Psychiatry and primary careTreating panic disorder in primary care: a collaborative care intervention
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
References (56)
- et al.
Behavioral treatment of panic disorder
Behavior Therapy
(1989) - et al.
Behavioral treatment of panic disordera two year follow-up
Behavior Therapy
(1991) - et al.
Distressed high utilizers of medical care. DSM III R diagnoses and treatment needs
General Hospital Psychiatry 1990
(1990) - et al.
Reduced therapist contact in the cognitive-behavioral treatment of panic disorder
Behavior Therapy
(1994) - et al.
Brief cognitive-behavioral versus non- directive therapy for panic disorder
Journal of Behaviour Therapy and Experimental Psychiatry
(1995) - et al.
The use of bibliotherapy in the treatment of panica preliminary investigation
Behavior Therapy
(1993) - et al.
Social support, stress and functional status in patients with osteoarthritis
Social Science and Medicine
(1990) - et al.
Tailor-made versus standardized therapy of phobic patients
Advances in Behavior Research and Therapy
(1992) - et al.
Psychotherapy by telephonea therapeutic tool for cancer patients
Psychosomatics
(1991) - et al.
Cognitive-behavioral therapy, imipramine, or their combination for panic disorderA randomized controlled trial
Journal of American Medican Association
(2000)
A comparison of cognitive therapy, applied relaxation, and imipramine in the treatment of panic disorder
British Journal of Psychiatry
Serotonin uptake inhibitors are superior to imipramine and alprazolam in alleviating panic attacksa meta analysis
International Clinical Psychopharmacology
Algorithm for the treatment of panic disorder with agoraphobia
Psychopharmacology Bulletin
Pharmacotherapy of panic disorderproposed guidelines for the family physician
Journal of the American Board of Family Practice
Panic, and phobia
Lifetime and 12 month prevalence of DSM-III-R psychiatric disorders in the United States. Results from the National Comorbidity Survey
Archives of General Psychiatry
The social costs of anxiety disorders
British Journal of Psychiatry
Anxiety disorders in primary care
Bull Menninger Clin
Occurrence, recognition, and outcome of psychological disorders in primary care
American Journal of Psychiatry
Where do panic attack sufferers seek care?
Journal of Family Practice
Panic disorder in the medically ill
Journal of Clinical Psychiatry
Public health service national center for health statistics, national medical care utilization and expenditure survey
Psychiatric disorder and functional somatic symptoms as predictors of health care use
Psychiatric Medicine
Panic attacks in the community. Social morbidity and health care utilization
Journal of American Medical Association
Panic disorder in emergency department chest pain patientsprevalence, comorbidity, suicidal ideation, and physician recognition
American Journal of Medicine
Depression in medical outpatientsunder recognition and misdiagnosis
Archives of Internal Medicine
Utility of a new procedure for diagnosing mental d disorders in primary care: The PRIME MD 1000 study
Journal of American Medical Association 1994
Cited by (38)
Collaborative care for depression management in primary care: A randomized roll-out trial using a type 2 hybrid effectiveness-implementation design
2021, Contemporary Clinical Trials CommunicationsCitation Excerpt :We also envision successful implementation of CBHP for depression laying the foundation for expanding the model to other common mental health conditions, such as anxiety, substance abuse, trauma, and cognitive problems (e.g., dementia). Although CoCM has been used for the treatment of anxiety [85], bipolar disorder [86], substance abuse [87], and other problems [88,89], these adaptations have thus far not been widely implemented as has been the case for depression. At the time of this submission, we have started CBHP in all 11 practices.
Cooperation between primary care and mental health services
2009, Atencion PrimariaEpidemiologic Trends and Costs of Fragmentation
2006, Medical Clinics of North AmericaCitation Excerpt :Studies of inpatient and outpatient programs that integrate general medical and mental health screening and treatment have demonstrated improved outcomes [80,124–127] in comparison with other models, such as usual care or screening results provided to primary care physicians [128–130] (also see the article by Smith and Clarke elsewhere in this issue). Evidence-based data from prospective, randomized, controlled studies in primary care have demonstrated the effectiveness of integrated on-site models compared with treatment as usual in depression and panic disorder [66,68,80,96,131–136] as well as a high degree of patient satisfaction with on-site mental health treatment [135]. Similar results were demonstrated for interventions in the general hospital setting when mental health programs were integrated with the general medical team, as compared with screening alone [130,137–141] (also see the article by Smith and Clarke elsewhere in this issue).
CBT Intensity and Outcome for Panic Disorder in a Primary Care Setting
2006, Behavior TherapyCitation Excerpt :Weights were derived to control for these differences due to nonresponse. The intervention (described in greater detail elsewhere; Craske et al., 2002) was based on a collaborative care model and utilized a BHS to deliver CBT and coordinate care. Mostly master-level clinicians with minimal or no CBT experience were recruited to perform the BHS functions specifically to enhance generalizability to real-world settings.
Medical illness and response to treatment in primary care panic disorder
2005, General Hospital Psychiatry