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Freire RCR, Nardi AE. Is it possible to prevent relapse in panic disorder? Expert Rev Neurother 2023; 23:677-679. [PMID: 37357687 DOI: 10.1080/14737175.2023.2229955] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2023] [Accepted: 06/22/2023] [Indexed: 06/27/2023]
Affiliation(s)
- Rafael C R Freire
- Department of Psychiatry, Faculty of Health Sciences, Queen's University, Kingston, Canada
- Centre for Neuroscience Studies, Queen's University, Kingston, Canada
- Kingston General Hospital Research Institute, Kingston Health Sciences Centre, Kingston, Canada
- Laboratory of Panic and Respiration, Institute of Psychiatry, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
| | - Antonio E Nardi
- Laboratory of Panic and Respiration, Institute of Psychiatry, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
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Tyrer P, Tyrer H, Johnson T, Yang M. Thirty-year outcome of anxiety and depressive disorders and personality status: comprehensive evaluation of mixed symptoms and the general neurotic syndrome in the follow-up of a randomised controlled trial. Psychol Med 2021; 52:1-10. [PMID: 33843514 DOI: 10.1017/s0033291721000878] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND Cohort studies of the long-term outcome of anxiety, depression and personality status rarely join together. METHODS Two hundred and ten patients recruited with anxiety and depression to a randomised controlled trial between 1983 and 1987 (Nottingham Study of Neurotic Disorder) were followed up over 30 years. At trial entry personality status was assessed, together with the general neurotic syndrome, a combined diagnosis of mixed anxiety-depression (cothymia) linked to neurotic personality traits. Personality assessment used a procedure allowing conversion of data to the ICD-11 severity classification of personality disorder. After the original trial, seven further assessments were made. Observer and self-ratings of psychopathology and global outcome were also made. The primary outcome at 30 years was the proportion of those with no Diagnostic and Statistical Manual of Mental Disorders (DSM) diagnosis.Data were analysed using multilevel repeated measures models that adjusted for age and gender. Missing data were assumed to be missing at random, and the models allowed all subjects to be included in the analysis with missing data automatically handled in the model estimation. RESULTS At 30 years, 69% of those with a baseline diagnosis of panic disorder had no DSM diagnosis compared to 37-47% of those with generalised anxiety disorder, dysthymia or mixed symptoms (cothymia) (p = 0.027). Apart from those with no personality dysfunction at entry all patients had worse outcomes after 30 years with regard to total psychopathology, anxiety and depression, social function and global outcome. CONCLUSIONS The long-term outcome of disorders formerly called 'neurotic' is poor with the exception of panic disorder. Personality dysfunction accentuates poor recovery.
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Affiliation(s)
- Peter Tyrer
- Division of Psychiatry, Imperial College, W12 0NN, London, UK
| | - Helen Tyrer
- Division of Psychiatry, Imperial College, W12 0NN, London, UK
| | | | - Min Yang
- West China School of Public Health, Sichuan University, Chengdu, China
- Faculty of Health, Art and Design, Swinburne University of Technology, Melbourne, Australia
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Caldirola D, Alciati A, Daccò S, Micieli W, Perna G. Relapse prevention in panic disorder with pharmacotherapy: where are we now? Expert Opin Pharmacother 2020; 21:1699-1711. [PMID: 32543949 DOI: 10.1080/14656566.2020.1779220] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Introduction: A substantial number of patients with PD experience relapse after the discontinuation of effective pharmacotherapy, leading to detrimental effects on the individuals and considerable societal costs. This suggests the need to optimize pharmacotherapy to minimize relapse risk. Area covered: The present systematic review examines randomized, double-blind, placebo-controlled relapse prevention studies published over the last 20 years involving recommended medications. The authors aim to provide an overview of this topic and evaluate whether recent advances were achieved. Only seven studies were included, providing limited results. One-year maintenance pharmacotherapy with constant doses had protective effects against relapse in patients who had previously exhibited satisfactory responses to the same medication at the same doses. The duration of maintenance treatment did not influence relapse risk. No data were available concerning the use of lower doses or the predictors of relapse. Expert opinion: Relapse prevention in PD has received limited attention. Recent progress and conclusive indications are lacking. Rethinking pharmacological research in PD may be productive. Collecting a wide range of clinical and individual features/biomarkers in large-scale, multicenter long-term naturalistic studies, and implementing recent technological innovations (e.g., electronic medical records/'big data' platforms, wearable devices, and machine learning techniques) may help identify reliable predictive models.
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Affiliation(s)
- Daniela Caldirola
- Department of Clinical Neurosciences, Villa San Benedetto Menni Hospital, Hermanas Hospitalarias , Albese Con Cassano (Como), Italy.,Department of Biomedical Sciences, Humanitas University , Pieve Emanuele (Milan), Italy
| | - Alessandra Alciati
- Department of Clinical Neurosciences, Villa San Benedetto Menni Hospital, Hermanas Hospitalarias , Albese Con Cassano (Como), Italy.,Humanitas Clinical and Research Center, IRCCS , Rozzano (Milan), Italy
| | - Silvia Daccò
- Department of Clinical Neurosciences, Villa San Benedetto Menni Hospital, Hermanas Hospitalarias , Albese Con Cassano (Como), Italy.,Department of Biomedical Sciences, Humanitas University , Pieve Emanuele (Milan), Italy
| | - Wilma Micieli
- Department of Clinical Neurosciences, Villa San Benedetto Menni Hospital, Hermanas Hospitalarias , Albese Con Cassano (Como), Italy
| | - Giampaolo Perna
- Department of Clinical Neurosciences, Villa San Benedetto Menni Hospital, Hermanas Hospitalarias , Albese Con Cassano (Como), Italy.,Department of Biomedical Sciences, Humanitas University , Pieve Emanuele (Milan), Italy.,Department of Psychiatry and Neuropsychology, Faculty of Health, Medicine and Life Sciences, Maastricht University , Maastricht, The Netherlands.,Department of Psychiatry and Behavioral Sciences, Leonard Miller School of Medicine, Miami University , Miami, FL, USA
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Kipper L, Blaya C, Wachleski C, Dornelles M, Salum GA, Heldt E, Manfro GG. Trauma and defense style as response predictors of pharmacological treatment in panic patients. Eur Psychiatry 2020; 22:87-91. [PMID: 17188844 DOI: 10.1016/j.eurpsy.2006.09.009] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2006] [Revised: 09/29/2006] [Accepted: 09/30/2006] [Indexed: 10/23/2022] Open
Abstract
AbstractBackgroundAs panic disorder (PD) has a chronic course, it is important to identify predictors that might be related to non-remission. The aim of this study is to verify whether history of trauma and defense style are predictors to pharmacological treatment response in PD patients.MethodThe sample was composed by 47 PD patients according to DSM-IV who were treated with sertraline for 16 weeks. Evaluations were assessed by the C.G.I. (Clinical Global Impression), the Hamilton-Anxiety Scale, the Hamilton-Depression Scale, the Panic Inventory and the DSQ-40 (Defense Style Questionnaire) at baseline and after treatment.ResultsFull remission was observed in 61.7% of the sample. The predictors significantly associated with non-remission were: severity of PD (p = 0.012), age of onset (p = 0.02) and immature defenses (p = 0.032). In addition, the history of trauma was associated with early onset of PD (p = 0.043).ConclusionPanic patients had as predictors of worse response to pharmacological treatment the early onset and the severity of PD symptoms as well as the use of immature defenses at baseline. This finding corroborates the relevance of the evaluation of factors that might affect the response so as to enable the development of appropriate treatment for each patient.
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Affiliation(s)
- Letícia Kipper
- Psychiatry, School of Medicine, Universidade Federal do Rio Grande do Sul and Anxiety Disorders Program, Hospital de Clínicas de Porto Alegre, Ramiro Barcelos 2350, CEP: 90035-003, Porto Alegre, RS, Brazil
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Rubio G, López-Ibor JJ. What can be learnt from the natural history of anxiety disorders? Eur Psychiatry 2020; 22:80-6. [PMID: 17184975 DOI: 10.1016/j.eurpsy.2006.09.007] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2006] [Revised: 09/17/2006] [Accepted: 09/20/2006] [Indexed: 11/16/2022] Open
Abstract
AbstractBackgroundThere is insufficient knowledge of the long-term course of panic disorder (PD).AimTo determine the long-term course and prognostic variables in patients diagnosed with PD.MethodsPatients who were diagnosed of anxiety states between 1950 and 1961, were examined using a structured clinical interview (SCID-DSM-III-R) between 1984 and 1988 (n = 144). A re-examination was performed in the period 1997–2001 (N = 125). Mean length of follow-up from onset was 47 years.ResultsPD tends to be chronic. Among those who recovered, 93% had done so already by the 1980s. Lack of regular treatment compliance, progression to agoraphobia and number of episodes of panic disorder were associated with worse outcome. Agoraphobia without panic attacks and somatization symptoms were the most prevalent clinical status at follow-up.ConclusionAfter several decades, participants improve with regard to number of panic attacks, though most continue to have residual symptoms.
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Affiliation(s)
- Gabriel Rubio
- Retiro Mental Health Centre, Psychiatry, Lope de Rueda 43, 28009 Madrid, Spain.
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Breilmann J, Girlanda F, Guaiana G, Barbui C, Cipriani A, Castellazzi M, Bighelli I, Davies SJC, Furukawa TA, Koesters M. Benzodiazepines versus placebo for panic disorder in adults. Cochrane Database Syst Rev 2019; 3:CD010677. [PMID: 30921478 PMCID: PMC6438660 DOI: 10.1002/14651858.cd010677.pub2] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
BACKGROUND Panic disorder is characterised by recurrent unexpected panic attacks consisting of a wave of intense fear that reaches a peak within a few minutes. Panic disorder is a common disorder, with an estimated lifetime prevalence of 1% to 5% in the general population and a 7% to 10% prevalence in primary care settings. Its aetiology is not fully understood and is probably heterogeneous.Panic disorder is treated with psychological and pharmacological interventions, often used in combination. Although benzodiazepines are frequently used in the treatment of panic disorder, guidelines recommend antidepressants, mainly selective serotonin reuptake inhibitors (SSRIs), as first-line treatment for panic disorder, particularly due to their lower incidence of dependence and withdrawal reaction when compared to benzodiazepines. Despite these recommendations, benzodiazepines are widely used in the treatment of panic disorder, probably because of their rapid onset of action. OBJECTIVES To assess the efficacy and acceptability of benzodiazepines versus placebo in the treatment of panic disorder with or without agoraphobia in adults. SEARCH METHODS We searched the Cochrane Common Mental Disorders Controlled Trials Register (CCMDCTR Studies and References), the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE (1950-), Embase (1974-), and PsycINFO (1967-) up to 29 May 2018. We handsearched reference lists of relevant papers and previous systematic reviews. We contacted experts in the field for supplemental data. SELECTION CRITERIA All double-blind (blinding of patients and personnel) controlled trials randomising adults with panic disorder with or without agoraphobia to benzodiazepine or placebo. DATA COLLECTION AND ANALYSIS Two review authors independently checked the eligibility of studies and extracted data using a standardised form. Data were then entered data into Review Manager 5 using a double-check procedure. Information extracted included study characteristics, participant characteristics, intervention details, settings, and outcome measures in terms of efficacy, acceptability, and tolerability. MAIN RESULTS We included 24 studies in the review with a total of 4233 participants, of which 2124 were randomised to benzodiazepines and 1475 to placebo. The remaining 634 participants were randomised to other active treatments in three-arm trials. We assessed the overall methodological quality of the included studies as poor. We rated all studies as at unclear risk of bias in at least three domains. In addition, we judged 20 of the 24 included studies as having a high risk of bias in at least one domain.Two primary outcomes of efficacy and acceptability showed a possible advantage of benzodiazepines over placebo. The estimated risk ratio (RR) for a response to treatment was 1.65 (95% confidence interval (CI) 1.39 to 1.96) in favour of benzodiazepines, which corresponds to an estimated number needed to treat for an additional beneficial outcome (NNTB) of 4 (95% CI 3 to 7). The dropout rate was lower among participants treated with benzodiazepines (RR 0.50, 95% CI 0.39 to 0.64); the estimated NNTB was 6 (95% CI 5 to 9). We rated the quality of the evidence as low for both primary outcomes. The possible advantage of benzodiazepine was also seen for remission (RR 1.61, 95% CI 1.38 to 1.88) and the endpoint data for social functioning (standardised mean difference (SMD) -0.53, 95% CI -0.65 to -0.42), both with low-quality evidence. We assessed the evidence for the other secondary outcomes as of very low quality. With the exception of the analyses of the change score data for depression (SMD -0.22, 95% CI -0.48 to 0.04) and social functioning (SMD -0.32, 95% CI -0.88 to 0.24), all secondary outcome analyses showed an effect in favour of benzodiazepines compared to placebo. However, the number of dropouts due to adverse effects was higher with benzodiazepines than with placebo (RR 1.58, 95% CI 1.16 to 2.15; low-quality evidence). Furthermore, our analyses of adverse events showed that a higher proportion of participants experienced at least one adverse effect when treated with benzodiazepines (RR 1.18, 95% CI 1.02 to 1.37; low-quality evidence). AUTHORS' CONCLUSIONS Low-quality evidence shows a possible superiority of benzodiazepine over placebo in the short-term treatment of panic disorders. The validity of the included studies is questionable due to possible unmasking of allocated treatments, high dropout rates, and probable publication bias. Moreover, the included studies were only short-term studies and did not examine the long-term efficacy nor the risks of dependency and withdrawal symptoms. Due to these limitations, our results regarding the efficacy of benzodiazepines versus placebo provide only limited guidance for clinical practice. Furthermore, the clinician's choice is not between benzodiazepines and placebo, but between benzodiazepines and other agents, notably SSRIs, both in terms of efficacy and adverse effects. The choice of treatment should therefore be guided by the patient's preference and should balance benefits and harms from treatment in a long-term perspective.
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Affiliation(s)
- Johanna Breilmann
- Ulm UniversityDepartment of Psychiatry IILudwig‐Heilmeyer‐Str. 2GuenzburgGermany89312
| | - Francesca Girlanda
- Ulm UniversityDepartment of Psychiatry IILudwig‐Heilmeyer‐Str. 2GuenzburgGermany89312
| | - Giuseppe Guaiana
- Western UniversityDepartment of PsychiatrySaint Thomas Elgin General Hospital189 Elm StreetSt ThomasONCanadaN5R 5C4
| | - Corrado Barbui
- University of VeronaDepartment of Neurosciences, Biomedicine and Movement Sciences, Section of PsychiatryVeronaItaly
| | - Andrea Cipriani
- University of OxfordDepartment of PsychiatryWarneford HospitalOxfordUKOX3 7JX
| | - Mariasole Castellazzi
- University of VeronaDepartment of Neurosciences, Biomedicine and Movement Sciences, Section of PsychiatryVeronaItaly
| | - Irene Bighelli
- Klinikum rechts der Isar, Technische Universität MünchenDepartment of Psychiatry and PsychotherapyIsmaningerstr. 22MunichGermany
| | - Simon JC Davies
- University of TorontoGeriatric Psychiatry Division, CAMH6th Floor, 80 Workman WayTorontoCanadaM6J 1H4
| | - Toshi A Furukawa
- Kyoto University Graduate School of Medicine/School of Public HealthDepartment of Health Promotion and Human BehaviorYoshida Konoe‐cho, Sakyo‐ku,KyotoJapan606‐8501
| | - Markus Koesters
- Ulm UniversityDepartment of Psychiatry IILudwig‐Heilmeyer‐Str. 2GuenzburgGermany89312
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Royal Australian and New Zealand College of Psychiatrists clinical practice guidelines for the treatment of panic disorder, social anxiety disorder and generalised anxiety disorder. Aust N Z J Psychiatry 2018. [DOI: 10.1177/0004867418799453] [Citation(s) in RCA: 83] [Impact Index Per Article: 13.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
Objective: To provide practical clinical guidance for the treatment of adults with panic disorder, social anxiety disorder and generalised anxiety disorder in Australia and New Zealand. Method: Relevant systematic reviews and meta-analyses of clinical trials were identified by searching PsycINFO, Medline, Embase and Cochrane databases. Additional relevant studies were identified from reference lists of identified articles, grey literature and literature known to the working group. Evidence-based and consensus-based recommendations were formulated by synthesising the evidence from efficacy studies, considering effectiveness in routine practice, accessibility and availability of treatment options in Australia and New Zealand, fidelity, acceptability to patients, safety and costs. The draft guidelines were reviewed by expert and clinical advisors, key stakeholders, professional bodies, and specialist groups with interest and expertise in anxiety disorders. Results: The guidelines recommend a pragmatic approach beginning with psychoeducation and advice on lifestyle factors, followed by initial treatment selected in collaboration with the patient from evidence-based options, taking into account symptom severity, patient preference, accessibility and cost. Recommended initial treatment options for all three anxiety disorders are cognitive–behavioural therapy (face-to-face or delivered by computer, tablet or smartphone application), pharmacotherapy (a selective serotonin reuptake inhibitor or serotonin and noradrenaline reuptake inhibitor together with advice about graded exposure to anxiety triggers), or the combination of cognitive–behavioural therapy and pharmacotherapy. Conclusion: The Royal Australian and New Zealand College of Psychiatrists clinical practice guidelines for the treatment of panic disorder, social anxiety disorder and generalised anxiety disorder provide up-to-date guidance and advice on the management of these disorders for use by health professionals in Australia and New Zealand.
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Bighelli I, Castellazzi M, Cipriani A, Girlanda F, Guaiana G, Koesters M, Turrini G, Furukawa TA, Barbui C. Antidepressants versus placebo for panic disorder in adults. Cochrane Database Syst Rev 2018; 4:CD010676. [PMID: 29620793 PMCID: PMC6494573 DOI: 10.1002/14651858.cd010676.pub2] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
BACKGROUND Panic disorder is characterised by repeated, unexpected panic attacks, which represent a discrete period of fear or anxiety that has a rapid onset, reaches a peak within 10 minutes, and in which at least four of 13 characteristic symptoms are experienced, including racing heart, chest pain, sweating, shaking, dizziness, flushing, stomach churning, faintness and breathlessness. It is common in the general population with a lifetime prevalence of 1% to 4%. The treatment of panic disorder includes psychological and pharmacological interventions. Amongst pharmacological agents, the National Institute for Health and Care Excellence (NICE) and the British Association for Psychopharmacology consider antidepressants, mainly selective serotonin reuptake inhibitors (SSRIs), as the first-line treatment for panic disorder, due to their more favourable adverse effect profile over monoamine oxidase inhibitors (MAOIs) and tricyclic antidepressants (TCAs). Several classes of antidepressants have been studied and compared, but it is still unclear which antidepressants have a more or less favourable profile in terms of effectiveness and acceptability in the treatment of this condition. OBJECTIVES To assess the effects of antidepressants for panic disorder in adults, specifically:1. to determine the efficacy of antidepressants in alleviating symptoms of panic disorder, with or without agoraphobia, in comparison to placebo;2. to review the acceptability of antidepressants in panic disorder, with or without agoraphobia, in comparison with placebo; and3. to investigate the adverse effects of antidepressants in panic disorder, with or without agoraphobia, including the general prevalence of adverse effects, compared to placebo. SEARCH METHODS We searched the Cochrane Common Mental Disorders' (CCMD) Specialised Register, and CENTRAL, MEDLINE, EMBASE and PsycINFO up to May 2017. We handsearched reference lists of relevant papers and previous systematic reviews. SELECTION CRITERIA All double-blind, randomised, controlled trials (RCTs) allocating adults with panic disorder to antidepressants or placebo. DATA COLLECTION AND ANALYSIS Two review authors independently checked eligibility and extracted data using a standard form. We entered data into Review Manager 5 using a double-check procedure. Information extracted included study characteristics, participant characteristics, intervention details and settings. Primary outcomes included failure to respond, measured by a range of response scales, and treatment acceptability, measured by total number of dropouts for any reason. Secondary outcomes included failure to remit, panic symptom scales, frequency of panic attacks, agoraphobia, general anxiety, depression, social functioning, quality of life and patient satisfaction, measured by various scales as defined in individual studies. We used GRADE to assess the quality of the evidence for each outcome MAIN RESULTS: Forty-one unique RCTs including 9377 participants overall, of whom we included 8252 in the 49 placebo-controlled arms of interest (antidepressant as monotherapy and placebo alone) in this review. The majority of studies were of moderate to low quality due to inconsistency, imprecision and unclear risk of selection and performance bias.We found low-quality evidence that revealed a benefit for antidepressants as a group in comparison with placebo in terms of efficacy measured as failure to respond (risk ratio (RR) 0.72, 95% confidence interval (CI) 0.66 to 0.79; participants = 6500; studies = 30). The magnitude of effect corresponds to a number needed to treat for an additional beneficial outcome (NNTB) of 7 (95% CI 6 to 9): that means seven people would need to be treated with antidepressants in order for one to benefit. We observed the same finding when classes of antidepressants were compared with placebo.Moderate-quality evidence suggested a benefit for antidepressants compared to placebo when looking at number of dropouts due to any cause (RR 0.88, 95% CI 0.81 to 0.97; participants = 7850; studies = 30). The magnitude of effect corresponds to a NNTB of 27 (95% CI 17 to 105); treating 27 people will result in one person fewer dropping out. Considering antidepressant classes, TCAs showed a benefit over placebo, while for SSRIs and serotonin-norepinephrine reuptake inhibitor (SNRIs) we observed no difference.When looking at dropouts due to adverse effects, which can be considered as a measure of tolerability, we found moderate-quality evidence showing that antidepressants as a whole are less well tolerated than placebo. In particular, TCAs and SSRIs produced more dropouts due to adverse effects in comparison with placebo, while the confidence interval for SNRI, noradrenergic reuptake inhibitors (NRI) and other antidepressants were wide and included the possibility of no difference. AUTHORS' CONCLUSIONS The identified studies comprehensively address the objectives of the present review.Based on these results, antidepressants may be more effective than placebo in treating panic disorder. Efficacy can be quantified as a NNTB of 7, implying that seven people need to be treated with antidepressants in order for one to benefit. Antidepressants may also have benefit in comparison with placebo in terms of number of dropouts, but a less favourable profile in terms of dropout due to adverse effects. However, the tolerability profile varied between different classes of antidepressants.The choice of whether antidepressants should be prescribed in clinical practice cannot be made on the basis of this review.Limitations in results include funding of some studies by pharmaceutical companies, and only assessing short-term outcomes.Data from the present review will be included in a network meta-analysis of psychopharmacological treatment in panic disorder, which will hopefully provide further useful information on this issue.
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Affiliation(s)
- Irene Bighelli
- Klinikum rechts der Isar, Technische Universität MünchenDepartment of Psychiatry and PsychotherapyIsmaningerstr. 22MunichGermany
| | - Mariasole Castellazzi
- University of VeronaDepartment of Neuroscience, Biomedicine and Movement Sciences, Section of PsychiatryVeronaItaly
| | - Andrea Cipriani
- University of OxfordDepartment of PsychiatryWarneford HospitalOxfordUKOX3 7JX
| | | | - Giuseppe Guaiana
- Western UniversityDepartment of PsychiatrySaint Thomas Elgin General Hospital189 Elm StreetSt ThomasONCanadaN5R 5C4
| | | | - Giulia Turrini
- University of VeronaDepartment of Neuroscience, Biomedicine and Movement Sciences, Section of PsychiatryVeronaItaly
| | - Toshi A Furukawa
- Kyoto University Graduate School of Medicine/School of Public HealthDepartment of Health Promotion and Human BehaviorYoshida Konoe‐cho, Sakyo‐ku,KyotoJapan606‐8501
| | - Corrado Barbui
- University of VeronaDepartment of Neuroscience, Biomedicine and Movement Sciences, Section of PsychiatryVeronaItaly
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Starcevic V. Benzodiazepines for anxiety disorders: maximising the benefits and minimising the risks. ACTA ACUST UNITED AC 2018. [DOI: 10.1192/apt.bp.110.008631] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
SummaryBenzodiazepines still play an important role in the management of anxiety disorders but dependence is associated with their therapeutic use. The key to effective and safe long-term use of benzodiazepines is: the careful selection of patients who might benefit from them; administration in clinical situations in which they are more likely to be beneficial; use of lower doses and in conjunction with an antidepressant, if possible; monitoring and managing their side-effects; and minimising the risk of withdrawal symptoms and relapse, mainly through tapering the dose and/or combining with effective psychological interventions.
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Bighelli I, Trespidi C, Castellazzi M, Cipriani A, Furukawa TA, Girlanda F, Guaiana G, Koesters M, Barbui C. Antidepressants and benzodiazepines for panic disorder in adults. Cochrane Database Syst Rev 2016; 9:CD011567. [PMID: 27618521 PMCID: PMC6457579 DOI: 10.1002/14651858.cd011567.pub2] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
BACKGROUND A panic attack is a discrete period of fear or anxiety that has a rapid onset, reaches a peak within 10 minutes and in which at least four of 13 characteristic symptoms are experienced, including racing heart, chest pain, sweating, shaking, dizziness, flushing, stomach churning, faintness and breathlessness. Panic disorder is common in the general population with a lifetime prevalence of 1% to 4%. The treatment of panic disorder includes psychological and pharmacological interventions. Amongst pharmacological agents, antidepressants and benzodiazepines are the mainstay of treatment for panic disorder. Different classes of antidepressants have been compared; and the British Association for Psychopharmacology, and National Institute for Health and Care Excellence (NICE) consider antidepressants (mainly selective serotonin reuptake inhibitors (SSRIs)) as the first-line treatment for panic disorder, due to their more favourable adverse effect profile over monoamine oxidase inhibitors (MAOIs) and tricyclic antidepressants (TCAs). In addition to antidepressants, benzodiazepines are widely prescribed for the treatment of panic disorder. OBJECTIVES To assess the evidence for the effects of antidepressants and benzodiazepines for panic disorder in adults. SEARCH METHODS The Specialised Register of the Cochrane Common Mental Disorders Group (CCMDCTR) to 11 September 2015. This register includes relevant randomised controlled trials from the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE (1950-), Embase (1974-) and PsycINFO (1967-). Reference lists of relevant papers and previous systematic reviews were handsearched. We contacted experts in this field for supplemental data. SELECTION CRITERIA All double-blind randomised controlled trials allocating adult patients with panic disorder to antidepressants or benzodiazepines versus any other active treatment with antidepressants or benzodiazepines. DATA COLLECTION AND ANALYSIS Two review authors independently checked eligibility and extracted data using a standard form. Data were entered in RevMan 5.3 using a double-check procedure. Information extracted included study characteristics, participant characteristics, intervention details, settings and outcome measures in terms of efficacy, acceptability and tolerability. MAIN RESULTS Thirty-five studies, including 6785 participants overall (of which 5365 in the arms of interest (antidepressant and benzodiazepines as monotherapy)) were included in this review; however, since studies addressed many different comparisons, only a few trials provided data for primary outcomes. We found low-quality evidence suggesting no difference between antidepressants and benzodiazepines in terms of response rate (risk ratio (RR) 0.99, 95% confidence interval (CI) 0.67 to 1.47; participants = 215; studies = 2). Very low-quality evidence suggested a benefit for benzodiazepines compared to antidepressants in terms of dropouts due to any cause, even if confidence interval (CI) ranges from almost no difference to benefit with benzodiazepines (RR 1.64, 95% CI 1.03 to 2.63; participants = 1449; studies = 7). We found some evidence suggesting that serotonin reuptake inhibitors (SSRIs) are better tolerated than TCAs (when looking at the number of patients experiencing adverse effects). We failed to find clinically significant differences between individual benzodiazepines. The majority of studies did not report details on random sequence generation and allocation concealment; similarly, no details were provided about strategies to ensure blinding. The study protocol was not available for almost all studies so it is difficult to make a judgment on the possibility of outcome reporting bias. Information on adverse effects was very limited. AUTHORS' CONCLUSIONS The identified studies are not sufficient to comprehensively address the objectives of the present review. The majority of studies enrolled a small number of participants and did not provide data for all the outcomes specified in the protocol. For these reasons most of the analyses were underpowered and this limits the overall completeness of evidence. In general, based on the results of the current review, the possible role of antidepressants and benzodiazepines should be assessed by the clinician on an individual basis. The choice of which antidepressant and/or benzodiazepine is prescribed can not be made on the basis of this review only, and should be based on evidence of antidepressants and benzodiazepines efficacy and tolerability, including data from placebo-controlled studies, as a whole. Data on long-term tolerability issues associated with antidepressants and benzodiazepines exposure should also be carefully considered.The present review highlights the need for further higher-quality studies comparing antidepressants with benzodiazepines, which should be conducted with high-methodological standards and including pragmatic outcome measures to provide clinicians with useful and practical data. Data from the present review will be included in a network meta-analysis of psychopharmacological treatment in panic disorder, which will hopefully provide further useful information on this issue.
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Affiliation(s)
- Irene Bighelli
- University of VeronaNeuroscience, Biomedicine and Movement Sciences, Section of PsychiatryVeronaItaly
| | - Carlotta Trespidi
- University of VeronaNeuroscience, Biomedicine and Movement Sciences, Section of PsychiatryVeronaItaly
| | - Mariasole Castellazzi
- University of VeronaNeuroscience, Biomedicine and Movement Sciences, Section of PsychiatryVeronaItaly
| | - Andrea Cipriani
- University of OxfordDepartment of PsychiatryWarneford HospitalOxfordUKOX3 7JX
| | - Toshi A Furukawa
- Kyoto University Graduate School of Medicine/School of Public HealthDepartment of Health Promotion and Human BehaviorYoshida Konoe‐cho, Sakyo‐ku,KyotoJapan606‐8501
| | - Francesca Girlanda
- University of VeronaDepartment of Public Health and Community Medicine, Section of PsychiatryPoliclinico "G.B.Rossi"Piazzale L.A. Scuro, 10VeronaItaly37134
| | - Giuseppe Guaiana
- Western UniversityDepartment of PsychiatrySaint Thomas Elgin General Hospital189 Elm StreetSt ThomasONCanadaN5R 5C4
| | - Markus Koesters
- Ulm UniversityDepartment of Psychiatry IILudwig‐Heilmeyer‐Str. 2GuenzburgGermanyD‐89312
| | - Corrado Barbui
- University of VeronaNeuroscience, Biomedicine and Movement Sciences, Section of PsychiatryVeronaItaly
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Abstract
Many aspects of long-term pharmacological treatments for anxiety disorders (AnxDs) are still debated. We undertook an updated systematic review of long-term pharmacological studies on panic disorder (PD), generalized anxiety disorder (GAD), and social anxiety disorder (SAD). Relevant studies dating from January 1, 2012 to August 31, 2015 were identified using the PubMed database and a review of bibliographies. Of 372 records identified in the search, five studies on PD and 15 on GAD were included in the review. No studies on SAD were found. Our review confirms the usefulness of long-term pharmacological treatments for PD and GAD and suggests that they can provide further improvement over that obtained during short-term therapy. Paroxetine, escitalopram, and clonazepam can be effective for long-term treatment of PD. However, further studies are needed to draw conclusions about the long-term benzodiazepine use in PD, particularly for the possible cognitive side-effects over time. Pregabalin and quetiapine can be effective for long-term treatment of GAD, while preliminary suggestions emerged for agomelatine and vortioxetine. We did not find any evidence for determining the optimal length and/or dosage of medications to minimize the relapse risk. Few investigations have attempted to identify potential predictors of long-term treatment response. Personalized treatments for AnxDs can be implemented using predictive tools to explore those factors affecting treatment response/tolerability heterogeneity, including neurobiological functions/clinical profiles, comorbidity, biomarkers, and genetic features, and to tailor medications according to each patient's unique features.
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Fujii K, Uchida H, Suzuki T, Mimura M. Dependence on benzodiazepines in patients with panic disorder: a cross-sectional study. Psychiatry Clin Neurosci 2015; 69:93-9. [PMID: 24836178 DOI: 10.1111/pcn.12203] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2014] [Revised: 04/18/2014] [Accepted: 05/11/2014] [Indexed: 11/30/2022]
Abstract
AIMS The aim of this cross-sectional study was to examine the prevalence of psychological dependence on benzodiazepines in outpatients with panic disorder and elucidate demographic and clinical characteristics associated with this condition. METHODS Subjects were eligible if they were outpatients in four clinics in Tokyo, Japan, aged 18 years or older and met the diagnostic criteria for panic disorder according to the ICD-10. The subjects received the following assessments: the Severity of Dependence Scale, Japanese Version (SDS), the Self-Report Version of Panic Disorder Severity Scale, Japanese Version (PDSS-SR), and the Quick Inventory of Depressive Symptomatology-Self Report, Japanese Version. The following information was also collected: age, sex, ethnicity, duration of illness, physical and psychiatric comorbidities, and details of prescribed psychotropic medications. RESULTS The data from 51 outpatients showed that 31 patients (60.8%) showed psychological dependence (i.e. a total score of ≥5 in the SDS). The proportion of patients with dependence was significantly lower in remitted patients (i.e. a total score of ≤4 in the PDSS) (44.1%, n = 15/34) than those who were not (94.1%, n = 16/17) (Pearson χ(2) = 11.9, P < 0.001). A multiple regression analysis showed that the PDSS scores showed a positive correlation with the SDS total scores (β = 0.60, 95% confidence interval = 0.30-0.90, P = 0.0001). CONCLUSION These findings emphasize the need for enhanced awareness about benzodiazepine dependence in patients and psychiatrists, as well as especially close attention to patients with panic disorder who present severe symptomatology.
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Affiliation(s)
- Kazuhito Fujii
- Department of Neuropsychiatry, Keio University School of Medicine, Tokyo, Japan; Azumabashi New Tower Clinic, Tokyo, Japan
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13
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Bullis JR, Fortune MR, Farchione TJ, Barlow DH. A preliminary investigation of the long-term outcome of the Unified Protocol for Transdiagnostic Treatment of Emotional Disorders. Compr Psychiatry 2014; 55:1920-7. [PMID: 25113056 PMCID: PMC4252968 DOI: 10.1016/j.comppsych.2014.07.016] [Citation(s) in RCA: 67] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2014] [Revised: 07/15/2014] [Accepted: 07/17/2014] [Indexed: 11/26/2022] Open
Abstract
OBJECTIVE The aim of this study is to conduct a preliminary examination of long-term outcomes on a broad range of affective disorder symptoms treated with a newly developed intervention: The Unified Protocol for Transdiagnostic Treatment of Emotional Disorders (UP). METHOD Maintenance of treatment gains at long-term follow-up (LTFU) were explored in patients (N=15, mean age=32.27; 60% female) who completed a clinical trial of the UP. RESULTS Treatment gains observed at 6-month follow-up (6MFU) on measures of clinical severity, general symptoms of depression and anxiety, and a measure of symptom interference in daily functioning were largely maintained 12months later (at an average of 18months posttreatment), and any significant changes from 6MFU to LTFU reflected small increases in symptoms that remained, on average, in the subclinical range. CONCLUSIONS These findings provide the first initial support for the durability of broad treatment gains following transdiagnostic treatment.
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Affiliation(s)
| | - Meghan R Fortune
- Boston University, 648 Beacon Street, 6th floor, Boston, MA 02215, USA.
| | - Todd J Farchione
- Boston University, 648 Beacon Street, 6th floor, Boston, MA 02215, USA.
| | - David H Barlow
- Boston University, 648 Beacon Street, 6th floor, Boston, MA 02215, USA.
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Starcevic V. The reappraisal of benzodiazepines in the treatment of anxiety and related disorders. Expert Rev Neurother 2014; 14:1275-86. [PMID: 25242262 DOI: 10.1586/14737175.2014.963057] [Citation(s) in RCA: 60] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Benzodiazepines (BDZs) continue to be shrouded in controversy, mainly because of dependence associated with their long-term use and some of their side effects. Despite treatment recommendations favoring newer antidepressants, BDZs are still commonly prescribed for anxiety and related disorders. Recent studies have demonstrated that long-term use of BDZs for these conditions can be effective and safe and that BDZs can be combined with psychological therapy and antidepressants to produce optimal outcomes. Such findings, along with a failure to convincingly demonstrate the overall superiority of alternative pharmacotherapy for anxiety and related disorders, have given an impetus to a reconsideration of the role of BDZs. This article reviews BDZs and other pharmacotherapy options for anxiety and related disorders and suggests that treatment guidelines should acknowledge that BDZs can be used as first-line, long-term pharmacological treatment for panic disorder, generalized anxiety disorder and social anxiety disorder.
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Affiliation(s)
- Vladan Starcevic
- Department of Psychiatry, Sydney Medical School - Nepean, University of Sydney, Nepean Hospital, PO Box 63; Penrith NSW 2751, Sydney, Australia
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15
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Gloster AT, Hauke C, Höfler M, Einsle F, Fydrich T, Hamm A, Sthröhle A, Wittchen HU. Long-term stability of cognitive behavioral therapy effects for panic disorder with agoraphobia: A two-year follow-up study. Behav Res Ther 2013; 51:830-9. [DOI: 10.1016/j.brat.2013.09.009] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2012] [Revised: 08/22/2013] [Accepted: 09/30/2013] [Indexed: 12/18/2022]
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Steinert C, Hofmann M, Leichsenring F, Kruse J. What do we know today about the prospective long-term course of social anxiety disorder? A systematic literature review. J Anxiety Disord 2013; 27:692-702. [PMID: 24176803 DOI: 10.1016/j.janxdis.2013.08.002] [Citation(s) in RCA: 56] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2013] [Revised: 06/28/2013] [Accepted: 08/16/2013] [Indexed: 12/18/2022]
Abstract
While we know that social anxiety disorder (SAD) is today's most common anxiety disorder knowledge on its prospective long-term course is sparse. We conducted a systematic literature search using databases Medline and PsycINFO for naturalistic and psychotherapy outcome studies with follow-up durations of at least 24 months. Four naturalistic cohorts and nine psychotherapy trials were included in the review. The naturalistic course in clinical was less favorable than in non-clinical samples (27% vs. 40% recovery rate after 5 years). Psychotherapy trials, all applying (cognitive) behavioral methods, yielded stable outcomes with overall large pre- to follow-up effect sizes on self-report scales. Observer rated remission rates varied considerably (36% to 100%) depending on study design and follow-up length. The results of psychotherapy trials and that of naturalistic studies can hardly be compared due to differences in methodology. More standardized remission and recovery criteria are needed to enhance the understanding of the longitudinal course.
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Affiliation(s)
- Christiane Steinert
- Clinic for Psychosomatic Medicine and Psychotherapy, University of Giessen, Ludwigstrasse 76, 35392 Giessen, Germany.
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17
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Nay W, Brown R, Roberson-Nay R. Longitudinal course of panic disorder with and without agoraphobia using the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC). Psychiatry Res 2013; 208:54-61. [PMID: 23587657 DOI: 10.1016/j.psychres.2013.03.006] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2012] [Revised: 03/05/2013] [Accepted: 03/07/2013] [Indexed: 01/22/2023]
Abstract
Few naturalistic, longitudinal studies of panic disorder with and without agoraphobia (PD/PDA) exist, limiting our knowledge of the temporal rates of incidence, relapse, and chronicity, or the factors that predict category transition. Data from the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC) wave 1 (n=43,093) and wave 2 (n=34,653) were utilized to determine transitional rates, and predictors of category transitions, over a 3-year period. Analyses revealed very high 3-year remission rates for PD and PDA (75% and 67%, respectively), although relapse also was relatively frequent (PD=12%; PDA=21%). Logistic regression revealed previous history of panic attacks, generalized anxiety disorder/major depression (GAD/MDD), nicotine dependence, female sex, younger age, and major financial crises to be reliable predictors of incidence and relapse. The direction and magnitude of association of many predictor variables were similar for PD and PDA, with notable exceptions for social anxiety and romantic relationship factors. Clinicians should be aware of the relapsing-remitting nature of PD and PDA and, thus, take caution to not reduce or eliminate effective treatments prematurely. Similarly, the current study suggests clinicians pay particular attention to concurrent factors relevant to relapse in PD/PDA that may also be clinically addressed (e.g., co-morbid MDD/GAD and nicotine dependence).
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Affiliation(s)
- William Nay
- Virginia Commonwealth University, Department of Psychiatry, P.O. Box 980253, Richmond, VA 23298-0253, USA.
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18
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The Autonomic Nervous System Questionnaire and the Brief Patient Health Questionnaire as screening instruments for panic disorder in Finnish primary care. Eur Psychiatry 2013; 28:442-7. [PMID: 23273422 DOI: 10.1016/j.eurpsy.2012.03.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2011] [Revised: 03/11/2012] [Accepted: 03/12/2012] [Indexed: 11/20/2022] Open
Abstract
PURPOSE As panic disorder often remains unrecognized in the health care system, some screening methods have been developed to enhance its recognition. The aim of this study was to test and compare the Autonomic Nervous System Questionnaire (ANS) and the Brief Patient Health Questionnaire (BPHQ) in primary care. SUBJECTS AND METHODS A total sample of 211 primary care outpatients was studied. The Structured Clinical Interview for DSM-IV was the criterion standard for the presence of panic disorder. Indices of diagnostic utility for both screening methods were calculated and compared. RESULTS The AUC (area under the ROC curve) was 0.885 for the ANS and 0.877 for the BPHQ. At the optimal cut-off level, the ANS had the sensitivity of 0.88 and specificity of 0.77; the BPHQ had the sensitivity of 0.79 and the specificity of 0.87. There was not any statistically significant difference between the screens. CONCLUSIONS Both screening methods can be recommended both for clinical practice and research use. In busy primary care practice, the BPHQ may be more useful, as it can be used together with the depression module of the BPHQ.
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Hara N, Nishimura Y, Yokoyama C, Inoue K, Nishida A, Tanii H, Okada M, Kaiya H, Okazaki Y. The development of agoraphobia is associated with the symptoms and location of a patient's first panic attack. Biopsychosoc Med 2012; 6:12. [PMID: 22494552 PMCID: PMC3349583 DOI: 10.1186/1751-0759-6-12] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2011] [Accepted: 04/11/2012] [Indexed: 11/12/2022] Open
Abstract
Background The place where a patient experiences his/her first panic attack (FPA) may be related to their agoraphobia later in life. However, no investigations have been done into the clinical features according to the place where the FPA was experienced. In particular, there is an absence of detailed research examining patients who experienced their FPA at home. In this study, patients were classified by the location of their FPA and the differences in their clinical features were explored (e.g., symptoms of FPA, frequency of agoraphobia, and severity of FPA). Methods The subjects comprised 830 panic disorder patients who were classified into 5 groups based on the place of their FPA (home, school/office, driving a car, in a public transportation vehicle, outside of home), The clinical features of these patients were investigated. Additionally, for panic disorder patients with agoraphobia at their initial clinic visit, the clinical features of patients who experienced their FPA at home were compared to those who experienced their attack elsewhere. Results In comparison of the FPAs of the 5 groups, significant differences were seen among the 7 descriptors (sex ratio, drinking status, smoking status, severity of the panic attack, depression score, ratio of agoraphobia, and degree of avoidance behavior) and 4 symptoms (sweating, chest pain, feeling dizzy, and fear of dying). The driving and public transportation group patients showed a higher incidence of co-morbid agoraphobia than did the other groups. Additionally, for panic disorder patients with co-morbid agoraphobia, the at-home group had a higher frequency of fear of dying compared to the patients in the outside-of-home group and felt more severe distress elicited by their FPA. Conclusion The results of this study suggest that the clinical features of panic disorder patients vary according to the place of their FPA. The at-home group patients experienced "fear of dying" more frequently and felt more distress during their FPA than did the subjects in the other groups. These results indicate that patients experiencing their FPA at home should be treated with a focus on the fear and distress elicited by the attack.
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Affiliation(s)
- Naomi Hara
- Department of Psychiatry, Division of Neuroscience, Graduate School of Medicine, Mie University, Mie, Japan.
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20
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Affiliation(s)
- Vladan Starcevic
- Discipline of Psychiatry, Sydney Medical School, University of Sydney, Sydney, Australia.
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21
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Moylan S, Giorlando F, Nordfjærn T, Berk M. The role of alprazolam for the treatment of panic disorder in Australia. Aust N Z J Psychiatry 2012; 46:212-24. [PMID: 22391278 DOI: 10.1177/0004867411432074] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVE To investigate the potential impact of increasing prescription rates of alprazolam for the treatment of panic disorder (PD) in Australia through a review of efficacy, tolerability and adverse outcome literature. METHODS Data were sourced by a literature search using MEDLINE, Embase, PsycINFO and a manual search of scientific journals to identify relevant articles. Clinical practice guidelines from the American Psychiatric Association, National Institute of Clinical Excellence, Royal Australian and New Zealand College of Psychiatrists and World Federation of Societies of Biological Psychiatry were sourced. Prescription data were sourced from Australian governmental sources. RESULTS Alprazolam has shown efficacy for control of PD symptoms, particularly in short-term controlled clinical trials, but is no longer recommended as a first-line pharmacological treatment due to concerns about the risks of developing tolerance, dependence and abuse potential. Almost no evidence is available comparing alprazolam to current first-line pharmacological treatment. Despite this, prescription rates are increasing. A number of potential issues including use in overdose and impact on car accidents are noted. conclusion: Although effective for PD symptoms in clinical trials, a number of potential issues may exist with use. Consideration of its future place in PD treatment in Australia may be warranted.
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Affiliation(s)
- Steven Moylan
- School of Medicine, Deakin University, Geelong, Australia.
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22
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Durham RC, Higgins C, Chambers JA, Swan JS, Dow MGT. Long-term outcome of eight clinical trials of CBT for anxiety disorders: symptom profile of sustained recovery and treatment-resistant groups. J Affect Disord 2012; 136:875-81. [PMID: 22014916 DOI: 10.1016/j.jad.2011.09.017] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2011] [Revised: 09/15/2011] [Accepted: 09/15/2011] [Indexed: 10/16/2022]
Abstract
BACKGROUND Few clinical trials of cognitive behaviour therapy (CBT) for anxiety disorders have conducted follow-up beyond one year post-treatment. This paper summarises the long-term outcome of eight clinical trials of CBT for anxiety disorders in terms of diagnostic status, healthcare usage and symptom severity and compares the symptom profile of participants with the best and worst outcomes relative to chronic depression and the normal population. METHODS Follow-up at 2-14years with 396 patients (51% of those available to contact) employed structured diagnostic interview, assessment of healthcare usage and self-report measures of symptom severity. This paper concerns 336 participants who had either no disorder or at least one anxiety disorder and information on healthcare usage over the follow-up period. RESULTS Only 38% recovered with little or no treatment over the follow-up period while 30% had a very poor outcome despite extensive treatment for anxiety over many years. The symptom profile of this 'treatment-resistant' group was comparable to 76 patients with chronic depression and significantly worse than normative data for psychiatric outpatients. Chronic anxiety disorder with co-morbid depression has a more severe symptom profile than chronic anxiety disorder alone. LIMITATIONS The follow-up sample, although broadly representative, may have a bias towards a more favourable picture of overall outcome. CONCLUSIONS The long-term outcome of anxiety disorders, irrespective of diagnosis or active treatment, is diverse but with a tendency towards chronicity. Distinctions between acute and chronic presentations of common mental disorders are more important than distinctions between chronic anxiety and chronic depression.
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Affiliation(s)
- Robert C Durham
- Centre for Neuroscience, Ninewells Hospital & Medical School, University of Dundee, Dundee, Scotland, United Kingdom.
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A randomized, naturalistic, parallel-group study for the long-term treatment of panic disorder with clonazepam or paroxetine. J Clin Psychopharmacol 2012; 32:120-6. [PMID: 22198456 DOI: 10.1097/jcp.0b013e31823fe4bd] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
This long-term extension of an 8-week randomized, naturalistic study in patients with panic disorder with or without agoraphobia compared the efficacy and safety of clonazepam (n = 47) and paroxetine (n = 37) over a 3-year total treatment duration. Target doses for all patients were 2 mg/d clonazepam and 40 mg/d paroxetine (both taken at bedtime). This study reports data from the long-term period (34 months), following the initial 8-week treatment phase. Thus, total treatment duration was 36 months. Patients with a good primary outcome during acute treatment continued monotherapy with clonazepam or paroxetine, but patients with partial primary treatment success were switched to the combination therapy. At initiation of the long-term study, the mean doses of clonazepam and paroxetine were 1.9 (SD, 0.30) and 38.4 (SD, 3.74) mg/d, respectively. These doses were maintained until month 36 (clonazepam 1.9 [SD, 0.29] mg/d and paroxetine 38.2 [SD, 3.87] mg/d). Long-term treatment with clonazepam led to a small but significantly better Clinical Global Impression (CGI)-Improvement rating than treatment with paroxetine (mean difference: CGI-Severity scale -3.48 vs -3.24, respectively, P = 0.02; CGI-Improvement scale 1.06 vs 1.11, respectively, P = 0.04). Both treatments similarly reduced the number of panic attacks and severity of anxiety. Patients treated with clonazepam had significantly fewer adverse events than those treated with paroxetine (28.9% vs 70.6%, P < 0.001). The efficacy of clonazepam and paroxetine for the treatment of panic disorder was maintained over the long-term course. There was a significant advantage with clonazepam over paroxetine with respect to the frequency and nature of adverse events.
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The efficacy and safety of alprazolam versus other benzodiazepines in the treatment of panic disorder. J Clin Psychopharmacol 2011; 31:647-52. [PMID: 21869686 DOI: 10.1097/jcp.0b013e31822d0012] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
We performed a meta-analysis of all single- or double-blind, randomized controlled trials comparing alprazolam to another benzodiazepine in the treatment of adult patients meeting the Diagnostic and Statistical Manual of Mental Disorders, Third or Fourth Edition, criteria for panic disorder or agoraphobia with panic attacks. Eight studies met inclusion criteria, describing a total of at least 631 randomized patients. In the pooled results, there were no significant differences in efficacy between alprazolam and the comparator benzodiazepines on any of the prespecified outcomes: improvement in mean panic attack frequency (between-arm weighted mean difference of 0.6 panic attacks per week; 95% confidence interval [CI], -0.3 to 1.6), improvement in Hamilton Anxiety Rating Scale score (weighted mean difference of 0.8 points; 95% CI, -0.5 to 2.1), and proportion of patients free of panic attacks at the final evaluation (pooled relative risk, 1.1; 95% CI, 0.9-1.4). Statistical heterogeneity on prespecified outcomes was not eliminated by stratification on baseline anxiety level. The available evidence fails to demonstrate alprazolam as superior to other benzodiazepines for the treatment of panic disorder.
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Kipper L, Wachleski C, Salum GA, Heldt E, Blaya C, Manfro GG. Can psychopharmacological treatment change personality traits in patients with panic disorder? BRAZILIAN JOURNAL OF PSYCHIATRY 2011; 31:307-13. [PMID: 20098823 DOI: 10.1590/s1516-44462009000400005] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/30/2009] [Accepted: 04/15/2009] [Indexed: 11/21/2022]
Abstract
OBJECTIVE The aim of this study was to evaluate the effects that a particular psychopharmacological treatment has on personality patterns in patients with panic disorder. METHOD Forty-seven patients with panic disorder and 40 controls were included in the study. The Mini International Neuropsychiatric Interview and Minnesota Multiphasic Personality Inventory were used to assess Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, diagnoses and personality traits, respectively. Patients were treated with sertraline for 16 weeks. RESULTS There was a significant decrease in the score on 8 of the 10 Minnesota Multiphasic Personality Inventory scales. In addition, neurotic triad and psychasthenia personality scores were higher among panic disorder patients, even during the posttreatment asymptomatic phase, than among controls. CONCLUSION In the asymptomatic phase of the disease, panic disorder patients present a particular neurotic/anxious personality pattern. This pattern, although altered in the presence of acute symptoms, could be a focus of research.
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Affiliation(s)
- Letícia Kipper
- Postgraduate Program in Medical Sciences: Psychiatry, Universidade Federal do Rio Grande do Sul, Porto Alegre, RS, Brazil
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Abstract
OBJECTIVE To examine the association between several subtypes of anxiety disorders and various cortisol indicators in a large cohort study. Anxiety disorders have been suggested to be linked to hypothalamic-pituitary-adrenal (HPA) axis activity, although results are scarce and inconsistent. No earlier studies have examined consistency of HPA axis findings across several anxiety subtypes and whether associations are state or trait dependent. METHODS Data are derived from 1427 participants of the Netherlands Study of Depression and Anxiety. Three groups were compared: 342 control participants without psychiatric disorders; 311 persons with a remitted (no current) anxiety disorder (social phobia, generalized anxiety disorder, panic disorder); and 774 persons with a current anxiety disorder, as diagnosed using the Composite International Diagnostic Interview psychiatric interview. Cortisol levels were measured in seven saliva samples, determining the 1-hour cortisol awakening response, evening cortisol, and cortisol response after 0.5 mg of dexamethasone ingestion. RESULTS Current anxiety disorder was associated with higher awakening cortisol levels (p = .002). These findings were mainly present for patients with panic disorder with agoraphobia and anxious patients with comorbid depressive disorder. Remitted anxiety only showed a trend toward higher morning cortisol (p = .08). No associations were observed for anxiety status and evening cortisol level or cortisol suppression after dexamethasone. CONCLUSIONS This study showed a modest but significantly higher 1-hour cortisol awakening response among anxiety patients, which was driven by those with panic disorder with agoraphobia and those with comorbid depression.
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Abstract
PURPOSE OF REVIEW Although anxiety disorders are acknowledged as chronic, the issue of the pharmacological treatment duration remains unsettled. This review focuses on the long-term outcome of patients with anxiety disorders as demonstrated by randomized controlled trials. RECENT FINDINGS Results from long-term randomized controlled trials of antidepressants in anxiety disorders indicate that maintenance treatment significantly reduces the odds of relapse, whatever the anxiety disorder is. This result appears to be similar to what is reported in long-term studies in depressive disorders. In addition, regarding the natural course of depressive disorders, acknowledged as mostly recurrent, some patients may require very long-term treatment, that is, more than 2 years. Moreover, naturalistic studies in anxiety disorders indicate that the relapse risk after discontinuation is not associated with the treatment duration. Finally, there is no predictor to identify those patients who require long-term pharmacotherapy for anxiety disorders. SUMMARY In light of this review, other long-term studies in anxiety disorders have to be undertaken to identify predictors of relapse after treatment discontinuation. As it is now acknowledged for depressive disorders, some patients may require very long-term pharmacological treatment for anxiety disorders.
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Nine-year follow-up of panic disorder in chest pain patients: clinical course and predictors of outcome. Gen Hosp Psychiatry 2008; 30:138-46. [PMID: 18291295 DOI: 10.1016/j.genhosppsych.2007.12.009] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/04/2007] [Revised: 12/11/2007] [Accepted: 12/12/2007] [Indexed: 11/23/2022]
Abstract
OBJECTIVE The aim was to investigate the association between panic disorder (PD) and long-term outcomes in terms of psychiatric morbidity, psychological distress and health-related quality of life (HRQOL), and to identify predictors of poor outcome for PD in chest pain patients. METHOD Nine-year follow-up study of chest pain patients (n=199) referred to cardiology outpatient investigation. Assessments included Structured Clinical Interview for DSM-IV, Symptom Checklist-90-R (SCL-90-R), Illness Attitude Scale, Agoraphobia Cognitions Questionnaire, the Mobility Inventory for Agoraphobia, Personality Diagnostic Questionnaire and the Medical Outcome Study Short Form-36. At baseline, 76 patients suffered from PD. RESULTS Of 184 eligible patients, 150 participated in the follow-up study. Panic disorder at baseline was associated with a higher prevalence of comorbid Axis I disorders, psychological distress and poorer HRQOL at follow-up compared with patients without PD. Of the participants with PD at baseline (n=55), 14 suffered from persistent PD at follow-up. Patients with persistent PD had particularly poor outcomes regarding comorbid Axis I disorders, suicidal ideation (21%) and HRQOL. A mean baseline SCL-90-R somatization score above 1.4 predicted a 5-fold increased risk of persistent PD. CONCLUSION Chest pain patients with PD have a negative long-term outcome and those who score high on somatization require special attention because of particularly poor outcomes.
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Choy Y, Peselow ED, Case BG, Pressman MA, Luff JA, Laje G, Paizis M, Ying P, Guardino MT. Three-year medication prophylaxis in panic disorder: to continue or discontinue? A naturalistic study. Compr Psychiatry 2007; 48:419-25. [PMID: 17707249 DOI: 10.1016/j.comppsych.2007.04.003] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2006] [Revised: 03/22/2007] [Accepted: 04/05/2007] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVE Little is known about maintenance treatment for panic disorder. The purpose of this naturalistic study is to compare outcomes of remitted panic disorder patients continued on versus those successfully discontinued from maintenance medication. METHODS After 3 years of sustained remission with medication in a naturalistic setting, 168 patients were continued on, whereas 37 successfully discontinued from medication. Continued and discontinued groups were followed for an additional 4 to 8 years and compared for differences in treatment outcome using chi(2) and Wilcoxon rank sum tests. Times to relapse were analyzed using the Kaplan-Meier product-limit method, and risk factors for relapse were assessed using Cox proportional hazards regression. RESULTS The discontinued group was healthier at baseline but had a significantly worse outcome compared with the continued group. Panic-free survival probabilities for the continued group at 1, 2, 3, and 4 years were 0.87, 0.81, 0.71, and 0.64, respectively, and were significantly higher than respective probabilities of 0.53, 0.35, 0.29, and 0.15 for the discontinued group. Median survival time in the continued group was significantly longer, at 5.67 years, than in the discontinued group, at 1.17 years. Cognitive behavioral therapy significantly reduced hazard in the discontinued but not in the continued group. Residual symptoms in either group at time of assignment predicted poorer outcome. CONCLUSION Our small study suggests that relapse of panic disorder in routine clinical practice occurs even after long-standing remission on maintenance medication, and that relapse risk appears to be markedly higher after medication discontinuation. Discontinuation may be more successful in candidates who received cognitive behavioral therapy and have minimal residual symptoms.
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Affiliation(s)
- Yujuan Choy
- Freedom from Fear, Staten Island, NY 10305, USA.
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Abstract
OBJECTIVE To review the most salient issues in the pharmacotherapy of anxiety disorders. These pertain to means of achieving greater efficacy, accelerating the onset of therapeutic action, improving side-effect profile and tolerability, decreasing the propensity to induce therapeutic dependence and achieving better long-term outcome. CONCLUSIONS By and large, pharmacological agents with greater efficacy in anxiety disorders have yet to be developed. Several strategies have been used with some success to make medications for anxiety disorders work faster and to lessen their side-effect burden. The field of psychopharmacology has yet to find ways of lessening or eliminating the problem of therapeutic drug dependence and, even more so, of minimizing the risk of relapse following the cessation of medication.
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Affiliation(s)
- Vladan Starcevic
- Discipline of Psychological Medicine, University of Sydney, and Nepean Hospital, Sydney, NSW, Australia.
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Bruce SE, Yonkers KA, Otto MW, Eisen JL, Weisberg RB, Pagano M, Shea MT, Keller MB. Influence of psychiatric comorbidity on recovery and recurrence in generalized anxiety disorder, social phobia, and panic disorder: a 12-year prospective study. Am J Psychiatry 2005; 162:1179-87. [PMID: 15930067 PMCID: PMC3272761 DOI: 10.1176/appi.ajp.162.6.1179] [Citation(s) in RCA: 580] [Impact Index Per Article: 30.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
OBJECTIVE The authors sought to observe the long-term clinical course of anxiety disorders over 12 years and to examine the influence of comorbid psychiatric disorders on recovery from or recurrence of panic disorder, generalized anxiety disorder, and social phobia. METHOD Data were drawn from the Harvard/Brown Anxiety Disorders Research Program, a prospective, naturalistic, longitudinal, multicenter study of adults with a current or past history of anxiety disorders. Probabilities of recovery and recurrence were calculated by using standard survival analysis methods. Proportional hazards regression analyses with time-varying covariates were conducted to determine risk ratios for possible comorbid psychiatric predictors of recovery and recurrence. RESULTS Survival analyses revealed an overall chronic course for the majority of the anxiety disorders. Social phobia had the smallest probability of recovery after 12 years of follow-up. Moreover, patients who had prospectively observed recovery from their intake anxiety disorder had a high probability of recurrence over the follow-up period. The overall clinical course was worsened by several comorbid psychiatric conditions, including major depression and alcohol and other substance use disorders, and by comorbidity of generalized anxiety disorder and panic disorder with agoraphobia. CONCLUSIONS These data depict the anxiety disorders as insidious, with a chronic clinical course, low rates of recovery, and relatively high probabilities of recurrence. The presence of particular comorbid psychiatric disorders significantly lowered the likelihood of recovery from anxiety disorders and increased the likelihood of their recurrence. The findings add to the understanding of the nosology and treatment of these disorders.
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Affiliation(s)
- Steven E Bruce
- Department of Psychiatry and Human Behavior, Brown University, RI 02906, USA.
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Kenardy J, Robinson S, Dob R. Cognitive Behaviour Therapy for Panic Disorder: Long‐term Follow‐up. Cogn Behav Ther 2005; 34:75-8. [PMID: 15986783 DOI: 10.1080/16506070410005410] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
This paper describes a long-term follow-up of patients with panic disorder who received cognitive behaviour therapy within a randomized controlled trial. Of 89 patients eligible for follow-up, 28 (31.5%) were reassessed 6-8 years after commencement of treatment in the trial. No differences were found between those who were followed up and those lost to follow-up on most baseline measures including measures of panic-related psychopathology, or depression. Outcomes at long-term follow-up were significantly better than baseline measures of panic, avoidance and depression. In this sub-sample the effect of cognitive behaviour therapy for panic disorder appears to maintain over the long-term.
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Affiliation(s)
- Justin Kenardy
- Centre of National Research on Disability and Rehabilitation Medicine, School of Medicine, University of Queensland, Herston, Australia.
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