Transcript Are benzodiazepines still the medication of choice for patients with

Are Benzodiazepines Still the
Medication of Choice for
Patients With Panic Disorder
With or Without Agoraphobia?
By : s.bruce , PhD et al
(Am J Psychiatry 2003; 160:1432-1438)
Introduction
Panic disorder (PD):
Is a disabling psychiatric condition
associated with significant impairment
in psychosocial & occupational
functioning , the lifetime prevalence
rate (2-4%).
Introduction
Drugs used:
TCA.
MAOIs.
Benzodiazepines .
Introduction
1- Currently, (SSRIs) indicated as the
first line treatment for (PD).
2-The APA’s Practice Guidelines for
Treatment of Patients With Panic
Disorder states that SSRIs are likely to
have the most favorable balance of
efficacy and adverse effects.
Introduction
- (SSRIs) have an advantage over
other treatment agents in that they
are safer in overdose & their ability to
effectively treat comorbid disorders
(e.g. MDD,OCD & social anxiety
disorder).
Objective
To examine how the use of
psychotropic drugs has shifted over the
course of 10 years to determine if
prescribing patterns have changed to
reflect these revised treatment
guidelines.
Method
The harvard\brown anxiety research
project(naturalistic,longtudinal,multicenter
study of adults w current or past hx of
anxiety dis.)
Number of subjects = 711, 30 clinicians’
practice
Inclusion criteria ??
Method
Exclusion criteria :
- Organic brain syndrome.
- History of schizophrenia or
current psychosis at intake.
Insufficient for inclusion, but frequently
seen as comorbid conditions, were
diagnoses of simple phobia, PTSD,
OCD, anxiety dis not otherwise
specified.
Method
A total of (443) patients at intake met
the criteria for (PD) w or w/o
agoraphobia.
The present data derive from structured
diagnostic interview administrated at
intake (1989-1991) & subsequent
semiannual & annual follow up
interviews over 10 y (1991-2001).
Method
The initial comprehensive evaluation
assessed lifetime history with:
# Structured Clinical Interview for DSMIII-R
Non-Affective Disorders.
# The Research Diagnostic Criteria (RDC)
# Schedule for Affective Disorders
&Schizophrenia-Lifetime Version
(SADS-L).
# follow up ??
Method
A participant was considered to have
remitted panic dis if he/she
experience 8 consecutive wk of
psychiatric status rating of 2 or fewer.
Pts were judge to have relapsed if their
psychiatric status rating increased to
a score of 5 or 6 for two consecutive
weeks.
Method
The evaluation gathered weekly information
about the presence of specific symptom
criteria, psychiatric comorbidity &
psychosocial functioning.
Information regarding pharmacological
treatment form the pt was collected every 612 months, retrospectively, including
medications type, average daily dose,
whether pts were taking it as needed.
Results
an additional (44) subjects had a new
onset of (PD) w or w/o agoraphobia
were included in these f/u analysis.
* Demographic characteristics:
-89% Caucasian.
-68% Female.
-38% Had a college
education or higher.
Results
No significant differences regarding
demographic characteristics between
patients w or w/o agoraphobia or
between patients with (PD)
Age at onset bet. PD with agoraphobia
and without ??
Use of pharmacological agents over
follow-up
The results indicated :
Slight decline in benzo. use across the
follow-up interval.
Moderate increase in SSRIs use.
However, of the pts taking an SSRI, about 2/3
were also taking a benzo. in combination.
Use of pharmacological agents over
follow-up
Comparisons of the patients who were
having panic attacks at f/u with the
patients who were in remission ??
The patients with PD & comorbid MDD
were 3.5 times more likely to use an
SSRI than those without MDD.
Use of pharmacological agents over
follow-up
Previous use of benzodiazepines &
SSRIs in the F\U ??.
Other comorbid conditions such as
alcohol/substance use disorders &
additional comorbid anxiety disorders
V
V
SSRIs & the F \ U ??
Pharmacological treatment &
clinical course
The patients whose disorder remitted
BEFORE REMITION ??
Discussion
The result from this study indicate:
Use of SSRIs & gudidelines ?
Benzodiazepine being the most common
class of drugs used to treat PD.
The effect of comorbid MDD on medication
treatment patterns in patients with PD was
found to be a significant predictor of
greater use of SSRI.
Discussion
These results are consistent with those
of (Uhlenhuth & colleagues ) who
reported a negligible decrease in
overall frequency of expert
recommendations for benzodiazepine
as a first-line treatment of PD over a 5
years interval in the 1990s.
Discussion
although physicians` self-reports indicated a
change in the way in which they practice,
actual behavior had change little.
*** Why would a high percentage of these
patient`s physicians not prescribe
SSRIs for PD despite treatment
guidelines endorsing SSRIs as a firstchoice ?
Discussion
(Dugan & cohen) suggested that “before
physician view guidelines as precise tool
to use in the construction of optimal
patient care, they must be convinced
that guidelines contain clear, evidencebased recommendations, and that there
is a distinct advantage to them in
changing practice styles to follow
guidelines”
Discussion
rapid onset of action of the benzo. make
their use more favorable than newer
SSRIs.
non-compliance SSRIs found in some studies
because of unwanted sexual side effects.
(Otto &colleagues ) found no evidence to
support the hypothesis that SSRIs are
more effective than older antidepressants
for the treatment of PD !!!!.
Limitations
This study did not include data from patients’
treating physicians, it is impossible to
determine whether SSRIs were not being
prescribed to the patients or……..
Lack of patients education about :
side effects \ The onset of action
Limitations
Since the pts were recruited from
(1989-1991), most SSRIs had not yet
become available.
Therefore, the finding from this study
may not be indicative of individuals
who are newly diagnosed with PD &
seeking treatment for the first time.
Conclusion
gap between pharmacological
treatment guidelines and actual
delivery of care
Future studied should address this
apparent gap, including whether or
not the clinical guidelines to use
SSRIs as first-line treatment is
premature.
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