Incremental Cost-effectiveness of Pharmacotherapy and Two Brief Cognitive-Behavioral Therapies Compared With Usual Care for Panic Disorder and Noncardiac Chest Pain
and §Family Medicine Department, Université de Sherbrooke, Sherbrooke, Quebec, Canada.The Journal of nervous and mental disease (Impact Factor: 1.69). 09/2013; 201(9):753-9. DOI: 10.1097/NMD.0b013e3182a2127d
The aim of this study was to assess the incremental cost-effectiveness ratios (ICERs) of two brief cognitive-behavioral therapy (CBT)-based interventions and a pharmacological treatment, compared with usual care, initiated in the emergency department (ED) for individuals with panic disorder (PD) with a chief complaint of noncardiac chest pain. A total of 69 patients were followed up to 6 months. The primary outcome variables were direct and indirect costs of treatment and PD severity. Panic management (PM) had an ICER of $124.05, per the Anxiety Disorders Interview Schedule for Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, severity score change (95% confidence interval [CI], $54.63-$314.57), compared with pharmacotherapy (paroxetine), with an ICER of $213.90 (95% CI, $133.51-$394.94), and brief CBT, with an ICER of $309.31 (95% CI, $151.27-$548.28). The pharmacological and CBT interventions were associated with a greater clinical improvement compared with usual care at posttest. PM presented a superior ICER, suggesting that it may be a promising treatment option to implement in EDs.
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ABSTRACT: 1) To determine whether the frequencies of panic disorder (PD) and depression (DEP) in an emergency department (ED) population were comparable to those in other primary care groups; 2) to evaluate whether patients without the clinical diagnosis of acute cardiac ischemia (ACI) had higher frequencies of these disorders; and 3) to identify characteristic clinical findings in patients with PD or DEP. An urban teaching hospital ED. Three hundred thirty-four patients with acute chest pain were evaluated prospectively over an eight-week period. The cohort participating (69%-229/334) completed psychiatric screening measures, including the Panic Disorder Self-Rating Scale, the Beck Depression Inventory, and the Zung Self-Rating Anxiety Scale. A symptom profile consistent with PD was identified in 17.5% of the patients (40/229), DEP in 23.1% (53/229), and either disorder in 35% (80/229). The prevalences of PD were similar in those with and without ACI (19.4% vs 16.6%, respectively, p > 0.05). The likelihoods of one or more ED visits for chest pain in the previous year were significantly greater in those with PD (57.5% vs 36%, p < 0.05) and DEP (54% vs 35%, p < 0.05) than in those without these psychiatric disorders. This study suggests that approximately one in three patients presenting to the ED with acute pain has symptoms consistent with a psychiatric disorder. These disorders occur frequently in both those with and those without acute cardiac ischemia, and clinical variables may help identify these frequent ED utilizers.Journal of General Internal Medicine 05/1993; 8(5):231-5. DOI:10.1007/BF02600087 · 3.45 Impact Factor
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ABSTRACT: To determine the rate of failure of patient reassurance after a normal test result and study the determinants of failure. Replicated single case study with qualitative and quantitative data analysis. University teaching hospital. 40 consecutive patients referred for echocardiography either because of symptoms (10 patients) or because of a heart murmur (30). 39 were shown to have a normal heart. Medical consultations and semistructured patient interviews were tape recorded. Structured interviews with consultant cardiologists were recorded in survey form. Patient recall of the explanation and residual understanding, doubt, and anxiety about the heart after the test and post-test consultation. All 10 patients presenting with symptoms were left with anxiety about the heart despite a normal test result and reassurance by the consultant. Of 28 patients referred because of a murmur but shown to have no heart abnormality, 20 became anxious after detection of the murmur; 11 had residual anxiety despite the normal test result. Reassurance of the "worried well"-anxious patients with symptoms or patients concerned by a health query resulting from a routine medical examination or from screening-constitutes a large part of medical practice. It seems to be widely assumed that explaining that tests have shown no abnormality is enough to reassure. The results of this study refute this and emphasise the importance of personal and social factors as obstacles to reassurance.BMJ Clinical Research 09/1996; 313(7053):329-32. DOI:10.1136/bmj.313.7053.329 · 14.09 Impact Factor
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ABSTRACT: The majority of patients presenting to cardiac clinics with chest pain who are reassured they do not have heart disease or other serious physical disorder continue to experience symptoms, worry about heart disease and restrict their activities. This randomized trial investigated the effectiveness of psychological treatment within routine cardiac care. Consecutive patients presenting with chest pain and reassured by a cardiologist they do not have heart disease were reassessed 6 weeks later. Those with persistent limiting symptoms were offered the opportunity to participate in a trial of cognitive behavioural therapy. Thirty-seven subjects agreed to take part. A number of subjects were unenthusiastic about psychological intervention or, following explanation of the study, regarded further treatment as not being necessary. At 3 months there were significant differences between the treatment group and the control group on key outcome measures of symptoms, mood and activity. At 6 months there were fewer differences but significant advantages of treatment in terms of limitation of activities and worry about physical symptoms. We conclude that there is a need for 'stepped' further care following reassurance in the cardiac clinic and that cognitive behavioural treatment is effective with those with persistent disabling symptoms.Psychological Medicine 10/1997; 27(5):1021-31. DOI:10.1017/S0033291797005254 · 5.94 Impact Factor
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