Incremental cost-effectiveness of pharmacotherapy and two brief cognitive-behavioral therapies compared with usual care for panic disorder and noncardiac chest pain

Clinical efficacy of Kuanxiong aerosol for patients with prehospital chest pain: A randomized controlled trial

BACKGROUND

Kuanxiong Aerosol (KXA)(CardioVent®), consisting of Asarum sieboldii Miq. oil, Santalum album L. oil, Alpinia officinarum Hance oil, Piper longum L. oil and borneol, seems to relieve the symptoms of chest pain and serve as a supplementary treatment for prehospital chest pain in emergency department.

STYLE OF THE STUDY

This randomized controlled trial aimed to determine the clinical effect and safety of KXA for patients with prehospital chest pain.

METHODS

A total of 200 patients were recruited from Guangdong Provincial Hospital of Chinese Medicine and randomly divided into KXA group (n = 100) and Nitroglycerin Aerosol (NA) group (n = 100) by SAS 9.2 software. All patients were treated with standardized Western medicine according to the pre-hospital procedure. The experimental group and NA group was additionally treated with KXA and NA respectively. The primary outcome was the relieving time of prehospital chest pain (presented as relief rate) after first-time treatment. The secondary outcomes included the evaluation of chest pain (NRS scores, degree of chest pain, frequency of chest pain after first-time treatment), efficacy in follow-up time (the frequency of average aerosol use, emergency department visits, 120 calls, medical observations and hospitalization at 4 weeks, 8 weeks, 12 weeks), alleviation of chest pain (Seattle angina questionnaire, chest pain occurrence, and degree of chest pain at 12-weeks treatment) and the change of TCM symptoms before and after 12-weeks treatment. In addition, the safety of KXA was also assessed by the occurrence of adverse events. The database was created using Epidata software, and statistical analysis was conducted by SPSS 23.0 software.

RESULTS

A total of 194 participants finally completed the trial, the results showed that after first-time treatment, KXA had a higher relief rate (72.2%) of chest pain within 30 min than that of NA group (59.4%, p = 0.038), KXA group had a lower degree of chest pain (p = 0.005), lower NRS score (p = 0.011) and higher reduction of NRS score (p = 0.005) than the NA. In the follow-up period, KXA group decreased the frequency of 120 call better than that of NA group at 4 weeks (p = 0.040), but KXA had a similar efficacy as NA in the improvement on the of frequency of chest pain, aerosol use, emergency department visits, 120 call, medical observation and hospitalization at 4 weeks, 8 weeks and 12 weeks (p>0.05). There also had no difference between the two groups on the occurrence of chest pain, degree of chest pain, physical limitation, angina stability, treatment satisfaction, and disease perception between the two groups at 12 weeks (p>0.05). In addition, KXA and NA both improved the patient's chest pain, but not the TCM symptoms. In terms of safety, KXA showed similar safety as NA in this study.

CONCLUSIONS

KXA relieved prehospital chest pain faster than NA and had a better remission effect on the prehospital chest pain than that of the NA group in short-period. In long-period, KXA showed similar efficacy on the improvement of prehospital chest pain as NA. KXA may be a safe and reliable therapy for prehospital chest pain.

Protocol for a multi-site randomized controlled trial of a stepped-care intervention for emergency department patients with panic-related anxiety

BACKGROUND

Approximately 40% of Emergency Department (ED) patients with chest pain meet diagnostic criteria for panic-related anxiety, but only 1-2% are correctly diagnosed and appropriately managed in the ED. A stepped-care model, which focuses on providing evidence-based interventions in a resource-efficient manner, is the state-of-the art for treating panic disorder patients in medical settings such as primary care. Stepped-care has yet to be tested in the ED setting, which is the first point of contact with the healthcare system for most patients with panic symptoms.

METHODS

This multi-site randomized controlled trial (RCT) aims to evaluate the clinical, patient-centred, and economic effectiveness of a stepped-care intervention in a sample of 212 patients with panic-related anxiety presenting to the ED of Singapore's largest public healthcare group. Participants will be randomly assigned to either: 1) an enhanced care arm consisting of a stepped-care intervention for panic-related anxiety; or 2) a control arm consisting of screening for panic attacks and panic disorder. Screening will be followed by baseline assessments and blocked randomization in a 1:1 ratio. Masked follow-up assessments will be conducted at 1, 3, 6, and 12 months. Clinical outcomes will be panic symptom severity and rates of panic disorder. Patient-centred outcomes will be health-related quality of life, daily functioning, psychiatric comorbidity, and health services utilization. Economic effectiveness outcomes will be the incremental cost-effectiveness ratio of the stepped-care intervention relative to screening alone.

DISCUSSION

This trial will examine the impact of early intervention for patients with panic-related anxiety in the ED setting. The results will be used to propose a clinically-meaningful and cost-effective model of care for ED patients with panic-related anxiety.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03632356. Retrospectively registered 15 August 2018.

Changes in Prefrontal Gamma-Aminobutyric Acid and Perfusion After the Computerized Relaxation Training in Women With Psychological Distress: A Preliminary Report

Computerized relaxation training has been suggested as an effective and easily accessible intervention for individuals with psychological distress. To better elucidate the neural mechanism that underpins the effects of relaxation training, we investigated whether a 10-session computerized relaxation training program changed prefrontal gamma-aminobutyric acid (GABA) levels and cerebral blood flow (CBF) in women with psychological distress. We specifically focused on women since they were reported to be more vulnerable to develop stress-related disorders than men. Nineteen women with psychological distress but without a diagnosis of psychiatric disorders received the 10-day computerized relaxation training program that consisted of 30-min cognitive-relaxation training and 10-min breathing-relaxation training per day. At baseline and post-intervention, perceived stress levels, anxiety, fatigue, and sleep quality were assessed by self-report questionnaires. Brain magnetic resonance spectroscopy and arterial spin labeling scans were also performed before and after the intervention to evaluate GABA levels and relative CBF in the prefrontal region. Levels of perceived stress (t = 4.02, P < 0.001), anxiety (z = 2.33, P = 0.02), fatigue (t = 3.35, P = 0.004), and sleep quality (t = 4.14, P < 0.001) improved following 10 sessions of computerized relaxation training, resulting in a significant relief in composite scores of stress-related symptoms (t = -5.25, P < 0.001). The prefrontal GABA levels decreased (t = 2.53, P = 0.02), while relative CBF increased (t = -3.32, P = 0.004) after the intervention. In addition, a greater increase in relative prefrontal CBF was associated with better composite scores of stress-related symptoms following the intervention (t = 2.22, P = 0.04). The current findings suggest that computerized relaxation training may improve stress-related symptoms through modulating the prefrontal GABA levels and CBF in women with psychological distress.

Early intervention for subthreshold panic disorder in the Netherlands: A model-based economic evaluation from a societal perspective

Background

Panic disorder (PD) is associated with impaired functioning and reduced quality of life. In the Netherlands, almost 2% of the population experiences clinically relevant panic symptoms without meeting the diagnostic criteria for PD, which is referred to as subthreshold PD (STHPD). Evidence suggests that subthreshold mental disorders may have a similar impact on quality of life and functioning in comparison with full-blown mental disorders, which draws attention to the need for interventions for STHPD. These interventions are currently not systematically provided in clinical practice. This study aims to investigate the population cost-effectiveness of adding a CBT-based early intervention for adults with STHPD to the existing health care for people with PD in the Netherlands.

Methods

A health-economic Markov model was constructed in order to compare quality adjusted life-years (QALYs) and societal costs of adding an early intervention to usual care for PD. The model compares usual care with an alternative program in which usual care is supplemented with a CBT-based early intervention. Input parameters for the model were derived from national sources and published literature where possible, and based on expert opinion otherwise. Probabilistic and deterministic sensitivity analyses were conducted to evaluate the uncertainty of the model input parameters.

Results

On average, the added CBT-based early intervention was dominant in comparison with usual care, meaning that the early intervention yielded more QALYs at lower costs. At a willingness-to-pay threshold of €20,000 per QALY, the cost-effectiveness probability of the added early intervention was 98%. Sensitivity analyses showed that the results were robust.

Conclusions

This study showed that offering an early intervention in addition to usual care for PD is potentially cost-effective, but it should be further investigated to what extent trial results can be extrapolated to the level of the population before such interventions are implemented on a large scale.

Heart-focused anxiety and health care seeking in patients with non-cardiac chest pain: A prospective study

OBJECTIVES

This study aimed to estimate the incidence of medical consultations six months after an emergency department (ED) consultation for non-cardiac chest pain (NCCP). It also investigated the role of heart-focused anxiety (HFA) and other factors in predicting an increased healthcare utilization in these patients.

METHOD

This was a prospective study of 428 patients who came to an ED with NCCP. Patients completed an interview and questionnaires assessing HFA, psychological distress, the characteristics of NCCP, and comorbidities. Their medical consultations were assessed by telephone interview six months later. The contribution of each factor was assessed using a binomial negative regression.

RESULTS

Eighty-three percent of patients reported at least one medical consultation (mean=3.1, standard deviation=3.9). HFA (incident rate ratio 1.01; 95% CI, 1.00-1.02), the presence of a medical condition (2.14; 1.51-3.03), NCCP frequency (1.49; 1.16-1.91) and NCCP-related interference (1.08; 1.04-1.13) were predictive of further medical consultations.

CONCLUSIONS

A significant proportion of patients with NCCP are at risk of multiple medical consultations following discharge from the ED. HFA appears as a determinant of medical consultations after controlling for multiple confounding factors.

Cost-effectiveness of interventions for treating anxiety disorders: A systematic review

BACKGROUND

Anxiety disorders are highly prevalent mental disorders that constitute a major burden on patients and society. As a consequence, economic evaluations of the interventions have become increasingly important. However, no recent overview of these economic evaluations is currently available and the quality of the published economic evaluations has not yet been assessed. Therefore, the current study has two aims: to provide an overview of the evidence regarding the cost-effectiveness of interventions for anxiety disorders, and to assess the quality of the studies identified.

METHODS

A systematic review was conducted using PubMed, PsycINFO, NHS-EED, and the CEA registry. We included full economic evaluations on interventions for all anxiety disorders published before April 2016, with no restrictions on study populations and comparators. Preventive interventions were excluded. Study characteristics and cost-effectiveness data were collected. The quality of the studies was appraised using the Consensus on Health Economic Criteria.

RESULTS

Forty-two out of 826 identified studies met the inclusion criteria. The studies were heterogeneous and the quality was variable. Internet-delivered cognitive behavioural therapy (iCBT) appeared to be cost-effective in comparison with the control conditions. Four out of five studies comparing psychological interventions with pharmacological interventions showed that psychological interventions were more cost-effective than pharmacotherapy.

LIMITATIONS

Comparability was limited by heterogeneity in terms of interventions, study design, outcome and study quality.

CONCLUSIONS

Forty-two studies reporting cost-effectiveness of interventions for anxiety disorders were identified. iCBT was cost-effective in comparison with the control conditions. Psychological interventions for anxiety disorders might be more cost-effective than pharmacological interventions.

The effect of Korean-group cognitive behavioural therapy among patients with panic disorder in clinic settings

WHAT IS KNOWN ON THE SUBJECT?: Panic disorder patients display various panic-related physical symptoms and catastrophic misinterpretation of bodily sensations, which lower their quality of life by interfering with daily activities. Cognitive behavioural therapy (CBT) is a useful strategy for panic disorder patients to manage symptoms associated with inaccurate cognitive interpretation of situations resulting from the patient's cognitive vulnerability. In South Korea, however, despite the increasing prevalence of panic disorder, CBT is not a common element of nursing care plans for panic disorder patients. Moreover, few Korean researchers have attempted to assess the effects of CBT on such patients. WHAT THIS PAPER ADD TO EXISTING KNOWLEDGE?: In a strategy combining CBT and routine treatments, patients with panic disorder can experience greater positive effects in the acute treatment phase than those they experience when receiving only routine treatment. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: Mental health professionals, especially psychiatric nurses in local clinics who operate most special mental health programmes for panic disorder patients, should apply a panic disorder management programme that integrates CBT and routine treatments. The integrated approach is more effective for reducing the number of panic attacks and cognitive misinterpretation in patients than providing routine treatment alone. For patients with panic disorder, the objective of CBT is to understand the relationship between psychological panic disorder sensations, emotions, thoughts and behaviours. Therefore, nurses can help patients address and improve biological, social and psychological aspects of physical health problems as well as help them improve their coping skills in general.

ABSTRACT

Introduction In panic disorder, sensitivity to bodily sensations increases due to the patient's cognitive vulnerability. Cognitive behavioural therapy (CBT) can help to decrease sensitivity to bodily sensations by correcting these cognitive distortions by controlling negative thoughts and panic attacks. Aims This study verified whether group CBT is more effective than treatment as usual (TAU) in South Korean patients with panic disorder. Methods The study participants consisted of 76 panic disorder patients. Patients in the therapy condition attended sessions once a week for a total of 12 sessions in addition to drug treatment. Results In the therapy condition, there were significant decreases in panic-related bodily sensations and ranking and belief scores for catastrophic misinterpretation of external events. Discussion Group CBT, in comparison to TAU, decreases panic and agoraphobia symptom severity in South Korean patients with panic disorder. Our study provides evidence for the effectiveness of a panic disorder management programme that integrates group CBT and traditional pharmacotherapeutic treatment for patients with panic disorder. Implications for Practice The cognitive behavioural approach is needed to reduce panic and agoraphobia symptoms for hospitalized patients with panic disorder more than activity therapies, medications and supportive counselling by doctors and nurses.

Psychological interventions for symptomatic management of non-specific chest pain in patients with normal coronary anatomy

BACKGROUND

Recurrent chest pain in the absence of coronary artery disease is a common problem which sometimes leads to excess use of medical care. Although many studies have examined the causes of pain in these patients, few clinical trials have evaluated treatment. This is an update of a Cochrane review originally published in 2005 and last updated in 2010. The studies reviewed in this paper provide an insight into the effectiveness of psychological interventions for this group of patients.

OBJECTIVES

To assess the effects of psychological interventions for chest pain, quality of life and psychological parameters in people with non-specific chest pain.

SEARCH METHODS

We searched the Cochrane Library (CENTRAL, Issue 4 of 12, 2014 and DARE Issue 2 of 4, 2014), MEDLINE (OVID, 1966 to April week 4 2014), EMBASE (OVID, 1980 to week 18 2014), CINAHL (EBSCO, 1982 to April 2014), PsycINFO (OVID, 1887 to April week 5 2014) and BIOSIS Previews (Web of Knowledge, 1969 to 2 May 2014). We also searched citation lists and contacted study authors.

SELECTION CRITERIA

Randomised controlled trials (RCTs) with standardised outcome methodology that tested any form of psychotherapy for chest pain with normal anatomy. Diagnoses included non-specific chest pain (NSCP), atypical chest pain, syndrome X or chest pain with normal coronary anatomy (as either inpatients or outpatients).

DATA COLLECTION AND ANALYSIS

Two review authors independently selected studies for inclusion, extracted data and assessed quality of studies. We contacted trial authors for further information about the included RCTs.

MAIN RESULTS

We included two new papers, one of which was an update of a previously included study. Therefore, a total of 17 RCTs with 1006 randomised participants met the inclusion criteria, with the one new study contributing an additional 113 participants. There was a significant reduction in reports of chest pain in the first three months following the intervention: random-effects relative risk = 0.70 (95% CI 0.53 to 0.92). This was maintained from three to nine months afterwards: relative risk 0.59 (95% CI 0.45 to 0.76). There was also a significant increase in the number of chest pain-free days up to three months following the intervention: mean difference (MD) 3.00 (95% CI 0.23 to 5.77). This was associated with reduced chest pain frequency (random-effects MD -2.26, 95% CI -4.41 to -0.12) but there was no evidence of effect of treatment on chest pain frequency from three to twelve months (random-effects MD -0.81, 95% CI -2.35 to 0.74). There was no effect on severity (random-effects MD -4.64 (95% CI -12.18 to 2.89) up to three months after the intervention. Due to the nature of the main interventions of interest, it was impossible to blind the therapists as to whether the participant was in the intervention or control arm. In addition, in three studies the blinding of participants was expressly forbidden by the local ethics committee because of issues in obtaining fully informed consent . For this reason, all studies had a high risk of performance bias. In addition, three studies were thought to have a high risk of outcome bias. In general, there was a low risk of bias in the other domains. However, there was high heterogeneity and caution is required in interpreting these results. The wide variability in secondary outcome measures made it difficult to integrate findings from studies.

AUTHORS' CONCLUSIONS

This Cochrane review suggests a modest to moderate benefit for psychological interventions, particularly those using a cognitive-behavioural framework, which was largely restricted to the first three months after the intervention. Hypnotherapy is also a possible alternative. However, these conclusions are limited by high heterogeneity in many of the results and low numbers of participants in individual studies. The evidence for other brief interventions was less clear. Further RCTs of psychological interventions for NSCP with follow-up periods of at least 12 months are needed.