Outcome assessment and clinical improvement in panic disorder: evidence from a randomized controlled trial of fluoxetine and placebo. The Fluoxetine Panic Disorder Study Group.
ABSTRACT Although panic attacks account for only a portion of the morbidity of panic disorder and panic attack frequency assessments are unreliable, studies of drug efficacy in panic disorder have generally used reduction in panic attack frequency as the primary measure of improvement. The authors studied the efficacy of fluoxetine treatment in panic disorder and measured the relative contributions of changes in symptoms to overall improvement.
Patients with a diagnosis of panic disorder (N = 243) were randomly assigned to treatment with 10 or 20 mg/day of fluoxetine or placebo. Primary outcome measures were change in panic attack frequency and clinician-rated Clinical Global Impression improvement scores. Other assessments included a panic attack inventory, clinician-rated and patient-rated versions of the Panic and Phobic Disorder Change Scale, a phobia rating scale, the Hamilton Anxiety Rating Scale, the 21-item Hamilton Depression Rating Scale, and the Sheehan Disability Scale. Correlations were determined between outcomes in individual symptom domains and overall clinical outcome.
Fluoxetine, particularly the 20-mg/day dose, was associated with more improvement than was placebo in patients with panic disorder across multiple symptom measures, including global improvement, total panic attack frequency, phobic symptoms, and functional impairment. Global improvement was most highly correlated with reductions in overall anxiety and phobic symptoms and least correlated with reduction in panic attacks. Fluoxetine treatment for panic disorder was well tolerated, with a safety profile consistent with that observed for fluoxetine in other disorders.
These data provide support for the efficacy and safety of fluoxetine treatment in reducing panic attacks, phobic symptoms, anxiety, and depressive symptoms in patients with panic disorder. Reductions in panic attack frequency in subjects given either fluoxetine or placebo were less closely related to overall clinical improvement than reductions in phobic avoidance, anxiety, depressive symptoms, and functional impairment, suggesting that outcome measures in this disorder should be more broadly based.
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ABSTRACT: In this report, recommendations for the pharmacological treatment of anxiety and obsessive-compulsive disorders are presented, based on available randomized, placebo- or comparator-controlled clinical studies. Selective serotonin reuptake inhibitors (SSRIs) are the first-line treatment for panic disorder. Tri2-cyclic antidepressants (TCAs) are equally effective, but they are less well tolerated than the SSRIs. In treatment-resistant cases, benzodiazepines like alprazolam may be used when the patient does not have a history of dependency and tolerance. Due to possible serious side effects and interactions with other drugs and food components, the irreversible monamine oxidase inhibitor (MAOI) phenelzine should be used only when first-line drugs have failed. In generalised anxiety disorder, venlafaxine and SSRIs can be recommended, while buspirone and imipramine may be alternatives. For social phobia, SSRIs are recommended for the first line, and MAOIs, moclobemide and benzodiazepines as second line. Obsessive-compulsive disorder is best treated with SSRIs or clomipramine.The World Journal of Biological Psychiatry 11/2002; 3(4):171-99. DOI:10.3109/15622970209150621 · 4.23 Impact Factor
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ABSTRACT: Background. Patients with anxiety disorders suffer marked functional impairment in their activities of daily living. Many studies have documented that improvements in anxiety symptom severity predict functioning improvements. However, no studies have investigated how improvements in functioning simultaneously predict symptom reduction. We hypothesized that symptom levels at a given time point will predict functioning at the subsequent time point, and simultaneously that functioning at a given time point will predict symptom levels at a subsequent time point. Method. Patients were recruited from primary-care centers for the Coordinated Anxiety Learning and Management (CALM) study and were randomized to receive either computer-assisted cognitive-behavioral therapy and/or medication management (ITV) or usual care (UC). A cross-lagged panel design examined the relationship between functional impairment and anxiety and depression symptom severity at baseline, 6-, 12-, and 18-month follow-up assessments. Results. Prospective prediction of functioning from symptoms and symptoms from functioning were both important in modeling these associations. Anxiety and depression predicted functioning as strongly as functioning predicted anxiety and depression. There were some differences in these associations between UC and ITV. Where differences emerged, the UC group was best modeled with prospective paths predicting functioning from symptoms, whereas symptoms and functioning were both important predictors in the ITV group. Conclusions. Treatment outcome is best captured by measures of functional impairment as well as symptom severity. Implications for treatment are discussed, as well as future directions of research.Psychological Medicine 10/2014; DOI:10.1017/S0033291714002062 · 5.43 Impact Factor
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ABSTRACT: Quality-of-life indices have been used in medical practice to estimate the impact of different diseases on functioning and well-being and to compare outcomes between different treatment modalities. An integrated view of the issue of quality of life in patients with anxiety disorders can provide important information regarding the nature and extent of the burden associated with these disorders and may be useful in the development of strategies to deal with it. A review of epidemiological and clinical studies that have investigated quality of life (broadly conceptualized) in patients with panic disorder, social phobia, posttraumatic stress disorder, generalized anxiety disorder, and obsessive-compulsive disorder was conducted by searching MEDLINE and PsycLIT citations from 1984 to 1999. A summary of the key articles published in this area is presented. The studies reviewed portray an almost uniform picture of anxiety disorders as illnesses that markedly compromise quality of life and psychosocial functioning. Significant impairment can also be found in individuals with subthreshold forms of anxiety disorders. Effective pharmacological or psychotherapeutic treatment has been shown to improve the quality of life for patients with panic disorder, social phobia, and posttraumatic stress disorder. Limitations in current knowledge in this area are identified, and suggestions for needed future research are provided. It is expected that a more thorough understanding of the impact on quality of life will lead to increased public awareness of anxiety disorders as serious mental disorders worthy of further investment in research, prevention, and treatment.American Journal of Psychiatry 06/2000; 157(5):669-82. DOI:10.1176/appi.ajp.157.5.669 · 13.56 Impact Factor