Elsevier

General Hospital Psychiatry

Volume 24, Issue 3, May–June 2002, Pages 148-155
General Hospital Psychiatry

Psychiatry and primary care
Treating panic disorder in primary care: a collaborative care intervention

https://doi.org/10.1016/S0163-8343(02)00174-3Get rights and content

Abstract

Efficacy research indicates the success of cognitive behavioral treatment and medication treatment for panic disorder with or without agoraphobia. However, research findings to date possess limited generalizability beyond specialty mental health settings. We present a model for collaborative care treatment for panic disorder in the primary care setting that combines cognitive behavioral therapy and medications, and involves a behavioral health specialist, psychiatrist, and primary care physician. Educational aids that are aimed to educate and activate patients to participate as partners in their care are provided. We outline the ways in which the standard treatment was modified, in light of the nature of the sample and setting, such as fewer sessions and management of comorbidity. Also, we provide evidence for acceptability of this intervention to primary care physicians and patients. This description is intended to lay the groundwork for continued research efforts in the extension of efficacious treatments into primary care settings.

Introduction

Significant psychosocial and pharmacological advances have been made in the treatment of panic disorder with or without agoraphobia. For example, controlled studies demonstrate the efficacy of cognitive behavioral therapy for panic disorder and agoraphobia in the short term and over follow-up [1], [2], [3], [4]. In addition, there is extensive evidence for the efficacy of tricyclic antidepressants, monoamine oxidase inhibitors, benzodiazapines and selective serotonin reuptake inhibitors, with the latter now considered the medication of choice [5], [6], [7]. However, these results are based largely on nonrepresentative samples from specialized settings with expert clinicians and restricted outcome measures. In this paper, we present our model for extending these efficacious treatment approaches for panic disorder to naturalistic samples, settings and providers [8]. By so doing, we aim to facilitate continued research efforts through replication and extension. Results concerning the effectiveness of our intervention in comparison to treatment-as-usual in primary care settings will be presented in subsequent papers.

Panic disorder is prevalent and costly in primary care settings, making the need for effective interventions paramount. Community prevalence studies [9], [10] indicate a current (last 12 months) prevalence rate for panic disorder of 1 to 3% of the population, whereas estimates from primary care settings range from 1.5 to 13%, with a median of 4 to 6% [11], [12], [13].

Elevated prevalence in primary care settings may be in part due to the high comorbidity between panic disorder and unexplained physical symptoms, and the tendency for patients to interpret panic-related symptoms as evidence of medical illness [14], [15]. Consequently, panic disorder patients use primary care services at three times the rate of other patients [16] exceeding that of depressed patients [17], and patients with other psychiatric disorders [18].

Unfortunately, panic disorder is poorly recognized in primary care [19], [20], [21]. Moreover, even when recognized by primary care physicians, panic and anxiety disorders appear to be inadequately treated [22], [23], [24]. According to our own investigation [25] of 43 primary care panic disorder patients followed for six to ten months, 63% did not receive any form of therapy, only 11% received liberally defined cognitive behavioral therapy, less than 50% received medications, and only 26% received an efficacious medication regimen.

Thus, we have developed an intervention for panic disorder that is tailored to a primary care setting. Differences between specialized mental health care and primary care guided our intervention strategy. For example, panic disorder patients in primary care are likely to differ from patients who self-initiate mental health treatment in terms of psychiatric and medical comorbidity, education and income level, ethnicity and motivation and attitudes about mental health and its treatment.

Section snippets

A collaborative care approach

Despite being the first contact for many patients seeking mental health care, primary care physicians are not well positioned for delivery of such care, with their time limited to 10 to 15 min per patient, and by multiple competing demands. It may be for this reason that direct feedback to physicians about diagnosis and recommended treatments had very little impact on high health care utilizers with panic disorder [22]. Thus, some have begun to explore the effectiveness of integrating mental

Content of collaborative care treatment

In this section, we describe the actual steps involved in the collaborative treatment for panic disorder. The treatment manual is available upon request.

Summary

In summary, panic disorder is a prevalent and costly disorder in the primary care setting, yet one that is inadequately treated. We have extended efficacy research principles to develop a feasible intervention for primary care patients. Our intervention combines cognitive-behavioral therapy and psychopharmacology and is conducted in a collaborative model in the primary care setting, involving a behavioral health specialist, psychiatrist, and primary care physician. In addition, patient

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