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

Future Trends in Disability and Its Determinants Among Chinese Community Patients With Anxiety Disorders: Evidence From a 5-Year Follow-Up Study

Background: Anxiety disorders (ADs) are a group of disorders with a high disability rate and bring a huge social burden. In China, information on future trends in the disability among community ADs patients and its determinants are rare. The objectives of this study are to describe the future trends in the disability among ADs patients living in community and to investigate the determinants of the disability. Methods: Participants diagnosed with 12-month ADs in the China Mental Health Survey (CMHS) were followed up by telephone from April to June 2018 to assess the future trends in the disability in a 5-year interval using the World Health Organization's Disability Assessment Schedule 2.0. The disability rate was reported and its determinants were analyzed by complex sample design multivariate logistic regression. Results: Totally 271 patients were interviewed by telephone and 33 informants finished proxy interviews. The disability rates were 45.9% and 14.3% among ADs patients at baseline and during the follow-up. Patients with general anxiety disorder (GAD) or agoraphobia with/without panic disorder (AGP) had the lower decrease and higher disability during the follow-up than patients with other subtypes. Patients aged in middle age (aged 40-49 years old, OR = 11.12, 95% CI: 4.16-29.72), having disability at baseline (OR = 7.18, 95% CI: 1.37-37.73), having comorbidity with three or more physical diseases (OR = 9.27, 95% CI: 2.48-34.71), and having comorbidity with other mental disorders (OR = 3.97, 95% CI: 1.13-13.96) had higher disability during the follow-up. Conclusions: The disability rate tends to decrease among ADs patients living in communities. Treatment priority should be given for ADs patients with disability and those in middle age. Treatments for the comorbidity of other mental disorders or physical diseases should be considered when treating anxiety.

Treatment-refractory anxiety; definition, risk factors, and treatment challenges

A sizable proportion of psychiatric patients will seek clinical evaluation and treatment for anxiety symptoms reportedly refractory to treatment. This apparent lack of response is either due to “pseudo-resistance” (a failure to have received and adhered to a recognized and effective treatment or treatments for their condition) or to true “treatment resistance.” Pseudo-resistance can be due to clinician errors in selecting and delivering an appropriate treatment effectively, or to patient nonadherence to a course of treatment. True treatment resistance can be due to unrecognized exogenous anxiogenic factors (eg, caffeine overuse, sleep deprivation, use of alcohol or marijuana) or an incorrect diagnosis (eg, atypical bipolar illness, occult substance abuse, attention deficit-hyperactivity disorder). Once the above factors are eliminated, treatment should focus on combining effective medications and cognitive behavioral therapy, combining several medications (augmentation), or employing novel medications or psychotherapies not typically indicated as first-line evidence-based anxiety treatments.

Collaborative care for depression and anxiety problems

BACKGROUND

Common mental health problems, such as depression and anxiety, are estimated to affect up to 15% of the UK population at any one time, and health care systems worldwide need to implement interventions to reduce the impact and burden of these conditions. Collaborative care is a complex intervention based on chronic disease management models that may be effective in the management of these common mental health problems.

OBJECTIVES

To assess the effectiveness of collaborative care for patients with depression or anxiety.

SEARCH METHODS

We searched the following databases to February 2012: The Cochrane Collaboration Depression, Anxiety and Neurosis Group (CCDAN) trials registers (CCDANCTR-References and CCDANCTR-Studies) which include relevant randomised controlled trials (RCTs) from MEDLINE (1950 to present), EMBASE (1974 to present), PsycINFO (1967 to present) and the Cochrane Central Register of Controlled Trials (CENTRAL, all years); the World Health Organization (WHO) trials portal (ICTRP); ClinicalTrials.gov; and CINAHL (to November 2010 only). We screened the reference lists of reports of all included studies and published systematic reviews for reports of additional studies.

SELECTION CRITERIA

Randomised controlled trials (RCTs) of collaborative care for participants of all ages with depression or anxiety.

DATA COLLECTION AND ANALYSIS

Two independent researchers extracted data using a standardised data extraction sheet. Two independent researchers made 'Risk of bias' assessments using criteria from The Cochrane Collaboration. We combined continuous measures of outcome using standardised mean differences (SMDs) with 95% confidence intervals (CIs). We combined dichotomous measures using risk ratios (RRs) with 95% CIs. Sensitivity analyses tested the robustness of the results.

MAIN RESULTS

We included seventy-nine RCTs (including 90 relevant comparisons) involving 24,308 participants in the review. Studies varied in terms of risk of bias.The results of primary analyses demonstrated significantly greater improvement in depression outcomes for adults with depression treated with the collaborative care model in the short-term (SMD -0.34, 95% CI -0.41 to -0.27; RR 1.32, 95% CI 1.22 to 1.43), medium-term (SMD -0.28, 95% CI -0.41 to -0.15; RR 1.31, 95% CI 1.17 to 1.48), and long-term (SMD -0.35, 95% CI -0.46 to -0.24; RR 1.29, 95% CI 1.18 to 1.41). However, these significant benefits were not demonstrated into the very long-term (RR 1.12, 95% CI 0.98 to 1.27).The results also demonstrated significantly greater improvement in anxiety outcomes for adults with anxiety treated with the collaborative care model in the short-term (SMD -0.30, 95% CI -0.44 to -0.17; RR 1.50, 95% CI 1.21 to 1.87), medium-term (SMD -0.33, 95% CI -0.47 to -0.19; RR 1.41, 95% CI 1.18 to 1.69), and long-term (SMD -0.20, 95% CI -0.34 to -0.06; RR 1.26, 95% CI 1.11 to 1.42). No comparisons examined the effects of the intervention on anxiety outcomes in the very long-term.There was evidence of benefit in secondary outcomes including medication use, mental health quality of life, and patient satisfaction, although there was less evidence of benefit in physical quality of life.

AUTHORS' CONCLUSIONS

Collaborative care is associated with significant improvement in depression and anxiety outcomes compared with usual care, and represents a useful addition to clinical pathways for adult patients with depression and anxiety.

The Harvard/Brown Anxiety Research Project-Phase II (HARP-II): rationale, methods, and features of the sample at intake

We describe the rationale, method, and intake demographic and clinical findings of the Harvard/Brown Anxiety Research Project-Phase II (HARP-II). HARP-II is the first prospective, observational, longitudinal study to describe the characteristics and course of anxiety in African American, Latino, and Non-Latino White individuals. Participants met criteria for at least one of the following disorders: Generalized Anxiety Disorder, Social Phobia, Panic Disorder with or without Agoraphobia, Agoraphobia without history of Panic Disorder, Post-traumatic Stress Disorder. Initial intake data, collected between 2004 and 2011, are presented for 165 African American, 150 Latino, and 172 Non-Latino White participants. Participants evidenced substantial psychiatric comorbidity (mean number of Axis I disorders=3.4), and moderate to severe symptoms and functional impairment. HARP-II will examine clinical course, in the context of potential socio-cultural and individual moderators (e.g., discrimination, acculturation, negative affect). Results should lead to improved understanding, prognostics, and treatment of anxiety in diverse populations.

Anxiety disorders in a public mental health system: clinical characteristics and service use patterns

BACKGROUND

Anxiety disorders are among the most common forms of psychiatric disorder, yet few investigations have examined the prevalence or service use of clients with anxiety disorders in the public mental health sector.

METHODS

We examined demographics, clinical information, and service use in clients with anxiety disorders enrolled in San Diego County Adult and Older Adult Mental Health Services in fiscal 2002-2003.

RESULTS

Almost 15% of the sample had a diagnosis of an anxiety disorder based on administrative billing data. Most anxiety disorder clients had additional psychiatric diagnoses, most commonly depression. Clients with both anxiety disorders and depression were more likely than those with anxiety or depression alone to use emergency psychiatric services and outpatient services than those with depression alone. Those with anxiety disorders alone used more outpatient services than those with depression alone.

LIMITATION

Data were taken from an administrative database.

CONCLUSIONS

Data indicate that anxiety disorders are not uncommon in public mental health settings and are associated with higher utilization of outpatient mental health services.

Effect of Dissociative Experiences on Drug Treatment of Panic Disorder

BACKGROUND AND OBJECTIVE

Dissociative experiences are widespread among patients with panic disorder and have a negative impact on cognitive-behavioural therapy. In this study we aimed to investigate whether or not dissociative experiences affect response to drug treatment for panic disorder.

METHODS

Thirty-five patients, 20 women and 15 men, with a mean age of 35.4 years and a diagnosis of panic disorder, were enrolled in the study. Paroxetine 20 mg/day was administered over 6 weeks. Patients were assessed on the Dissociative Experience Scale (DES) and Panic and Agoraphobia Scale (PAS) at the commencement of therapy, and on the PAS again after therapy.

RESULTS

The average DES score was determined as 30.3. Agoraphobia was identified in 34.3% of patients. DES scores were higher in patients with agoraphobia than in those without agoraphobia. Agoraphobia scores were higher in patients with high DES scores. When patients were divided into those with low DES scores (< or =30) and those with high DES scores (>30), a decrease in PAS scores with treatment was observed in both groups, but the decrease was greater in those with low DES scores (18.8 +/- 6.8 vs 5.7 +/- 5.7 in the high-DES score group; Z = 4.486, p = 0.00000053). Similarly, while a decrease in PAS scores with treatment was observed both in patients with agoraphobia (p < 0.05) and in those without agoraphobia, PAS scores decreased more in non-agoraphobic patients (16.7 +/- 7.5 vs 4.8 +/- 6.6 in patients with agoraphobia; Z = 3.799, p = 0.000047). In addition, the decrease in PAS scores was significantly correlated with baseline DES score (beta = 0.706, T = 5.727, p = 0.0000022).

CONCLUSION

This study shows that dissociative experiences reduce the response to drug therapy in patients with panic disorder.

Differential performance on tasks of affective processing and decision-making in patients with Panic Disorder and Panic Disorder with comorbid Major Depressive Disorder

BACKGROUND

Neuropsychological studies have provided evidence for deficits in psychiatric disorders, such as schizophrenia and mood disorders. However, neuropsychological function in Panic Disorder (PD) or PD with a comorbid diagnosis of Major Depressive Disorder (MDD) has not been comprehensively studied. The present study investigated neuropsychological functioning in patients with PD and PD + MDD by focusing on tasks that assess attention, psychomotor speed, executive function, decision-making, and affective processing.

METHODS

Twenty-two unmedicated patients with PD, eleven of whom had a secondary diagnosis of MDD, were compared to twenty-two healthy controls, matched for gender, age, and intelligence on tasks of attention, memory, psychomotor speed, executive function, decision-making, and affective processing from the Cambridge Neuropsychological Test Automated Battery (CANTAB), Cambridge Gamble Task, and Affective Go/No-go Task.

RESULTS

Relative to matched healthy controls, patients with PD + MDD displayed an attentional bias toward negatively-valenced verbal stimuli (Affective Go/No-go Task) and longer decision-making latencies (Cambridge Gamble Task). Furthermore, the PD + MDD group committed more errors on a task of memory and visual discrimination compared to their controls. In contrast, no group differences were found for PD patients relative to matched control subjects.

LIMITATIONS

The sample size was limited, however, all patients were drug-free at the time of testing.

CONCLUSIONS

The PD + MDD patients demonstrated deficits on a task involving visual discrimination and working memory, and an attentional bias towards negatively-valenced stimuli. In addition, patients with comorbid depression provided qualitatively different responses in the areas of affective and decision-making processes.

Panic disorder and suicidal ideation in primary care

The purpose of this study was to ascertain whether panic disorder (PD) and suicidal ideation are associated in an inner-city primary care clinic and whether this association remains significant after controlling for commonly co-occurring psychiatric disorders. We surveyed 2,043 patients attending a primary care clinic using the Primary Care Evaluation of Mental Disorders (PRIME-MD) Patient Health Questionnaire, a screening instrument that yields provisional diagnoses of selected psychiatric disorders. We estimated the prevalence of current suicidal ideation and of common psychiatric disorders including panic disorder and major depression. A provisional diagnosis of current PD was received by 127 patients (6.2%). After adjusting for potential confounders (age, gender, major depressive disorder [MDD], generalized anxiety disorder, and substance use disorders), patients with PD were about twice as likely to present with current suicidal ideation, as compared to those without PD (adjusted odds ratio [AOR] = 1.84; 95% confidence interval [CI]: 1.06-3.18; P = .03). After adjusting for PD and the above-mentioned potential confounders, patients with MDD had a sevenfold increase in the odds of suicidal ideation, as compared to those without MDD (AOR = 7.00; 95% CI: 4.42-11.08; P < .0001). Primary care patients with PD are at high risk for suicidal ideation, and patients with PD and co-occurring MDD are at especially high risk. PD patients in primary care thus should be assessed routinely for suicidal ideation and depression.