Understanding and treating panic disorder in the primary care setting.

According to studies, the median prevalence of panic disorder in the primary care setting is 4%. Rates are higher among certain patient populations, such as those with cardiac (20% to 50%) or gastrointestinal presentations (28% to 40%). Consequently, patients with panic disorder are high utilizers of medical services and are heavily represented among patients classified as high health care utilizers, compared with other psychiatric or non-psychiatric groups. Despite its frequency in the primary care setting, panic disorder is significantly under-recognized by medical providers. Corresponding with inadequate recognition is the substantial proportion of these patients who fail to receive appropriate treatment (pharmacotherapy and psychotherapy). Most experts have concluded that panic disorder is poorly managed in the primary care setting because of the process of care and patient engagement. In terms of process of care, primary care practice still operates on an acute disease model (leaving no time for initial patient education or follow-up), which is a poor fit for the management of chronic diseases. Insufficient patient engagement in treatment (i.e., being involved in the treatment process, "buying into" rationale for treatment, and being willing to collaborate with clinician and adhere to recommendations) is the second important contributor to inadequate treatment. Use of a chronic disease self-management approach would enhance treatment of panic disorder. This model requires that patients, in collaboration with the health care provider/system, take day-to-day responsibility for managing their illness by doing 3 things: adhering to recommended medical management, adopting improved health habits/coping skills, and assisting in ongoing monitoring of illness status/change. Future approaches to treating panic disorder in primary care would be enhanced by including assessments of patient beliefs and preferences, spending more time in preparing the patient for treatment, utilizing a simple pharmacotherapy algorithm, utilizing simple rating scales to monitor outcomes, and training providers in brief CBT interventions.