Assessment of sleep quality of patients with panic disorder and generalized anxiety disorder during remission: a case-control study

Abstract Background Sleep disorders are common in psychiatric diseases. Panic disorder (PD) and generalized anxiety disorder (GAD) are two major anxiety disorders that are associated with sleep disorders. Objective We hypothesized that poor sleep quality continues in PD and GAD during remission. Therefore, in this study we aimed to compare the sleep quality of patients with PD and GAD to that of healthy controls. Methods The study included patients with PD (n = 42) and GAD (n = 40) who had been in remission for at least 3 months and healthy control volunteers (n = 45). The patients were administered the Pittsburgh Sleep Quality Index (PSQI), Beck Anxiety Inventory (BAI), and Beck Depression Inventory (BDI). Results The total PSQI scores of the GAD group were significantly increased in comparison to those of the PD (p = 0.009) and control (p < 0.001) groups. The rate of poor sleep quality in GAD during remission (77.5%) was greater than that of the PD (47.6%) and control (51.1%) groups (p = 0.011). Discussion GAD is a chronic and recurrent disease. In this study, it was found that the deterioration in sleep quality of patients with GAD may continue during remission. In the follow-up and treatment of patients, it is appropriate to question about sleep symptoms and to plan interventions according to these symptoms.

Análisis de costo-efectividad del escitalopram comparado con paroxetina, sertralina, fluoxetina, imipramina y fluvoxamina como terapia de mantenimiento para pacientes con trastorno de pánico en Colombia / nalysis cost-effectiveness of escitalopram compared to paroxetine, sertraline, fluoxetine, imipramine and fluvoxamine as maintenance therapy for patients with panic disorder in Colombia

PROBLEMA DE INVESTIGACIÓN: Describir los costos y la efectividad de escitalopram comparado con paroxetina, sertralina, fluoxetina, imipramina y fluvoxamina como terapia de mantenimiento en adultos con diagnóstico de trastorno de pánico en Colombia. TIPO DE EVALUACIÓN ECONÓMICA: Análisis de costo-efectividad. POBLACIÓN OBJETIVO: Adultos colombianos con diagnóstico de trastorno de pánico. INTERVENCIÓN Y COMPARADORES: Intervención: escitalopram; Comparadores: paroxetina, sertralina, fluoxetina, imipramina y fluvoxamina. HORIZONTE TEMPORAL: 32 semanas. PERSPECTIVA: SGSSS de Colombia. TASA DE DESCUENTO: No aplica. ESTRUCTURA DEL MODELO: Se estructuró un árbol de decisión, teniendo en cuenta modelos publicados en la literatura. FUENTES DE DATOS DE EFECTIVIDAD Y SEGURIDAD: Reporte de efectividad y seguridad elaborado en diciembre de 2014 en el IETS; Ensayos clínicos aleatorizados. DESENLACES Y VALORACIÓN: Ausencia de crisis de pánico; Semanas libres de crisis de pánico. COSTOS INCLUIDOS: Costo de los medicamentos; Costo de procedimientos; Costo de los eventos adversos. FUENTES DE DATOS DE COSTOS: SISMED; Manual tarifario ISS 2001. RESULTADOS DEL CASO BASE: Para el caso base, escitalopram, fluvoxamina y fluoxetina e imipramina fueron tecnologías dominadas por sertralina y paroxetina. El costo adicional por crisis de pánico evitada en tratamiento con paroxetina comparado contra sertralina se estimó en $4.814.953. ANÁLISIS DE SENSIBILIDAD: Los análisis de sensibilidad y el diagrama de tornado muestran a la probabilidad de lograr ausencia de crisis de pánico y la probabilidad de recaída, como a las variables con mayor impacto sobre las estimaciones de la razón de costo-efectividad. CONCLUSIONES Y DISCUSIÓN: De acuerdo con los hallazgos aquí presentados, paroxetina, ofrece mayor razón de costo-efectividad, respecto a sus comparadores. No obstante, es necesario tener en cuenta que cualquiera de las alternativas aquí estudiadas, puede ser costo-efectiva, debido a que las pequeñas variaciones en la probabilidad de ausencia de crisis de pánico pueden cambiar el resultado. La principal limitación de este estudio es la ausencia de información proveniente de estudios de investigación clínica, que muestre el desempeño comparativo entre las tecnologías, así como el seguimiento de los participantes en los estudios, en escenarios de más largo plazo que los existentes al momento de elaborar este documento.(AU)

Efectividad y seguridad del escitalopram y la risperidona comparado con fluoxetina, sertralina, paroxetina, citalopram, fluvoxamina, imipramina y psicoterapia en pacientes con trastorno de pánico / Effectiveness and safety of escitalopram and risperidone compared to fluoxetine, sertraline, paroxetine, citalopram, fluvoxamine, imipramine, and psychotherapy in patients with panic disorder

Introducción: La prevalencia de Trastorno de Pánico en la población general es del 2,7%; en Colombia tiene mayor incidencia en mujeres. El TP puede ir acompañado de depresión, consumo de sustancias adictivas como el alcohol, drogas, incrementando el riesgo de suicidio. El escitalopram y la risperidona, ha demostrado tener una respuesta adecuada en el control de los síntomas. Objetivo: Examinar los beneficios y riesgos del uso del escitalopram y la risperidona en el Trastorno de Pánico, como uno de los criterios para informar la toma de decisiones relacionada con la posible inclusión de tecnologías en el Plan Obligatorio de Salud, en el marco de su actualización integral para el año 2015. Metodología: A partir de la pregunta PICO se establecieron los criterios de elegibilidad para la realización de la búsqueda de la evidencia científica (a ensayos clínicos, revisiones sistemáticas de estudios observacionales y estudios de cohortes analíticas), se realizó la tamización y selección de la evidencia evaluando su calidad y posteriormente se realizó la extracción de datos y la síntesis de la evidencia. Resultados: El escitalopram es considerado medicamento de primera línea para el tratamiento de esta entidad mostrando mayor efectividad y seguridad que otros medicamentos. La risperidona a dosis no convencionales es efectiva en el control de síntomas y no presenta diferencia en la presencia de efectos adversos comparados con otros medicamentos utilizados para el tratamiento de esta entidad; no es considerado tratamiento de primera línea. Conclusiones: La interpretación de los resultados deben ser evaluados con precaución teniendo en cuenta las limitaciones de la evidencia científica y metodológica de los estudios incluidos. El escitalopram o la risperidona mostraron ser eficaces y seguros en el manejo del Trastorno de Pánico comparado con otros medicamentos que se emplean para el tratamiento de este mismo trastorno. (AU)

Cost-effectiveness of CBT, SSRI, and CBT+SSRI in the treatment for panic disorder.

OBJECTIVE: The objective of this study was to assess the cost-effectiveness of three empirically supported treatments for panic disorder with or without agoraphobia: cognitive behavioral therapy (CBT), pharmacotherapy using a selective serotonin reuptake inhibitor (SSRI), or the combination of both (CBT+SSRI). METHOD: Cost-effectiveness was examined based on the data from a multicenter randomized controlled trial. The Hamilton Anxiety Rating Scale was selected as a primary health outcome measure. Data on costs from a societal perspective (i.e., direct medical, direct non-medical, and indirect non-medical costs) were collected in the study sample (N=150) throughout a 24-month period in which patients received active treatment during the first twelve months and were seen twice for follow-up in the next twelve months. RESULTS: Total costs were largely influenced by costs of the interventions and productivity losses. The mean total societal costs were lower for CBT as compared to SSRI and CBT+SSRI. Costs of medication use were substantial for both SSRI and CBT+SSRI. When examining the balance between costs and health outcomes, both CBT and CBT+SSRI led to more positive outcomes than SSRI. CONCLUSION: Cognitive behavioral therapy is associated with the lowest societal costs. Cognitive behavioral therapy and CBT+SSRI are more cost-effective treatments for panic disorder with or without agoraphobia as compared to SSRI only.

Transtornos de Ansiedade III: eficácia e segurança de sertralina, citalopram e venlafaxina no tratamento de Transtorno Obsessivo-Compulsivo e Síndrome do Pânico / Anxiety Disorders III: efficacy and safety of sertraline, citalopram and venlafaxine in the treatment of Obsessive-Compulsive Disorder and Panic Disorder / Trastornos de Ansiedad III: eficacia y seguridad de la sertralina, citalopram y venlafaxina en el tratamiento del Trastorno Obsesivo-Compulsivo y Trastorno de Pánico

TECNOLOGIAS: Venlafaxina, citalopram e sertralina. INDICAÇÃO: Tratamento de Síndrome do Pânico e Transtorno Obsessivo-Compulsivo. CARACTERIZAÇÃO DA TECNOLOGIA: As tecnologias citalopram e sertralina pertencem à classe dos Inibidores Seletivos da Recaptação da Serotonina (ISRS) e a venlafaxina pertence à classe dos Inibidores da Recaptação de Serotonina e Norepinefrina (IRSN). PERGUNTA: Venlafaxina, citaloprame sertralina são mais eficazes e seguras no tratamento de pacientes com Síndrome do Pânico e Transtorno Obsessivo-Compulsivo do que as tecnologias disponíveis no SUS (clomipramina, diazepam, clonazepam, clobazam e fluoxetina)? BUSCA E ANÁLISE DE EVIDÊNCIAS CIENTÍFICAS: Foram pesquisadas as bases The Cochrane Library (via Bireme), Medline (via Pubmed), Lilacs, APA PsycNET (via PsychINFO) e Centre for Reviews and Dissemination (CRD). Buscaram-se revisões sistemáticas (RS) de ensaios clínicos que comparassem os medicamentos entre si e com outras opções terapêuticas disponíveis no Sistema Único de Saúde para o tratamento de transtornos de ansiedade. Foram selecionadas também avaliações de tecnologias em saúde (ATS) em websites de agências internacionais e da Rede Brasileira de Avaliação de Tecnologia em Saúde . Foram selecionados estudos publicados em inglês, português ou espanhol. RESUMO DOS RESULTADOS DOS ESTUDOS SELECIONADOS: Foram incluídas seis revisões sistemáticas: uma acerca da Síndrome do Pânico (SP) e cinco de Transtorno Obsessivo-Compulsivo (TOC). Em nenhuma das revisões foram encontrados estudos científicos que comparassem estes medicamentos diretamente entre si ou entre as alternativas incorporadas no Sistema Único de Saúde (SUS) sendo que, de maneira geral, nas comparações versus placebo, os medicamentos demonstraram eficácia estatisticamente significante. Foram consideradas ainda seis Avaliações de Tecnologias em Saúde (ATS) de organismos internacionais acerca do tema. Em nenhuma dessas avaliações houve indicação de terapia farmacológica como primeira opção sendo que esses estudos preconizavam intervenções psicológicas. Estas avaliações indicaram antidepressivos como segunda linha para o tratamento. Os estudos não recomendaram a terapia com benzodiazepínicos e antipsicóticos. RECOMENDAÇÕES: Os medicamentos venlafaxina, citalopram e sertralina apresentaram perfil de eficácia e segurança semelhantes aos dos medicamentos clomipramina e fluoxetina, disponíveis no SUS. Dessa forma, recomenda-se o uso de clomipramina para síndrome do pânico e de fluoxe na ou clomipramina para TOC.(AU)

TECHNOLOGIES: Venlafaxine, Citalopram and Sertraline. INDICATION: Treatment of panic disorder and obsessive-compulsive disorder. CHARACTERIZATION OF TECHNOLOGY: Citalopram and Sertraline belong to the class of Selective Serotonin Reuptake Inhibitors (SSRIs) and Velafaxine belong the class of Serotonin and Norepinephrine Reuptake Inhibitors (SNRIs). Question: Venlafaxine, Citalopram and Sertraline are safer and more effective in trea ng pa ents with panic disorder and obsessive-compulsive disorder than the technologies incorporated into the Brazilian Public Health System (SUS)? Search And Analysis Of Scien Fic Evidence: The databases The Cochrane Library (via Bireme), Medline (via Pubmed), Lilacs, APA PsycNET (via PsychINFO) and Centre for Reviews and Dissemination (CRD) were inves gated. We searched for systematic reviews (SR) of clinical trials that compared the drugs within each other and with other therapeutic options incorporated in SUS for the treatment of anxiety disorders. Health Technology Assessments (HTA) in international agencies sites and in Brazilian Network for Health Technology Assessment (REBRATS) were also selected. Studies published in English, Portuguese or Spanish were selected. SUMMARY OF RESULTS OF THE SELECTED STUDIES: Six systema c reviews, one about panic disorder and 5 about obsessive-compulsive, were included. None of the reviews of scien fic studies compared these drugs directly between themselves or between the alterna ves incorporated into SUS and, in general, was found statistically significant efficacy in studies comparing drugs versus placebo. SixHTA´s of international organizations on the subject were considered. These HTA´sfound no indication of drug therapy as first choice and these studies advocated psychological interventions. These evaluations have demonstrated the effectiveness of an depressants as second choice for the treatment of anxiety disorders. The studies did not recommend therapy with benzodiazepines (BZD) and an"psycho cs. RECOMMENDATIONS: Venlafaxine, citalopram and sertraline presented similar efficacy and safety profiles when compared to clomipramine and fluoxetine, available in SUS. Thus, we recommend the use of clomipramine for panic disorder and fluoxetine or clomipramine for OCD.(AU)

TECNOLOGÍAS: La venlafaxina, citalopram y sertralina. INDICACIÓN: Tratamiento de Trastorno Obsesivo Compulsivo y trastorno de pánico. CARACTERIZACIÓN DE LA TECNOLOGÍA: Las tecnologías de citalopram y sertralina pertenecen a la clase de los inhibidores selec vos de la recaptación de serotonina (ISRS) y Venlafaxina pertenece a la clase de los inhibidores de la recaptación de serotonina y norepinefrina (IRSN). PREGUNTA: ¿La venlafaxina, citalopram y sertralina son más seguros y más eficaces en el tratamiento de pacientes con Trastorno Obsesivo Compulsivo y trastorno de pánico que las tecnologías incorporadas en el SNS? BÚSQUEDA Y ANÁLISIS DE LA EVIDENCIA CIENTÍFICA: las fundaciones The Cochrane Library (vía Bireme), MEDLINE (vía PubMed), Lilacs, APA PsycNET (vía PsychINFO) y Centro de Revisiones y Difusión (CRD) fueron inves gados. Hemos tratado de revisiones sistemá cas (RS) de los ensayos clínicos que compararon los fármacos entre sí y con otras opciones terapéu cas incorporadas en el sistema nacional de salud para el tratamiento de los trastornos de ansiedad. También fueron seleccionados comentarios de tecnologías sanitarias (ATS) en las agencias de un si o y la Red Brasileña de Evaluación de Tecnologías Sanitarias. Los estudios publicados en inglés, se seleccionaron portugués o español. RESUMEN DE LOS RESULTADOS DE LOS ESTUDIOS SELECCIONADOS: Fueran incluidas seis revisiones sistemá cas, una acerca de lo trastorno de pánico e cinco acerca de lo trastorno obsesivo compulsivo. En ninguna de las revisiones de estudios cien ficos que comparan estos fármacos directamente entre sí o entre las alterna vas incluidas en el Sistema Único de Salud (SUS) y, en general, las comparaciones frente a los medicamentos de placebo demostraron estadís camente se encontraron una eficacia significa va. Seis estudios de Tecnologías en Salud (ATS) de las organizaciones internacionales en la materia fueron considerados. En ninguno de estos exámenes hubo indicación de la terapia con medicamentos como primera opción y estos estudios abogó intervenciones psicológicas. Estas evaluaciones han demostrado la eficacia de los an depresivos en general, como segunda opción para el tratamiento de trastornos de ansiedad. Los estudios no recomiendan el tratamiento con benzodiacepinas (BZD) y an psicó cos. RECOMENDACIONES: La venlafaxina, el citalopram y la sertralinapresentaron eficacia y seguridad semejante a de laclomipramina y la fluoxe na,disponibles enSUS. Por lo tanto, se recomienda el uso de clomipramina para el trastorno de pánico y la fluoxe na o clomipramina para el TOC.(AU)

Prevalence and management of panic attacks during infliximab infusion in psoriatic patients.

BACKGROUND: Psoriasis is a chronic, inflammatory skin disease associated with anxiety and depression. Infliximab (IFX) is a human/mouse chimeric anti-TNF-α antibody effective in the treatment of psoriasis. OBJECTIVE: The aim of this study was to evaluate the prevalence of panic disorders in psoriatic patients during IFX infusions. METHODS: A retrospective study was performed on patients affected with psoriasis who were treated with IFX from 2002 to 2011 at a single center. Panic disorders were defined using the clinical criteria of the Diagnostic and Statistical Manual of Mental Disorders, 4th edition. A population of dermatological patients under treatment with IVG, rituximab, apheresis, intravenous corticosteroids and antibiotics was considered as the control group. RESULTS: A total of 141 patients were evaluated. Of these, 6 (4.25%) experienced panic attacks during the infusion; 16 (11.3%) had a medical history of panic attack and of those 5/16 (31%) experienced panic attacks during IFX infusion. In the control group panic attacks were not recorded. CONCLUSION: We describe 6 cases of patients in whom panic attacks were triggered by IFX infusion. Premedication with oral benzodiazepine and a slow rate of infusion is recommended.

Assessment of anxiolytic and panicolytic effects of dichloromethane fraction from stems of Kielmeyera coriacea.

Kielmeyera coriacea Mart. (Calophyllaceae) is known popularly as "Pau Santo". The hydroethanolic extract (HE) of Kielmeyera coriacea stems and its semi-pure dichloromethane (DCM) constituent produced an antidepressant-like effect in rats. The purpose of this study was to investigate the effects of repeated administration (21 days) by gavage of the DCM fraction (5, 10 or 15mg/kg) in rats submitted to the elevated T-maze (ETM), a model of generalized anxiety and panic disorders. The tricyclic antidepressant imipramine (15mg/kg) was used as a positive control. Rat locomotion was assessed using the open field test (OFT) following each drug treatment. The 2-hydroxy-1-methoxyxanthone (1), aucuparin (2), swertinin (3), 1,3,7-trihydroxy-2-(3-methylbut-2-enyl)-xanthone (4) and 1,3,5-trihydroxy-2-(3-methylbut-2-enyl)-xanthone (5) were identified in DCM fraction, and suggest that the xanthone (4) is related with the antidepressant-like profile of this plant. Pharmacological evaluation showed that DCM fraction (10 and 15 mg/kg) decreased the inhibitory avoidance latency from the closed arm and increased the one-way escape latency from the open arm in the ETM, which is indicative of anxiolytic and panicolytic effects, respectively, as occurs with the positive control, imipramine (15 mg/kg), when compared to their control group (vehicle). Locomotor activity was not significantly altered by the different treatments. This study suggests that the DCM fraction from stems of Kielmeyera coriacea can be an important therapeutic alternative in the treatment of anxiety disorders, such as generalized anxiety and panic disorders.

Cost-efficacy of individual and combined treatments for panic disorder.

OBJECTIVE: The objective of this study was to examine the relative cost-efficacy of empirically supported treatments for panic disorder. As psychosocial, pharmacologic, and combined treatments have all demonstrated efficacy in the treatment of panic disorder, cost-efficacy analysis provides an additional source of information to guide clinical decision making. METHOD: Cost-efficacy was examined based on results from the Multicenter Comparative Treatment Study of Panic Disorder, a randomized controlled trial of treatment for panic disorder (DSM-III-R). The trial was conducted from May 1991 to April 1998. Cost-efficacy ratios representing the cost per 1-unit improvement in Panic Disorder Severity Scale mean item score were calculated for 3 monotherapies (cognitive-behavioral therapy [CBT], imipramine, and paroxetine) and 2 combination treatments (CBT-imipramine and CBT-paroxetine) at the end of acute, maintenance, and follow-up phases. RESULTS: Results demonstrated consistently greater cost-efficacy for individual over combined treatments, with imipramine representing the most cost-efficacious treatment option at the completion of the acute phase (cost-efficacy ratio = $972) and CBT representing the most cost-efficacious option at the end of maintenance treatment (cost efficacy ratio = $1449) and 6 months after treatment termination (cost-efficacy ratio = $1227). CONCLUSION: In the context of similar efficacy for combined treatments, but poorer cost-efficacy, current monotherapies should be considered the first-line treatment of choice for panic disorder. Additionally, CBT emerged as the most durable and cost-effective monotherapy and, hence, should be considered as a particularly valuable treatment from the perspective of cost accountability.

Adherence to treatment among economically disadvantaged patients with panic disorder.

OBJECTIVE: The purpose of this study was to examine the feelings of disadvantaged patients about and experiences of treatment for anxiety disorders in primary care settings. METHODS: The patients had participated in the Collaborative Care for Anxiety and Panic study, which tested the effectiveness of an intervention to help primary care providers treat panic disorder. The treatment comprised cognitive behavioral therapy (CBT) combined with pharmacotherapy administered by primary care physicians with the expert advice of a psychiatrist. Post hoc semistructured interviews were conducted with 21 intervention participants who were classified according to adherence or nonadherence to treatment. The interview focused on reactions to CBT; reactions to the different features of the intervention, such as therapy sessions, demonstration videotapes, exercises, and a workbook; and comfort with the therapist. Two members of the research team independently coded, analyzed, and interpreted the data. RESULTS: Three themes emerged: information was empowering and reduced the sense of isolation experienced by participants, participants engaged in a dynamic and iterative personalized assessment of the intervention, and barriers to adherence were predominantly logistical. CONCLUSIONS: Results indicate that the extent to which patients chose to remain in treatment and follow treatment recommendations was rarely an all-or-nothing phenomenon. In a disadvantaged population such decisions seem to be influenced by the beliefs of the patient about what will and will not be effective in his or her individual case, an ongoing self-assessment of well-being, and the logistical barriers that come into play.

Incremental cost-effectiveness of a collaborative care intervention for panic disorder.

BACKGROUND: Panic disorder is a prevalent, often disabling, disorder among primary-care patients, but there are large gaps in quality of treatment in primary care. This study describes the incremental cost-effectiveness of a combined cognitive behavioral therapy (CBT) and pharmacotherapy intervention for patients with panic disorder versus usual primary-care treatment. METHOD: This randomized control trial recruited 232 primary-care patients meeting DSM-IV criteria for panic disorder from March 2000 to March 2002 from six primary-care clinics from university-affiliated clinics at the University of Washington (Seattle) and University of California (Los Angeles and San Diego). Patients were randomly assigned to receive either treatment as usual or a combined CBT and pharmacotherapy intervention for panic disorder delivered in primary care by a mental health therapist. Intervention patients had up to six sessions of CBT modified for the primary-care setting in the first 12 weeks, and up to six telephone follow-ups over the next 9 months. The primary outcome variables were total out-patient costs, anxiety-free days (AFDs) and quality adjusted life-years (QALYs). RESULTS: Relative to usual care, intervention patients experienced 60.4 [95% confidence interval (CI) 42.9-77.9] more AFDs over a 12-month period. Total incremental out-patient costs were 492 US dollars higher (95% CI 236-747 US dollars ) in intervention versus usual care patients with a cost per additional AFD of 8.40 US dollars (95% CI 2.80-14.0 US dollars ) and a cost per QALY ranging from 14,158 US dollars (95% CI 6,791-21,496 US dollars ) to 24,776 US dollars (95% CI 11,885-37,618 US dollars ). The cost per QALY estimate is well within the range of other commonly accepted medical interventions such as statin use and treatment of hypertension. CONCLUSIONS: The combined CBT and pharmacotherapy intervention was associated with a robust clinical improvement compared to usual care with a moderate increase in ambulatory costs.

Medical illness and response to treatment in primary care panic disorder.

OBJECTIVE: Although studies have suggested that comorbid medical illness can affect the outcome of patients with depression, little is known about whether medical illness comorbidity affects treatment outcome in patients with anxiety. METHOD: Primary care patients with panic disorder (n=232), participating in a randomized collaborative care intervention of CBT and pharmacology, were divided into those above (n=125) and below (n=107) the median for burden of chronic medical illness and assessed at 3, 6, 9 and 12 months. RESULTS: Subjects with a greater burden of medical illness were more psychiatrically ill at baseline, with greater anxiety symptom severity, greater disability and more psychiatric comorbidity. The intervention produced significant and similar increases in amount of evidence-based care, and reductions in clinical symptoms and disability that were comparable in the more and less medically ill groups. CONCLUSIONS: The comparable response of individuals with more severe medical illness suggests that CBT and pharmacotherapy for panic disorder work equally well regardless of medical illness comorbidity. However, the more severe psychiatric illness both at baseline and follow-up in these same individuals suggest that treatment programs may need to be extended in time to optimize treatment outcome.

Use of psychotropic medications for patients with office visits who receive a diagnosis of panic disorder.

OBJECTIVE: We sought to examine trends in the medication management of panic disorder from a nationally representative sample of visits to psychiatrists and primary care physicians in office-based practice. METHOD: We analyzed physician-reported data from the 1992-1995 and 1996-1999 National Ambulatory Medical Care Survey, focusing on medication management of panic disorder by primary care physicians and psychiatrists. Rates for which doctors prescribed medication for patients with a diagnosis of panic disorder were compared over the course of time to identify changes in medication management between physician groups. We used logistic regression models to identify predictors of medication prescription, adjusting for the presence of other covariates. RESULTS: Both physician groups prescribed a psychotropic medication to a majority of patients for panic disorder in each time period. In 1992-1995, primary care physicians were less likely than psychiatrists to prescribe psychotropic medications. This difference was not evident in 1996-1999. The prescribing of benzodiazepines was common in both physician groups and time periods. Overall rates of psychotropic prescriptions by physician groups converged over time, although no single drug class accounted individually for the convergence. CONCLUSION: In recent years, changes in the medication management of patients with panic disorder by primary care physicians have resulted in greater similarity with the pharmacologic treatment of panic disorder provided in psychiatric practice.

Evaluating the economic consequences of early antidepressant treatment discontinuation: a comparison between controlled-release and immediate-release paroxetine.

INTRODUCTION: Early antidepressant discontinuation has been linked to significant clinical and economic consequences. Clinical practice guidelines suggest that treatment should last for at least 3 to 9 months into the continuation phase; however, 30% of patients discontinue therapy within 30 days, and over 40% discontinue therapy within 90 days of initiation, primarily due to adverse events. Clinical trials have shown that controlled-release (CR) paroxetine has a favorable tolerability profile when compared to immediate-release (IR) paroxetine, which may result in lower discontinuation rates and improved economic outcomes. This is the first study to directly compare treatment discontinuation rates and health care expenditures of a CR selective serotonin reuptake inhibitors with its IR counterpart. METHODS: This matched retrospective study used claims from a national managed care database to assess differences in discontinuation rates and health care expenditures between paroxetine CR and IR for treating depression and/or anxiety. Discontinuation was assessed by survival analysis, and health care expenditure was assessed using average monthly medical and pharmacy charges. RESULTS: There were 1275 paroxetine CR patients and 2550 paroxetine IR patients matched in the analysis. At 90 days, 62% of paroxetine CR patients continued therapy versus 56% of paroxetine IR patients. At 180 days, 51% of paroxetine CR patients continued therapy versus 42% of paroxetine IR patients. When evaluating all medical charges, paroxetine CR patients incurred US 119 dollars less per month than paroxetine IR patients (P = 0.054). CONCLUSIONS: Patients receiving paroxetine CR remained on therapy longer than patients on paroxetine IR, which resulted in lower total monthly medical costs for patients receiving paroxetine CR. Differences in costs were primarily driven by reduction in hospitalization expenditures.

Cost-effectiveness of psychological and pharmacological interventions for generalized anxiety disorder and panic disorder.

OBJECTIVE: To assess from a health sector perspective the incremental cost-effectiveness of interventions for generalized anxiety disorder (cognitive behavioural therapy [CBT] and serotonin and noradrenaline reuptake inhibitors [SNRIs]) and panic disorder (CBT, selective serotonin reuptake inhibitors [SSRIs] and tricyclic antidepressants [TCAs]). METHOD: The health benefit is measured as a reduction in disability-adjusted life years (DALYs), based on effect size calculations from meta-analyses of randomised controlled trials. An assessment on second stage filter criteria ("equity", "strength of evidence", "feasibility" and "acceptability to stakeholders") is also undertaken to incorporate additional factors that impact on resource allocation decisions. Costs and benefits are calculated for a period of one year for the eligible population (prevalent cases of generalized anxiety disorder/panic disorder identified in the National Survey of Mental Health and Wellbeing, extrapolated to the Australian population in the year 2000 for those aged 18 years and older). Simulation modelling techniques are used to present 95% uncertainty intervals (UI) around the incremental cost-effectiveness ratios (ICERs). RESULTS: Compared to current practice, CBT by a psychologist on a public salary is the most cost-effective intervention for both generalized anxiety disorder (A$6900/DALY saved; 95% UI A$4000 to A$12 000) and panic disorder (A$6800/DALY saved; 95% UI A$2900 to A$15 000). Cognitive behavioural therapy results in a greater total health benefit than the drug interventions for both anxiety disorders, although equity and feasibility concerns for CBT interventions are also greater. CONCLUSIONS: Cognitive behavioural therapy is the most effective and cost-effective intervention for generalized anxiety disorder and panic disorder. However, its implementation would require policy change to enable more widespread access to a sufficient number of trained therapists for the treatment of anxiety disorders.

[Analysis of the cost and the effectiveness of a psychotherapy for panic disorder with agoraphobia (PDA) versus a treatment combining pharmacotherapy and psychotherapy]. / Analyse des coûts et de l'efficacité d'une psychothérapie pour le Trouble panique avec agoraphobie versus un traitement combinant la pharmacothérapie et la psychothérapie.

Pharmacotherapy and cognitive-behavioral therapy (CBT) are efficient treatments for Panic disorder with agoraphobia (PDA) yet they remain expensive. This study aims to compare the cost/effectiveness ratio of a CBT for PDA versus a combined treatment of CBT and pharmacotherapy. Eighty-four people followed a CBT either alone or combined with medication. They have been evaluated before treatment, immediately after, as well as one and two years later. The therapy efficacy is calculated at each assessment according to a "Global Functioning Index". Direct and indirect costs are calculated with the "Health Cost Interview". Results suggest that both treatments are equally effective. However, CBT alone is less expensive than CBT with pharmacotherapy. Thus, it offers a better cost-effectiveness ratio that even increases in the long term.

Australian and New Zealand clinical practice guidelines for the treatment of panic disorder and agoraphobia.

BACKGROUND: The Royal Australian and New Zealand College of Psychiatrists is co-ordinating the development of clinical practice guidelines (CPGs) in psychiatry, funded under the National Mental Health Strategy (Australia) and the New Zealand Health Funding Authority. METHOD: For these guidelines, the CPG team reviewed the treatment outcome literature, consulted with practitioners and patients and conducted a meta-analysis of recent outcome research. TREATMENT RECOMMENDATIONS: Education for the patient and significant others covering: (i) the nature and course of panic disorder and agoraphobia; (ii) an explanation of the psychopathology of anxiety, panic and agoraphobia; (iii) rationale for the treatment, likelihood of a positive response, and expected time frame. Cognitive behaviour therapy (CBT) is more effective and more cost-effective than medication. Tricyclic antidepressants (TCAs) and serotonin selective reuptake inhibitors are equal in efficacy and both are to be preferred to benzodiazepines. Treatment choice depends on the skill of the clinician and the patient's circumstances. Drug treatment should be complemented by behaviour therapy. If the response to an adequate trial of a first-line treatment is poor, another evidence-based treatment should be used. A second opinion can be useful. The presence of severe agoraphobia is a negative prognostic indicator, whereas comorbid depression, if properly treated, has no consistent effect on outcome.

Psychiatric medication use among Manhattan residents following the World Trade Center disaster.

To assess medication use in New York after the September 11th attacks, a telephone survey was conducted in October 2001 (N = 1,008). The prevalence of psychiatric medication use 30 days before the disaster was 8.9 and 11.6% 30 days after, a small but significant increase. The most important factor predicting postdisaster use was predisaster use--92% of those who used medications postdisaster used them predisaster. In addition, 3.3% used psychiatric medications 30 days postdisaster, but not 30 days before. Those who had panic attacks, posttraumatic stress disorder (PTSD), and insurance coverage, were the most likely medicated (26.5%). However, among those who used postdisaster medications (n = 129), new users tended to be those with panic attacks (44.1%) and those with panic attacks and PTSD (69.2%).

Cost-effectiveness and cost offset of a collaborative care intervention for primary care patients with panic disorder.

BACKGROUND: A collaborative care (CC) intervention for patients with panic disorder that provided increased patient education and integrated a psychiatrist into primary care was associated with improved symptomatic and functional outcomes. This report evaluates the incremental cost-effectiveness and potential cost offset of a CC treatment program for primary care patients with panic disorder from the perspective of the payer. METHODS: We randomly assigned 115 primary care patients with panic disorder to a CC intervention that included systematic patient education and approximately 2 visits with an on-site consulting psychiatrist, compared with usual primary care. Telephone assessments of clinical outcomes were performed at 3, 6, 9, and 12 months. Use of health care services and costs were assessed using administrative data from the primary care clinics and self-report data. RESULTS: Patients receiving CC experienced a mean of 74.2 more anxiety-free days during the 12-month intervention (95% confidence interval [CI], 15.8-122.0). The incremental mental health cost of the CC intervention was $205 (95% CI, -$135 to $501), with the additional mental health costs of the intervention explained by expenditures for antidepressant medication and outpatient mental health visits. Total outpatient cost was $325 (95% CI, -$1460 to $448) less for the CC than for the usual care group. The incremental cost-effectiveness ratio for total ambulatory cost was -$4 (95% CI, -$23 to $14) per anxiety-free day. Results of a bootstrap analysis suggested a 0.70 probability that the CC intervention was dominant (eg, lower costs and greater effectiveness). CONCLUSION: A CC intervention for patients with panic disorder was associated with significantly more anxiety-free days, no significant differences in total outpatient costs, and a distribution of the cost-effectiveness ratio based on total outpatient costs that suggests a 70% probability that the intervention was dominant, compared with usual care.