Jill Stein

March 01, 2010

March 1, 2010 (Munich, Germany) — A lifestyle-based intervention for adults with panic disorder that is implemented by occupational therapists in the primary care setting is at least as good as routine care by a general practitioner (GP), according to data presented at the European Psychiatric Association 18th European Congress of Psychiatry.

"Panic disorder in the UK is most often treated with medication and psychological therapy; however, both approaches yield modest outcomes at best and more often poor outcomes along with high relapse rates," Rod Lambert, DipCOT, CHSM, MA, PhD, University of East Anglia in Norwich, United Kingdom, told Medscape Psychiatry.

Dr. Lambert and colleagues compared a 16-week lifestyle intervention and routine GP care in patients 18 to 65 years of age who satisfied Diagnostic and Statistical Manual of Mental Disorders (Fourth Edition) criteria for panic disorder with or without agoraphobia. The lifestyle intervention addressed diet, fluid intake, exercise, and the habitual use of alcohol, nicotine, and caffeine.

Dr. Rod Lambert

"Current treatment guidelines for panic disorder recommend medication or psychological treatment such as cognitive behavioral therapy (CBT) or counseling either as solo treatment or in combination as being the best evidence-based treatment," Dr. Lambert said. The guidelines he was referring to were issued by the UK’s National Institute for Clinical Excellence (NICE) in 2004 and represent the most recent guidelines on panic disorder.

Notably, lifestyle interventions are not included in clinical guidelines despite the fact that national and global health initiatives have advocated the notion that routine lifestyle practices affect health for nearly 50 years, he added.

"About 20% of primary care patients are likely to experience at least one anxiety disorder; however, current treatments are limited to medications and psychological therapies," Dr. Lambert said. "Lifestyle interventions offer an additional early-stage treatment option for these prevalent conditions."

Goal Setting

Overall, 199 patients were referred for the study from 15 primary care practices.

Study participants were randomized to receive either routine GP care or an occupational therapy–led lifestyle approach.

Patients assigned to the lifestyle group met with the same occupational therapist up to 10 times during the 16-week study. Appointments typically lasted 30 to 60 minutes.

During the first few appointments, the therapist reviewed the patient’s lifestyle using self-reported mood and lifestyle journals and explained to the patient the adverse health effects of behaviors such as smoking cigarettes and maintaining a poor diet, as well as the favorable health effects of behaviors such as routine exercise and adequate fluid intake.

Subsequently, the therapist and patient jointly worked out lifestyle goals after which the therapist monitored and reviewed the patient’s progress along with changes in panic symptoms.

Routine GP care was "not constrained" and was identified using GP practice records of attendance, prescriptions, and referrals.

The primary outcome measure was the change in scores on the Beck Anxiety Inventory (BAI), a widely validated instrument for measuring anxiety severity at 20 weeks, measured at 20 weeks — 4 weeks after the completion of the intervention or GP care.

A BAI score of 0 to 7 indicates minimal anxiety, 8 to 15 denotes mild anxiety, 16 to 25 refers to moderate anxiety, and 26 to 63 reflects severe anxiety.

Complete data were available in 31 patients in the lifestyle group and 36 patients in the GP group.

Durable Effect

At the 20-week assessment, results showed a significant improvement in BAI scores. Mean scores decreased from 29.5 to 9.2 in the lifestyle group, whereas scores were reduced from 29.4 to 17.2 in the GP group (P < .001).

At 10-month follow-up, scores continued to be superior in the lifestyle cohort; however, the differences between the 2 groups were not significant. Scores were 13.3 and 16.4 for the 2 groups, respectively (P = .167).

Dr. Lambert pointed out that relapses in the lifestyle group at 10-month follow-up may have occurred because the study did not include maintenance appointments.

"We believe that if patients continued to see the occupational therapist at regular intervals after the 16-week intervention, the relapse rate might have been lower," he said.

"Thus, our data demonstrate that the lifestyle approach may not be effective over the long term for all patients since about one-third of them returned to their prior lifestyle habits and anxiety patterns," said Dr. Lambert.

However, he added, it’s important to keep in mind that this is also the case with other recommended treatments for panic disorder, such as medication and CBT.

"We should also keep in mind that for two-thirds of patients in the lifestyle arm, favorable changes in BAI scores were maintained at 10-months follow-up and were associated with continued improvements."

According to Dr. Lambert, using lifestyle provides patients with a rational explanation for some of the symptoms they experience.

"If lifestyle changes are accompanied by a strategy to reduce the impact of these symptoms, then the fear of the panic symptoms disappears. Regaining control at a personal level by itself reduces anxiety, and developing positive lifestyle behaviors also has broader health benefits for general as well as mental health," he said.

Finally, Dr. Lambert emphasized that although the lifestyle intervention was implemented by occupational therapists in this study, further research may identify a role for other health care professionals in this regard.

"Hopefully, research like ours will have an influence on NICE treatment guidelines for panic disorder," he said. "At the moment, lifestyle is not given due consideration in treatment guidelines."

Current Guidelines Flawed

Stuart Montgomery, MD, PhD, emeritus professor of psychiatry at Imperial College in London, UK, told Medscape Psychiatry that studies evaluating new treatments for panic disorder, like other psychiatric and nonpsychiatric disorders, are always invaluable. What’s more, current NICE guidelines are deeply flawed.

"We always need new treatments, preferably ones that are better, easier to use, more patient-friendly, and those things are all obvious," he said.

"The NICE guidelines are probably the worst guidelines in the world because they ask us to use a generic cheap drug with limited evidence of efficacy — at this moment, they are pushing citalopram — as first-line treatment for all depression and anxiety disorders, and there is no evidence that citalopram is effective in panic disorder," said Dr. Montgomery.

"It may or may not be, but it’s never been tested for this use. So the idea that guidelines recommend using a drug for an unlicensed off-label indication as official government policy is to make a mockery of evidence-based medicine. “

Dr. Lambert and Dr. Montgomery have disclosed no relevant financial relationships.

European Psychiatric Association (EPA) 18th European Congress of Psychiatry: Abstract 768. Presented February 28, 2010.


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