The American Psychiatric Association Practice Guideline for the Treatment of Patients With Panic Disorder: Recommendations and Controversies

Fredric N. Busch, MD and Barbara L. Milrod, MD

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Long-term Outcome

Although the guideline notes that panic disorder can have a chronic course and is associated with significant morbidity, and also that the length of treatment required is unclear, there is an implication that short-term treatment interventions can have significant long-term impact. The guideline presents a dearth of data about long-term outcome. Three studies with at least 1-year follow up are mentioned from the cognitive behavioral literature and are noted to show "promising results" (p 9). A closer look at the results in one study[5] showed that the percentage of patients remaining panic free through a 24-month period was 50%, and only 21% were panic free and had achieved "high end state functioning" (p 9) consistently throughout the follow-up period. High end state functioning refers to low severity of overall panic symptoms, including anticipatory anxiety with limited symptom episodes and phobic avoidance, in addition to panic attacks. Although the results of the cognitive behavioral follow-up studies are described as comparable to those found in medication treatments, the guideline also notes that relapse is common following medication discontinuation. It states that medication discontinuation may be attempted after 12 to 18 months of maintenance treatment if there has been significant improvement or remission, but many patients relapse and may benefit from prolonged periods of treatment. Thirty percent to 45% of patients are likely to remain well after medication discontinuation.

An independent review of the studies in which there is a follow-up outcome of specific treatment interventions for panic disorder was assessed. This revealed several methodologic problems.[6] In addition to an occasional study with unclear diagnosis or treatment, many studies were found to contain untracked nonstudy treatments during the study treatment and follow-up period. For example, Beck and colleagues,[19] in a comparison of treatments of 33 patients who met DSM III criteria for panic disorder or agoraphobia with panic attacks, found that cognitive therapy had a higher success rate than supportive psychotherapy. The investigators noted that 16 of 33 subjects in the study were on medication, but did not provide information as to which were not tracked, nor is there information on whether patients received additional psychotherapy in a follow-up period after the study treatment was completed. The sparse available data from studies that did not contain these problems provide limited evidence for long-term maintenance of short-term treatment gains if no further treatment is obtained. Given the distress experienced by panic patients and [their high utilization of medical and psychiatric services],[20,21] long-term impact of treatments is a significant issue for patients with panic disorder.

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