Nearly one-half of patients with panic attacks do not seek care for their problem. Patients may endure symptoms for years before they seek treatment. For others, it may take years for their symptoms and disorder to be correctly diagnosed and adequately treated. One study reported that it routinely takes more than 10 years for the correct diagnosis of an anxiety disorder to be made.Early studies found that 70% of patients may have to consult over 10 physicians for relief of symptoms.

Attitudes and behaviors on both the patients’ and practitioners’ behalf contribute to the patient’s reticence in seeking treatment. Patients may think, “Am I the only person who has this problem?” or, “I should be able to get over this on my own.” or, “What do I have to be anxious about?” Practitioners and their staff may trivialize the illness or concur with the patient’s doubts over, “What do you have to be anxious about?” Practitioners may offer ineffective recommendations, such as, “Just relax”, or, “There’s nothing to worry about.” or, “Go for a walk… take the day off.” These recommendations, coupled with past ineffective pharmacological treatments, may prevent many patients from seeking treatment for a condition in which both the patient and practitioner have concern that the condition actually exists. Patients who experience cardiovascular symptoms may seek treatment in the emergency department for a wide range of catastrophic fears, from that of having a “heart attack” to a “stroke,” only to be told, “There is nothing wrong with you. You are perfectly healthy!” The objective signs of anxiety are often transient, and there is a wide overlap with other possible disorders. Coupled with a lack of sophisticated technology to detect a panic attack, both patients and practitioners may have persistent doubt as to the validity of a panic attack.

Patients may feel embarrassed when describing symptoms or be at a loss to adequately describe them and feel inadequate for not having a better description. They may fear that others will judge them harshly. Alternatively, they may judge themselves harshly, with thoughts such as: “Nothing can be done,” “There’s nothing wrong,” “I think I’m going crazy,” “People will think I’m crazy,” or, “I will be committed to a mental institution.”

When anxiety disorders, especially panic disorder, remain untreated or are inadequately treated, one can expect patients to contribute to high medical utilization with subsequent increase in costs, time, and procedures, and a decrease in available services to others.

Where Patients Seek Treatment

A large number of patients with an anxiety disorder never seek treatment. These reasons will be discussed in depth in the next section. Those who do seek help often turn to practitioners in acute care clinics or emergency departments. As many as 28% to 57% of patients with panic attacks will seek treatment in the emergency room of a hospital. This is the most logical place for the patient to go, since a panic attack is usually experienced as “life-threatening” to the patient. Patients seldom seek initial treatment from psychiatrists, even though psychiatrists are often the best informed and educated to deliver effective treatment.

Because so many patients seek treatment from their primary care providers, there has been an increased effort to train these practitioners to recognize and treat the most common anxiety disorders. Primary care settings in which patients may seek treatment include family medicine, obstetrics-gynecology, and dermatology. Often, patients may seek treatment from specialists based on the primary organ system that is affected; patients tend to focus on one symptom above the others and seek out specialists to treat that problem.

Of the adrenergic nervous system’s many functions, one, the “fight or flight” response, has served humans well. This response occurs whenever one encounters a dangerous situation in which one’s survival depends upon either an aggressive stance or a more passive stance, such as fleeing the scene. Both situations call for the potential for a great deal of strenuous, physical work to be done. For an organism to complete either of these tasks successfully, massive amounts of neurotransmitters such as epinephrine, norepinephrine, and cortisol are released quickly throughout the circulatory system. The neurotransmitters then have direct and indirect effects on almost all major organ systems.

When the adrenergic nervous system is forced into excessive stimulation both in intensity and duration, numerous negative consequences can result, especially when this system did not need to be activated at all. Some of these negative consequences include possible increased cardiovascular risk, such as hypertension and heart disease, and direct psychiatric effects, such as depression and suicide. In addition, excessive cortisol production/release has been shown to result in decreased brain size.

When the adrenergic nervous system is continuously being activated in patients with untreated panic disorder, the indirect results are decreased enjoyment in daily activities, decreased work, and increased disability. Increased utilization of health services can occur from both an acute need, such as seen with an increased number of emergency room visits, and in ongoing needs, such as in seeking diagnostic help and treatment for many chronic manifestations of panic attacks.The costs incurred by unrecognized panic disorder have been examined for patients in primary care settings and have been found quite high.

A common component of an anxiety disorder is the panic attack. A panic attack may be a familiar experience to many, as 15% of people have reported the occurrence of one over their lifetime. It is defined as a discrete period of intense fear or discomfort in the absence of real danger that is accompanied by 4 of 13 somatic or cognitive symptoms. This attack can occur suddenly and peak quickly, usually within 10 minutes or less. A panic attack can be unexpected or situational in nature. A partial panic attack incorporates 1 to 3 of the characteristic symptoms of a panic attack.

This article will utilize the panic attack as a model for better insight into all of the anxiety disorders. If one can understand the symptomatology and characteristics of a panic attack, one can apply this knowledge to all of the anxiety disorders if certain modifications and limitations of this model are considered.

In a panic attack, a message of misperceived, severe danger is sent from the brainstem area to several other areas of the brain, including the cortex. There the message is intercepted as an acute lack of oxygen in the body, prompting a sense of physiological emergency and imminent threat to life. In fact, however, this message is incorrect; physiological sensors have misinterpreted the amount of carbon dioxide (CO₂) in the bloodstream (as “too much,” when levels are normal) and consequently misinterpreted the amount of oxygen O₂ in the bloodstream (as “too low,” when levels also are normal). In a panic attack, sensors have assessed that conditions in the body will soon be incompatible with life; thus, the sensors have sent emergency requests to other organs to respond to the “emergency.” As a result, the body attempts to (1) obtain more oxygen by increasing the depth and rate of breathing, (2) disperse oxygen to all parts of the body by increasing heart rate and volume, (3) prevent overheating the body by increasing perspiration, and (4) prepare the body for action by shifting blood flow away from normal vegetative functions and toward the muscles.

Despite the body’s misguided shift into physiological emergency preparedness, carbon dioxide and oxygen levels are normal. This misperception is accompanied by massive release of the neurotransmitters norepinephrine (NE) and epinephrine (E) to help the body prepare for this “emergency”…none of which is needed. This aberrant signal, or CO₂ hypersensitivity, is also known as the suffocation false-alarm theory. The false signal regarding the body’s CO₂/O₂ balance can occur anytime, such as when one is eating, relaxing, working, sleeping, or doing any other human activity, whether safe or dangerous, stressful or relaxing.

Panic Disorder (With and Without Agoraphobia)

Panic disorder (PD) is defined as a condition in which recurrent, unexpected panic attacks occur, followed by at least one month’s duration of persistent concern about having more attacks, or worry about the effects of having a panic attack (e.g., having a heart attack or “going crazy”) or a major change in behavior because of the attacks. The attacks are not related to the direct effects of a drug/medication or a known medical condition or accounted for by another known psychiatric disorder.

A number of possible medical conditions must be considered in the differential diagnosis of panic disorder. Anemia, dysrhythmias, asthma, transient ischemic attacks, and hyperthyroidism constitute a few of these conditions. Drugs capable of inducing panic attacks include most central nervous system (CNS) stimulants such as cocaine, amphetamines, and methylphenidate, as well as all antidepressants. Caffeine, nicotine, hallucinogens, and bronchodilators, such as albuterol, can also produce a panic attack. Nonprescription medications such as pseudoephedrine (found in decongestants) and ephedrine (found in herbal products) can also cause a panic attack.

The proposed hypotheses for the etiology of panic disorder include possible dysregulation of the locus ceruleus, hypersensitivity of 5-HT autoreceptors, abnormal cholecystokinin function,and the CO2 hypersensitivity theory presented earlier in this article.

Characteristics of panic disorder occur more frequently in women and have a bimodal age of onset, with the first peak occurring in late adolescence and the second one in the patient’s mid-30s.Patients with untreated panic disorder have been found to have increased rates of depression. Suicide attempts have been reported in 12% of patients with panic attacks and 20% of those with panic disorder.

Patients with panic disorder can develop agoraphobia, which is avoidance and anxiety about situations or places from which escape may be difficult or embarrassing, or help would be unavailable if a panic attack were to occur. Patients typically avoid these situations partially or completely or they may tolerate and endure them with extreme anxiety.

Anxiety is a physiological and psychological state of increased arousal that is universal in humans. It can be considered one of the vital factors for the basis of continuing life. Anxiety improves performance, improves survival, and keeps us alive. Every person has some anxiety, and each person will experience it differently. The key words “some” and “differently” are pivotal to understanding the role of anxiety in a healthy individual versus an anxiety disorder. Every individual needs some level of anxiety to motivate him or her to perform the daily functions required in one’s life. However, excessive anxiety causes a patient to become “frozen with fear” and incapable of taking action when needed. When, for a specific situation, a person has too much anxiety for too long a period of time, that person may be characterized as having an anxiety disorder. The disorder causes significant subjective and objective discomfort or bad feelings and lasts for a specific time period. In addition, anxiety or its effects cause marked, negative consequences in important areas of the patient’s life, such as in his or her family life, social life and/or occupation.

Misconceptions About Anxiety

Because anxiety is universal and every individual has experienced it at some point in his or her life, it may seem logical for a person to view another’s experience with anxiety through his or her own “eyes.” If one has never experienced a significant amount of anxiety for a prolonged time (and consequently does not have an anxiety disorder), the person may interpret the meaning and experience of anxiety in another person as mild and acceptable rather than a disorder that requires attention and treatment. Consequently, the public as well as many healthcare professionals may not view anxiety disorders as serious health problems with problematic and even tragic consequences when left untreated. They may have less difficulty relating to other psychiatric disorders illnesses such as schizophrenia or bipolar disorders as a problem because these are often outside the realm of normal human experiences. Often, anxiety disorders are discounted in terms of their levels of intensity and their need for treatment. Some people may view an anxiety disorder as the psychiatric equivalent of the common cold. However, given the high prevalence of these disorders and the impairment they cause, healthcare professionals need to re-examine their understanding of what constitutes an anxiety disorder.

Prevalence of Anxiety Disorders

Before recent epidemiological studies were conducted, many practitioners thought of anxiety disorders as occurring relatively infrequently and posing minor difficulties in people’s lives. Two important studies, the Epidemiologic Catchment Area (ECA) Study, conducted in 1989, and the National Comorbidity Study (NCS), conducted in 1992, yielded a much more impressive picture. In the ECA study, as many as 20% of the adult population was found to have an anxiety disorder. In addition, 1 in 5 people had not sought treatment in the last year. The NCS results further refined these numbers and found that up to 25% of the American adult population can expect to have an anxiety disorder in their lifetime. The actual incidence can vary between 15%-25% when taking into account whether these disorders interfere with daily functioning or impair social and occupational areas of a person’s life. One of the most common psychiatric illnesses, anxiety disorders affect females more than males. TABLE 1 shows the lifetime prevalence of the anxiety disorders in the United States.

Common Anxiety Disorders

Once the essentials of a panic attack are understood, the specific disorders that fall under the umbrella of “anxiety disorders” can be put into perspective. There are five common, but distinctly different, types of anxiety disorders: panic disorder (PD), generalized anxiety disorder (GAD), social phobia (SP), obsessive compulsive disorder (OCD), and post-traumatic stress disorder (PTSD). (Specific phobia and acute stress disorder, while clinically significant, will not be discussed, as there is very limited pharmacologic treatment for these two disorders.) All of these disorders are distinct entities with their own characteristic presentation; however, the similarities will be emphasized to promote better understanding and to help pharmacists recognize these undertreated and often-overlooked disorders.

Brian Leonard and Paul Spenser, eds.

Colchester: Portland Press, 1991, 516 pp

ISBN 1-869868-74-9

The Royal College of Psychiatrists and the Royal College of General Practitioners launched a 5-year Defeat Depression Campaign on 30 January 1992. The first year of the campaign is intended to educate health professionals in the recognition and treatment of depression.

This book, which is the proceedings of the Conference of the British Society for Psycho-Pharmacology held in Ireland in September 1988, provides an overview of the current pharmacological options in the treatment of depression. Thirty years have elapsed since the almost simultaneous discovery of the therapeutic effect of MOA inhibitors and Imipramine in a substantial percentage of patients with severe depression. Antidepressants are the leading category of CNS drugs in research and development, occupying 11th place of all therapeutic categories, with more than 100 new chemical entities at various stages of development at the time of the Conference. One hundred and nineteen contributors helped to place the current use of antidepressants in context and the nine sections of the book cover a wide range: biochemical mechanisms thought to underlie drug action; animal models of depression and laboratory methods of discovering new drugs; biochemical markers of depression and the discussion of toxicity and side effects of both older and new antidepressants. The section with clinical emphasis covers treatment issues, in particular the problem of resistant depression, with advice on management and indications for psycho-surgery. There is also advice on drug treatment for the depressed elderly, depression as seen in general practice with particular reference to the side effects of treatment and the corresponding problems with patient compliance.

This book will be of wide interest both to researchers concerned with the development of future antidepressants and to clinicians wishing to have a fuller understanding of the mechanism of action of these frequently prescribed drugs.

54%–75% of adolescents “wish for more sleep”

It is widely recognized that many older Americans suffer from a variety of sleep disorders. In fact, more than half of all Americans older than age 65 have a sleep problem, and disturbed sleep is among the most frequently cited problems affecting institutionalized older Americans. As the population ages, it is estimated that at the end of this decade nearly 80 million Americans will have a sleep problem.

Problem of the Young

It is not so universally recognized that sleep disorders also affect the young. Although there are few large-scale epidemiologic studies of daytime sleepiness in adolescents and young adults, existing data suggest that problem sleepiness affects a significant percentage of youths. About 25% of American children aged 1–5 experience some kind of sleep disturbance. From 20%–25% of 9th through 12th grade students reportedly experience behaviors associated with problem sleepiness, such as difficulty getting up for school, falling asleep in school, or struggling to stay awake while doing homework. According to one report, 54%–75% of adolescents and young adults expressed “a wish for more sleep” because they were experiencing morning tiredness. In a survey of high school students, it was found that many students got less than 6.5 hours of sleep on school nights; only 15% reported sleeping 8.5 hours or more.

Together, these data indicate a widespread pattern in childhood of inadequate sleep and consequent problem sleepiness. The chart lists some of the more common problems associated with poor sleep patterns.

Physician Visits

Sleep problems in children 16 years old or younger are severe enough to trigger many visits to physicians by anxious parents. The most widely prescribed drugs for sleep disorders are psychotherapeutics, sedatives, and antihistamines. Drugs regularly prescribed include diphenhydra-mine, chloral hydrate and Imipramine (sold as Antideprin, Deprimin, Deprinol, Depsonil, Dynaprin, Eupramin, Imipramil, Irmin, Janimine, Melipramin, Surplix, Tofranil).

The American Psychiatric Association (1983) reports that recurrent episodes occur in at least 50% of patients who seek treatment for major depressive disorder (MDD). Most studies, though, have examined only single occurrences. To help describe the episodic nature of MDD, the National Institute of Mental Health initiated the Collaborative Program on the Psychobiology of Depression, a prospective, naturalistic, longitudinal investigation. This program’s early research found the cumulative probability of recurrence was nearly 30% six months after recovery from an index episode of unipolar major depression.

Since the 1983 report, many of the original study subjects have experienced multiple recurrences of major depressive disorder (MDD). In a study published in the Feb. issue of The American Journal of Psychiatry, David A. Solomon, M.D., and colleagues prospectively focused on the time to recurrence of MDD across multiple episodes. They predicted that the risk of recurrence would decrease as time of recovery increased. They also predicted that each recurrence would increase the risk of a subsequent recurrence.

The original collaborative depression group had a total of 955 patients. Of those, 318 recovered from their intake episode of major depression and were at risk of recurrence during the 10-year follow-up period. The study group for the Solomon et al. analysis consisted of these 318 subjects. Recovery was defined as at least eight consecutive weeks “with either no symptoms of major depressive disorder or only one or two symptoms at a mild level of severity”. Recurrence, which could occur only after recovery from the preceding depressive episode, was defined as the reappearance of major depressive disorder (MDD) meeting the full criteria for at least two consecutive weeks, beginning with the first of these two weeks. Episodes meeting criteria for minor depression and chronic intermittent depression were not included.

For the first five years of the follow-up study, patients were assessed every six months, and annually after that, using the Longitudinal Interval Follow-Up Evaluation. The analyses encompass data for up to 520 weeks of follow-up. As an observational study, treatment was not randomized or in any way controlled by anyone connected to the study.

Of the 318 subjects, 263 (83%) were followed for at least five years, and 208 (65%) were followed for the entire 10-year period. During those 10 years, 481 recurrences were observed. The mean number of episodes of major depressive disorder (MDD) per year of follow-up was 0.21 (SD=0.24).

Once the first eight-week recovery period was completed for the 318 subjects, 202 suffered a recurrence. Of those subjects, 172 recovered and remained healthy for the following eight-week period. A second recurrence was suffered by 115 of those patients. The median time to recurrence for the first episode was 150 weeks; for the second, 83 weeks; and for the third 77 weeks. These intervals were significantly longer than the time to recurrence for subsequent recurrences.

The investigators were also interested in the probability of a well patient experiencing a recurrence during a six-month period (the patient having began that period still well). They found the mean probability for recurrence during the first six months after recovery was 20% (SD=6) across the five prospectively observed recurrences. They wrote, “This indicates that, on average, of the subjects at risk for recurrence, 20% had a recurrence in the first 6 months after the onset of recovery from the preceding depressive episode”.

They found that rate of recurrence decreased in subsequent six-month intervals. In the second six months the probability of recurrence was 19% (SD=7), in the third six months it was 15% (SD=6), in the fourth six months it was 13% (SD=3), in the fifth six months it was 11% (SD=3). In the final six months after the onset of recovery from the preceding depressive episode the probability of recurrence was 9% (SD=6).

Solomon et al. found that the risk for recurrence increased by 16% for each successive episode of major depression. The number of lifetime episodes of major depressive disorder (MDD) was significantly associated with recurrence during this 10-year follow-up period. Analysis showed that there was very little consistency in the time to recurrence within the subject group.

When the researchers looked at treatment of these subjects, they called the low level of maintenance pharmacotherapy during any of the four weeks immediately preceding any of the prospectively observed recurrences striking. Up to 47% to 50% of subjects received no pharmacotherapy during the four weeks immediately preceding the first three recurrences. One-third received no pharmacotherapy in the four weeks immediately preceding the fourth and fifth recurrences. During any of the preceding four-week periods, only 33% to 45% of subjects received at least 100 mg/d of imipramine (Tofranil) or its equivalent. Only 18% to 30% of subjects received at least 200 mg/d of imipramine or its equivalent during the same time period prior to any of the five prospectively observed recurrences.

Solomon et al. wrote that, as predicted, “as the duration of recovery increases, the risk of recurrences decreases or decays.” Also as predicted, “With each successive recurrence, the risk of a subsequent recurrence increases by 16%.” Consistency in time to recurrence, however, was highly variable among this group, indicating that time to recurrence is also highly variable for any individual.

Limitations of this study, the researchers pointed out, included the progressively smaller group size following each recurrence. They speculate that this caused the data analyses to underestimate rates of recurrence over a patient lifetime. Another limitation was the exclusion of minor or intermittent depression, causing a possible underreporting of the extent of psychopathology in the subject group. Finally, the researchers suggest that variability in treatment may have influenced the findings. Patients may have discontinued treatment following recovery, putting themselves at greater risk of recurrence. Recurrence may have caused other patients to discontinue treatment due to discouragement, putting these patients at risk for further recurrence as well. Solomon et al. found the lack of maintenance pharmacotherapy unfortunate, given its role in preventing recurrences

Success shown with drugs and psychotherapy

People plagued by panic attacks need not fear one thing: Treatment works.

Panic disorders respond well to psychotherapy, drug treatment and a combination of the two, according to one of the largest studies of the condition.

Panic disorder affects several million Americans, crippling them with recurrent bouts of profound anxiety and physical symptoms that can include chest pain and pounding, as well as rapid heartbeats and shortness of breath. Many people also feel that, in the midst of an attack, they’re in danger of dying.

Perhaps it’s understandable, then, that people with this condition often feel there’s no hope of treatment. Fortunately for them, they’re wrong.

This conclusion won’t come as a surprise to specialists, who’ve been treating the condition with drugs and psychotherapy for many years. But, the researchers say, it should reinforce the message that panic disorder is a real diagnosis, and one that can be brought under control. Their findings appear in this week’s issue of the Journal of the American Medical Association.

Boston University researcher David Barlow and colleagues at three other clinics treated 312 patients from 1991 to 1998. Participants received one of five treatments: up to 300 milligrams a day of the antidepressant imipramine; a combination of imipramine and cognitive-behavioral therapy [CBT]; CBT alone; CBT plus a placebo; or a placebo alone.

Cognitive-behavioral therapy [CBT] tries to give people more control over their runaway fears by helping them recognize and stave off impending attacks through breathing exercises, desensitization techniques and other devices.

Participants received treatment once a week for three months. If they showed improvement, their treatment was eased back to once a month over a six-month maintenance period. They then were observed for an additional six months.

Using one psychiatric yardstick, known as the Panic Disorder Severity Scale, both the drug and psychotherapy treatments scored better than no treatment at reducing symptoms of panic disorder during the first phase of the study. However, neither bested the placebo when measured on another yardstick, the Clinical Global Impression Scale.

Among the people who improved during the first three months, both treatments were definitively better on each scale than the placebo during the maintenance stage. And the combination of the two was more effective than either treatment alone.

The researchers note, however, that more participants abandoned imipramine than psychotherapy because of the drug’s unpleasant side effects, which include dry mouth and dizziness.

“Our results demonstrate that both imipramine and cognitive-behavioral therapy [CBT] are better than pill placebo for treatment” of panic disorder, the researchers write in the journal report. “Imipramine produced a superior quality of response, but CBT was more durable and was somewhat better tolerated.”

Dr. Richard Glass, a Chicago psychiatrist and deputy editor of the Journal of the American Medical Association, says the study emphasizes the importance of viewing panic disorder as a treatable, chronic illness. “It hasn’t been as widely known as it should be,” says Glass, who wrote an editorial accompanying the journal article.

Panic attacks, which occur about twice as commonly in women as men, can mimic some of the symptoms of heart attack. As a result, many doctors may overlook the emotional disorder as a cause of chest symptoms and do nothing about it when they find that a patient isn’t having a heart episode, Glass says.

Similarly, many people who have panic attacks are unaware they have a wide range of treatment options, he says.

In addition to imipramine, which has been available for some two decades, newer antidepressants like Zoloft and Paxil also have been approved for treatment of panic disorder. These drugs are as effective as imipramine, Glass says, but have the advantage of not being fatal if taken in overdose amounts.

What To Do

“We know that these treatments work, but we don’t yet know which treatments work best for which people,” says Jerilyn Ross, a Washington, D.C., social worker and president of the Anxiety Disorders Association of America.

Ross, author of Triumph Over Fear (Bantam, 1994), says the worst thing a person with panic disorder can do is neglect it because the condition can lead to depression and substance abuse if unchecked.

Nor should patients who fail one therapy lose hope and think they’ll be luckless with others, she says.

Depression treatment in the United States has been getting a bad name in a number of quarters recently. Patients who responded to Caredata.com’s 1999 Commercial Health Plan Survey, for example, ranked treatment of depression as one of the most poorly rated of the 27 conditions studied. Of those respondents, 20% rated their depression care as “not adequate,” and another 38% said it was only “adequate.” Of the 74 health plans whose members participated in the survey, only 10 plans received an overall “excellent” rating for depression treatment. The plans surveyed included HMOs, point of service plans and preferred provider plans.

In a study of collaborative care for depression treatment at the University of Washington Medical School, only 63.5% of the control group – which received “usual” care – rated their quality of care as good to excellent.

Kenneth B. Wells, M.D., of RAND, a Santa Monica, Calif.-based think tank, and the University of California, Los Angeles, Neuropsychiatric Institute, was more emphatic. In reporting the results of the Patient Outcomes Research Team (PORT) on depression in JAMA this past January, Wells et al. (2000) wrote, “Quality of care for depression in managed primary care settings is moderate to poor with resultant poor outcomes.”

Both the University of Washington and PORT studies, however, have shown that enhanced interventions can measurably improve both outcomes and patient satisfaction. These findings may offer new fuel to the managed care debate over costs versus efficacy.

Collaborative Care

In the University of Washington study, a team led by Wayne Katon, M.D., compared the effects of a stepped, collaborative care intervention in a primary care setting with a control group receiving usual care. In most cases, usual care consisted of a prescription for antidepressant medication, two or three visits during the first three months of treatment and the option of referral to a mental health program.

Intervention patients were provided with a book and videotape prepared by the study team. These tools reviewed the biology of depression, depression’s relationship to stress, how medications and psychotherapy help depression, and how patients and their significant others could be active partners with their physician in caring for their depressive illness. In addition, patients with severe psychosocial stressors were encouraged to seek psychotherapy or were referred to community-based support groups.

A psychiatrist worked with all of the intervention patients’ primary care physicians to optimize medication usage and to find alternatives if side effects developed. The psychiatrist also monitored the patients’ adherence to the medication regimen through the use of automated pharmacy records and alerted the primary care physician if it appeared the patient had discontinued using the drugs.

Patients in the intervention group were significantly more likely to adhere to the medication regimen than were patients in the control group. At the end of three months, 78.6% of the intervention patients and 62.1% of the control patients had adhered to the medication schedule; at six months, 73.2% of the intervention group versus 50.5% of the control group were still following the medication schedule. Pharmacy records indicated that 68.8% of the intervention patients versus 43.8% of the usual care group received antidepressant medication (at or above the lowest recommended dosage) for at least 90 days.

Response to treatment was based on a Structured Clinical Interview for DSM-IV finding of 0 or 1 of the nine major depressive symptoms at three and six months. At three months, 40% of the intervention patients versus 23% of the usual care patients were asymptomatic (p=0.01); at six months, 44% versus 31% were asymptomatic (p=0.05).

Katon et al. concluded, “The cost per case successfully treated was lower for collaborative care than for usual care because the success rate of treatment was increased more than the total costs of treatment per case.”

Katon also assisted the PORT team, lead author Wells told Mental Health Economics. “Wayne helped on the medication arm of our study. A lot of what we did was learn from what he’s learned about how to support primary care practices and how to package and disseminate the tools without exerting a lot control.”

The PORT Depression Study

The PORT study tested the use of evidence-based materials including training guides, slides, brochures and videos for clinicians, nurse specialists, psychotherapists and patients. Researchers compared the results of quality improvement (QI) programs with usual care at 46 primary care clinics in six managed care organizations.

The research team studied two variant QI programs: one with enhanced resources for supporting medication management (QI-meds) and the other with enhanced resources for providing psychotherapy for depression (QI-therapy). The common elements for each variant included: 1) institutional commitment on the part of the health plan; 2) training of local leaders, including a primary care clinician, a nursing supervisor and a mental health specialist, in each clinical setting; 3) training for local staff; and 4) patient identification.

In QI-therapy, local psychotherapists were trained to provide manualized individual and group therapy for 10 to 16 sessions. In QI-meds, nurse specialists were trained to provide follow-up assessments and support adherence through monthly contacts with the patients for six or 12 months.

At the end of six months, 50.9% of the QI patients and 39.7% of the controls had counseling or used antidepressant medication at an appropriate dosage; at 12 months, 59.2% of the QI patients versus 50.1% (p=0.006) of the controls had done so.

The QI patients showed a markedly greater rate of improvement than the controls. At six months, only 39.9% of the QI patients still met the criteria for probable depressive disorder, compared with 49.9% of the control group (p=0.001). QI patients were 8% to 10% less likely to have probable disorder at six and 12 months; in addition, QI patients showed a 5% increase in employment retention.

“To our knowledge,” the team wrote, “no QI study has demonstrated improved employment, although perceived interpersonal work functioning improves with efficacious treatment for major depression.”

Wells told Mental Health Economics the PORT study showed “when practices that are not academically based make a modest effort to do the right thing and organize their resources to support doctors’ and patients’ decisions, the patients will benefit over a long period of time”