Medical utilisation and costs in panic disorder: a comparison with social phobia

Economic Burden of Anxiety Disorders: A Systematic Review and Meta-Analysis

BACKGROUND

Anxiety disorders (AD) are common mental disorders, for which several cost-of-illness (COI) studies have been conducted in the past.

OBJECTIVE

The aim of this review was to provide a systematic overview of these studies and an aggregation of their results.

METHODS

A systematic literature search limited to studies published after 1999 was conducted in PubMed/MEDLINE in November 2018. We included top-down COI studies reporting costs for AD, and bottom-up COI studies reporting costs for AD and a non-diseased control group, and extracted data manually. Results of the top-down COI studies were aggregated by calculating the mean percentage of costs on gross domestic product (GDP) and health expenditure, while the results of the bottom-up studies were analyzed meta-analytically using the 'ratio of means' method and inverse-variance pooling. In this review, the logarithm of the relative difference in a continuous outcome between two groups is calculated and aggregated over the studies. The results can be interpreted as the relative change in costs imposed by a specific disease compared with baseline costs.

RESULTS

We identified 13 top-down and 11 bottom-up COI studies. All top-down COI studies and four bottom-up COI studies reported costs for AD as a diagnostic group, four for generalized anxiety disorder (GAD), four for social anxiety disorder (SAD), and one for panic disorder. In top-down COI studies, direct costs of AD, on average, corresponded to 2.08% of health care costs and 0.22% of GDP, whereas indirect costs, on average, corresponded to 0.23% of GDP. In bottom-up COI studies, direct costs of patients with AD were increased by factor 2.17 (1.29-3.67; p = 0.004) and indirect costs were increased by factor 1.92 (1.05-3.53; p = 0.04), whereas total costs increased by factor 2.52 (1.73-3.68; p < 0.001). Subgroup analysis revealed an increase in direct costs by 1.60 (1.16-2.22; p = 0.005) for SAD and 2.60 (2.01-3.36; p < 0.001) for GAD. Measures of heterogeneity indicated high heterogeneity when pooling studies for direct costs, indirect costs, and total costs, but low to moderate heterogeneity when pooling studies for SAD or GAD.

CONCLUSIONS

Using methods that focused on relative rather than absolute costs, we were able to aggregate costs reported in different COI studies for ADs. We found that ADs were associated with a low proportion of health care costs on a population level, but significantly increased health care costs on an individual level compared with healthy controls. Our disorder-specific subgroup analysis showed that study findings are most homogeneous within specific ADs. Therefore, to get a more detailed picture of the costs of ADs, more studies for currently under researched ADs, such as panic disorder, are needed.

Patient factors associated with initiation of behavioral weight loss treatment: a prospective observational study in an integrated care setting

Low enrollment in behavioral weight loss treatments limits their impact. We aimed to identify factors associated with treatment initiation. The participants were outpatients (n = 198) at Veterans Affairs (VA) healthcare facilities who were referred to a free VA-based behavioral weight loss treatment. Participants were assessed on psychosocial factors potentially relevant to treatment initiation. Subsequent treatment initiation was determined via medical record review. Study participants were 77 % male, 60 % African American, and 54 % initiated treatment. In multivariable analyses, treatment initiation was associated with being single, higher anxiety, and patients' perceptions that referring provider supported their weight autonomy. Endorsement of treatment barriers was not associated with treatment initiation. Treatments offering in-person sessions and mood management components were rated as more preferred. Initiation of behavioral weight loss treatments may increase if patients believe that providers respect their weight control autonomy and if healthcare organizations offer treatments that match patients' preferences.

Excess costs of social anxiety disorder in Germany

BACKGROUND

Social anxiety disorder is one of the most frequent mental disorders. It is often associated with mental comorbidities and causes a high economic burden. The aim of our analysis was to estimate the excess costs of patients with social anxiety disorder compared to persons without anxiety disorder in Germany.

METHODS

Excess costs of social anxiety disorder were determined by comparing two data sets. Patient data came from the SOPHO-NET study A1 (n=495), whereas data of persons without anxiety disorder originated from a representative phone survey (n=3213) of the general German population. Missing data were handled by "Multiple Imputation by Chained Equations". Both data sets were matched using "Entropy Balancing". Excess costs were calculated from a societal perspective for the year 2014 using general linear regression with a gamma distribution and log-link function. Analyses considered direct costs (in- and outpatient treatment, rehabilitation, and professional and informal care) and indirect costs due to absenteeism from work.

RESULTS

Total six-month excess costs amounted to 451€ (95% CI: 199€-703€). Excess costs were mainly caused by indirect excess costs due to absenteeism from work of 317€ (95% CI: 172€-461€), whereas direct excess costs amounted to 134€ (95% CI: 110€-159€).

LIMITATIONS

Costs for medication, unemployment and disability pension was not evaluated.

CONCLUSIONS

Social anxiety disorder was associated with statistically significant excess costs, in particular due to indirect costs. As patients in general are often unaware of their disorder or its severity, awareness should be strengthened. Prevention and early treatment might reduce long-term indirect costs.

Intensive behavioral therapy for agoraphobia

BACKGROUND

We investigated the efficacy of an intensive 1-week behavioral therapy program focusing on agoraphobia for panic disorder patients with agoraphobia (PDA).

DESIGN AND METHODS

The study design was a case-control study. Main outcome measure was the agoraphobia score of the Fear Questionnaire (FQ-AGO). The outcomes on the FQ-AGO of a 1-week intensive therapy (96 patients) and a twice-weekly therapy (98 patients) were compared.

RESULTS

Agoraphobia improved significantly in both groups, 1 week and 3 months after therapy. Effect size for changes in the 1-week intensive therapy on the FQ-AGO was 0.75.

LIMITATIONS

Limitations are use of antidepressants, no placebo group, and no long term follow-up.

CONCLUSION

Behavioral therapy for agoraphobia can be shortened significantly if intensified without affecting therapy outcome, thus allowing patients a more rapid return to work and resumption of daily activities.

Does help-seeking alter the risk for incident psychopathology in adolescents and young adults with and without fearful spells or panic attacks? Findings from a 10-year prospective-longitudinal community study

BACKGROUND

Although fearful spells (FS) and panic attacks (PA) increase the risk for various mental disorders, few studies have examined whether help-seeking in those with FS/PA attenuates the risk for incident psychopathology.

METHODS

A community sample of adolescents and young adults (N=2978, aged 14-24 at baseline) was followed up in up to 3 assessment waves over 10 years. FS, PA, psychopathology, and help-seeking were assessed using the DSM-IV/M-CIDI. Logistic regressions with interaction terms (adjusted for sex and age) were used to test interactions between FS/PA and help-seeking at baseline on predicting incident psychopathology at follow-up. Cases with panic disorder (PD) at baseline were excluded from all analyses.

RESULTS

FS/PA at baseline predicted the onset of any disorder, any anxiety disorder, PD, agoraphobia, generalized anxiety disorder, social phobia, and depression at follow-up (Odds Ratios, OR 1.62-5.80). FS/PA and help-seeking at baseline interacted on predicting incident PD (OR=0.09) and depression (OR=0.22) at follow-up in a way that FS/PA only predicted the respective disorders in individuals not seeking help at baseline. In those with FS/PA, a higher number of panic symptoms interacted with help-seeking on predicting incident PD (OR=0.63) in a way that a higher number of panic symptoms only increased the risk for PD in those without help-seeking at baseline.

LIMITATIONS

Help-seeking at baseline was not restricted to panic-specific interventions, but included treatment due to other psychological problems as well.

CONCLUSIONS

Findings suggest that early help-seeking might modify psychopathology trajectories and prevent incident disorders in high-risk individuals with FS/PA.

A study of myocardial perfusion in patients with panic disorder and low risk coronary artery disease after 35% CO2 challenge

BACKGROUND

We have previously reported that 35% CO2 challenge induced myocardial ischemia in 81% of coronary artery disease (CAD) patients with comorbid panic disorder (PD) and previous positive nuclear exercise stress tests. However, it is yet unclear whether this is the case among CAD patients with PD and normal nuclear exercise stress test results. We hypothesized that a potent mental stressor such as a panic challenge among CAD patients with PD would also induce ischemia in patients with normal exercise stress tests.

METHODS

Forty-one coronary artery disease patients with normal nuclear exercise stress tests (21 patients with PD and 20 without PD) were submitted to a well-established panic challenge test (with 1 vital capacity inhalation of a gas mixture containing 35% CO2 and 65% O2) and injected with Tc-99m-tetrofosmin (Myoview), upon inhalation. Single photon emission computed tomography imaging was used to assess per-panic challenge reversible myocardial ischemia and HR, BP, and a 12 lead ECG was continuously measured during the procedure.

RESULTS

Fifty-eight percent of panic disorder patients (12/21) had a panic attack during the panic challenge vs 15% (3/20) of controls (p=0.005). Only 10% of patients in each group displayed myocardial ischemia per panic challenge.

CONCLUSIONS

These findings suggest that panic attacks among panic disorder patients with lower-risk coronary artery disease may not confer a risk for myocardial ischemia.

Incremental direct medical expenditures associated with anxiety disorders for the U.S. adult population: evidence from the Medical Expenditure Panel Survey

Data from the 2009 and 2010 Medical Expenditure Panel Survey (MEPS) were used to estimate the annual incremental healthcare expenditures associated with anxiety disorders, for the ambulatory adult population of the U.S. Individuals 18 years and older, who reported a diagnosis of, or had a medical event associated with anxiety disorder(s), were classified as anxiety population. Multivariate regression analyses, using generalized linear models, were conducted to calculate incremental costs associated with anxiety disorders. 8.74% of adult respondents reported being diagnosed with anxiety disorder(s). The annual overall healthcare expenditure associated with anxiety disorders was estimated at $1657.52 per person (SE: $238.83; p<0.001). Inpatient visits, prescription medications, and office-based visits together accounted for almost 93% of the overall cost. Given the prevalence of self-reported anxiety disorders in MEPS, their total direct medical expenditure is estimated at approximately $33.71 billion in 2013 US dollars, meaning this category of mental illnesses absorbs a significant portion of the U.S. healthcare resources.

Evidence-based pharmacotherapy of panic disorder: an update

The evidence-based pharmacotherapy of panic disorder continues to evolve. This paper reviews data on first-line pharmacotherapy, evidence for maintenance treatment, and management options for treatment-refractory patients. A Medline search of research on pharmacotherapy was undertaken, and a previous systematic review on the evidence-based pharmacotherapy of panic disorder was updated. Selective serotonin reuptake inhibitors remain a first-line pharmacotherapy of panic disorder, with the serotonin noradrenaline reuptake inhibitor venlafaxine also an acceptable early option. Temporary co-administration of benzodiazepines can be considered. Maintenance treatment reduces relapse rates, but further research to determine optimal duration is needed. For patients not responding to first-line agents several pharmacotherapy options are available, but there is a notable paucity of data on the optimal choice.

Unexplained chest pain in the ED: could it be panic?

PURPOSE

This study aimed at (1) establishing the prevalence of paniclike anxiety in emergency department (ED) patients with unexplained chest pain (UCP); (2) describing and comparing the sociodemographic, medical, and psychiatric characteristics of UCP patients with and without paniclike anxiety; and (3) measuring the rate of identification of panic in this population.

BASIC PROCEDURE

A structured interview, the Anxiety Disorders Interview Schedule for the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, was administered to identify paniclike anxiety and evaluate patients' psychiatric status. Anxious and depressive symptoms were evaluated with self-report questionnaires. Medical information was extracted from patients' medical records.

MAIN FINDINGS

The prevalence of paniclike anxiety was 44% (95% CI, 40%-48%) in the sample (n = 771). Psychiatric disorders were more common in panic patients (63.4% vs 20.1%), as were suicidal thoughts (21.3% vs 11.3%). Emergency physician diagnosed only 7.4% of panic cases.

PRINCIPAL CONCLUSIONS

Paniclike anxiety is common in ED patients with UCP, and this condition is rarely diagnosed in this population.

Psychiatric treatment received by primary care patients with panic disorder with and without agoraphobia

OBJECTIVE

Although the majority of individuals with panic disorder first present to the primary care setting, little is known about the psychiatric treatment that primary care patients with the disorder typically receive. The purpose of this study was to explore characteristics of treatment received by patients with panic disorder with agoraphobia and by those with panic disorder without agoraphobia, examine demographic and clinical predictors of receiving treatment, and explore treatment barriers.

METHODS

This study used data from the Primary Care Anxiety Project (PCAP), which is a naturalistic, longitudinal study of anxiety disorders among primary care patients. This study presents data for 235 PCAP participants diagnosed at the study intake assessment as having panic disorder with agoraphobia (N=150) or without agoraphobia (N=85).

RESULTS

Many patients with panic disorder were not receiving psychiatric treatment at study intake (38%), with those without agoraphobia being less likely to receive treatment. Psychotropic medications were the treatment of choice, with selective serotonin reuptake inhibitors or serotonin and norepinephrine reuptake inhibitors being the most commonly received class of medications (34%). Only 38% of those with panic disorder with agoraphobia and 24% of those with panic disorder without agoraphobia were receiving psychotherapy, and the use of empirically supported interventions was rare. The most common treatment barriers were not believing in using medication or therapy for emotional problems and not receiving a treatment recommendation from one's provider.

CONCLUSIONS

The findings suggest a need for better treatment dissemination, in addition to making interventions more accessible or adapting them to the particular needs of primary care patients.

Cost-of-illness studies and cost-effectiveness analyses in anxiety disorders: a systematic review

AIMS

To review cost-of-illness studies (COI) and cost-effectiveness analyses (CEA) conducted for anxiety disorders.

METHODS

Based on a database search in Pubmed, PsychINFO and NHS EED, studies were classified according to various criteria. Cost data were inflated and converted to 2005 US-$ purchasing power parities (PPP).

RESULTS

We finally identified 20 COI and 11 CEA of which most concentrated on panic disorder (PD) and generalized anxiety disorder (GAD). Differing inclusion of cost categories limited comparability of COI. PD and GAD tended to show higher direct costs per case, but lower direct cost per inhabitant than social and specific phobias. Different measures of effectiveness severely limited comparability of CEA. Overall CEA analysed 26 therapeutic or interventional strategies mostly compared to standard treatment, 8 of them resulting in lower better effectiveness and costs than the comparator.

CONCLUSIONS

Anxiety disorders cause considerable costs. More research on phobias, more standardised inclusion of cost categories in COI and a wider use of comparable effectiveness measures (like QALYs) in CEA is needed.

Health service utilization in patients with major depression and co-morbid pain

AIMS

Patients with depression often have co-morbid pain symptoms. However, rates of service utilization by psychiatric in-patients with co-morbid pain symptoms are unknown. The purpose of this study is to estimate whether patients with major depression and co-morbid pain access medical treatment for their pain as much as their counterparts with psychiatric diagnoses other than major depression.

METHODS

A total of 103 patients (62 female; 41 male) were assessed for a diagnosis of major depression applying a psychiatric clinical interview followed by a self-report pain questionnaire, which assessed physical pain in psychiatric patients.

RESULTS

Patients with major depression reported higher rates of pain symptoms in the past 6 and 12 months than their counterparts with a psychiatric diagnosis other than major depression. Analysis of variance showed that patients with depression were less likely to attend medical and specialist services for their pain symptoms than their counterparts. On the contrary, depressed patients with pain attended more frequently general in-patient services than non-depressed patients with pain.

CONCLUSIONS

Patients with depression suffer high rates of pain symptoms, but are at higher risk of not accessing appropriate services suggesting inadequate service utilization. The results have implications for screening and health care delivery for psychiatric patients with pain.

Medical utilization across the anxiety disorders

Individuals with panic disorder often seek medical care for their symptoms prior to receiving effective treatment. However, little is known about how often, and in what settings, patients with other anxiety disorders present for medical treatment. In the present study, utilization of general and specialty medical services was coded via electronic chart review for 171 consecutive outpatients referred to an anxiety disorders clinic. Results indicated that panic disorder patients accrued the most medical visits overall, as well as the most frequent visits to cardiology, family medicine, and emergency medicine. Few differences in medical utilization were evident among patients with generalized anxiety disorder, obsessive-compulsive disorder, social phobia, and specific phobias. Patients with anxiety disorders appear to be frequent utilizers of medical services prior to receiving effective treatment. Our findings highlight the need for improved recognition and treatment of anxiety disorders, particularly panic disorder, in a number of medical settings.

Economic costs of full-blown and subthreshold panic disorder

BACKGROUND

Data on the societal costs of mental disorders are necessary to inform health policies.

METHODS

This study assessed the costs of panic disorder and subthreshold panic disorder, compared these with costs of other mental disorders, and assessed the effects of (psychiatric and somatic) comorbidity and agoraphobia on the costs of panic. Using a large, population-based study in The Netherlands (n=5504), both medical and production costs were estimated from a societal perspective within a one-year timeframe.

RESULTS

Annual per capita costs of panic disorder were 10,269 euros, while subthreshold panic disorder generated 6384 euros. These costs were higher than those of the other mental disorders studied. About one quarter of the costs could be attributed to comorbidity. Agoraphobia was associated with higher costs.

LIMITATIONS

Methodological choices influence cost estimates. In the present study most of these will result in conservative cost estimates.

CONCLUSIONS

Panic thus causes substantial societal costs. Given the availability of effective treatment, treatment may not only benefit individual patients, but also have economic returns for society.

Body vigilance in nonclinical and anxiety disorder samples: structure, correlates, and prediction of health concerns

The Body Vigilance Scale (BVS) is a measure developed to assess one's conscious attendance to internal cues. The present report investigated the structure, correlates, and predictive utility of the BVS in nonclinical (N=442) and anxiety (N=135) disorder samples. The findings of Study 1 suggest that the BVS is 1-dimensional in a nonclinical sample, and Study 2 replicated the factor structure of the BVS in an anxiety disorder sample. Correlations between the BVS and related (i.e., anxiety sensitivity) and unrelated (i.e., social anxiety) variables were consistent with predictions in both studies. Study 2 also showed that body vigilance is primarily elevated in patients with panic disorder relative to other anxiety disorders. Relative elevations in body vigilance were also observed for patients with hypochondriasis and generalized anxiety disorder. The BVS also demonstrated a specific association with medical utilization and health-related safety-seeking behaviors after controlling for related variables in nonclinical and anxiety disorder samples. The implications of our findings for the nature and measurement of body vigilance as a predictor of health concerns in anxiety disorders are considered.

Using five questions to screen for five common mental disorders in primary care: diagnostic accuracy of the Anxiety and Depression Detector

OBJECTIVE

Primary care providers are increasingly taking on the role of ad hoc mental health provider. However, before patients in primary care can be treated, they must be identified. This study set out to validate a very brief screening instrument for identifying primary care patients with anxiety and depression.

METHOD

Eight hundred one primary care patients completed a questionnaire screening for (1) panic disorder, posttraumatic stress disorder (PTSD) and social phobia, or (2) panic disorder, generalized anxiety disorder (GAD) and major depression. Screening was followed by a diagnostic interview. The properties of the questionnaires were examined to identify a small set of items that effectively and efficiently screened for panic disorder, PTSD, social phobia, GAD and depression.

RESULTS

Five items were selected across the two versions of the questionnaire, comprising the Anxiety and Depression Detector (the ADD). The sensitivities for the items ranged from 0.62 to 1.00, and the specificity values ranged from 0.56 to 0.83. When a "yes" answer to any of the screening questions was used to predict the presence of any diagnosis, sensitivity values were 0.92 to 0.96 and specificity values were 0.57 to 0.82. Sensitivity and specificity values varied little by gender, age or ethnicity.

CONCLUSIONS

The five items of the ADD appear to comprise a useful screening device for anxiety and depressive disorders in primary care settings.

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

La pharmacothérapie et la thérapie cognitive-comportementale (TCC) sont des traitements de choix pour le Trouble panique avec agoraphobie (TPA) mais demeurent généralement dispendieux. La présente étude vise à comparer les ratios coûts/efficacité d’une TCC pour le TPA versus un traitement combinant la TCC à une pharmacothérapie. Quatre-vingt-quatre participants suivent une TCC combinée ou non avec une médication. Ils sont évalués avant et après le traitement ainsi qu’au suivi d’un an et de deux ans. L’efficacité de la thérapie est calculée à partir d’un « Index de fonctionnement global » pour chaque temps de mesure. Les coûts directs et indirects pour leur part, sont calculés grâce à une « Entrevue sur les coûts de la santé ». Les résultats suggèrent que pour une efficacité équivalente, la TCC seule demeure moins dispendieuse qu’une TCC combinée à une pharmacothérapie. Elle offre donc un meilleur ratio coûts/efficacité. Ce ratio tend même à augmenter avec le temps.

Healthcare Utilization Following Cognitive‐Behavioral Treatment for Panic Disorder with Agoraphobia

The aim of this study was to examine the overall changes in healthcare services utilization after providing an empirically supported cognitive-behavioral treatment for panic disorder with agoraphobia. Data on healthcare utilization were collected for a total of 84 adults meeting DSM-IV criteria. Participants were completers of a cognitive-behavioral treatment for panic disorder with agoraphobia. Data on utilization of healthcare services and medication were obtained from semi-structured interviews from baseline to 1-year after treatment. Results of the Friedman non-parametric analysis reveal a significant decrease in overall and mental health-related costs following treatment. This study shows a significant reduction in healthcare costs following cognitive behavior therapy for panic disorder with agoraphobia. More studies are needed to examine the potential long-term cost-offset effect of empirically supported treatments for panic disorder.

Alprazolam extended-release in panic disorder

Alprazolam-XR is an extended-release formulation of alprazolam designed to deliver sustained therapeutic concentrations for 24 h after once-daily dosing. Plasma concentrations gradually decline as the time for the next dose approaches, but still remain above therapeutic minimum levels. The anti-panic efficacy of alprazolam-XR appears to be comparable to the original formulation of alprazolam. The main advantage of the new extended-release formulation appears to be its greater tolerability and safety. The speed with which high-potency benzodiazepines are absorbed, and rise to peak concentrations is correlated with both abuse potential and with the incidence and severity of common adverse events, such as sedation and cognitive and psychomotor impairment. Alprazolam-XR does not exhibit the sudden increases in plasma concentration characteristic of the original formulation of alprazolam. This pharmacokinetic difference appears to translate into a reduced liability of abuse and a reduced incidence of sedation and cognitive and psychomotor impairment during acute therapy. This would appear to give alprazolam-XR a more favourable benefit:risk profile than the original formulation of alprazolam. In addition, the once-daily dosing (as opposed to three or four times per day) reduces clock-watching, increases compliance and it eliminates the penalty of breakthrough anxiety and panic that many patients experience if they inadvertently miss a dose. It should be noted that long-term therapy with alprazolam-XR carries the same risk of dependence and withdrawal during discontinuation as the original formulation of alprazolam.

Sociocultural interpretations of social phobia in a non-heterosexual female

Social Phobia is a prominent anxiety disorder that is not well-understood, especially among socially marginalized, non-heterosexual individuals. A case description of Social Phobia symptoms in a female who is unsure of her sexual identity is presented and analyzed. The diagnostic assumptions of Social Phobia as applied to the case are critically examined. The goal is to highlight unanswered questions regarding social anxiety among non-heterosexuals and to open a discussion of cultural etiological theory. Implications for treating Social Phobia with a cultural component are discussed.

Comorbidities and associated treatment charges in patients with anxiety disorders

OBJECTIVE

To describe comorbidities and treatment charges in patients receiving initial anxiolytic therapy for anxiety disorders.

DESIGN

Retrospective data analysis.

PATIENTS

Six thousand six hundred forty-seven patients with anxiety disorders.

MEASUREMENTS AND MAIN RESULTS

Analysis was conducted using medical and pharmacy data for patients in 26 United States health plans from the PharMetrics Integrated Outcomes database. Data were collected for 12 months before and after the first anxiolytic prescription date (index date) during the study period (January 1, 1998-December 31, 2000). The sample comprised patients with a diagnosis of anxiety disorder whose original anxiolytic prescription had been refilled within 120 days. International Classification of Diseases, 9th revision, Clinical Modification (ICD-9-CM) codes and medical and prescription data identified the existence of comorbidities, and medical and prescription charges. The most common diagnoses of anxiety disorder were anxiety not otherwise specified (67%), panic disorder (14%), and generalized anxiety disorder (13%). The most commonly prescribed anxiolytics were benzodiazepines, such as alprazolam (43%) and lorazepam (27%). Hypertension was the most common nonpsychiatric comorbidity (22%) and depression the most common psychiatric comorbidity (37%). Other comorbidities observed were lipid disorders (17%), chronic obstructive pulmonary disease (9%), and asthma (7%). Total treatment charges 12 months before and after initial anxiety diagnosis and anxiolytic prescription were dollar 6279 and dollar 9270, respectively (p < 0.0001).

CONCLUSION

Chronic conditions are commonly associated with anxiety disorders. Recognizing these psychiatric and nonpsychiatric comorbidities is important when treating patients with these disorders. Treatment charges are significantly higher when a patient is diagnosed with an anxiety disorder, highlighting the impact of anxiety on the total cost of treatment for these patients.

Anxiety symptoms and healthcare utilization among a sample of outpatients in an internal medicine clinic

OBJECTIVE

In this study, we explored the role of anxiety symptoms (i.e., symptoms that would probably not fulfill DSM criteria) in relationship to healthcare utilization.

METHOD

We surveyed 117 outpatients in an internal medicine clinic regarding four types of anxiety symptoms (i.e., mixed anxiety features, generalized anxiety, obsessive-compulsive personality features, worry), and through a retrospective review of medical records, examined healthcare utilization patterns.

RESULTS

Nearly 28% of participants endorsed "positive" results on at least three of the anxiety-symptom measures. When examined for relationships to healthcare utilization, only obsessive-compulsive personality features demonstrated a significant relationship.

CONCLUSIONS

While anxiety symptoms were common in this primary care sample, their impact on healthcare utilization was limited, in that only obsessive-compulsive personality features demonstrated a relationship.

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.

Marital relationship and the treatment of panic disorder with agoraphobia: a critical review

The purpose of this paper is (1) to specify, among studies on the links between marital relationship and cognitive-behavioral treatment of panic disorder with agoraphobia (PDA), the conceptual and methodological limitations that may have produced inconsistent results in this field so far; and (2) to propose avenues of research that will help in remedying current weaknesses and answering important questions in this area. Following definition of PDA and a survey of its socioeconomic consequences, the authors examine results of the various ways research has tried to specify the links between marital relationship and the development, maintenance, and treatment of this disorder: the study of major life events before and after the onset of PDA, interpersonal problems and quality of marital relationship in the presence of PDA, the links between marital relationship and PDA treatment outcome, variability of experimental outcomes according to types of measure used to study these links, the effect of the spouse as co-therapist in PDA treatment, and the impact of a PDA treatment based on marital communication and problem-solving. Research hypotheses and methodological procedures are proposed to improve understanding of PDA and its treatment outcome.

Considerations in the treatment of anxiety disorders: a pharmacoeconomic review

Anxiety disorders are a group of common mental disorders that impose a significant economic burden on the healthcare system and society. For this review of published literature on the pharmacoeconomics of treating anxiety disorders, various studies of the cost, resource use and the economic outcomes of pharmacological treatment were examined. Numerous studies have been published that document how the excessive costs associated with anxiety disorders, especially panic disorder, result from a combination of factors including under-recognition and misdiagnosis of the problem by primary healthcare providers, high medical resource utilisation including unnecessary or inappropriate diagnostic tests and high levels of medical help-seeking behaviour by patients. Little information has been available on the economic effects of pharmacotherapy for anxiety disorders but recent studies have shown that selective serotonin re-uptake inhibitors (SSRIs) are associated with a shift in medical resource utilisation (lower rates of emergency department and laboratory visits) which can potentially result in decreased healthcare expenditures. Facilitating an increased awareness among primary healthcare providers of the anxiety disorders and utilising appropriate diagnostic and treatment strategies can benefit patients while providing more efficient and effective healthcare spending leading to an overall reduction in the burden of disease.

Panic disorder in primary care: patients' attributions of illness causes and willingness to accept psychiatric treatment

OBJECTIVE

This study assessed the causes that primary care patients with panic disorder (PD) attribute to their panic symptoms, and their acceptance of various psychiatric treatment options.

METHODS

In a cross-sectional assessment of 306 patients treated at two primary care clinics, 42 met criteria for DSM-IV PD in the past year. The authors classified these 42 PD-positive patients to one of two groups: those receiving both primary and specialty mental health care (PC+MH; n = 19) and those receiving only primary care (PC-only; n = 23). Patients rated the probability of four possible causes of their panic symptoms, and level of acceptability of three psychiatric and two medical treatments for PD. To place primary care patients' ratings into a broader context, a third contrast group of PD-positive patients, recruited from clinical trials of investigational PD pharmacotherapies (n = 31), also rated causes and treatment acceptability.

RESULTS

Participants of the three treatment groups attributed psychiatric causes for their panic symptoms in approximately the same proportion (78 percent to 90 percent; p = ns). PC-only participants attributed medical causes for panic symptoms more frequently than PC+MH and PD Clinical Trials participants (48 percent vs. 5 percent and 32 percent; p = .01). Remarkably, the great majority of patients across all groups expressed willingness to see psychiatrists (84 percent to 94 percent) and psychotherapists (95 percent to 100 percent), and to take psychotropic medications (87 percent to 100 percent).

CONCLUSIONS

In this study most patients attributed a psychiatric cause for panic symptoms and communicated strong acceptance of psychiatric treatment. Thus, we recommend that primary care clinicians more assertively inform their patients of PD diagnoses and recommend psychiatric treatments with less fear about stigmatizing and alienating them.