ORLANDO, FLA. - Panic disorders cause considerable long-term morbidity and may have a more significant impact on quality of life than clinicians realize.
At the recent annual meeting of the Anxiety Disorders Association of America here, a special session was held to make delegates aware of how chronic a condition -- and how hard to treat -- panic disorder can be.
Good news from the session primarily involved promising preliminary data involving treating panic disorder with a combination of drugs and cognitive-behavioral therapy.
"We're dealing with a condition that remains persistent," said Dr. Jonathan Davidson, professor of psychiatry and director of the anxiety and traumatic stress disorders program at Duke University Medical Center in Durham, N.C.
He said studies show patients with panic disorder or agoraphobia frequently relapse and few remain in complete remission even one year after successful treatment.
Dr. Jerrold Rosenbaum, associate professor of psychiatry at Harvard Medical School and chief of the clinical psychopharmacology unit at Massachusetts General Hospital, said after successful short-term therapy, 30% to 75% of panic disorder patients will continue to have panic attacks and phobias.
He said studies have shown the mean length of remission for these patients is 9.2 months and more than half will remain on drug therapy up to eight years after starting treatment.
Dr. Davidson said there is also evidence patients with panic disorder are at increased risk for other medical conditions such as hypertension, stroke and heart attacks.
Such patients are also prone to unemployment, suicide and significant degrees of mental and physical impairment.
Dr. Davidson said studies have shown the degree of impairment associated with panic disorder is comparable to that seen with major depression.
But he added a study from Catalonia in Spain shows successful treatment can drastically reduce the morbidity and costs associated with anxiety disorders.
The per patient costs dropped from $1,554 (U.S.) in the year before treatment to $986 (U.S.) after successful therapy, he said. (See graph)
Overall for the 61 patients in the study, medical costs dropped from $94,801 (U.S.) to $60,139 (U.S.). Much of this saving came from a significant fall in costs associated with visits to a psychiatrist.
"Those data are, I think, quite compelling and important," Dr. Davidson said.
Dr. Rosenbaum said a variety of drugs available can treat panic disorder and, while successful drug therapy can make a "dramatic difference" in quality of life, no one treatment has proven effective for all patients. Long-term studies have shown many patients require ongoing treatment, often with a combination of drugs.
"The message really is ... you have to have a mentality of seeking incremental gains and not stopping," Dr. Rosenbaum said.
He believes serotonin selective reuptake inhibitors (SSRIs) are one of the more promising new classes of drugs for this disorder. Clinical trials support making these drugs available as first-line treatment for the disorder.
But he said the best option may be a combination of pharmacotherapy and a behavioral approach.
Dr. David Barlow, (PhD), who has just become professor of psychotherapy at Boston University after directing the phobia and anxiety disorders clinic at the University of Albany State University of New York, said:
"The one thing that we've learned ... now that more data are in, is that we're not really as good as we thought we were" when it comes to finding an effective treatment for panic disorders.
A meta-analysis has shown cognitive-behavioral therapy can be more effective than drugs in controlling anxiety disorders. But even with this approach, "very few become symptom-free and stay symptom-free," Dr. Barlow said.
Recent behavioral approaches which deal with panic attacks directly can leave about 80% of patients panic free after treatment, but he added this "does not equal high-end state functioning."
New studies have investigated the value of attempting to prevent relapses in patients receiving behavioral therapy. Researchers, he said, "are beginning to look very seriously at introducing relapse prevention techniques into behavioral treatments" by means of a variety of coping strategies.
A Swedish study showed relapse prevention therapy reduced the number of patients requiring further treatment to 10%, compared with 25% who did not receive relapse prevention therapy.
Dr. Barlow said this type of study implies patient support groups can play a "crucial" role even with those panic disorder patients who have been successfully treated.
The other approach involves combining drugs and behavioral therapy. Dr. Barlow said a very small study of a couple of dozen patients showed on an intent-to-treat basis this combined therapy worked better than medical or behavioral therapy alone.
Copyright © 1996 Maclean Hunter Publishing Limited
Reprinted with permission.
Internet Mental Health (www.mentalhealth.com) copyright © 1995-2011 by Phillip W. Long, M.D.