantly (p <.05) more likely to be white, employed, in higher income strata, and in the intervention group and had less medical comorbidity and phobia severity, fewer recent hospitalizations and emergency room visits, and higher reported Medical Outcomes Study 36-Item Short Form physical and role functioning. The final regression model indicated that responders were more likely to be in the intervention group, be employed, and lack a recent emergency room visit. CONCLUSION: While some of the univariate findings partially replicate previous results linking greater illness severity with poorer response, univariate findings linking medical comorbidity and low socioeconomic status with poor response, as well as multivariate findings that unemployment and recent emergency room use are the most potent predictors of poor response, have not been previously reported.     

Prevalence and features of panic disorder and comparison to posttraumatic stress disorder in VA primary care

Objective

Although panic disorder (PD) is a highly prevalent condition in both community and community primary care settings, little is known about PD in veteran populations, especially in comparison to posttraumatic stress disorder (PTSD). The present study investigated prevalence, comorbidity, physical and mental health impairment, and health care utilization of veterans with PD and PTSD.

Method

A total of 884 veterans participated in a cross-sectional investigation in primary care clinics in four Veteran Affairs Medical Centers (VAMCs). Participants completed diagnostic interviews and self-report questionnaires, and a chart review was completed to assess their VAMC health care utilization.

Results

A large number of veterans (8.3%) met the diagnostic criteria for PD and reported significantly more severe physical health impairment (pain, general health), mental health impairment (emotional well-being, role limitations) and social functioning than veterans without PD. Veterans with PD also had increased health care utilization for mental health. Further, PD was highly comorbid with PTSD, with similar symptoms across all measures.

Conclusions

These findings demonstrate the high prevalence and severe impairment associated with PD in veterans and highlight the need for improved recognition, assessment and specialized treatments for PD in VAMCs and other care settings.     

Panic disorder in primary care: patients' attributions of illness causes and willingness to accept psychiatric treatment

OBJECTIVE: This study assessed the causes that primary care patients with panic disorder (PD) attribute to their panic symptoms, and their acceptance of various psychiatric treatment options. METHODS: In a cross-sectional assessment of 306 patients treated at two primary care clinics, 42 met criteria for DSM-IV PD in the past year. The authors classified these 42 PD-positive patients to one of two groups: those receiving both primary and specialty mental health care (PC+MH; n = 19) and those receiving only primary care (PC-only; n = 23). Patients rated the probability of four possible causes of their panic symptoms, and level of acceptability of three psychiatric and two medical treatments for PD. To place primary care patients' ratings into a broader context, a third contrast group of PD-positive patients, recruited from clinical trials of investigational PD pharmacotherapies (n = 31), also rated causes and treatment acceptability. RESULTS: Participants of the three treatment groups attributed psychiatric causes for their panic symptoms in approximately the same proportion (78 percent to 90 percent; p = ns). PC-only participants attributed medical causes for panic symptoms more frequently than PC+MH and PD Clinical Trials participants (48 percent vs. 5 percent and 32 percent; p = .01). Remarkably, the great majority of patients across all groups expressed willingness to see psychiatrists (84 percent to 94 percent) and psychotherapists (95 percent to 100 percent), and to take psychotropic medications (87 percent to 100 percent). CONCLUSIONS: In this study most patients attributed a psychiatric cause for panic symptoms and communicated strong acceptance of psychiatric treatment. Thus, we recommend that primary care clinicians more assertively inform their patients of PD diagnoses and recommend psychiatric treatments with less fear about stigmatizing and alienating them.     

Placebo response in panic disorder

Of 43 patients with panic disorder or agoraphobia with panic attacks who took placebo for 8 weeks in two double-blind studies, one in four markedly improved. Those with consistently normal dexamethasone suppression test results were significantly more likely to show a placebo response as were those with lower anxiety ratings at the outset of treatment.     

Increased sympathetic response to standing in panic disorder

Although autonomic function has been investigated in panic disorder (PD), previous studies have not used non-invasive beat by beat blood pressure (BP) monitoring to assess the rapid dynamics of BP during autonomic reflex tests. The hypothesis of the current study was that patients with PD would show increased cardiovascular sympathetic reactivity compared with healthy or anxious controls, as assessed by the initial overshoot of diastolic BP during the immediate response to standing. Patients with PD (n=56), social phobia (n=28) and healthy volunteers (n=56) were tested using finger photoplethysmography during an orthostatic challenge. Panic disorder patients showed an increased BP overshoot compared with both control groups. Moreover, in a preliminary assessment of selective serotonin reuptake inhibitor treatment effects, the BP overshoot was significantly reduced towards normal values. These findings are consistent with recent evidence for increased sympathetic baroreflex function in PD and may be relevant to the pathophysiology of the disorder.     

Lactate-induced panic in primary affective disorder

Intravenous sodium lactate was given to seven patients with primary depression and secondary panic attacks and 26 patients with panic disorder or agoraphobia with panic attacks. The two groups had similar rates of panic response. These results challenge the diagnostic specificity of lactate-induced panic.     

Patterns of response during placebo treatment of panic disorder

Data from the cross-national study of panic disorder are used for an analysis of response patterns. The main purpose of the study is a search for specific placebo patterns and a discussion of possible differences in patterns from patients treated with alprazolam, imipramine, and placebo. Four outcome measures were registered at baseline and weekly during the treatment period: the number of panic attacks, Physician's Global Evaluation of treatment effect, the Overall Phobia Score and the level on the Hamilton Rating Scale for Anxiety. Response patterns from the 3 treatment groups are described and compared, and subsequently categorized with regard to completeness and persistency. No specific placebo pattern is recognized. Some differences are found, however, as many placebo patients demonstrate an early and temporary remission. The variations in response patterns do not compromise the blindness of the study, and their predictive validity is low.     

Psychophysiological response patterns in panic disorder

To determine whether panic disorder patients exhibit physiological hyperarousal during rest or during mild, non-panic-inducing stress, 18 patients who experienced frequent panic attacks were compared with nonanxious controls on a battery of physiological assessments. During baseline, patients with panic disorder exhibited higher forehead electromyographic activity, higher systolic blood pressure and higher heart rates than non-anxious volunteers. During psychological stress, heart rate and systolic blood pressure rose more in patients with panic disorder than in nonanxious controls. The skin conductance response, however, was greater and more variable in the nonanxious controls. The results suggest that panic disorder patients with frequent panic attacks exhibit heightened cardiovascular arousal and decreased electrodermal flexibility than nonanxious people, even in nonthreatening situations.     

Alprazolam plasma concentrations and treatment response in panic disorder and agoraphobia.

OBJECTIVE: The authors' goal was to evaluate the relationship between plasma concentrations of alprazolam and both treatment response and side effects in patients with panic disorder and agoraphobia. METHOD: Ninety-six patients with panic disorder and agoraphobia were treated at three sites in a 6-week, fixed-dose, double-blind, placebo-controlled, dose-response study of 2 mg/day or 6 mg/day of alprazolam. Assessments were made of panic attacks, avoidance behavior, generalized anxiety, and global response. Blood samples were collected throughout the study and analyzed for alprazolam and other benzodiazepines. RESULTS: Patient compliance with the protocol was judged to be good on the basis of plasma concentrations. According to logistic regression analysis, the relationships between plasma alprazolam concentration and response, as reflected by number of panic attacks reported, phobia ratings, physicians' and patients' ratings of global improvement, and the emergence of side effects, were significant. However, there was no significant relationship between plasma alprazolam concentration and the degree of generalized anxiety symptoms. CONCLUSIONS: The authors conclude that plasma concentration of alprazolam is related to treatment response, particularly in panic attacks. The alprazolam concentration associated with treatment response or with emergence of a given side effect varied widely among individuals, highlighting the necessity for individualized dose adjustment to obtain optimal treatment response while minimizing side effects.     

Therapeutic response to phenelzine in patients with panic disorder and agoraphobia with panic attacks

The therapeutic response to phenelzine sulfate was evaluated during 6 months' treatment of 35 outpatients meeting DSM-III criteria for panic disorder or agoraphobia with panic attacks. The possible influence of nonspecific predictors of drug efficacy and some biochemical parameters were investigated. Therapeutic response was assessed on standardized rating scales. Agoraphobic patients showed a significantly higher frequency of panic attacks when compared to the subjects with uncomplicated panic disorder. Phenelzine treatment blocked panic attacks in 100% of the patients with panic disorder and in 94.7% of the agoraphobics. Anticipatory anxiety and avoidant behavior improved markedly, although not statistically significantly, in 73.6% of the agoraphobics.