Assessment of beliefs about psychotropic medication and psychotherapy: development of a measure for patients with anxiety disorders

Mediators of Ethnic Differences in Dropout Rates From a Randomized Controlled Treatment Trial Among Latinx and Non-Latinx White Primary Care Patients With Anxiety Disorders

ABSTRACT

Disparities in treatment engagement and adherence based on ethnicity have been widely recognized but are inadequately understood. Few studies have examined treatment dropout among Latinx and non-Latinx White (NLW) individuals. Using Andersen's Behavioral Model of Health Service Use (A behavioral model of families' use of health services. 1968; J Health Soc Behav. 1995; 36:1-10) as a framework, we examine whether pretreatment variables (categorized as predisposing, enabling, and need factors) mediate the relationship between ethnicity and premature dropout in a sample of Latinx and NLW primary care patients with anxiety disorders who participated in a randomized controlled trial (RCT) of cognitive behavioral therapy. Data from a total of 353 primary care patients were examined; 96 Latinx and 257 NLW patients participated. Results indicated that Latinx patients dropped out of treatment more often than NLW patients, resulting in roughly 58% of Latinx patients failing to complete treatment compared with 42% of NLW, and approximately 29% of Latinx patients dropping out before engaging in modules related to cognitive restructuring or exposure, relative to 11% of NLW patients. Mediation analyses suggest that social support and somatization partially explained the relationship between ethnicity and treatment dropout, highlighting the importance of these variables in understanding treatment disparities.

Anxiety treatment preferences among veteran primary care patients: Demographic, mental health, and treatment-related correlates

INTRODUCTION

Anxiety symptoms are common, yet undertreated, among primary care patients. Accommodating patient treatment preferences improves engagement and retention. In contrast to depression, little is known about primary care patients' preferences for anxiety treatment.

METHOD

Participants were 144 veterans experiencing anxiety symptoms but not receiving psychotherapy who were recruited from primary care. Preferences for 11 anxiety treatment attributes (method; location; type; format; provider; frequency, length, and number of appointments; psychotherapy orientation; symptom focus; and topic/skill) and demographic, mental health (e.g., anxiety symptom severity), and treatment-related (e.g., psychotherapy history) variables were assessed via mailed survey. We used chi-square goodness of fit tests to identify patient preferences for each attribute and multivariate multinomial logistic regression models to explore demographic, mental health, and treatment-related correlates of treatment preferences.

RESULTS

Patient preferences were largely consistent with integrated primary care models, particularly Primary Care Behavioral Health, with a few exceptions. Patients preferred longer appointments (e.g., 45-60 minutes) and a longer duration of treatment (e.g., ≥13 appointments) than is typically offered in primary care. Several variables, particularly education level, perceived need for help, anxiety symptom severity, and attitudes toward psychotherapy, were repeatedly associated with preferences for various anxiety treatment attributes.

DISCUSSION

Results from this study suggest that patients tend to have distinct preferences for anxiety treatment in primary care that are largely consistent with common integrated primary care models. Results also identify several variables that may be associated with specific preferences, which may help match patients to their preferred type of care. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Treatment Beliefs in Patients with Mental Disorders in Psychosomatic Rehabilitation

Abstract. Background: The efficacy of inpatient psychosomatic rehabilitation in Germany can be considered proven. However, a significant number of patients with mental disorders remain unsatisfied with rehabilitation or being non-responders. Illness beliefs, as the core element of the Common-Sense Model of Self-Regulation (CSM), are widely known as predictors of various health outcomes. Yet, little is known about treatment beliefs as an extension of the CSM and their impact on health outcomes. Aim: As treatment beliefs differ in relation to the treatment, this study aimed to explore rehabilitation-related treatment beliefs in psychosomatic rehabilitation patients with mental disorders before inpatient admission. Thus, knowledge of the concept of rehabilitation-related treatment beliefs will be added. Methods: N = 10 semi-structured telephone interviews were conducted in September/October 2018. A purposive sampling approach was chosen based on the criteria gender, age, and diagnosis. Participants were asked about their rehabilitation expectations starting with an open narrative question. Interviews were analyzed using qualitative content analysis. Results: Participants had a mean age of 48.3 years ( SD = 9.42); five participants were female and five male. 9 main themes with 32 subthemes as components of the rehabilitation-related treatment beliefs were identified: reasons for rehabilitation, conditions within the clinic, rehabilitation planning, organization of the rehabilitation, the content of the rehabilitation, results of the rehabilitation, concerns, expectations toward one’s behavior, and contact to other patients. Limitation: Our sample was too small to analyze the data for different subgroups. Conclusion: Results show that rehabilitation-related treatment beliefs are multidimensional, addressing different aspects of psychosomatic rehabilitation.

Testing Clinical Intuitions About Barriers to Improvement in Cognitive-Behavioral Therapy for Panic Disorder

Although clinical intuitions influence psychotherapeutic practice and are a rich source of novel hypotheses for research, many remain to be empirically tested. This study evaluates whether clinicians' beliefs about barriers to progress in cognitive-behavioral therapy (CBT) for panic disorder are supported by data. Data from a randomized-controlled trial comparing CBT to panic-focused psychodynamic psychotherapy (PFPP) for adults with primary panic disorder (N = 161) were used to evaluate 15 factors endorsed by clinicians as impediments to CBT in a recent survey. Panic severity was assessed before, during (at Weeks 1, 5, and 9), and at termination of treatment (Week 12) using the Panic Disorder Severity Scale. Hierarchical linear modeling revealed that none of the perceived barriers were predictive of poor outcome. Contrary to clinicians' intuitions, dissociation during panic attacks was associated with greater symptomatic improvement in both treatment arms (β = -0.69, p < .05), above the effect of established predictors. Moderation analyses revealed that when patients had PTSD diagnosed with the Anxiety Disorders Interview Schedule (β = 1.71, p < .05) or less severe panic disorder (β = 0.45, p = .04), they changed more rapidly in CBT than in PFPP. Overall, clinician agreement was inversely related to the strength of a predictor (r = -.24, p = .39). Although clinical intuitions can be useful as clinical and empirical signals, such beliefs should be critically examined before informing practice. Dialogue between academics and clinicians might be enhanced through research that incorporates input from front-line practitioners.

Problem recognition and treatment beliefs relate to mental health utilization among veteran primary care patients

Mental health concerns are prevalent among primary care patients, but many do not utilize services for these conditions. This study aims to conduct a comprehensive assessment of barriers and facilitators to mental health care utilization among veteran primary care patients with common mental health concerns. We hypothesized that beliefs and knowledge about mental illness and mental health care would be more strongly associated with recent mental health care utilization than stigma, help-seeking behaviors, or logistical barriers. Veterans (n = 116) enrolled in primary care with current symptoms of depression (58%), posttraumatic stress disorder (37%), and/or hazardous alcohol use (50%) who either recently used mental health services (47%) or had no recent mental health treatment utilization (53%) completed a telephone-based screening, medical records review, and mail survey of 10 measures of barriers and facilitators to mental health treatment utilization. Recognition of problems as a cause for concern, odds ratio = 5.95, 95% confidence interval [2.36, 15.01], and beliefs about psychotherapy, odds ratio = 2.53, 95% confidence interval [1.39, 4.60], emerged as stronger correlates of recent mental health care utilization than stigma, self-efficacy, and external barriers to treatment. Results suggest the use of specific theories, measures, and interventions that focus on patient recognition of problems and beliefs about treatment over those that focus on other treatment barriers and facilitators. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Beyond stigma: Understanding the "inclined abstainers" in military behavioral health-care utilization

Low treatment utilization in Soldiers with combat-related Posttraumatic Stress Disorder (PTSD) is an ongoing issue. The critical concern is to better understand factors which prohibit a Soldier with PTSD who wants help from seeking treatment (an "inclined abstainer"). A total of 537 Active Duty Soldiers on a US Army post completed a brief survey comprising psychometrically validated measures of stigma, behavioral health treatment beliefs, resilience, PTSD symptoms, and treatment intentions. Health-care records were prospectively tracked for 12 months to determine the relation between survey answers and treatment utilization. Sixty-three percent of those who acknowledged having a mental health-related problem did not seek help within a one-year period. Greater severity of PTSD symptoms was associated with an increased likelihood of behavioral health engagement. Soldiers that were classified as "inclined abstainers" were also more likely to endorse negative beliefs about psychotherapy and report higher levels of resilience as compared to "inclined actors." These results suggest that a treatment model of PTSD emphasizing self-efficacy and self-reliance, while addressing negative beliefs about psychotherapy, may help promote engagement of behavioral health services among Active Duty Soldiers.

Gender differences in rates and predictors of individual psychotherapy initiation and completion among Veterans Health Administration users recently diagnosed with PTSD

OBJECTIVE

Most veterans with posttraumatic stress disorder (PTSD) who receive care from the Veterans Health Administration (VHA) do not receive individual psychotherapy. The purpose of this study was to explore gender differences in initiation and completion of a sufficient course (defined as attending 8 or more sessions) of individual psychotherapy among male and female VHA users recently diagnosed with PTSD.

METHOD

Participants (N = 7,218) were veterans in a prospective national cohort survey of VHA users diagnosed with PTSD; oversampling was used to increase representation of women and minority veterans.

RESULTS

Forty-two percent of the sample (40.1% of men, 52.3% of women) initiated individual psychotherapy within 6 months of their index PTSD diagnosis. Of those who initiated, 12.1% (10.8% of men, 17.7% of women) completed a sufficient course of individual psychotherapy. Women were generally more likely than men to initiate individual psychotherapy. However, we found an interaction between gender and age, such that younger men were more likely to initiate psychotherapy than older men; age was not significantly associated with initiation among women. Regarding completion of individual psychotherapy, an interaction between gender and beliefs about psychotherapy was found, such that men were less likely to complete individual psychotherapy when they held more negative beliefs about psychotherapy; these beliefs did not significantly impact female veterans' likelihood of completing psychotherapy.

CONCLUSIONS

Overall, while female veterans are more likely than male veterans with PTSD to initiate individual psychotherapy, rates of initiation and completion of individual psychotherapy for both genders remain relatively low. Interventions are needed to increase engagement in individual psychotherapy, particularly for male veterans with PTSD. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Interactive effects of stress and individual differences on alcohol use and posttraumatic stress disorder among personnel deployed to Guantanamo Bay

This study examines the role of factors such as perceived stress, neuroticism, beliefs in psychotherapy stigma, resilience, and demographics in understanding posttraumatic stress disorder (PTSD) and alcohol use disorder (AUD) among deployed military personnel. Results show that personnel who screened positive for PTSD were more likely to screen positive for AUD (versus those who did not screen positive for PTSD). Perceived stress, neuroticism, and psychotherapy stigma all have direct multivariate relationships with PTSD symptoms. Moderated regression analyses show that the positive relationship between perceived stress and PTSD symptoms is significantly stronger among those scoring high on neuroticism and psychotherapy stigma. The positive relationship between perceived stress and AUD symptoms is only significant among those scoring high on psychotherapy stigma. Given the moderating role of psychotherapy stigma in the relationship between perceived stress and PTSD symptoms and the relationship between perceived stress and AUD symptoms efforts to reduce the stigma associated with mental health care in the military should be expanded. Also, the current research adds to the literature highlighting the role of neuroticism as a key variable in understanding PTSD.

Illness and treatment perceptions of patients with chronic low back pain: characteristics and relation to individual, disease and interaction variables

The significance of various cognitive and psychosocial factors in the development, progression and persistence of chronic low back pain (CLBP) is well demonstrated. However, only a few studies have addressed CLBP patients' cognitive representations or beliefs about their disease and its treatment. The present study aimed to: (1) describe the illness and treatment beliefs of patients with CLBP, e.g., expected timeline, controllability or treatment related concerns; and (2) explore the relation of these illness and treatment beliefs to individual-, disease- and interaction-related variables. We conducted a cross-sectional survey with N = 201 patients at four inpatient rehabilitation centers. The characteristics of illness and treatment perceptions were analyzed using descriptive statistics. Multiple regression analysis was used to test the associations with disease-related, individual-related and interaction-related variables. The results demonstrated large inter-individual variability in the illness and treatment perceptions among patients with CLBP and pointed to several associations with disease-related variables, patients' personal characteristics and interaction experiences. The variables most strongly related to individuals' perceptions were those reflecting disease severity and individual disease experience. Further research is needed on CLBP patients' illness and treatment perceptions, and these personal disease experiences should be considered when designing new treatment approaches.

The neural basis of testable and non-testable beliefs

Beliefs about the state of the world are an important influence on both normal behavior and psychopathology. However, understanding of the neural basis of belief processing remains incomplete, and several aspects of belief processing have only recently been explored. Specifically, different types of beliefs may involve fundamentally different inferential processes and thus recruit distinct brain regions. Additionally, neural processing of truth and falsity may differ from processing of certainty and uncertainty. The purpose of this study was to investigate the neural underpinnings of assessment of testable and non-testable propositions in terms of truth or falsity and the level of certainty in a belief. Functional magnetic resonance imaging (fMRI) was used to study 14 adults while they rated propositions as true or false and also rated the level of certainty in their judgments. Each proposition was classified as testable or non-testable. Testable propositions activated the DLPFC and posterior cingulate cortex, while non-testable statements activated areas including inferior frontal gyrus, superior temporal gyrus, and an anterior region of the superior frontal gyrus. No areas were more active when a proposition was accepted, while the dorsal anterior cingulate was activated when a proposition was rejected. Regardless of whether a proposition was testable or not, certainty that the proposition was true or false activated a common network of regions including the medial prefrontal cortex, caudate, posterior cingulate, and a region of middle temporal gyrus near the temporo-parietal junction. Certainty in the truth or falsity of a non-testable proposition (a strong belief without empirical evidence) activated the insula. The results suggest that different brain regions contribute to the assessment of propositions based on the type of content, while a common network may mediate the influence of beliefs on motivation and behavior based on the level of certainty in the belief.

Determinants of prospective engagement in mental health treatment among symptomatic Iraq/Afghanistan veterans

There is considerable public and professional concern about the mental health status of veterans deployed to Iraq and Afghanistan as well as how to engage and retain symptomatic veterans in treatment. This study examined demographic, psychiatric, and psychosocial determinants of prospective initiation and retention in mental health services among symptomatic Iraq/Afghanistan veterans. One hundred thirty-seven symptomatic veterans who were referred to mental health screening completed a survey at the time of their first mental health visit. Associations between survey variables and subsequent Veterans Affairs service utilization were evaluated. The most consistent determinants of mental health service initiation and retention were severity of posttraumatic stress disorder (PTSD) and depressive symptoms. Notably, whereas PTSD-related re-experiencing symptoms were independently associated with initiation of mental health treatment, PTSD-related numbing symptoms were independently associated with retention in treatment. Stigma, barriers to care, and beliefs about mental health treatment were not associated with either mental health initiation or retention.

Self-stigma and attitudes about treatment in depressed patients in a hospital setting

AIMS

Many patients have stigma about depression, which may inhibit treatment seeking. However, most previous research in this area has been conducted in outpatient samples. The current study investigated self-stigma and its relationship with treatment beliefs in depressed patients receiving psychiatric hospital treatment.

METHOD

The sample consisted of 55 hospitalized patients with depressive disorders who completed measures of self-stigma, medication beliefs, psychotherapy beliefs and depression.

RESULTS

Multiple regression analyses controlling for demographic variables demonstrated that higher depression severity was associated with increased self-stigma related to treatment and having depression. Higher self-stigma about treatment was associated with more negative beliefs about psychiatric medications, but more positive beliefs about psychotherapy. In contrast, self-stigma about depression was associated with negative beliefs about medications, but not psychotherapy.

CONCLUSIONS

Psychiatric hospital treatment, particularly in the USA, emphasizes medication treatment while de-emphasizing evidence-based psychosocial interventions. Individuals with negative views about psychiatric medications and positive views about the value of psychotherapy have higher treatment self-stigma, which may discourage them from seeking hospital treatment when needed or negatively affect their treatment response.

"How will it help me?" Reasons underlying treatment preferences between sertraline and prolonged exposure in posttraumatic stress disorder

Individuals with posttraumatic stress disorder (PTSD) often wait years before seeking treatment. Improving treatment initiation and adherence requires a better understanding of patient beliefs that lead to treatment preferences. Using a treatment-seeking sample (N = 200) with chronic PTSD, qualitative reasons underlying treatment preferences for either prolonged exposure (PE) or sertraline (SER) were examined. Reasons for treatment preference primarily focused on how the treatment was perceived to reduce PTSD symptoms rather than practical ones. The patients were more positive about PE than SER. Individual differences did not reliably predict underlying preference reasons, suggesting that what makes a treatment desirable is not strongly determined by current functioning, treatment, or trauma history. Taken together, this information is critical for treatment providers, arguing for enhancing psychoeducation about how treatment works and acknowledging preexisting biases against pharmacotherapy for PTSD that should be addressed. This knowledge has the potential to optimize and better personalize PTSD patient care.

Race and beliefs about mental health treatment among anxious primary care patients

Large racial disparities in the use of mental health care persist. Differences in treatment preferences could partially explain the differences in care between minority and nonminority populations. We compared beliefs about mental illness and treatment preferences between adult African-Americans, Hispanics, Asian Americans, Native Americans, and White Americans with diagnosed anxiety disorders. Measures of beliefs about mental illness and treatment were drawn from the National Comorbidity Survey Replication and from our previous work. There were no significant differences in beliefs between the African-Americans and the White Americans. The beliefs of the Hispanics and the Native Americans were most distinctive, but the differences were small in magnitude. Across race/ethnicity, the associations between beliefs and service use were generally weak and statistically insignificant. The differences in illness beliefs and treatment preferences do not fully explain the large, persistent racial disparities in mental health care. Other crucial barriers to quality care exist in our health care system and our society as a whole.

Collaborative care for depression and anxiety problems

BACKGROUND

Common mental health problems, such as depression and anxiety, are estimated to affect up to 15% of the UK population at any one time, and health care systems worldwide need to implement interventions to reduce the impact and burden of these conditions. Collaborative care is a complex intervention based on chronic disease management models that may be effective in the management of these common mental health problems.

OBJECTIVES

To assess the effectiveness of collaborative care for patients with depression or anxiety.

SEARCH METHODS

We searched the following databases to February 2012: The Cochrane Collaboration Depression, Anxiety and Neurosis Group (CCDAN) trials registers (CCDANCTR-References and CCDANCTR-Studies) which include relevant randomised controlled trials (RCTs) from MEDLINE (1950 to present), EMBASE (1974 to present), PsycINFO (1967 to present) and the Cochrane Central Register of Controlled Trials (CENTRAL, all years); the World Health Organization (WHO) trials portal (ICTRP); ClinicalTrials.gov; and CINAHL (to November 2010 only). We screened the reference lists of reports of all included studies and published systematic reviews for reports of additional studies.

SELECTION CRITERIA

Randomised controlled trials (RCTs) of collaborative care for participants of all ages with depression or anxiety.

DATA COLLECTION AND ANALYSIS

Two independent researchers extracted data using a standardised data extraction sheet. Two independent researchers made 'Risk of bias' assessments using criteria from The Cochrane Collaboration. We combined continuous measures of outcome using standardised mean differences (SMDs) with 95% confidence intervals (CIs). We combined dichotomous measures using risk ratios (RRs) with 95% CIs. Sensitivity analyses tested the robustness of the results.

MAIN RESULTS

We included seventy-nine RCTs (including 90 relevant comparisons) involving 24,308 participants in the review. Studies varied in terms of risk of bias.The results of primary analyses demonstrated significantly greater improvement in depression outcomes for adults with depression treated with the collaborative care model in the short-term (SMD -0.34, 95% CI -0.41 to -0.27; RR 1.32, 95% CI 1.22 to 1.43), medium-term (SMD -0.28, 95% CI -0.41 to -0.15; RR 1.31, 95% CI 1.17 to 1.48), and long-term (SMD -0.35, 95% CI -0.46 to -0.24; RR 1.29, 95% CI 1.18 to 1.41). However, these significant benefits were not demonstrated into the very long-term (RR 1.12, 95% CI 0.98 to 1.27).The results also demonstrated significantly greater improvement in anxiety outcomes for adults with anxiety treated with the collaborative care model in the short-term (SMD -0.30, 95% CI -0.44 to -0.17; RR 1.50, 95% CI 1.21 to 1.87), medium-term (SMD -0.33, 95% CI -0.47 to -0.19; RR 1.41, 95% CI 1.18 to 1.69), and long-term (SMD -0.20, 95% CI -0.34 to -0.06; RR 1.26, 95% CI 1.11 to 1.42). No comparisons examined the effects of the intervention on anxiety outcomes in the very long-term.There was evidence of benefit in secondary outcomes including medication use, mental health quality of life, and patient satisfaction, although there was less evidence of benefit in physical quality of life.

AUTHORS' CONCLUSIONS

Collaborative care is associated with significant improvement in depression and anxiety outcomes compared with usual care, and represents a useful addition to clinical pathways for adult patients with depression and anxiety.

Predictors of clinical improvement in a randomized effectiveness trial for primary care patients with panic disorder

This study's aim was to prospectively examine and identify a model of demographic, clinical, and attitudinal variables that impact improvement among patients with panic disorder. Subjects were 232 primary care patients meeting criteria for DSM-IV panic disorder. Eligible patients were randomly assigned to a collaborative care intervention or to treatment as usual. Assessments occurred at 3-month intervals during the course of 1 year. In final multivariate logistic regression models, patients with higher anxiety sensitivity and higher neuroticism scores at baseline were less likely to show clinical improvement (using a criterion of 20 or less on the Anxiety Sensitivity Index) at 3 months. Those who were non-white, had higher anxiety sensitivity, and higher overall phobic avoidance at baseline were less likely to show clinical improvement at 12 months. A greater understanding of these predictors may help clinicians identify who is at greatest risk for persistent panic-related symptoms and to plan the intensity of interventions accordingly.

Older adults' help-seeking attitudes and treatment beliefs concerning mental health problems

OBJECTIVES

Older adults with mental health problems are especially unlikely to seek professional mental health services. It is not clear, however, whether their help-seeking attitudes and treatment beliefs contribute to this problem. The objectives of this study were to compare older adults' attitudes and beliefs to younger adults' and to examine the influence of age on these variables after controlling for other demographic variables, prior help-seeking, and mental disorders.

METHODS

The authors analyzed cross-sectional data from Part 2 of the National Comorbidity Survey Replication. This dataset includes 5,692 community-dwelling adults, including 1,341 adults who were 55 years of age and older. Participants responded to three questions assessing attitudes toward seeking professional mental health services and one question examining beliefs about the percentage of people with serious mental health concerns who benefit from professional help. The authors used logistic regression to predict positive versus negative attitudes and beliefs from age, gender, education, and race/ethnicity, as well as prior help seeking and mood and/or anxiety disorder diagnosis.

RESULTS

Overall, more than 80% of participants exhibited positive help-seeking attitudes and more than 70% reported positive treatment beliefs. In contrast to the modest effect of age on beliefs, adults 55-74 years of age were approximately two to three times more likely to report positive help-seeking attitudes than younger adults.

CONCLUSIONS

Older adults' positive attitudes and treatment beliefs are unlikely barriers to their use of mental health services. This finding, which is consistent with recent positive views of aging, suggests that enabling resources and need factors are more likely explanations for older adults' low rates of mental health service use.

Patient decision-making regarding entry into psychotherapy to treat depression

Many individuals with depression want treatment, and most believe that psychotherapy will treat symptoms of depression, yet many do not initiate care beyond their primary care physicians. This becomes critical given the low to moderate adherence rate to antidepressant medications among depressed patients treated in primary care. Many are left untreated or under-treated. The purpose of this study was to investigate whether attitudes toward psychotherapy in a population of primary care patients newly diagnosed with depression influenced the likelihood that they initiated psychotherapy. Participants were asked to complete two attitudinal questionnaires and respond to a three-month follow-up phone call regarding therapy initiation. Reported attitudes toward psychotherapy were positive. Many perceived therapy as both effective and preferred over medications. Despite positive attitudes, the rate of initiation into psychotherapy remained alarmingly low.

[What our patients want and need to know about generalized anxiety disorder]

Persons with generalized anxiety disorder often do not seek treatment, and if they do, it is more often for the somatic symptoms (muscle tension, insomnia) or for a secondary depression than because of the cardinal feature of generalized anxiety disorder: worry. The worry aspect becomes apparent when the patient is proposed to try anxiolytic medication. The physician will then need to be prepared to answer many questions regarding the potential hazards and benefits of such medication. These patients tend to have a sceptical attitude, having informed themselves on websites that display claims that are based on anything from evidence-based scientific guidelines to distorted, erroneous and unfounded allegations. Which are the frequent questions that worried patients pose to the physician before accepting anxiolytic pharmacotherapy? Having seen anxious patients in my practice during 25 years, and having conducted several clinical trials of anxiolytics I have put together evidence-based answers in plain language to these questions in this paper.

A 1-year follow-up study of chest-pain patients with and without panic disorder

OBJECTIVE

The aims of this study were to (a) study the persistence of panic disorder (PD); (b) investigate the association between PD at baseline and outcome [chest pain, psychiatric morbidity, health care utilization, suicidal thoughts, work impairment and health-related quality of life (HRQOL)]; (c) study the course of pain, distress, symptom attribution and HRQOL; and (d) describe treatment and perceived treatment needs of patients with PD.

METHOD

A 1-year follow-up study of 199 chest-pain patients referred to cardiac outpatient investigation was completed. Assessments included Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (SCID), Short-Form McGill Pain Questionnaire, Symptom Checklist-90-Revised, the Illness Attitude Scales, the 36-item Short-Form Health Survey and a chest-pain questionnaire.

RESULTS

At follow-up, 57 of the 153 patients reassessed with the SCID suffered from PD. Forty-three of the 55 patients (78%) who were diagnosed with PD at baseline still suffered from PD at follow-up. PD at baseline was associated with pain persistence, psychiatric morbidity (current major depression, pain disorder and simple phobia), significantly higher scores on psychological distress, hypochondriasis, negative outcome expectation, lower scores on seven of the eight dimensions of HRQOL and more general practitioner consultations. Only 6% of the patients with PD used effective treatment, and 3% reported a treatment need at follow-up.

CONCLUSION

Despite chronic distress and impairment, we found significant undertreatment of PD, which needs to be addressed in future studies.