Incidence of panic disorder in patients with non-cardiac chest pain and panic attacks.

This study documented the 6-month incidence of panic disorder and its predictors in emergency department patients with panic attacks and non-cardiac chest pain. The assessment included a validated structured interview to identify panic attacks and questionnaires measuring the potential predictors of panic disorder. Presence of panic disorder was assessed 6 months later. The incidence of panic disorder was 10.1 percent (n = 14/138). Anxiety sensitivity was the only significant predictor of the incidence of panic disorder (odds ratio = 1.06; 95% confidence interval = 1.01-1.12). Patients with panic attacks and non-cardiac chest pain are at an elevated risk for panic disorder. This vulnerability appears to increase with anxiety sensitivity.

Physical activity and disability in patients with noncardiac chest pain: a longitudinal cohort study.

BACKGROUND: Noncardiac chest pain (NCCP) is one of the leading reasons for emergency department visits and significantly limits patients' daily functioning. The protective effect of physical activity has been established in a number of pain problems, but its role in the course of NCCP is unknown. This study aimed to document the level of physical activity in patients with NCCP and its association with NCCP-related disability in the 6 months following an emergency department visit. METHODS: In this prospective, longitudinal, cohort study, participants with NCCP were recruited in two emergency departments. They were contacted by telephone for the purpose of conducting a medical and sociodemographic interview, after which a set of questionnaires was sent to them. Participants were contacted again 6 months later for an interview aimed to assess their NCCP-related disability. RESULTS: The final sample consisted of 279 participants (57.0% females), whose mean age was 54.6 (standard deviation = 15.3) years. Overall, the proportion of participants who were physically active in their leisure time, based on the Actimètre questionnaire criteria, was 22.0%. Being physically active at the first measurement time point was associated with a 38% reduction in the risk of reporting NCCP-related disability in the following 6 months (ρ = .047). This association remained significant after controlling for confounding variables. CONCLUSIONS: Being physically active seems to have a protective effect on the occurrence of NCCP-related disability in the 6 months following an emergency department visit with NCCP. These results point to the importance of further exploring the benefits of physical activity in this population.

A closer look at the relationships between panic attacks, emergency department visits and non-cardiac chest pain.

This study examined the prevalence of emergency department visits prompted by panic attacks in patients with non-cardiac chest pain. A validated structured telephone interview was used to assess panic attacks and their association with the emergency department consultation in 1327 emergency department patients with non-cardiac chest pain. Patients reported at least one panic attack in the past 6 months in 34.5 per cent (95% confidence interval: 32.0%-37.1%) of cases, and 77.1 per cent (95% confidence interval: 73.0%-80.7%) of patients who reported panic attacks had visited the emergency department with non-cardiac chest pain following a panic attack. These results indicate that panic attacks may explain a significant proportion of emergency department visits for non-cardiac chest pain.

The Revised-Panic Screening Score for emergency department patients with noncardiac chest pain.

OBJECTIVES: We sought to reduce the 90% rate of missed diagnoses of panic-like anxiety (panic attacks with or without panic disorder) among emergency department patients with low risk noncardiac chest pain by validating and improving the Panic Screening Score (PSS). METHOD: A total of 1,102 patients with low risk noncardiac chest pain were prospectively and consecutively recruited in two emergency departments. Each patient completed a telephone interview that included the PSS, a brief 4-item screening instrument, new candidate predictors of panic-like anxiety, and the Anxiety Disorder Interview for the Diagnostic and Statistical Manual of Mental Disorders. Fourth Edition to identify panic-like anxiety. RESULTS: The original 4-item PSS demonstrated a sensitivity of 51.8% (95% CI [48.4, 57.0]) and a specificity of 74.8% (95% CI [71.3, 78.1]) for panic-like anxiety. Analyses prompted the development of the Revised-PSS; this 6-item instrument was 19.1% (95% CI [12.7, 25.5]) more sensitive than the original PSS in identifying panic-like anxiety in this sample (χ2(1, N = 351) = 23.89 p < .001) while maintaining a similar specificity (χ2(1, N = 659) = 0.754, p = .385; 0.4%, 95% CI [-3.6, 4.5]). The discriminant validity of the Revised-PSS proved stable over the course of a 10-fold cross-validation. CONCLUSIONS: The Revised-PSS has significant potential for improving identification of panic-like anxiety in emergency department patients with low risk noncardiac chest pain and promoting early access to treatment. External validation and impact analysis of the Revised-PSS are warranted prior to clinical implementation. (PsycINFO Database Record

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.

Nonfearful Panic Attacks in Patients With Noncardiac Chest Pain.

OBJECTIVE: To document the prevalence and characteristics of nonfearful panic attacks (NFPA) and their consequences on panic identification and access to mental health services in patients with noncardiac chest pain. METHOD: This cross-sectional sample included 339 patients with noncardiac chest pain and panic attacks. A structured interview was used to collect data on panic attacks, psychiatric morbidity, sociodemographic variables, and previous consultations with a psychiatrist or psychologist. Medical files were reviewed to assess the rate of NFPA identification in the emergency department. RESULTS: In our sample of patients with noncardiac chest pain, 39% of those with panic attacks reported NFPA. Psychiatric morbidity was lower in patients with NFPA than in patients with typical panic attacks (49.6% vs 71.1%), as was the mean number of panic symptoms (6 vs 7.8). The rate of panic attack identification was similar in both the groups, but patients with NFPA were less likely to have consulted a psychiatrist or psychologist during their lifetime (34% vs 46%). CONCLUSIONS: NFPA were highly prevalent in our sample of emergency department patients with noncardiac chest pain. NFPA is associated with significant psychiatric morbidity but these patients were less likely to follow through with referral to a psychiatrist or psychologist than patients with typical panic attacks were.

A prospective cohort study to refine and validate the Panic Screening Score for identifying panic attacks associated with unexplained chest pain in the emergency department.

INTRODUCTION: Panic-like anxiety (panic attacks with or without panic disorder), a highly treatable condition, is the most prevalent condition associated with unexplained chest pain in the emergency department. Panic-like anxiety may be responsible for a significant portion of the negative consequences of unexplained chest pain, such as functional limitations and chronicity. However, more than 92% of panic-like anxiety cases remain undiagnosed at the time of discharge from the emergency department. The 4-item Panic Screening Score (PSS) questionnaire was derived in order to increase the identification of panic-like anxiety in emergency department patients with unexplained chest pain. METHODS AND ANALYSIS: The goals of this prospective cohort study were to (1) refine the PSS; (2) validate the revised version of the PSS; (3) measure the reliability of the revised version of the PSS and (4) assess the acceptability of the instrument among emergency physicians. Eligible and consenting patients will be administered the PSS in a large emergency department. Patients will be contacted by phone for administration of the criterion standard for panic attacks as well as by a standardised interview to collect information for other predictors of panic attacks. Multivariate analysis will be used to refine the PSS. The new version will be prospectively validated in an independent sample and inter-rater agreement will be assessed in 10% of cases. The screening instrument acceptability will be assessed with the Ottawa Acceptability of Decision Rules Instrument. ETHICS AND DISSEMINATION: This study protocol has been reviewed and approved by the Alphonse-Desjardins research ethics committee. The results of the study will be presented in scientific conferences and published in peer-reviewed scientific journals. Further dissemination via workshops and a dedicated website is planned.

The impact of anxiety disorders on assessment of myocardial ischemia and exercise stress test performance.

PURPOSE: To evaluate the sensitivity of electrocardiogram (ECG) versus single photon emission computed tomography (SPECT) assessments of ischemia in patients with anxiety disorders (AD) and the extent to which patients exhibit poorer exercise performance, compared with patients without AD. METHODS: Patients referred for nuclear exercise stress testing (N = 2271) underwent a structured psychiatric interview (PRIME-MD) to assess for AD. Exercise performance parameters were assessed during ECG treadmill testing, after which patients underwent SPECT imaging. RESULTS: Analyses revealed that patients with AD exhibited lower peak exercise systolic blood pressure and rate pressure product than patients without AD. When major depressive disorder was included as an additional covariate, the previous results became trends. Results also indicated a lower rate of electrically positive ecg tests and a higher rate of false-negative diagnoses of myocardial ischemia according to ecg among patients with AD. Including major depressive disorder as a covariate rendered the effects of ad nonsignificant. There was no evidence of reduced exercise performance in patients with AD. CONCLUSIONS: Findings suggest that AD may be associated with mild impairments in cardiovascular exercise reactivity and may also alter the detection of myocardial ischemia using ecg assessments in patients referred for exercise stress testing. However, the influence of AD appears to be moderated by comorbid depression. Results suggest that exercise test performance and detection of ischemia may be influenced by mood and/or anxiety disorders and that greater efforts should be made to include routine mood and/or anxiety disorder screening as part of exercise stress testing protocols.

Heart rate variability in coronary artery disease patients with and without panic disorder.

Panic disorder (PD) and coronary artery disease (CAD) often co-occur, and CAD patients with comorbid PD suffer greater cardiovascular morbidity and mortality relative to CAD patients without PD. However, the mechanisms underlying these associations are still unknown. Reduced heart rate variability (HRV), a non-invasive measure of cardiac autonomic modulation, is an important predictor of adverse cardiac events. Interestingly, reduced HRV has been observed in patients with panic-like anxiety and PD, as well as in various CAD populations. However, the extent to which HRV is altered in patients with both PD and CAD is unknown. This study evaluated HRV in 42 CAD patients with (n=20) and without (n=22) PD. Patients underwent 48-h electrocardiographic monitoring. Power spectral analysis of HRV indicated that CAD patients with PD exhibited significantly lower LF/HF ratios, which may reflect lower sympathetic modulation, compared with non-PD patients. Additionally, total power in PD patients was made up of a significantly higher proportion of HF power and a significantly lower proportion of VLF power than in non-PD patients. No other significant differences in HRV indices were observed. Results suggest that contrary to what has been observed in the majority of PD-only and CAD-only populations; patients with both PD and CAD appear to exhibit lower sympathetic modulation during ordinary daily life conditions. Though preliminary, these findings suggest that changes in HRV may not be the mechanism underlying greater cardiovascular morbidity and mortality among CAD patients with PD.

Are exercise stress tests appropriate for assessing myocardial ischemia in patients with major depressive disorder?

BACKGROUND: Major depressive disorder (MDD) disproportionately affects patients with coronary artery disease (CAD). Evidence of myocardial ischemia with electrocardiography (ECG) or single-photon-emission-computed-tomography (SPECT) assessments during exercise testing is an important determinant of CAD prognosis. However, many key symptoms of MDD, such as reduced interest in daily activities, lack of energy, and fatigue, may affect exercise performance and the detection of ischemia in patients with MDD. This study evaluated the extent to which MDD and depressive symptomatology moderate exercise test performance and compared the ability of ECG versus SPECT for detecting ischemia in 1367 consecutive patients who underwent exercise testing. METHODS: All patients underwent a brief, structured psychiatric interview (PRIME-MD) and completed the Beck Depression Inventory (BDI) on the day of their exercise (treadmill) test. RESULTS: A total of 183 patients (13%) met diagnostic criteria for MDD. Patients with MDD achieved a significantly lower percent of maximal predicted heart rate (%MPHR), exhibited lower peak exercise mets, and spent less time exercising compared with patients without MDD (all P values <.05). BDI scores were also negatively correlated with all 3 indices of exercise performance (all P values <.01). There were no differences in rates of SPECT ischemia in patients with MDD (40%) versus patients without MDD (45%; P =.23); however, rates of ECG ischemia were significantly lower (30%) in patients with MDD than in patients without MDD (48%; P <.0001). CONCLUSIONS: Results suggest that patients with CAD who have MDD, depressive symptomatology, or both exhibit poor exercise tolerance and performance and that ECG, as compared with SPECT, may not be as reliable in detecting ischemia in patients who are depressed.

Two-year follow-up status of emergency department patients with chest pain: Was it panic disorder?

OBJECTIVES: We previously reported that 25% (108/441) of consecutive patients presenting to the emergency department (ED) of the Montreal Heart Institute with a chief complaint of chest pain suffered from panic disorder (PD). The purpose of the present study was to re-examine these patients (with and without PD) 2 years after their initial ED visit to determine their psychiatric and psychosocial status. METHODS: An interviewer, who was kept blind to patients' initial medical and psychiatric diagnoses, attempted to contact all patients who participated in the initial study by phone. Patients who completed the phone interview were sent a battery of psychological questionnaires by mail. RESULTS: A total of 301 (70%) patients completed the phone interview, and 228 (52%) patients completed the self-report questionnaires. Participants and non-participants did not differ with respect to age, gender, initial self-report scores, or initial cardiac or psychiatric diagnoses. At follow-up, significantly (p < 0.05) more PD+ than non-PD (PD-) patients reported: 1) chest pains in the last month (57% vs. 31%); 2) one or more ED consultations in the past year for chest pain (40% vs. 14%); 3) one or more hospitalizations in the past year (31% vs. 11%); and 4) perceiving their general health as "poor" (22% vs. 9%). PD+ patients displayed a significant (p < 0.05) worsening of their panic symptoms, agoraphobic avoidance, depression, and trait anxiety, and reported significantly (p < 0.05) greater suicidal ideation compared to PD- patients (32% vs. 9%). Of all PD+ patients, only 22% (18/82) reported receiving some form of mental health treatment for their symptoms. CONCLUSIONS: Unrecognized and untreated PD has a chronic and disabling course. Greater efforts should be made to screen for PD in patients complaining of chest pain in EDs.

Should psychologists be granted prescription privileges? A review of the prescription privilege debate for psychiatrists.

BACKGROUND: The debate over whether clinical psychologists should be granted the right to prescribe psychoactive medication has received considerable attention over the last 2 decades in the US, but there has been relatively little discussion of this controversial topic among Canadian mental health professionals, namely psychologists and psychiatrists. Proponents of prescription privileges (PPs), including the American Psychological Association (APA), argue that psychologists do not and cannot function as independent professionals because the medical profession places many restrictions on their practice. It is believed that PPs would help circumvent professional psychology's impending marginalization by increasing psychology's scope of practice. Proponents also argue that PPs would enhance mental health services by increasing public access to professionals who can prescribe. OBJECTIVE: The purpose of this article is to inform psychiatrists about the major arguments presented for and against PPs for psychologists and to discuss the major implications of PPs for both professional psychology and psychiatry. METHODS: We conducted a literature search of relevant articles published from 1980 to the present appearing on Psychlit and Medline databases, using "prescription privileges" and "psychologists" as search titles. CONCLUSION: Although proponents present several compelling arguments in favour of PPs for psychologists, pilot projects relating to feasibility and efficacy are either sparse or incomplete. Thus, it is too soon to tell whether PPs could or should be pursued. Clearly, more research is needed before we conclude that PPs for psychologists are a safe and necessary solution to psychology's alleged impending marginalization.