PRACTICE GUIDELINE FOR THE Treatment of Patients With Panic Disorder

Practice Guideline for the Treatment of Patients With Panic Disorder, 2nd EditionTreatment of Patients With Panic Disorder
Second Edition
Murray B. Stein, M.D., M.P.H., Chair
Marcia K. Goin, M.D., Ph.D. Mark H. Pollack, M.D. Peter Roy-Byrne, M.D. Jitender Sareen, M.D. Naomi M. Simon, M.D., M.Sc. Laura Campbell-Sills, Ph.D., consultant
STEERING COMMITTEE ON PRACTICE GUIDELINES
John S. McIntyre, M.D., Chair
Sara C. Charles, M.D., Vice-Chair Daniel J. Anzia, M.D. Ian A. Cook, M.D. Molly T. Finnerty, M.D. Bradley R. Johnson, M.D. James E. Nininger, M.D. Barbara Schneidman, M.D. Paul Summergrad, M.D. Sherwyn M. Woods, M.D., Ph.D. Anthony J. Carino, M.D. (fellow) Zachary Z. Freyberg, M.D., Ph.D. (fellow) Sheila Hafter Gray, M.D. (liaison)
STAFF
Robert Kunkle, M.A., Senior Program Manager Robert M. Plovnick, M.D., M.S., Director, Dept. of Quality Improvement and Psychiatric Services Darrel A. Regier, M.D., M.P.H., Director, Division of Research
MEDICAL EDITOR
Laura J. Fochtmann, M.D.
Copyright 2010, American Psychiatric Association. APA makes this practice guideline freely available to promote its dissemination and use; however, copyright protections are enforced in full. No part of this guideline may be reproduced except as permitted under Sections 107 and 108 of U.S. Copyright Act. For permission for reuse, visit APPI Permissions & Licensing Center at http://www.appi.org/CustomerService/Pages/Permissions.aspx.
This practice guideline was approved in July 2008 and published in January 2009.
A guideline watch, summarizing significant developments in the scientific literature since publication of this guideline, may be available at http://www.psychiatryonline.com/pracGuide/pracGuideTopic_9.aspx.
For the period from September 2005 to June 2008, Dr. Stein reports receiving research grants from the National Institute of Mental Health, the Department of Veterans Affairs, the Department of Defense, Eli Lilly and Company, Forest Pharmaceuticals, Inc., Hoffmann-La Roche, Inc., Novartis, Pfizer, GlaxoSmithKline, Solvay, UCB, and Wyeth. He reports receiving consultant fees from Allergan, Inc., ALZA Corporation, Alexza Molecular Delivery Corp., AstraZeneca, Avera Pharmaceuticals, BrainCells Inc., Bristol-Myers Squibb, Cephalon, Comprehensive NeuroScience, Eli Lilly and Company, EPI-Q Inc., Forest Pharmaceuticals, Inc., GlaxoSmithKline, Hoffmann-La Roche, Inc., Integral Health Decisions Inc., Janssen Research Foundation, Jazz Pharmaceuticals, Inc., Johnson & Johnson, Mindsite, Pfizer, sanofi- aventis, Solvay, Transcept Pharmaceuticals, Inc., UCB, and Wyeth. He reports receiving honoraria from Eli Lilly and Company, GlaxoSmithKline, Solvay, and Wyeth.
For the period from October 2005 to June 2008, Dr. Goin reports no competing interests. For the period from September 2005 to June 2008, Dr. Pollack reports serving on advisory boards and doing
consultation for AstraZeneca, BrainCells Inc., Bristol-Myers Squibb, Cephalon, Dov Pharmaceutical Inc., Forest Pharmaceuticals, Inc., GlaxoSmithKline, Janssen, Jazz Pharmaceuticals, Inc., Eli Lilly and Company, MedAvante, Neurocrine Biosciences, Neurogen Corp., Novartis, Otsuka Pharmaceutical, Pfizer, Predix Pharmaceuticals, Roche, sanofi-aventis, Sepracor Inc., Solvay, Tikvah Therapeutics, Inc., Transcept Pharmaceuticals, Inc., UCB, and Wyeth. He reports receiving research grants from AstraZeneca, Bristol-Myers Squibb, Cephalon, Cyberonics, Forest Pharmaceuticals, Inc., GlaxoSmithKline, Janssen, Eli Lilly and Company, National Alliance for Research on Schizophrenia and Depression, the National Institute on Drug Abuse, the National Institute of Mental Health, Pfizer, Roche, Sepracor Inc., UCB, and Wyeth. He reports receiving speaker fees from Bristol-Myers Squibb, Forest Pharmaceuticals, Inc., GlaxoSmithKline, Janssen, Eli Lilly and Company, Pfizer, Solvay, and Wyeth. He reports equity holdings in MedAvante and Mensante Corporation. He reports receiving copyright royalties for the Structured Interview Guide to the Hamilton-A (SIGH-A) and SAFER.
For the period from August 2004 to June 2008, Dr. Roy-Byrne reports receiving consultant or advisory fees from Jazz Pharmaceuticals, Inc., and Solvay. He reports receiving speaker honoraria (via a continuing medical education company) from Forest Pharmaceuticals, Inc., Pfizer, and Wyeth.
For the period from August 2005 to June 2008, Dr. Sareen reports receiving honoraria from Wyeth, AstraZeneca, Lundbeck, and GlaxoSmithKline.
For the period from September 2005 to June 2008, Dr. Simon reports receiving research support from Cephalon, Pfizer, AstraZeneca, Forest Pharmaceuticals, Inc., GlaxoSmithKline, UCB, Sepracor Inc., Janssen Research Foundation, Eli Lilly and Company, National Alliance for Research on Schizophrenia and Depression, and the National Institute of Mental Health. She reports receiving consultant fees or honoraria from Paramount BioSciences, Anxiety Disorders Association of America, American Psychiatric Association, American Foundation for Suicide Prevention, Forest Pharmaceuticals, Inc., Solvay, Sepracor Inc., UCB, and Pfizer.
For the period from November 2005 to June 2008, Dr. Campbell-Sills reports no competing interests.
The Executive Committee on Practice Guidelines has reviewed this guideline and found no evidence of influence from these relationships.
Copyright 2010, American Psychiatric Association. APA makes this practice guideline freely available to promote its dissemination and use; however, copyright protections are enforced in full. No part of this guideline may be reproduced except as permitted under Sections 107 and 108 of U.S. Copyright Act. For permission for reuse, visit APPI Permissions & Licensing Center at http://www.appi.org/CustomerService/Pages/Permissions.aspx.
CONTENTS
GUIDE TO USING THIS PRACTICE GUIDELINE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
OFF-LABEL USE OF MEDICATIONS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
PART A: TREATMENT RECOMMENDATIONS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
I. EXECUTIVE SUMMARY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9 A. Coding System . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9 B. Psychiatric Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
1. Establishing a therapeutic alliance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9 2. Performing the psychiatric assessment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9 3. Tailoring the treatment plan for the individual patient . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10 4. Evaluating the safety of the patient . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10 5. Evaluating types and severity of functional impairment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10 6. Establishing goals for treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10 7. Monitoring the patient’s psychiatric status. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10 8. Providing education to the patient and, when appropriate, to the family . . . . . . . . . . . . . . . . . . . . . 10 9. Coordinating the patient’s care with other clinicians . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
10. Enhancing treatment adherence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10 11. Working with the patient to address early signs of relapse . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
C. Formulation and Implementation of a Treatment Plan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11 1. Choosing a treatment setting . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11 2. Choosing an initial treatment modality . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11 3. Evaluating whether the treatment is working . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12 4. Determining if and when to change treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12 5. Approaches to try when a first-line treatment is unsuccessful . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12 6. Specific psychosocial interventions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12 7. Specific pharmacological interventions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
D. Maintaining or Discontinuing Treatment After Response . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
II. FORMULATION AND IMPLEMENTATION OF A TREATMENT PLAN . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15 A. Psychiatric Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
1. Establishing a therapeutic alliance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15 2. Performing the psychiatric assessment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15 3. Tailoring the treatment plan for the individual patient . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19 4. Evaluating the safety of the patient . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19 5. Evaluating types and severity of functional impairment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20 6. Establishing goals for treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20 7. Monitoring the patient’s psychiatric status. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20
Copyright 2010, American Psychiatric Association. APA makes this practice guideline freely available to promote its dissemination and use; however, copyright protections are enforced in full. No part of this guideline may be reproduced except as permitted under Sections 107 and 108 of U.S. Copyright Act. For permission for reuse, visit APPI Permissions & Licensing Center at http://www.appi.org/CustomerService/Pages/Permissions.aspx.
8. Providing education to the patient and, when appropriate, to the family . . . . . . . . . . . . . . . . . . . . . 21 9. Coordinating the patient’s care with other clinicians . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21
10. Enhancing treatment adherence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22 11. Working with the patient to address early signs of relapse . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23
B. Choosing a Treatment Setting . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23 C. Choosing an Initial Treatment Modality . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23 D. Evaluating Whether the Treatment Is Working. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24 E. Determining If and When to Change Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24 F. Approaches to Try When a First-Line Treatment Is Unsuccessful . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25 G. Specific Psychosocial Interventions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26
1. Cognitive-behavioral therapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27 2. Psychodynamic psychotherapy. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29 3. Supportive psychotherapy. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30 4. Eye movement desensitization and reprocessing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31 5. Group therapy . . . . . . . . . . . .…